2025 AHIP Final Exam study guide, Exams of Advanced Education

Download 2025 AHIP Final Exam study guide and more Exams Advanced Education in PDF only on Docsity! AHIP Final Exam Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his prescription drug costs? - Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. 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? - After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 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? - 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. Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for- Service (FFS) Medicare. What could you tell him? - Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare. 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? - Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. 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? - 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? - Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. 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? - 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. 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? - 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. Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? - She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period after the last month on her employer plan that differs from the standard general enrollment period, during which she may enroll in Medicare Part B. 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? - 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. 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? - To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes. 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? - 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. 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? - 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. 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? - She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. 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? - He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. 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? - 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. 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? - 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. 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? - She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan. Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? - He may receive health care services from any doctor allowed to bill Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing. 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? - 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. 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? - 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. Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA) Plans? - MSAs may have either a partial network, full network, or no network of providers. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? - Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. 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? - Medicare Advantage Plans do not necessarily have to cover all of the Original Medicare Part A and Part B services but must include a maximum out-of-pocket limit. Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap Incorporated and contributed to the Medicare system. Juan suffers from diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent. How would you respond? - Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Juan should go to the Social Security website to enroll in Medicare Part A and B if he has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan. Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? - In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network). 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 Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? - If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered. 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? - 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. Mrs. Fields wants to know whether applying for the Part D low-income subsidy will be worth the time to fill out the paperwork. What could you tell her? - The Part D low-income subsidy could substantially lower her overall costs. She can apply by contacting her state Medicaid office or calling the Social Security Administration. 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? - In general, he must select a single Part D premium payment mechanism that will be used throughout the year. 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 one.Beneficiaries enrolled in a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan? - She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution. 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? - The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government. Wendy Park becomes eligible for Medicare for the first time in July. With the help of Agent James Chan, she enrolls in FeelBetter Medicare Advantage plan with an effective date of July 1st. Which statement best describes how Agent Chan may be compensated under CMS rules? - FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. Park remains enrolled the following year. Melissa Meadows is a marketing representative for Best Care which has recently introduced a Medicare Advantage plan offering comprehensive dental benefits for $15 per month. Best Care has not submitted any potential posts to CMS for approval. Melissa would like to use the power of social media to reach potential prospects. What advice would you give her? - As soon as CMS approves Best Care's social media posts, Agent Meadows could post a tweet stating that "Best Care offers an array of Medicare Advantage benefit packages. One might be right for you. Call me to find out more!" You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation? - You will not be able to represent any Medicare Advantage or Part D plan until you complete the training and achieve an adequate score. However, you will not have to take a test if you exclusively market employer/union group plans and the companies do not require testing. 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? - 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." Agent Daniel Webber has properly set up a sales appointment to meet with client Edward Young at Agent Webber's office. At the agreed upon appointment time, Mr. Young arrives with his elderly neighbor - Clara Burton, who wants to learn about her Medicare Advantage options. What should Agent Daniel Webber do? - After executing a scope of appointment (SOA) with Clara Burton, meet with Edward Young and Clara Burton to discuss their Medicare Advantage options. Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same marketing requirements as the plans themselves. How should you respond to such a statement? - Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. Linda Sanchez is conducting a previously agreed upon appointment with client, Maria Gomez about a MA-Part D plan she represents. Before an enrollment form is completed, Linda needs to provide Maria with information about ____ - whether or not Maria's primary care provider is in the plan's network. whether Maria's current prescriptions are covered by the plan. the monthly premium cost(s). Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel? - During the MA-OEP, Miguel can have one-on-one meetings with beneficiaries who have requested such meetings. Evan Marsh is a newly appointed agent. Evan intends to conduct an educational session on Medicare at a senior citizens center near his home. He has advertised the session as an educational event. Evan asks you what is permissible at such an event. What should you say? - Evan may provide a meal as long as its value is $15 or less per attendee and he may make available business reply cards (BRCs). You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? - Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility. Your client, Alexis Jones, calls you on December 4th about changing her Medicare Advantage plan during the annual election period which ends December 7th. What should you do? - Complete a scope of appointment (SOA) during the call and indicate that they will meet to discuss Medicare Advantage plans during an appointment the following day. You have sought permission from a hospital to place brochures for your product in their gift shop and cafeteria. The hospital administration expresses some hesitation about allowing marketing in a health care facility. What should you tell them? - Marketing in health care facilities is an acceptable practice, as long as it takes place in common areas where patients are not receiving health care services. Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual? - The plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? - You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. Sal D'Angelo is new to the Medicare marketplace having previously been focused on life insurance and disability income protection products. He intends to conduct an educational seminar during the AEP at a local hotel and then invite those who attend to a subsequent marketing meeting to discuss the benefits of next year's plans. How would you advise Sal? - Sal should conduct the education seminar as an early morning meeting and the marketing meeting on the following day in the late afternoon so that there are at least 12 hours between the two meetings. Your friend's mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him? - You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? - Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided. Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do? - You may provide her with the required enrollment materials and take her completed enrollment application. 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? - 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. Torie Jones is a new marketing representative. Torie asks you for advice as to what topics must be discussed with a Medicare beneficiary prior to enrollment in a Medicare Advantage (MA-PD) plan. What should you say? - Torie, there are many required questions and topics regarding beneficiary needs to be discussed prior to enrollment in an MA plan. These include information regarding primary care providers and specialists whether they are in the plan network, whether or not a beneficiary's current prescriptions are covered as well as premiums, benefits, and costs of health care services. 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? - Telephone enrollment request calls must be recorded. Telephonic enrollments must include all required elements necessary to complete an enrollment. You are doing a sales presentation for Mrs. Pearson. You know that Medicare marketing guidelines prohibit certain types of statements. Apply those guidelines to the following statements and identify which would be prohibited. - "If you're not in very good health, you will probably do better with a different product." Mrs. Margolis contacts you in August because she will become eligible for Medicare for the first time in November. She would like to meet and discuss plan choices with you. What advice should you give her? - Tell her to wait until October to discuss plan choices with you so that you can share plan benefits for the current year as well as any changes for the following year that may impact her choice. A client wants to give you an enrollment application on October 1 before the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him? - You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins. Ms. Gonzales decided to remain in Original Medicare (Parts A and B) and Part D during the Annual Enrollment Period (AEP). At the beginning of January, her neighbor told her about the Medicare Advantage (MA) plan he selected. He also told her there was an open enrollment period that she might be able to use to enroll in a MA plan. Ms. Gonzales comes to you for advice shortly after speaking to her neighbor. What should you tell her? - There is a MA Open Enrollment Period (OEP) that takes place between January 1 and March 31, but Ms. Gonzales cannot use it because eligibility to use the OEP is available only to MA enrollees. Mary Samuels recently suffered a stroke while visiting her daughter and grandchildren. As a result, Mary has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Mary regarding her health plan coverage? - Mary may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan. Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him? - He is currently in the Part D Initial Enrollment Period (IEP) and, during this time, he may make one Part D enrollment choice, including enrollment in a stand-alone Part D plan or an MA-PD plan. Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special election periods (SEPs)? - Mr. Rockwell is eligible for a SEP due to his involuntary loss of creditable drug coverage; the SEP begins in June and ends on September 1- two months after the loss of creditable coverage. This year you decide to focus your efforts on marketing to employer and union groups. Which of the following statements best describes what you can and cannot do in order to stay in compliance? - You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur. Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. Ms. Levi often travels to visit relatives and is concerned that she may need emergency care outside of her plan's service area. What should you tell her about coverage of emergency care? - Plans are required to cover out-of- network emergency care. Agent Suma has recently had several clients request his assistance in completing their paper enrollment form. What advice would you give him? - In most instances, Agent Suma should be clearly indicating his name on their forms as their marketing representative. Mr. Wong is a single individual. He has had a successful business career and is now able to retire with a comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr. Wong has health coverage through his employer but will sign-up Medicare Part A, Part B and Part D when he leaves the workforce. How would you advise him as he budgets for Medicare premiums? - Due to his participation in the workforce he will not have to pay premiums for Part A but he will pay higher premiums for Part B and Part D due to the amount of his income. If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, what type of Medicare health plan could the individual also enroll in, without being automatically disenrolled from the stand-alone prescription drug plan? - The beneficiary could enroll in a private fee-for-service (PFFS) plan that does not include prescription drug coverage; a Cost plan; or a Medicare Medical Savings Account (MSA) plan. 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? - 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.