2025 AHIP Final Exam) Updated Questions and Answers (2024/2025) (Verified Answers, Exams of Nursing

Download 2025 AHIP Final Exam) Updated Questions and Answers (2024/2025) (Verified Answers and more Exams Nursing in PDF only on Docsity! 2025 AHIP Final Exam) Updated Questions and Answers (2024/2025) (Verified Answers 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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>Mrs. Duarte should Medicare? - Ans>>Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs. What impact, if any, have recent regulatory changes had on Medigap plans? - Ans>>The Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020. Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern? - Ans>>Medigap plans do not cover Original Medicare benefits, but they coordinate with Original Medicare coverage. Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know which of the following services Original Medicare will cover if the appropriate criteria are met. What could you tell her? - Ans>>Original Medicare covers ambulance services. Ms. Brooks has aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? - Ans>>Medicare covers hospice services, and they will be available for her. 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? - Ans>>Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has told her about the Medigap Plan F in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you tell her? - Ans>>You are sorry to disappoint Anita, but a Medigap F plan is no longer available to those who turn age 65 after January 1, 2020. Anita might instead consider other Medigap plans that offer foreign travel benefits but do not cover the Part B deductible. Hank's Fish Store, Inc. is a small company with just 15 employees located in Florida. Hank, the store owner, has provided excellent health benefits to the store's workforce. William, one of the store's long-time employees, will soon be reaching age 65 and eligible for Medicare. William is in good health. He intends to remain an active full-time employee, working several years after becoming eligible for Medicare. What type(s) of retiree health benefit will Hank's Fish Store be able to offer William? - Ans>>Hank's can continue to offer William the same employee health benefit plan, or, if 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? - Ans>>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? - Ans>>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. 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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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 him about this situation? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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 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? - Ans>>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. Who is most likely to benefit from the Medicare Prescription Payment Plan? - Ans>>Kevin, who suffered a heart attack at the beginning of the year requiring him to take an expensive brand name blood thinner on a daily, as well as an equally expensive injectable cholesterol medication on a bi-weekly basis for which he incurs high out-of-pocket costs. Mr. Rice is 68, actively working, and has coverage for medical services and medications through his employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B and switching to an MA-PD because he is paying a very large part of his group coverage premium, and it does not provide coverage for a number of his medications. Which of the following is NOT a consideration when making the change? - Ans>>Mr. Rice's retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his Medicare Part D plan. Mrs. Roswell is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? - Ans>>Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90-day transition period. Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him? - Ans>>He could check with the manufacturers of his medications to see if they offer an assistance program to help people with limited means to obtain the medications they need. Alternatively, he could check to see whether his state has a pharmacy assistance program to help him with his expenses. Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him? - Ans>>Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription to help to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? - Ans>>Medicare prescription drug plans are not permitted to cover the prescription medications the Vaughns are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Vaughns could look into that possibility. 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? - Ans>>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? - Ans>>In general, he must select a single Part D premium payment mechanism that will be used throughout the year. 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? - Ans>>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? - Ans>>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? - Ans>>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. - Ans>>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? - Ans>>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. 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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker's position, what would you do? - Ans>>Inquire whether the client qualifies for a special enrollment period, and if not, solicit an enrollment application once the annual open enrollment election period begins on October 15th. Which of the following individuals are likely to qualify for a special election period (SEP) for either a MA and/or Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's service area. II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area. III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available. IV. Henry makes a permanent move to a new state providing him with new MA and Part D options. - Ans>>II, III, and IV only. Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him? - Ans>>Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment. Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be June 1. Mr. Liu's ICEP and Part D IEP begin on March 1 and end on September 30. He wants prescription drug coverage with his Part A and Part B benefits. What advice can you provide him? - Ans>>He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A. Mr. and Mrs. Nunez attended one of your sales presentations. They've asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do? - Ans>>As long as she can do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. Mr. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available on January 1 next year. He is currently enrolled in Original Medicare. What should you do? - Ans>>Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins. Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). On December 1, he calls you up and says that he has changed his mind and would like to enroll in a MA-PD plan. What enrollment rules would apply in this case? - Ans>>He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made before the end of the period will be the effective one as of January 1. Mrs. Pierce would like to enroll in a Medicare Cost plan that offers Part D prescription drug coverage. She comes to you for advice about when she can enroll in a plan you have previously discussed. What should you tell her? - Ans>>Enrollment in Cost plans offering Part D coverage is available only during enrollment periods under the Part D program, and Cost plans must accept enrollments during these periods. Mr. Rodriguez is currently enrolled in a MA plan, but his plan doesn't sufficiently cover his prescription drug needs. He is interested in changing plans during the upcoming MA Open Enrollment Period. What are his options during the MA OEP? - Ans>>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? - Ans>>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 Advantage plan. She has been informed that her group coverage will end on her retirement effective date. How would you advise Ms. Thomas? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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? - Ans>>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. 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? - Ans>>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? - Ans>>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? - Ans>>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