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AHIP FINAL Examination Questions
With Correct Answers Latest
- Mr.gZachowghasgagconditiongforgwhichgthreegdrugsgaregavailable.gHeghasgtried twogbutghadgangallergicgreactiongtogthem.gOnlygthegthirdgdruggworksgforghimg andgitgi sgnotgonghisgPartgDgplan'sgformulary.gWhatgcouldgyougtellghimgtogdo?:gMr.gZachowgha sgagrightgtogrequestgagformularygexceptiongtogobtaingcoveragegforghisgPartg Dgdrug.gHegorghi sgphysiciangcouldgobtaingthegstandardizedgrequestgformgongthegplan'sg website,gfillgitgout,ga ndgsubmitgitgtoghisgplan.
- Mr.gPolanskiglikesgthegcostgofgangHMOgplangavailableginghisgarea,gbutgwouldg likegt ogbegablegtogvisitgonegorgtwogdoctorsgwhogaren'tgparticipatinggproviders.gHeg wantsgt ogknowgifgthegPointgofgServiceg(POS)goptiongavailablegwithgsomegHMOsg willgbegofga nyghelpgingthisgsituation.gWhatgshouldgyougtellghim?:gThegPOSgoptiong mightgbegaggoo dgsolutiongforghimgasgitgwillgallowghimgtogvisitgout-of- networkgproviders,g generallygwithoutgpriorgapproval.gHowever,ghegshouldgbegawaregthatgi tgisglikelyghegwillg havegtogpayghighergcost-sharinggforgservicesgfromgout-of- networkgproviders.
- Mr.gBarkerghadgsurgerygrecentlygandgexpectedgthatghegwouldghavegcertaing serv icesgandgitemsgcoveredgbygthegplangwithgminimalgout-of- pocketgcostsg becauseghisgMA- PDgcoverageghasgbeengveryggood.gHowever,gwhenghegreceivedg thegbill,ghegwasgsur
prisedgtogseeglargegchargesgingexcessgofghisgmaximum out-of- pocketglimitgthatgincludedgagnumbergofgservicesgandgitemsghegthoughtg wouldgbegf ullygcovered.gHegcalledgyougtogaskgwhatghegcouldgdo?gWhatgcouldg yougtellghim?:gY ougcangoffergtogreviewgthegplansgappealgprocessgtoghelpghimgaskgthegplangtogreviewgthegco veragegdecision.
- Ms.gStuartghasgheardgaboutgagspecialgneedsgplang(SNP)gthatgonegofghergfriendsg isge nrolledgingandgisginterestedgingthatgproduct.gShegwantsgtogbegsuregshe alsoghasgcoveragegforgprescriptiongdrugs.gWouldgshegbegablegtogobtaingdrugg cove ragegifgshegenrolledgingthegSNP?:ga.gYes.gAllgSNPsgaregrequiredgtogprovidegPartgDgcover agegforgprescriptiongdrugs. b. Yes,gbutgonlygifgshegqualifiesgforgPartgDgprescriptiongdruggcoveragegunderghergstategMe dicaidgprogram. c. No.gMedicaregbeneficiariesgwhogenrollgingangSNPgmustgalwaysgobtaingtheirgdrugg co veragegthroughgagstand- alonegPartgDgMedicaregprescriptiongdruggplangthatgtheyg signgupgforgindependentgofgthe irgenrollmentgingthegSNP. d. Maybe.gSomegSNPsgoffergPartgDgcoveragegforgprescriptiongdrugsgandgsomegdognot. =g?????
- PhionagworksgingthegITgDepartmentgofgBestCaregHealthgPlan.gPhionagisg place dgingchargegofgBestCare'sgeffortsgtogfacilitategelectronicgenrollmentging itsgMedic aregAdvantagegplans.gIngsettinggupgthegenrollmentgsite,gwhichgofgtheg followinggm ustgPhionagconsider?:gII.gAllgdatagelementsgrequiredgtogcompletegang enrollmentgrequ estgmustgbegcaptured.
excessgofg$100,000.gMr.gWongghasghealthgcoveragegthroughghisgemployerg butgwill gsign-upgMedicaregPartgA,gPartgBgandgPartgDgwhenghegleavesgthegwork- g force.gHowgwouldgyougadviseghimgasghegbudgetsgforgMedicaregpremiums?:ga.g Du egtogthegprovisionsgofgMACRA,ghisgPartgBgandgDgcoveragegwillgbegcombinedgandg covere dgthroughgaglow-costgMedigapgpolicygtogsupplementghisgPartgAgcoverage. b. DuegtoghisgparticipationgingthegworkforceghegwillgnotghavegtogpaygpremiumsgforgPartg Aga ndghegwillgpaygtheglowestgmonthlygpremiumgratesgforgPartgBgandgPartgD. c. DuegtoghisgparticipationgingthegworkforceghegwillgnotghavegtogpaygpremiumsgforgPartg Agb utghegwillgpayghighergpremiumsgforgPartgBgandgPartgDgduegtogthegamountgofghisg income. d. DuegtoghisgparticipationgingthegworkforceghegwillgnotghavegtogpaygpremiumsgforgPartg Aga ndgwillgpaygreducedgpremiumsgforgPartgBgandgPartgD. ?????
- Mr.gPrenticeghasgmanygclientsgwhogaregMedicaregbeneficiaries.gHegshouldg re viewgthegCentersgforgMedicareg&gMedicaidgServices'gcommunicationgand
MarketinggGuidelinesgtogensureghegisgcompliantgforgwhichgtypegofgproducts?- :gMedicaregAdvantageg(MA)gandgPrescriptiongDrugg(PDP)gplansgCorrect
- Ms.gHernandezghasgmarketedgseveralgdifferentgtypesgofginsurancegproductsg in gherghomegstategandghasgtypicallygsoughtgapprovalgofghergmaterialsgfromgherg Stat egDepartmentgofgInsurance.gWhatgwouldgyougadviseghergregardinggseekingg suchga pprovalgforgmaterialsgshegusesgtogmarketgMedicaregAdvantagegplans?:ga.g Statesgoft engvolunteergtogreviewgmarketinggmaterialsgongbehalfgofgthegMedicareg agency.gShegsho uldgcheckgwithghergDepartmentgofgInsurancegtogseegifgsuchgagreviewgisgavailablegandgwoul dgsatisfygCMSgrequirements. b. MaterialsgforgmarketinggMedicareghealthgplansgtogindividualsgaregsubjectgtog Medicar e'sguniformgnationalgrequirements.gTheygdognotgneedgtogbegreviewedgbygtheg state,gbutgth egcompanygshegrepresentsgmustgobtaingapprovalgfromgthegMedicareg agencyg(CMS)gfor ganygmaterialsgsheguses. c. ObtaininggapprovalgofghergmaterialsgfromgthegStategDepartmentgofgInsurancegisgag goo dgpracticegandgshegshouldgcontinuegitgwithgmaterialsgforgthegMedicareghealthgplansg shegrep resents. d. Materialsgneedgonlygbegreviewedgandgapprovedgbygthegcompany(s)gshegrepresents.
- Mrs.gMcIntiregisgenrolledginghergstate'sgMedicaidgplangandghasgjustgbecomeg eli giblegforgMedicaregasgwell.gWhatgcangshegexpectgwillghappengwithgrespectgtog hergd ruggcoverage?:gUnlessgshegchoosesgagMedicaregPartgDgprescriptiongdruggplang onghergo wn,gshegwillgbegautomaticallygenrolledgingonegavailableginghergarea.
- Mr.gCapadonagwouldglikegtogpurchasegagMedicaregAdvantageg(MA)gplangandg ag Medigapgplangtogpickgupgcostsgnotgcoveredgbygthatgplan.gWhatgshouldgyougtellg him ?:gItgisgillegalgforgyougtogsellgMr.gCapadonagagMedigapgplangifghegisgenrolledgingang MAgplan,g andgbesides,gMedigapgonlygworksgwithgOriginalgMedicare.
agfieldgmarketinggorganizationg(FMO).gMr.gCharlesgisgangindependentgagentgpaid forghisgworkgbygagthird- partygmarketinggorganizationg(TMO).gHowgdogthegCMSg compensationgrulesgapply gtogthesegthreegagents?:gBakergandgCharlesgaregsubjectg togCMS compensationgrulesgbecausegtheygaregpaidgbygthirdgparties.gAblegisgnotgbecauseg shegisg paidgdirectlygbygaghealthgplan.
- AgentgWillisghadgseveralgclientsgwhogdisenrolledgfromgthegplansghegrep- g resentsgduringgthegAEPgtogtrygnewgMedicaregAdvantagegplans.gAgentgWillisg belie vesgthatgthegchoicesgtheygmadegaregnotgidealgforgthemgandgwouldglikegtoggetg theirgbu sinessgbackgduringgthegMedicaregAdvantagegOpengEnrollmentgPeriodg (MA- OEP).gWhatgcangagentgWillisgdo?:gHegcangwaitguntilgOctobergandgsendgthemg informati ongaboutgthegplansghegrepresents.
- Mr.gGrecogisgingexcellentghealth,glivesginghisgownghome,gandghasgagsizeableg inc omegfromghisginvestments.gHeghasgagfriendgenrolledgingagMedicaregAdvan- g tagegSpecialgNeedsgPlang(SNP).gHisgfriendghasgmentionedgthatgthegSNPgchargesg ve ryglowgcost- sharinggamountsgandgMr.gGrecogwouldglikegtogjoingthatgplan.g Whatgshouldgyougtell ghim?:gSNPsglimitgenrollmentgtogcertaingsubgpopulationsgofg beneficiaries.gGivenghisgcurr entgsituation,ghegisgunlikelygtogqualifygandgwouldgnotgbeg ablegtogenrollgingthegSNP.
- Mrs.gPattersongisgagnewgenrolleegingthegHealthBestgMedicaregAdvantageg (MA- PD)gplan.gShegisgnewgtogthisgtypegofgcoveragegandgasksgyougwhatgmaterials,g ifgany,gs hegshouldgexpectgtogreceive.gHowgwouldgyougreply?:g1.gPlangratingsg information,gsu mmarygofgbenefits,gandgpre-enrollmentgchecklist
- Ms.gMooregplansgtogretiregwhengshegturnsg 65 gingagfewgmonths.gShegisging exc ellentghealthgandgwillghavegconsiderablegincomegwhengshegretires.gSheg isgcon
cernedgthatghergincomegwillgmakegitgimpossiblegforghergtogqualifygforg Medicar e.gWhatgcouldgyougtellghergtogaddressghergconcern?:gMedicaregisga programgforgpeoplegageg 65 gorgoldergandgthosegundergageg 65 gwithgcertaingdisabilities,g endg stagegrenalgdiseasegorgLougGehrig'sgdisease,gsogshe willgbegeligiblegforgMedicare.
- Anothergagentgworkinggforgyourgagencygclaimsgthatgbecausegyougaregnotg em ployedgbygthegMedicaregAdvantagegplansgthatgyougrepresent,gyougaregnotg subjec tgtogthegsamegrequirementsgasgthegplansgthemselves.gHowgshouldgyoug respondgt ogsuchgagstatement?:gYourgcoworkergisgnotgcorrect.gMarketinggongbehalfgofgagplangisgco nsideredgmarketinggbygthegplangandgrequiresgthatgallgcontractedgandg employedgagentsg complygwithgallgMedicaregmarketinggrules.
- Thisgyeargyoughavegdecidedgtogfocusgyourgeffortsgongmarketinggtogemployerg gr oupgplans.gOnegemployergprovidesgyougwithgaglistgofgtheirgretireesgand
10 caregAdvantagegplans.gHegasksgyougtogexplaingitgtoghimgsinceghegisg interestedginge nrollinggingagplangthatgisgnewlygavailableginghisgarea.gAftergyoug explaingthatgitgisgtheg waygforgconsumersgtogjudgegplangperformance,gwhatgelseg wouldgyougsay?:g???? ?? Beneficiariesgwhoglivegingthegservicegareagofgag 5 - stargplangandgaregenrolledgingangMAg orgPDPgplan,gorgbeginningging2013,gagCostgplan Beneficiariesgwhoglivegingthegservicegareagofgag 5 - stargplan,garegenrolledgingOriginalg Medicare,gandgmeetgthegeligibilitygrequirementsgforg MedicaregAdvantagegorgPartgDg plans ThegSEPgisgavailablegeachgyeargbeginninggongDecemberg 8 gandgmaygbegusedgonceg throu ghgNovemberg 30 gofgthegfollowinggyear.gForgexample,gthegSEPgforgcalendargyearg 2018 gcan gbe usedgfromgDecemberg8,g 2017 gthroughgNovemberg30,g2018. DisenrollgfromgangMAgplan,gPDPgorgCostgplangorgleaveg OriginalgMedicare Enrollgingag 5 - stargMAgplan,gPDPgorgCostgplangEligiblegindividualsgm aygenrollgingag 5 - stargplan
11 throughg 1 - 800 - MEDICARE,gMedicare.gov,gor directlygthroughgtheg 5 - stargplan.
- Mr.gDaviesgisgturningg 65 gnextgmonth.gHegwouldglikegtogenrollgingagMedicareg he althgplan,gbutgdoesgnotgwantgtogbeglimitedgingtermsgofgwhereghegobtains hisgcare.gWhatgshouldgyougtellghimgaboutghowgagMedicaregCostgPlangmightgfitg hisg needs?:gCostgplangenrolleesgcangchoosegtogreceivegMedicaregcoveredgservicesg underg thegplan'sgbenefitsgbyggoinggtogplangnetworkgprovidersgandgpayinggplangcostg sharing,gorg maygreceivegservices fromgnon-networkgprovidersgandgpaygcostgsharinggduegundergOriginalgMedicare.
- LastgyeargAgentgMelaniegMeyersgmarketedgandgenrolledgseveralgclientsging M edicaregAdvantageg(MA)ghealthgplans.gThisgyeargsheghasgdecidedgtogfocusg ongno n- MAgproducts.gWhatgadvicegwouldgyouggivegMelaniegifgshegwishesgtog continuegtog receivegrenewalgfees?:
- AlicegisgenrolledgingagMA- PDgplan.gShegmakesgagpermanentgmovegacrossgtheg countrygandgwondersgwhatghe rgoptionsgaregforgcontinuinggMA- PDgcoverage.g Whatgwouldgyougsaygtoghergingregardgtogagspecialgenrollmentgperio dg(SEP)?:
- Mr.gColeghasgbeengagMedicaidgbeneficiarygforgsomegtime,gandgrecentlygqual- g ifiedgforgMedicaregasgwell.gHegisgconcernedgaboutgchangesginghisgcost- sharing.g Whatgshouldgyougtellghim?:gHegshouldgknowgthatgMedicaidgwillgpaygcostgsha ringg onlygforgservicesgprovidedgbygMedicaidgparticipatinggproviders.
- Mr.gNguyengunderstandsgthatgMedicaregprescriptiongdruggplansgcangusegag fo rmularygorglistgofgcoveredgdrugs.gHegisgsuspiciousgaboutghowgplansgestablishg thes
13 shouldgyougtellghergaboutgcoveragegofgemergencygcare?:gPlansgaregrequiredgto covergout-ofgnetworkgemergencygcare.
- Whichgofgthegfollowinggindividualsgareglikelygtogqualifygforgagspecialgenroll- g mentgperiodg(SEP)gforgbothgMAgandgPartgDgduegtogagchangegofgresidence? I. Edwardg(enrolledgingMAgandgPartgD)gmovesgtogagnewghomegwithingthegsameg nei ghborhoodginghisgexistinggplan'sgservicegarea. II. Fionag(enrolledgingMAgandgPartgD)gmovesgcross- countrygtogangareagoutsideg hergexistinggplan'sgservicegarea. III. GilbertgmovesgintogagplangservicegareagwheregtheregisgnowgagPartgDgplang av ailablegtoghimgfromgagservicegareagwheregnogPartgDgplangwasgavailable. IV. HenrygmakesgagpermanentgmovegprovidingghimgwithgnewgMAgandgPartgDg op tions.:gII,gIII,gandgIVgonly
- Mr.gLynn,gangagentgforgAcmegInsurance,gInc.gthinksgthat,gsincegstateglawsgareg pre emptedgwithgregardgtogthegmarketinggofgMedicareghealthgplans,ghegdoesn'tg haveg muchgtogworrygabout.gWhatgmightgyou,gasghisgcolleague,gadviseghimg concerninggt hegtypegofgscrutinyghegwillgbegunder?:gOrganizationsgsponsoringg Medicare healthgplansgaregresponsiblegforgthegbehaviorgofgtheirgcontractedgrepresentativesgandg will gbegconducting monitoringgactivitiesgtogensuregcompliancegwithgallgapplicablegFederalg lawga ndgguidancegandgplangpolicies. Furthermore,gstategagentglicensureglawsgaregnotgpreemptedgandghegmustgabidegbyg theirg requirements.
- Mrs.gWellingtongisgenrolledgingPartsgAgandgBgofgOriginalgMedicare.gAgfriendg rec entlygtoldghergthatgtheregisgangexcellentgMedicaregAdvantageg(MA)gplangwithg agfive-
14 stargratinggservingghergarea.gOngJanuaryg 15 gshegcomesgtogyougforgadviceg asgtogwha tgoptions,gifgany,gsheghas.gWhatgshouldgyougsaygregardinggspecialg enrollmentgperi odsg(SEPs)?:gMrs.gWellingtongisgeligiblegforgagSEP thatgmaygbegusedgonceguntilgNovemberg 30 gtogenrollgingthegfivestargplan.
- Mrs.gBerkowitzgwantsgtogenrollgingagMedicaregAdvantagegplangthatgdoesgnotg in cludegdruggcoveragegandgalsogenrollgingagstand- alonegMedicaregprescriptiong druggplan.gUndergwhatgcircumstancesgcangshegdogt his?:gIfgthegMedicaregAdvan-g tagegplangisga PrivategFee-for- Serviceg(PFFS)gplang thatgdoesgnotgoffergd ruggcoveragegorga MedicalgSavingsgAccount,gMrs.gBerkowitzgcangdogthis.
16 uggcoverage,gsogAgentgRoderickgalsogenrollsgMrs.gMartinezgingagstandaloneg pres criptiongdruggplang(PDP).gWhatgCMSgcompensationgrulesgapplygtogthisgsituation ?:gThisgsituationgisgconsideredgag"dual enrollment"gandgCMSgcompensationgrulesgaregappliedgtogthegtwogplansgatgoncegandg ind ependentlygofgeachgother.
- Mrs.gRidgewaygenrolledgingOriginalgMedicaregandgMedigapgcoveragegfol- g lowingghergretirementsgseveralgyearsgago.gFourgmonthsgago,gMrs.gRidgewayg d roppedghergMedigapgpolicygtogenrollgingagMedicaregAdvantageg(MA)gplang forgth egfirstgtime.gUnfortunately,gMrs.gRidgewayghasgfoundgthatgmanygofgher providersgaregnotgingthegMAgplan'sgnetwork.gSheghasgcomegtogyougforgadvice? Whatgshouldgyougtellgher?:gShegqualifiesgforgagspecialgenrollment periodg(SEP)gthatgwillgallowghergtogmakegagone- timegelectiongtogreturngtogOriginalg Medicaregandgshegalsoghasgagguaranteedgeligibilitygperi odgtogrejoinghergMedigapgplan.
17
- Thisgyeargyougdecidegtogfocusgyourgeffortsgongmarketinggtogemployergand unionggroups.gWhichgofgthegfollowinggstatementsgbestgdescribesgwhatgyougcang an dgcannotgdogingordergtogstaygingcompliance?:gYougaregnotgrequiredgtogsubmitgcopiesg ofgdisseminatedgmaterialsgtogCMS atgthegtimegofguse,gbutgCMSgmaygrequestgandgreviewgcopiesgifgemployeegcomplainsg occu r.
- Sinceg 2004 gMs.gEisenbergghasghadgagMedigapgplangthatgprovidesgsomeg drugg coverage.gSheghasgrecentlygreceivedgaglettergfromghergMedigapgcarrierg informin gghergthatghergdruggcoveragegisgnotg"creditable."gShegwantsgtogknowg whatgthisgm eans.gWhatgshouldgyougtellgher?:
- Mr.gDavisgisg 52 gyearsgoldgandghasgrecentlygbeengdiagnosedgwithgend- stageg renalgdiseaseg(ESRD)gandgwillgsoongbegingdialysis.gHegisgwonderinggifghegc ang obtaingcoveragegundergMedicare.gWhatgshouldgyougtellghim?:gHegmaygsign- upg forgMedicaregatganygtimeghowevergcoveragegusuallygbeginsgongthegfourthgmonthgafterg dialysisgtreatmentsgstart.
- Mr.gHutchinsonghasgdruggcoveragegthroughghisgformergemployer'sgretireeg pl an.gHegisgconcernedgaboutgthegPartgDgpremiumgpenaltygifghegdoesgnotgenrollg ingag Medicaregprescriptiongdruggplan,gbutgdoesgnotgwantgtogpurchasegextrag coverageg thatghegwillgnotgneed.gWhatgshouldgyougtellghim?:gIfgthegdruggcoverageg heghasgisgnotge xpectedgtogpay,gongaverage,gatgleastgasgmuchgasgMedicare'sgstandardgPartgDgcoveragege xpectsgtogpay,gthenghegwillgneedgtogenrollgingMedicaregPartgDgduringghisginitialgeligibilitygperi odgtogavoidgtheglategenrollmentgpenalty.
- Nextgweekgyougwillgbegparticipatinggingyourgfirstg"educationalgevent"gforg pr ospectivegenrollees.gIngordergtogbegsuregthatgyougdognotgviolateganygofgtheg appli cablegguidelines,gingwhatgactivitiesgshouldgyougplangtogengage?
