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AHIP EXAM Assessment 2024-2025 Questions and Correct Answers
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Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included a number of
services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? - ANSWER-c. You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? - ANSWER-d. Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. Anita Magri will turn age 65 in August 2020. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has told her about the Medigap Part F plan in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for
Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her? - ANSWER-b. You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income. Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him? - ANSWER-b. After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell him? - ANSWER-b. He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B when first eligible and wants to know how much he will have to pay. What should you tell him? - ANSWER-d. Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? - ANSWER-b. Medicare Supplemental Insurance would help cover his Part A and Part B cost
because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? - ANSWER-c. Part D covers prescription drugs and she should look at her premiums, formulary, and cost- sharing among other factors to see if they have changed. Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him? - ANSWER-d. Mr. Singh can enroll in a stand- alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for- Service Medicare. Mrs. Paterson is concerned about the deductibles and co- payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern? - ANSWER-c. Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services. Mrs. Quinn recently turned 66 and decided after many years of work to begin receiving Social Security benefits.
Shortly thereafter Mrs. Quinn received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn? - ANSWER-d. Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% coinsurance for these services, in addition to an annual deductible. Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility? - ANSWER-b. Medicare will cover Mrs. Shield's skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days. Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the
concern? - ANSWER-d. Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for Medicare. What impact, if any, will recent regulatory changes have upon Medigap plans? - ANSWER-c. The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020. Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard that there are certain MA plans that might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open - ANSWER-d. If there is a special needs plan (SNP) in Mr. Wendt's area that specializes in caring for individuals with diabetes, he may enroll in the SNP at any time under a special enrollment period (SEP). Correct
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him? - ANSWER-a. C-SNP Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan's terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge? - ANSWER-b. Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15%of the Medicare rate. Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? - ANSWER-a. He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.
should you tell him? - ANSWER-d. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network). Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program? - ANSWER-c. They are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she would not have to put up with such poor access to care. What could you tell her? - ANSWER-b. She could file a grievance with her plan
to complain about the lack of timeliness in getting an appointment. Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? - ANSWER-b. She could enroll in a PFFS plan and a stand- alone Medicare prescription drug plan. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season? - ANSWER-a. She may remain in her ABC MA plan, enroll in another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare
could be obtained by also enrolling in a separate prescription drug plan. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - ANSWER-c. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her? - ANSWER-d. Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will have a higher cost- sharing amount if she sees a provider who/that is not a part of the PPO network. Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage (MA) plan? - ANSWER-b. She cannot enroll in an MA Medical Savings Account (MSA) plan.
Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her? - ANSWER-a. Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - ANSWER-c. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage? - ANSWER-b. She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan.
Mr. Bickford did not quite qualify for the extra help low- income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him? - ANSWER-b. He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? - ANSWER-c. Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries.
Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him? - ANSWER-d. If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums, and cost sharing. How can you explain this to him? - ANSWER-c. Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government. Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is
