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AHIP Final Exam with Questions and Answers
2024 new update
Question 1: 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 1: She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment.
Question 2: Edward IP suffered from serious kidney disease. As a result, Edward became eligible for Medicare coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and asks you if his Medicare coverage will continue. What should you say? Answer 2: Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part B but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs.
Question 3: Mildred Savage enrolled in Allcare Medicare Advantage plan several years ago. Mildred recently learned that she is suffering from inoperable cancer and has just a few months to live. She would like to spend these final months in hospice care. Mildred's family
asks you whether hospice benefits will be paid for under the Allcare Medicare Advantage plan. What should you say? Answer 3: Mildred may remain enrolled in Allcare and make a hospice election. Hospice benefits will be paid for by Original Medicare under Part A and Allcare will continue to pay for any non-hospice services.
Question 4: 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 4: Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan.
Question 5: 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 5: Medicare Supplemental Insurance would help cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.
Question 6: Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full-time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under Part A because she was not born in the United States. What should you tell her?
Question 10: 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 10: He may sign up for Medicare at any time; however, coverage usually begins on the fourth month after dialysis treatments start.
Question 11: Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed to 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 11: 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 to her substantial income.
Question 12: Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her? Answer 12: To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.
Question 13: Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan.
Question 14: 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 14: Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage.
Question 15: Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? Answer 15: 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. Here are the questions and answers clearly distinguished and labeled:
Question 1: Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him? Answer 1: It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
retroactive coverage back to the date of termination from Medicaid or coverage beginning the month after the month of enrollment.
Question 6: Anthony Boniface turned 65 in 2023. He was not receiving Social Security or Railroad Retirement Benefits on his 65th birthday. He was interested in obtaining Medicare coverage and is eligible for premium-free Part A. Before he could enroll in Medicare, his entire area was impacted by a hurricane causing massive flooding and severe wind damage. The Federal government declared this to be a natural disaster which has recently ended. During this period, Anthony's initial enrollment period expired. Anthony asks you how he can now obtain Medicare coverage. What should you say? Answer 6: Anthony is eligible for a special enrollment period (SEP) because he missed an enrollment period due to the impact of the Federally declared disaster. This SEP will allow Anthony to enroll in Part B up to six months after the end of the emergency declaration. Anthony may enroll in premium-free Part A at any time and his Part A coverage will be retroactive for up to 6 months.
Question 7: Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan? Answer 7: All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan.
Question 8: 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 8: 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 is not a part of the PPO network.
Question 9: Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him? Answer 9: He should compare the benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage for his prescription needs.
Question 10: 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 Advantage Special Needs Plans (SNPs). What could you tell him? Answer 10: SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well.
Question 11: 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 11: Dr. Brennan can charge Mary Rogers no more than the cost-sharing specified in the PFFS plan's terms and conditions of payment, which may include balance billing up to 15% of the Medicare rate.
Question 15: 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 some services and items he thought would be fully covered. He called you to ask what he could do. What could you tell him? Answer 15: You can offer to review the plan's appeal process to help him ask the plan to review the coverage decision.
Question 16: Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA) Plans? Answer 16:
- I. MSAs may have either a partial network, full network, or no network of providers.
- II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
- IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full.
Question 17: Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him? Answer 17: SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP.
Question 18: 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 18: C-SNP (Chronic Condition Special Needs Plan). Questions and Answers
- Question: 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: He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.
- Question: Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? Answer: Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan.
- Question: Mrs. Wang 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: Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of- pocket limit on Part A and Part B services.
- Question: Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? Answer: Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.
Answer: Mr. McCarthy's insulin costs for a one-month supply cannot be more than $35 in any coverage phase under the prescription drug plan beginning in 2023.
- Question: Mrs. Imelda Diaz is a Medicare beneficiary enrolled in a MA-PD plan you represent. Her neighbor recently suffered from a painful case of shingles. Mrs. Diaz hopes to avoid such an illness through vaccination. She asks you whether the cost of shingles vaccination will be covered under the plan you represent. What should you say? Answer: Yes, there is no cost sharing for the shingles vaccine even in the deductible phase of her prescription drug plan because it is an adult vaccine recommended by the Advisory Committee on Immunization Practices (ACIP).
- Question: Mr. Schultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Schultz has lost his employer group coverage within the last two weeks. How would you advise him? Answer: Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.
- Question: Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan? Answer: A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan.
- Question: Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? Answer: Jose, a grandfather who was granted asylum and has worked in the United States for many years. Jose, having been granted asylum, is legally present in the United States thus meeting one of the criteria for Part D eligibility.
- Question: 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: 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.
- Question: Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to? Answer: Yes. Mrs. Walters must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program.
- Question: 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: 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.
- Question: 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: 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.
- Question: Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage? Answer: Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.
Answer: Mr. Lozano will need to obtain routine services from the HMO's network of providers within his specific service area, but the plan will cover emergency services regardless of where they are provided.
- Question: Mrs. Mulcahy wants to know how her current Medicare supplement plan will work with the Medicare Advantage HMO she is considering. What should you tell her? Answer: Medicare supplement policies cannot be used with Medicare Advantage plans.
- Question: Mr. Gomez notes that Medicare Advantage HMO enrollment has increased. What might account for the increase? Answer: Medicare Advantage HMOs often provide extra benefits and services that are not covered under Original Medicare.
- Question: Mrs. Devlin wants to know how a Private Fee-for-Service (PFFS) plan might affect her access to providers. What should you tell her? Answer: If Mrs. Devlin joins a PFFS plan that has a network of providers, she may have reduced cost sharing if she sees network providers.
- Question: Mr. Nelson lives in Minnesota and has been notified that his Medicare Advantage HMO plan will no longer be available. Mr. Nelson asks for advice on what he can do. What would you advise him to do? Answer: Mr. Nelson will be given a Special Election Period to select a new Medicare Advantage plan or return to Original Medicare.
- Question: Mr. Eaton is enrolled in a MA-PD plan that provides medical care and prescription drug coverage. Recently, he has become dissatisfied with his MA-PD plan and wants to switch to Original Medicare. What should you tell him? Answer: Mr. Eaton may choose to switch to Original Medicare during the Medicare Advantage Open Enrollment Period, January 1 through March 31, and he may also choose a stand-alone prescription drug plan during this time.
- Question: Mr. Giles recently suffered a stroke but has not yet enrolled in Medicare Part B. His doctor prescribed occupational therapy for him, which is covered under Medicare Part B. What should you tell Mr. Giles? Answer: Mr. Giles must first enroll in Medicare Part B, then access Part B services such as occupational therapy.
- Question: Ms. Taveras is considering a Medicare Advantage HMO and is concerned about her ability to get care. What should you tell her? Answer: Ms. Taveras will generally need to get her care from providers who participate in the HMO's network.
- Question: Mrs. Roper asks whether there are any special eligibility requirements for Medicare Advantage. What should you say? Answer: Mrs. Roper must be enrolled in both Medicare Part A and Part B and live in the plan's service area.
- Question: Mrs. Ramos is currently enrolled in Original Medicare, and her neighbor told her she should look at the Medicare Advantage plans available in her area. What is the basic idea she should understand before looking at specific plans? Answer: Medicare Advantage is a way of having your Medicare benefits administered through private plans that are approved by Medicare. Here are the questions and their corresponding answers distinguished and labeled: Question 1: Hector Hernandez is an independent agent. Hector sells plans on behalf of three Medicare Advantage organizations that offer a total of 10 plans but does not represent all Medicare Advantage organizations offering plans that are available in his area. Which of the following statements best describes any steps Hector is required to take? Answer 1: During the first minute of a sales call, Hector must use a disclaimer that says "I do not represent every plan available in your area. I represent 3 organizations that offer 10 plans in your area. Please contact Medicare.gov, 1- 800 - MEDICARE, or your local State Health Insurance Program to get information on all your options."
Question 5: You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer's and is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and sign it for him? Answer 5: Mr. Tully's daughter can do so only if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions.
Question 6: Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her? Answer 6: Her daughter should come in November.
Question 7: Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a "potential at-risk" beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that's more suitable to his current prescription drug needs. He believes he's entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part D plan during a SEP for dual eligible individuals? Answer 7:
No. Once he is identified by the plan sponsor as a "potential at-risk" beneficiary, he cannot use the dual eligible SEP to change plans while this designation is in place.
Question 8: Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan. Answer 8: There is no specific question provided for this statement. It seems to be an incomplete entry.
Question 9: Mrs. Parker likes to handle most of her business matters through telephone calls. She currently is enrolled in Original Medicare Parts A and B but has heard about a Medicare Advantage plan offered by Senior Health from a neighbor. Mrs. Parker asks you whether she can enroll in Senior Health's MA plan over the telephone. What can you tell her? Answer 9: II. Telephone enrollment request calls must be recorded. III. Telephonic enrollments must include all required elements necessary to complete an enrollment. (II and III only) Question 10: Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? Answer 10: He will have one opportunity to enroll in a Medicare Advantage plan.
