2025 AHIP 2024 Final Exam Questions and Answers Graded A+, Exams of Nursing

Download 2025 AHIP 2024 Final Exam Questions and Answers Graded A+ and more Exams Nursing in PDF only on Docsity! 1 2025 AHIP 2024 Final Exam Questions and Answers 2 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? - correct answer 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. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through massage therapy. She is concerned about whether or not Medicare will cover these items and services. What should you tell her? - correct answer Medicare does not cover massage therapy, or, in general, glasses or dentures. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance? - correct answer She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible. Mr. Alonso receives some help paying for his two generic prescription drugs from his employer's retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug plan. What should you tell him? - correct answer He generally would pay a monthly premium, annual deductible, and per-prescription cost-sharing. Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one that provides drug coverage. What should you tell her? - correct answer 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. 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? - correct answer He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her? - correct 2025 AHIP 2024 Final Exam Questions and Answers 5 William enrolls in Medicare Part B, it can enroll him in a Medicare Advantage plan that is offered to the public. Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a Medicare Advantage plan, what will he have to do? - correct answer He will have to enroll in Part B. Mrs. Velasquez cares for her frail elderly mother, Maria, who lives in North Carolina. She is worried that without additional support, her mother will need to go into a nursing home. Mrs. Velasquez asks you if there is any Medicare plan that might allow her mother to remain in the community rather than going into a nursing home. How should you advise Mrs. Velasquez? - correct answer There are Programs of All-Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as needing a nursing home level of care but are able to live safely in the community at the time of enrolment. Which of the following statement(s) 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. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. - correct answer I, II, and IV only 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? - correct answer Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. 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? - correct answer 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. 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? - correct answer She 6 could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - correct answer Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Mr. Kelly wants to know whether he is eligible to sign up for a private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility? - correct answer You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. 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? - correct answer 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. 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? - correct answer She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. 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? - correct answer 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. Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you advise her to do before she can enroll in a Medicare Advantage plan? - correct answer To join a Medicare Advantage plan, she also must enroll in Part B. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - correct answer Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Mr. 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. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell 7 him about this situation? - correct answer He could enroll either in one of the MA plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. 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? - correct 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. 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? - correct answer She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. 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? - correct answer There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs. 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? - correct answer You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. 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? - correct answer She cannot enroll in an MA Medical Savings Account (MSA) plan. Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him? - correct answer The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part 10 Mr. Hildalgo complains to you that because he takes multiple expensive drugs, he has trouble paying his cost sharing for his prescription drugs, particularly at the beginning of the year during the deductible phase. He is happy with his plan and does not want to change. However, he said he had heard about a new program called the Medicare Prescription Payment Plan and asked whether it might help. What do you tell him? - correct answer The Medicare Prescription Payment Plan helps spread out beneficiary cost-sharing payments but does not decrease the total amount owed. Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him? - correct answer In general, he must select a single Part D premium payment mechanism that will be used throughout the year. One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors called TrOOP. She asks you to explain it. What do you say? - correct answer TrOOP stands for true out-of-pocket costs that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances amounts paid by or through qualified State Pharmaceutical Assistance Programs. Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What could you tell him to do? - correct answer Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her? - correct answer If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Mrs. Hernandez is one of your clients. She has read that there is a new program that may help her manage prescription drug costs. What do you tell her about the Medicare Prescription Payment Plan? - correct answer Part D enrollees can opt into the Medicare Prescription Payment Plan at the beginning of the plan year or any point during the year. Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? - correct answer She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in- network pharmacy. 11 During a sales presentation to Ms. Daley for a Medicare Advantage plan that has a 5- star rating in customer service and care coordination, and received an overall plan performance rating of a 4-star, which of the following would be the best statement to say to her? - correct answer The Medicare Advantage plan received a 5-star rating in customer service and care coordination with an overall performance rating of 4 stars. A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do? - correct answer You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion. While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointments? - correct answer You can present only health care related lines of business but must obtain the beneficiary's permission to do so before the presentation occurs and document that you have obtained that permission. One of your colleagues argues that it is better to focus your time and energy exclusively on neighborhoods with single-family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond? - correct answer This could be considered discriminatory activity and a prohibited practice. Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational? - correct answer Yes. When an event has been advertised as "educational," discussing plan-specific premiums is impermissible. Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services (CMS) Communication and Marketing Guidelines to ensure he is compliant with which type of products. - correct answer Medicare Advantage (MA) and Prescription Drug (PDP) plans. Next week you will be participating in your first "educational event" for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? - correct answer You should plan to ensure that the educational event is informative and must not conduct a sales presentation or distribute or accept enrollment forms at the event. 12 You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To comply with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plansl? - correct answer You will have to avoid calling any potential client unless he or she initiates contact with you and specifically asks that you give him or her a call. If you are to comply with Medicare's guidance regarding educational events, which of the following would be acceptable activities? - correct answer You may distribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent. By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Furthermore, you see that the plan you represent has a unique benefits package. What should you do to make sure your clients know about these pieces of information? - correct answer You may make comparisons between plans if you can support them with studies or statistical data and such comparisons are factually based and referenced. You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do? - correct answer Before conducting the presentation, obtain and document having obtained her permission to visit, along with her interest in the specific products you will present. Winthrop Brokerage wishes to place an advertisement in the local newspaper that says: "We offer Medicare Advantage plans offered by AB Health and Top Choice Health. Contact us if you would like to learn more." Which of the following best describes the obligation(s) of Winthrop Brokerage regarding the advertisement? - correct answer Winthrop Brokerage does not need to submit the advertisement to CMS for prior approval because it does not include information about the plans' benefits structures, cost-sharing, or information about measures or ranking standards. You are mailing invitations to new Medicare beneficiaries for a marketing event. You want an idea of how many people to expect, so you would like to request RSVPs. What should you keep in mind? - correct answer You may request RSVPs, but you are not permitted to require contact information. Your colleague works at a third-party marketing organization (TMO) and she said she did not need to take the Medicare training for brokers and agents or pass a test to market Medicare plans since her contract is with the TMO, not the plans that have the products she sells. What could you say to her? - correct answer You could tell her she is wrong, and that only agents selling employer/union group plans are permitted an exemption from testing, but some employer/union group plans may require testing to promote agent compliance with CMS marketing requirements. 15 Open Enrollment Period. What are his options during the MA OEP? - correct answer He can switch to a MA-PD plan. Ms. Lee is enrolled in an MA-PD plan but will be moving out of the plan's service area next month. She is worried that she will not be able to enroll in another plan available in her new residence until the Annual Election Period. What should you tell her? - correct answer She is eligible for a special election period (SEP) that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months. Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition, has a low premium. It won't cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him? - correct answer If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. 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 certain MA plans might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him? - correct answer 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 election period (SEP). Mr. Yoo's employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him? - correct answer It means that he qualifies for a one-time opportunity to enroll in an MA- PD or Part D prescription drug plan. Ms. Claggett is sixty-six (66) years old. She has been covered under Original Medicare for the last six years due to her disability and has never been enrolled in a Medicare Advantage or a Part D plan before. She wants to enroll in a Part D plan. She knows that there is such a thing as the "Part D Initial Enrollment Period" (IEP) and has concluded that, since she has never enrolled in such a plan before, she should be eligible to enroll under this period. What should you tell her about how the Part D Initial Enrollment Period applies to her situation? - correct answer Ms. Claggett has had two IEPs and missed them both. The first occurred three months before and three months after the month when she was first entitled to Part A OR enrolled in Part B. Because she was 16 eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired. Ms. Thomas has worked for many years and is turning 68 in June. She is eligible for Medicare Part A and did not enroll for Part B when first eligible because she has insurance through her employer - Coffee Brew, Inc. She also did not enroll in Part D because she had creditable coverage. She would like to retire in June and enroll in a Medicare Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas? - correct answer Ms. Thomas can enroll in Part B without a late penalty at any time she is still covered by her employer group and 8 months after her last month of employer group coverage without a penalty. However, because she wants to enroll in a MA plan after retirement, she should make sure her Part B coverage is effective in time to use the Medicare Advantage/Part D special election period for individuals changing from employer group coverage to enroll in a MA plan or MA-PD. The SEP begins while she has employer group coverage and will last until 2 months after the month after the month her employer coverage ends. If she wants Part D coverage she should enroll in an MA-PD or a PDP (depending on how she decides to receive her Part A and B benefits) during this time. Mr. Garcia was told he qualifies for a special election period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him? - correct answer If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. Mrs. Schmidt is moving and a friend told her she might qualify for a "special election period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a special election period is. What could you tell her? - correct answer It is a period, outside of the Annual Election Period, when a Medicare beneficiary can select a new or different Medicare Advantage and/or Part D prescription drug plan. Typically, the special election period is beneficiary specific and results from events, such as when the beneficiary moves outside of the service area. Mrs. Kendrick is in good health, has worked for many years, and is six months away from turning 65. She wants to know what she will have to do to enroll in a Medicare Advantage (MA) plan as soon as possible. What could you tell her? - correct answer She may enroll in an MA plan beginning three months immediately before her first entitlement to both Medicare Part A and Part B. Which of the following individuals has enrolled in a plan based on a fixed enrollment period? - correct answer Ben enrolls in a Medicare Advantage plan during the Medicare Advantage Open Enrollment Period (MA OEP). Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirement several years ago. Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the first time. Unfortunately, Mrs. 17 Ridgeway has found that many of her providers are not in the MA plan's network. She has come to you for advice. What should you tell her? - correct answer She qualifies for a special election period (SEP) that will allow her to make a one-time election to return to Original Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan. Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams? - correct answer This is a bad idea. Agents are generally prohibited from soliciting or accepting an enrollment form before the start of the AEP. Richard is a licensed agent who represents Spartan Health Plan and its Medicare Advantage (MA) plans. Richard has several clients who have recently come to him for help who are in their initial coverage election period (ICEP) and are interested in enrolling in one of Spartan Health Plan's MA plans. Alice will soon turn 65 and retire. Alice has coverage through Spartan Health Plan offered by her employer. Bob had health coverage through Spartan but dropped the coverage when he retired early to travel overseas. Bob, who has just turned age 65, is now back in the United States. Charlotte, who will turn 65 next month, has coverage through Athena Health plan - a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism? - correct answer Alice and Charlotte because each of them currently have health coverage and is in their initial coverage election period (ICEP). Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)? - correct answer She is likely to qualify for a SEP. She can choose an effective date of up to three months after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than the date of her permanent move. Ms. Morris will turn 65 on June 10th. She has never previously qualified for Medicare. She is entitled to Medicare Part A and intends to enroll in Part B. She wants to know if she is eligible to enroll in a Medicare Advantage plan that includes prescription drug coverage. What do you tell her? - correct answer Ms. Morris can enroll in an MA-PD plan now since her initial election period (IEP) for Part D prescription drug coverage and initial coverage period are occurring together beginning March 1st and ending September 30th. Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him? - correct answer Enrollees should pay using