Download AHIP - 2026 - Modules 1-5 and more Exams Nursing in PDF only on Docsity!
AHIP - 2026 - Modules 1- 5
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? - ANSWER - 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. 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? - ANSWER - Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage. 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? - ANSWER - Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program (SPAP). Mr. Vasquez is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization because of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? - ANSWER - 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. Mr. Moy will soon turn age 65. He is slightly younger than his wife. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? - ANSWER - Medicare Supplemental Insurance would help cover his Part A deductible and Part B coinsurance or copayments in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. 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 employees 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? - ANSWER - 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. 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 but Smallcap must continue to offer him coverage under its employer-sponsored group health plan and would become a secondary payor. Ms. Kumar plans to retire when she turns 65 in a few months. She is in excellent health and will have considerable income when she retires. She is concerned that her income will make it impossible for her to qualify for Medicare. What could you tell her to address her concern? - ANSWER - Medicare is a program for people age 65 or older and those under age 65 with
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? - ANSWER - After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 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? - ANSWER - 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. Anthony Boniface turned 65 in 2024. He was not receiving Social Security or Railroad Retirement Benefits on his 65th birthday. He was interested in obtaining Medicare coverage and is eligible for premium-free Part A. Before he could enroll in Medicare, his entire area was impacted by a hurricane causing massive flooding and severe wind damage. The Federal government declared this to be a natural disaster which has recently ended. During this period Anthony's initial enrollment period expired. Anthony asks you how he can now obtain Medicare coverage. What should you say? - ANSWER - Anthony is eligible for a special enrollment period (SEP) because he missed an enrollment period due to the impact of the Federally declared disaster. This SEP will allow Anthony to enroll in Part B up to six months after the end of the emergency declaration. Anthony may enroll in premium-free Part A at any time and his Part A coverage will be retroactive for up to 6 months. Ms. Lewis has aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? - ANSWER - Medicare covers hospice services, and they will be available for her.
Edward 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? - ANSWER - 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. Foster 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? - ANSWER - Medicare will cover Mrs. Foster'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. 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? - ANSWER - 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.
Mr. Arias, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. Mr. Arias 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? - ANSWER - He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B. Mrs. Lester is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in an 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. Lester? - ANSWER - Mrs. Lester may enroll in an MA MSA plan and remain in her current standalone Part D prescription drug plan. Herber Noble is turning 65 next month, Herber legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Herber has worked at Smallcap Incorporated and contributed to the Medicare system. Herber 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? - ANSWER - Herber is eligible to enroll in Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Herber 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. Bryant 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? - ANSWER - You can offer to review the plans appeal process to help him ask the plan to review the coverage decision. Mr. Dalton 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. Dalton would like to join that plan. What should you tell him? - ANSWER - 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. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? - ANSWER - 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). Mr. Anderson 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? - ANSWER - You would need to ask Mr. Anderson if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. Mr. Abbott 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? - ANSWER - There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
Mrs. Joy, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrolling in a Medicare Advantage plan (Part C). What should you advise her to do before she can enroll in a Medicare Advantage plan? - ANSWER - To join a Medicare Advantage plan, she also must enroll in Part B. Mr. Barrow 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? - ANSWER - SNPs have special programs for enrollees with chronic conditions, like Mr. Barrow, and they provide prescription drug coverage that could be very helpful as well. Mrs. Sanchez 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. Sanchez 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. Sanchez? - 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. Dr. Elizabeth Morgan does not contract with the ABC PFFS plan but accepts the plan's terms and conditions for payment. Mary Rodgers sees Dr. Morgan for treatment. How much may Dr. Morgan charge? - ANSWER - Dr. Morgan 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.
Mr. Pham is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare Advantage HMO. Shortly thereafter, Mr. Pham visits his primary care provider (PCP), Dr. Maria Sanchez. Mr. Pham complains of a bad cold and receives care - a Medicare-covered service. The normal copayment is $40. How much may Dr. Sanchez collects? - ANSWER - The minimal copayment that would apply under Medicaid, regardless of what the plan requires of other enrollees. Raymond is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him? - ANSWER - C-SNP Mrs. Nelson 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? - ANSWER - She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan. Mrs. Nguyen 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? - ANSWER - 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. Mrs. Duran is enrolled in a prescription drug plan. She has heard about something called True- Out-Pocket costs or "TrOOP" and asks you if any of the following count toward reaching the catastrophic coverage phase. What do you say?
Mrs. Russo 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?
- ANSWER - Yes. Mrs. Russo must be entitled to Part A and/or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. Mrs. Willis has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drugs are 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? - ANSWER - 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 needs. Mrs. McFarren is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage? - ANSWER - Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Mrs. Wood, 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? - ANSWER - 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. Wood is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan.
Mr. Sutton 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? - ANSWER - In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Mr. and Mrs. Cole both take a specialized multivitamin prescription each day. Mr. Cole takes a prescription to help regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? - ANSWER - Medicare prescription drug plans are not permitted to cover the prescription medications the Coles are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Coles could look into that possibility. Ms. Ramos 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? - 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. Mr. Chen 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. Chen has lost his employer group coverage within the last two weeks. How would you advise him? - ANSWER - Mr. Chen should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.
II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in an MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. - ANSWER - I, II, and III only Mrs. Sharma 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. Sharma consider before selecting a PFFS plan? - ANSWER - 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. Mr. Aguilar 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 formulary, 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? - ANSWER - None of the costs of Mr. Aguilar'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. Steban Marsh is a newly appointed agent. Steban 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. Steban asks you what is permissible at such an event. What should you say? - ANSWER - Steban may provide a meal as long as its value is $15 or less per attendee and he may make available business reply cards (BRCs). Maria Valesquez is a marketing representative with RitzCo, a third-party marketing organization (TPMO). Maria meets with Henry Smythe, who has a website that provides information about different ways to get Medicare. The website allows beneficiaries to put in their name and contact information in order to receive additional information. Henry offers to sell Maria leads obtained through the website. What should Maria do? - ANSWER - Maria should pass on Henry's offer. Henry's website is a TPMO, and for a TPMO to provide contact information to another TPMO (including an agent/broker or FMO), it has to have prior express written consent that identifies each entity that will receive the information. You are working with several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do? - ANSWER - You must ensure that the advertisements indicate it is an educational event, otherwise it will be considered a marketing event. Stephanie King 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? - ANSWER - FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. King remains enrolled the following year.
You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? - ANSWER - Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility. 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 concerning the type of scrutiny he will be under? - ANSWER - 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. You have been providing a pre-Thanksgiving meal during sales presentations in November for many years, and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do concerning meals? - ANSWER - You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of the total value of the meal. BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response? - ANSWER - Cooperate with the state and supply requested information. 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? - ANSWER - The
plan may withhold commission, require retraining, report the misconduct to a state department of insurance or terminate the contract. ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' information to market non-health related products such as life insurance and annuities. Which statement best describes ABC's obligation to its enrollees regarding marketing such products? - ANSWER - It must obtain a HIPAA compliant authorization from an enrollee that indicates the plan or plan sponsor may use their information for marketing purposes. Your client, Jaime 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? - ANSWER - 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 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? - ANSWER - 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. 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? - ANSWER - You appreciate the opportunity and would be happy to schedule an appointment with anyone at their request.
