2022-2023 AHIP Healthcare Final Exam With Answers (216 Solved Questions)

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AHIP Final Exam Test Questions andAnswers (2022/2023) (Verified Answers)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 underMedicare. What should you tell him?correct answersHe may sign-up for Medicare atanytime however coverage usually begins on the fourth month after dialysis treatmentsstart.Juan Perez, who is turning age 65 next month, intends to work for several more years atSmallcap, Incorporated. Smallcap has a workforce of15 employees and offersemployer-sponsored healthcare coverage. Juan is a naturalized citizen and hascontributed tothe Medicare system for over 20 years. Juan asks you if he will beentitled to Medicare and if he enrolls how that will impact his employer-sponsoredhealthcare coverage. How would you respond?correct answersJuan is likely to beeligible for Medicare oncehe turns age 65 and if he enrolls Medicare would become theprimary payor of his healthcare claims and Smallcap does not have to continue to offerhim coverage comparable to those under age 65 under its employer-sponsored grouphealth plan.Mr. Moy's wifehas a Medicare Advantage plan, but he wants to understand whatcoverage Medicare Supplemental Insurance provides since his health care needs aredifferent from his wife's needs. What could you tell Mr. Moy?correct answersMedicareSupplemental Insurance would help cover his Part A and Part B deductibles orcoinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly someservices that Medicare does not cover.Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire nextyear. She heard she must enroll in Part B at the beginning of the year to ensure no gapin coverage. What can you tell her?correct answersShe may enroll at any time whileshe is covered under her employer plan, but she will have a special eight-monthenrollment period after the last month on her employer plan that differs from thestandard general enrollment period, during which she may enroll in Medicare Part B.Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed fulltime,and paid taxes during that entire period. She is concerned that she will not qualifyfor coverage under part A because she was not born in the United States. What shouldyou tell her?correct answersMost individuals who are citizens and age 65 or over arecovered under Part A by virtue of having paid Medicare taxes while working, thoughsome may be covered as a result of paying monthly premiums.

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Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but itprovides no drug coverage. She would like to keep the coverage she has but replaceher existing Medigap plan with one that provides drug coverage. What should you tellher?correct answersMrs. Gonzalez cannot purchase a Medigap plan that covers drugs,but she could keep her Medigappolicy and enroll in a Part D prescription drug plan.Mrs. Westwears glasses and dentures and has enjoyed considerable pain relief fromarthritis through massage therapy. She is concerned about whether or not Medicare willcover these items and services. What should you tell her?correct answersMedicaredoes not cover massage therapy, or, in general, glasses or dentures.Mr. Patel is in good health and is preparing a budget in anticipation of his retirementwhen he turns 66. He wants to understand the health care costs he might be exposed tounder Medicare if he were to require hospitalization as a result of an illness. In generalterms, what could you tell him about his costs for inpatient hospital servicesunder Original Medicare?correct answersUnder Original Medicare, there is a singledeductible amount due for the first 60 days of any inpatient hospital stay, after which itconverts into a per-day coinsurance amount through day 90. After day 90, he would paya daily amount up to 60 days over his lifetime, after which he would be responsible forall costs.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 payingMedicare taxes. What should youtell her?correct answersTo obtain Part B coverage,she must pay a standard monthly premium, though it is higher for individuals with higherincomes.Mr. Alonso receives some help paying for his two generic prescription drugs from hisemployer's retiree coverage, but he wants to compare it to a Part D prescription drugplan. He asks you what costs he would generally expect to encounter when enrollinginto a standard MedicarePart D prescription drug plan. What should you tell him?correctanswersHe generallywould pay a monthly premium, annual deductible, and per-prescription cost-sharing.Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent healthand will have considerable income when she retires. She is concerned that her incomewill make it impossible for her to qualify for Medicare. What could you tell her to addressher concern?correct answersMedicare is a program for people age 65 or older andthose under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig'sdisease so she will be eligible for Medicare.Mr. Xi will soon turn age 65 and has come to you for advice as to what services areprovided under Original Medicare. What should you tell Mr. Xi that best describes thehealth coverage provided to Medicare beneficiaries?correct answersBeneficiaries underOriginal Medicare have no cost-sharing for most preventive services which includeimmunizations such as annual flu shots.

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Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewedher Medicare Summary Notice (MSN) and disagrees with a determination that partiallydenied one of her claims for services. What advice would you give her?correctanswersMrs. Duarte should file an appeal of this initial determination within 120 days ofthe date she received the MSN in the mail.Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigapplan to pick up costs not covered by that plan.What should you tell him?correct answersIt is illegal for you to sell Mr. CapadonaaMedigap plan if he is enrolled in an MA plan, and besides, Medigap only works withOriginal Medicare.Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tellMrs. Park that might be of assistance?correct answersShe should contact her stateMedicaid agency to see if she qualifies for one of several programs that can help withMedicare costs for which she is responsible.Mr. Rainey is experiencing paranoid delusions and his physician feels that he should behospitalized. What should you tell Mr. Rainey (or his representative) about the length ofan inpatient psychiatric hospital stay that Medicare will cover?correct answersMedicarewill cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entirelifetime.Mr. Schmidt would like to plan for retirement and has asked you what is covered underOriginal Fee-for-Service (FFS) Medicare? What could you tell him?correct answersPartA, which covers hospital, skilled nursing facility, hospice, and home health services andPart B, which covers professional services such as those provided by a doctor arecovered underOriginal Medicare.Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currentlyenrolled 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 providedrug benefits. How would you advise Agent John Miller to proceed?correct answersTellprospect Jerry Smith that he should consider adding a standalone Part D prescriptiondrug coverage policy to his present coverage.Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by theSocial Security Administration and has been receiving disability payments. He iswondering whether he can obtain coverage under Medicare. What should you tellhim?correct answersAfter receiving such disability payments for 24 months, he will beautomatically enrolled in Medicare, regardless of age.Mr. Buck has several family members who died from different cancers. He wants toknow if Medicare covers cancer screening.

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What should you tell him?correct answersMedicare covers the periodic performance ofa range of screening tests that are meant to provide early detection of disease. Mr.Buck will need to check specific tests before obtaining them to see if they will becovered.Which of the followingstatement is/are correct about a Medicare Savings Account(MSA) Plans?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.III. Anindividual who is enrolled in an MSA plan is responsible for a minimal deductibleof $500 indexed for inflation.IV. Non-network providers must accept the same amount that Original Medicare wouldpay them as payment in full.correct answersI, II, and IV onlyMr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent.It is one of three plans operated by the same organization in Mr. Lombardi's area. TheMA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardilikes the PPO plan that does not include drug coverage and intends to obtain his drugcoverage through a stand-alone Medicare prescription drug plan. What should you tellhim about this situation?correct answersHe could enroll either in one of the MA plansthat include prescription drug coverage or Original Medicare with a Medigap plan andstandalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPOplan and a stand-alone prescription drug plan.Mrs. Ramos is considering a Medicare Advantage PPO and has questions about whichproviders she can go to for her health care. What should you tell her?correctanswersMrs. Ramos can obtain care from any provider who participates in OriginalMedicare, but generally will have a higher cost-sharing amount if she sees a providerwho/that is not a part of the PPO network.Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsoredretiree group health plan that includes drug coverage with nominal copays. He heardabout a neighbor's MA-PD plan that you represent and because he takes numerousprescription drugs, he is considering signing up for it. What should you tell him?correctanswersHe should compare the benefits in his employer-sponsored retiree group healthplan with the benefits in his neighbor's MA-PD plan to determine which one will providesufficient coverage for his prescription needs.Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan'sterms and conditions for payment. MaryRodgers sees Dr. Brennan for treatment. Howmuch may Dr. Brennan charge?correct answersDr. Brennan can charge Mary Rogersno more than the cost sharing specified in the PFFS plan's terms and condition ofpayment which may include balance billing up to 15%of the Medicare rate.

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Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area hasan attractive premium. He wants to know if he must use doctors in a network as hiscurrent HMO plan requires him to do. What should you tell him?correct answersHe mayreceive health care services from any doctor allowed to bill Medicare, as long as heshows the doctor the plan's identification card and the doctor agrees to accept the PFFSplan's payment terms and conditions, which could include balance billing.Mr. Wells is trying to understand the difference between Original Medicare andMedicare Advantage. What would be the correct description?correct answersMedicareAdvantage is a way of covering all the Original Medicare benefits through private healthinsurance companies.Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. Shewishes to enroll in a MA MSA plan that she heard about from her neighbor. She alsowants to have prescription drug coverage since her doctor recently prescribed severalexpensive medications. Currently, she is enrolled in Original Medicare and a standalonePart D plan. How would you advise Mrs. Chi?correct answersMrs. Chi may enroll in aMA MSA plan and remain in her current standalone Part D prescription drug plan.Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting himat severe risk for pneumonia. Otherwise, he has no problems functioning. Which type ofSNP is likely to be most appropriate for him?correct answers.C-SNPMrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan andwas disappointed with the service she received from her primary care physicianbecause she was told she would have to wait five weeks to get an appointment whenshe was feeling ill. She called you to ask what she could do so she would not have toput up with such poor access to care. What could you tell her?correct answersShecould file a grievance with her plan to complain about the lack of timeliness in getting anappointment.Mr. Greco is in excellent health, lives in his own home, and has a sizeable income fromhis 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 amountsand Mr. Greco would like to join that plan. What should you tell him?correctanswersSNPs limit enrollment to certain subpopulations of beneficiaries. Given hiscurrent situation, he is unlikely to qualify and would not be able to enroll in the SNP.Mrs. Radford asks whether there are any special eligibility requirements for MedicareAdvantage. What should you tell her?correct answersMrs. Radford must be entitled toPart A and enrolled in Part B to enroll in Medicare Advantage.Mrs. Andrews asked howa Private Fee-for-Service (PFFS) plan might affect her accessto services since she receives some assistance for her health care costs from the State.

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What should you tell her?correct answersMedicaid may provide additional benefits, butMedicaid will coordinate benefits only with Medicaid participating providers.Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but hasrecently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. Hewould like to enroll ina Medicare Advantage (MA) plan and is still covered by Part A.What should you tell him?correct answersHe is not eligible to enroll in a MedicareAdvantage plan until he re-enrolls in Medicare Part B.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 nextopen enrollment season?correct answersShe may remain in her ABC MA plan, enroll inanother MA plan in her service area, or enroll in a Special Needs Plan (SNP) forindividuals suffering from ESRD if one is available in her area.Mr. Kumar is considering a Medicare Advantage HMO and has questions about hisability to access providers. What should you tell him?correct answersIn most MedicareAdvantage HMOs, Mr. Kumar must generally obtain his services only from providerswithin the plan's network (except in an emergency or where care is unavailable withinthe network).ur clients, Lauren Nichols, has heard about a MedicaMr. Barker enjoys a comfortable retirement income. He recently had surgery andexpected that he would have certain services and items covered by the plan withminimal out-of-pocket costs because hisMA-PD coverage has been very good.However, when he received the bill, he was surprised to see large charges in excess ofhis maximum out-of-pocket limit that included some services and items he thoughtwould be fully covered. He called you to ask what hecould do? What could you tellhim?correct answersYou can offer to review the plans appeal process to help him askthe plan to review the coverage decision.Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care hehas received under Original Medicare, but he would like to know more about MedicareAdvantage Special Needs Plans (SNPs). What could you tell him?correct answersSNPshave special programs for enrollees with chronic conditions, like Mr. Sinclair, and theyprovide prescription drug coverage that could be very helpful as well.Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" butis not sure about what type of plan designs are available through this program. Whatshould you tell him about the types of health plans that are available through theMedicare Advantage program?correct answersThey are Medicare health plans such asHMOs, PPOs, PFFS, and MSAs.Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part Bbecause he has coverage through an employer plan. If he wants to enroll in a MedicareAdvantage plan, what will he have to do?correct answersHe will have to enroll in Part B.

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Mr. Zachow has a condition for which three drugs are available. He has tried two buthad an allergic reaction to them. Only the third drug works for him and it is not on hisPart D plan's formulary. What could you tell him to do?correct answersMr. Zachow hasa right to request a formulary exception to obtain coverage for his Part D drug. He or hisphysician could obtain the standardized request form on the plan's website, fill it out,and submit it to his plan.Mr. Bickford did not quite qualify for the extra help low-income subsidy under theMedicare Part D Prescription Drug program and he is wondering if there is any otheroption he has for obtaining help with his considerable drug costs. What should you tellhim?correct answersHe could check with the manufacturers of his medications to see ifthey offer an assistance program to help people with limited means to obtain themedications they need. Alternatively, he could check to see whether his state has apharmacy assistance program to help him with his expenses.Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr.Vaughn takes a prescription for helping to regrow his hair. They are anxious to havetheir Medicare prescription drug plan cover these drug needs. What should youtellthem?correct answersMedicare prescription drug plans are not permitted to cover theprescription medications the Vaughns are interested in under Part D coverage,however, plans may cover them as supplemental benefits and the Vaughn's could lookinto that possibility.Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. Inaddition to drugs on his plan's formulary he takes several other medications. Theseinclude a prescription drug not on his plan's formulary, over-the-counter medications forcolds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy topromote hair growth and reduce joint swelling. His neighbor recently told him about aconcept called TrOOP and he asks you if any of his other medications could counttoward TrOOP should he ever reach the Part D catastrophic limit. What should yousay?correct answersNone of the costs of Mr. Wingate's other medications wouldcurrently count toward TrOOP but he may wish to ask his plan for an exceptionto coverthe prescription not on its formulary.Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drugplan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that shehas lost. How would you adviseher?correct answersShe may fill prescriptions forcovered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lostcreditablecoverage previously available through her husband's employer. She isinterested in enrolling in a Medicare Part D prescription drug plan (PDP). What shouldyou tell her?correct answersIf a Part D benefit is offered through her plan she maychoose to enrollin that plan or a standalone PDP.

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Mrs. Allen has a rare condition for which two different brand name drugs are the onlyavailable treatment. She is concerned that since no generic prescription drug isavailable and these drugs are very high cost, she will not be able to find a Medicare PartD prescription drug plan that covers either one of them. What should you tellher?correct answersMedicare prescription drug plans are required to cover drugs ineach therapeutic category. She should be able to enroll in a Medicare prescription drugplan that covers the medications she needs.Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income.She uses no medications and sees no reason to spend money on a Medicareprescription drug plan if she does not need the coverage. She currently does not havecreditable coverage. What could you tell her about the implications of such adecision?correct answersIf she does not sign up for a Medicare prescription drug planas soon as she is eligibleto do so, and if she does sign up at a later date, her premiumwill be permanently increased by 1% of the national average premium for every monththat she was not covered.Mr. Shultz was still working when he first qualified for Medicare. At that time,he hademployer 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 ayear later and Mr. Shultz has lost his employer group coverage within the last twoweeks. How would you advise him?correct answersMr. Schultz should enroll in a Part Dplan before he has a 63-day break in coverage in order to avoid a premium penalty.Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in aMedicare prescription drug plan because, although she is entitled to Part A, she is notenrolled under Medicare Part B. What should you tell her?correct answersAn individualwho is entitled to Part A or enrolled under Part B is eligible to enroll in aMedicareprescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not needto enroll under Part B before enrolling in a prescription drug plan.What types of tools can Medicare Part D prescription drug plans use that affect the waytheir enrollees can access medications?correct answersPart D plans do not have tocover all medications. As a result, their formularies, or lists of covered drugs, will varyfrom plan to plan. In addition, they can use cost containment techniques such as tieredco-payments and prior authorization.All plans must cover at least the standard Part D coverage or its actuarial equivalent.Which of the following statements best describes some of the costs a beneficiary wouldincur for prescription drugs under the standard coverage?correct answersStandard PartD coverage would require payment of an annual deductible, and once past thecatastrophic coverage threshold, the beneficiary pays whichever is greater of either theco-pays for generic and brand name drugs or coinsurance of 5%.

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Mr. Jacob understands that there is a standard Medicare Part D prescription drugbenefit, but when he looks at information on various plans available in his area, he seesa wide range in what they charge for deductibles, premiums, andcost sharing. How canyou explain this to him?correct answersMedicare Part D drug plans may have differentbenefit structures, but on average, they must all be at least as good as the standardmodel established by the government.Mr. Carlini has heard that Medicare prescription drug plans are only offered throughprivate companies under a program known as Medicare Advantage (MA), not by thegovernment. He likes Original Medicare and does not want to sign up for an MAproduct, but he also wants prescription drug coverage. What should you tell him?correctanswersMr. Carlini can stay with Original Medicare and also enroll in a Medicareprescription drug plan through a private company that has contracted with thegovernment to provide only such drug coverage to eligible Medicare beneficiaries.Which of the following individuals is most likely to be eligible to enroll in a Part DPlan?correct answersJose, a grandfather who was granted asylum and has worked inthe United States for many years.Mr. Hutchinson has drug coverage through his former employer's retiree plan. He isconcerned about the Part D premium penalty if he does not enroll in a Medicareprescription drug plan, but does not want to purchase extra coverage that he will notneed. What should you tell him?correct answersIf the drug coverage he has is notexpected to pay, on average, at least as much as Medicare's standard Part D coverageexpects to pay, then he will need to enroll in Medicare Part D during his initial eligibilityperiod to avoid the late enrollment penalty.Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible forMedicare as well. What can she expect will happen to her drug coverage?correctanswersUnless she chooses a Medicare Part D prescription drug plan on her own, shewill be automatically enrolled in one available in her area.Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drugcoverage and also enroll in a stand-alone Medicare prescription drug plan. Under whatcircumstances can she do this?correct answersIf the Medicare Advantage plan is aPrivate Fee-for-Service (PFFS) plan that does not offer drug coverage or a MedicalSavings Account plan, Mrs. Berkowitz can do this.Which of the following statements about Medicare Part D are correct?I. Part D plans must enroll any eligible beneficiary who applies regardless of healthstatus except in limited circumstances.II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network butmay choose to have one.III. Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtainPart D benefits through a standalone PDP.

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IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalonePDP or throughtheir plan.correct answersI, II, and III onlyMr. Torres has a small savings account. He would like to pay for his monthly Part Dpremiums with an automatic monthly withdrawal from his savings account until it isexhausted, and then have his premiums withheld from his Social Security check. Whatshould you tell him?correct answersIn general, he must select a single Part D premiumpayment mechanism that will be used throughout the year.You will be holding a sales event soon, at which you would like to offer door prizes toattendees. Under guidelines from the Medicare agency, what types of gifts or prizeswould not be allowed in this situation?correct answersGift cards or gift certificates of$15 or less that can be readily converted to cash.Another agentworking for your agency claims that because you are not employed bythe Medicare Advantage plans that you represent, you are not subject to the samemarketing requirements as the plans themselves. How should you respond to such astatement?correct answersYour coworker is not correct. Marketing on behalf of a plan isconsidered marketing by the plan and requires that all contracted and employed agentscomply with all Medicare marketing rules.Mrs. Lu is turning 65 in November and called to ask for your help deciding on aMedicare Advantage plan. She agreed to sign a scope of appointment form and meetwith you on October 15. During the appointment, what are you permitted to do?correctanswersYou may provide her with the required enrollment materials and takehercompleted enrollment application.One of your colleagues argues that it is better to focus your time and energy exclusivelyin neighborhoods with single-family homes. He further argues that their older ownersare more likely to have higher incomes and purchase the Medicare Advantage productsyou represent compared to those living in apartment complexes. How should yourespond?correct answersThis could be considered discriminatory activity and aprohibited practice.A Medicare beneficiary has walked into your office and requested that you sit down withher and discuss her options under the Medicare Advantage program. Before engagingin such a discussion, what should you do?correct answersYou must have her sign ascope of appointment form, indicating which products she wishes to discuss. You maythen proceed with the discussion.Your friend's mother just moved to an assisted living facility and he asked if you couldpresent a program for the residents about the MA-PD plans you market. What could youtell him?correct answersYou appreciate the opportunity and would be happy toschedule an appointment with anyone at their request.

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