AHIP 2023 Final Exam Test questions verified with 100% correct answers, Exams of Nursing

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AHIP 2023 Final Exam Test Questions and

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1. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her ANS Medicaid may provide additional benefits, but Medicaid will coordinate benefits only with Medicaid participating providers.
2. 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.
3. 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 They are

Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.

4. Mr. Romero is 64, retiring soon, and considering enrollment in his em- ployer-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 ANS When possible, it is always the best option to have both the employer's plan and the MA-PD, so he would have no out-of-pocket expenses. 5.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
5. Mrs. Willard 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 and must include a maximum out- of-pocket limit on Part A and Part B services.

7. 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 will be able to enroll in a Medicare Advantage plan ANS To join a Medicare Advantage plan, she also must enroll in Part B.
8. 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.: I, II, and IV

9. Mrs. Lyons is in good health, uses a single prescription, and lives indepen- dently 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 ANS 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. 10.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 11.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. 12.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 If she wants drug coverage and a PFFS plan, she could only enroll in a PFFS plan that includes Medicare prescription drug coverage 13.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 ANS Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan.

14. Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employ- ees and offers

employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact

his employer-sponsored healthcare coverage. How would you respond ANS Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer- sponsored group health plan. 15.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 ANS 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. 16.Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems func- tioning. Which type of SNP is likely to be most appropriate for him ANS C-SNP 17.Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him ANS 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).

18.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 ANS 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.

19. 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 prescrip- tion 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.

20.Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her ANS Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.

21. 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 ANS TrOOP stands for true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts. 22.Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her ANS An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. 23.Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan ANS A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan. 24.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 ANS 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. 25.Which of the following statements about Medicare Part D are correct ANS I, II, and III only 26.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 D prescription drug plan that covers either one of them. What should you tell her ANS Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should be able to enroll in a Medicare prescription drug plan that covers the medications she need 27.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 ANS 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

28. Mr. Rice has 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. 29.Mrs. Fiore is a retired federal worker with coverage under a Federal Em- ployee 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 ANS 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. 30.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. 31.Ms. Edwards is enrolled in a Medicare Advantage plan that includes pre- scription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her ANS She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. 32.What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications ANS Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered co-payments and prior authorization.

33. Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary he takes several other medications. These include a prescription drug not on his plan's for- mulary, over- the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count

toward TrOOP should he ever reach the Part D catastrophic limit. What should you say ANS None of the costs of Mr. Wingate's other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription not on its formulary. 34.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 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 Vaughn's could look into that possibility. 35.Mr. Schultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Schultz has lost his employer group coverage within the last two weeks. How would you advise him ANS Mr. Schultz should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty. 36.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 a number of

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. 37.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 would incur for prescription drugs under the standard cov- erage ANS Standard Part D coverage would require payment of an annual deductible, and once past the catastrophic coverage threshold, the beneficiary pays whichever is greater of either the co-pays for generic and brand name drugs or coinsurance of 5% 38.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 ANS 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.

39.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 ANS The extra help is available to beneficiaries whose income and assets do not exceed annual limits specified by the government 40.Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him ANS If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty. 41.If you are to comply with Medicare's guidance regarding educational events, which of the following would be acceptable activities ANS You may dis- tribute business cards to individuals who request information on how to contact you for further details on the plan(s) you represent. 42.Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior 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. 43.When you market Medicare Advantage and Part D plans, what may you offer as a gift to induce enrollment in a plan ANS You may provide gifts or prizes to all potential enrollees during an event that does not exceed $15 in retail value. 44.Mr. Edwards, a marketing representative of the ACME Insurance Company, scheduled a marketing event and expects about 40 people to attend. He has hired a magician for $200 to entertain attendees. Can he do this in a way that complies with guidance from the Medicare agency ANS He can do this because the estimated number of attendees is based on the venue size and response rate and the value of the gift does not exceed $15. 45.You are meeting with Mrs. Hall in her home. On her scope of appointment form, she asked to discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone prescription drug plan. She is leaving the next day to visit her family for a week in another state, so it is important for her to make a decision before she leaves. What must happen before that additional discussion can take place ANS Since Mrs. Hall specifically asked that you discuss

the stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form first, indicating that she wants to discuss the Part D plan. 46.BestCare Health Plan has received a request from a state insurance de- partment in connection with the investigation of several marketing repre- sentatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response ANS Cooperate with the state and supply requested information. 47.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 ANS You may request RSVPs, but you are not permitted to require contact information.

48. This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do ANS You may go ahead and call them. 49.Monica is an agent focused on serving seniors eligible for Medicare. As she reviews her records, she is trying to determine which of the following items are considered compensation. What do you tell her ANS I, II and IV only 50.Winthrop Brokerage wishes to place an advertisement in the

local newspa- per 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 advertise- ment 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. 51.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. 52.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 plans 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.

53. By contacting plans available in your area, you have learned that the plan you represent has a significantly lower monthly premium than the others. Fur-

thermore, 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 by studies or statistical data and such comparisons are factually based. 54.You are scheduled to give a sales presentation at a local senior center at which a drawing will be held for a prize. At the beginning of the presentation, which of the following must you do ANS Clearly state that no obligation exists to enroll if a gift or prize is being offered. 55.Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted concerning the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him con- cerning the type of scrutiny he will be under: Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements. 56.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 ANS

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. 57.Alice is a marketing representative employed by a health plan. Betty is a captive agent of a health plan who markets to multiple plans and sponsors. Carl is a captive agent who markets to only one plan/sponsor. Denise is an independent agent who markets to different types of groups. Edward is an independent agent who markets only to employer and union groups. CMS marketing representative compensation rules generally apply to:: Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply) 58.You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague's suggestion ANS You should tell your colleague no, because participation in an educational event may not include a sales presentation.

59. 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 appointment 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. 60.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 re- ceived an overall plan performance rating of a 4-star, which of the following would be the best statement to say to her ANS The Medicare Advantage plan is a top-rated plan. 61.Mr. Fitzgerald is selling his home to permanently move into a retirement facility near his daughter in a neighboring state before the Annual Election Period. He has a stand-alone prescription drug plan and has learned it is not available where he is moving. He doesn't know what he should do. What can you tell him ANS Because he is moving outside of the service area, the plan must automatically disenroll him. He will have a special election period to select a new plan. 62.Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard ANS Willard works as a representative focused on the senior marketplace. What would be considered prohibited activity by Willard?

63. 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. 64.Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form ANS Evidence of plan membership, information on how to obtain services, and the effective date of coverage. 65.Mrs. Reynolds is in her Medicare initial coverage election period (ICEP) and the date of her entitlement to Part A and B has already occurred. Mrs. Reynolds has just signed up for a Medicare Advantage plan on the second of the month. She is leaving for vacation in two weeks and wants to know if her new coverage will start before she leaves. What should you tell her ANS Typically, her coverage would begin on the first day of the next month, so she should not expect her coverage to begin before she leaves
64. 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 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.

67. 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 tell her ANS II and III only 68.Mrs. Jenkins is enrolled in both Part A and Part B of

Medicare. She has recently also become eligible for Medicaid and would like to enroll in a MA-PD plan. Since this is her first experience with Medicare Advantage, she is con- cerned that she will be locked into a plan and unable to make any coverage changes for at least a year if not longer. What should you tell her ANS Since Mrs. Jenkins has Medicare Part A and Part B and receives Medicaid, she has a special election period (SEP) that will allow her to enroll or disenroll from an MA or MA-PD plan during the first 9 months of each calendar year. 69.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 ANS 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 eligible for Medicare before age 65, Ms. Claggett had a second IEP based on turning age 65, which has also expired.