AHIP Final Exam 2025 EXAM NEW VERSION LATEST UPDATE 2024-2025 WITH ACCURATE ANSWERS, Exams of Nursing

Download AHIP Final Exam 2025 EXAM NEW VERSION LATEST UPDATE 2024-2025 WITH ACCURATE ANSWERS and more Exams Nursing in PDF only on Docsity! AHIP Final Exam 2025 EXAM NEW VERSION LATEST UPDATE 2024-2025 WITH ACCURATE ANSWERS GUARANTEED PASS BEST STUDYING MATERIAL WITH 100+ QUESTIONS 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? - ANSWER Mr. Diaz will not pay any penalty because he had continuous coverage under his employer's plan. 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? - ANSWER Medicare will cover Mrs. Shield's skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days. Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she had been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn? - ANSWER Part B primarily covers physician services. She will be paying a monthly premium and, except for many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible. 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? - ANSWER Original Medicare covers ambulance services. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance? - ANSWER She should contact her state Medicaid agency to see if she qualifies for one of several programs that can help with Medicare costs for which she is responsible. What impact, if any, have recent regulatory changes had on Medigap plans? - ANSWER The Part B deductible is no longer covered for individuals newly eligible for Medicare starting January 1, 2020. 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? - ANSWER Medicare does not cover massage therapy, or, in general, glasses or dentures. Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes during that entire period. She is concerned that she will not qualify for coverage under part A because she was not born in the United States. What should you tell her? - ANSWER You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area. 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? - ANSWER Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services. Mrs. 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? - ANSWER Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan. 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? - ANSWER 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. 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? - ANSWER In general, he must select a single Part D premium payment mechanism that will be used throughout the year. 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? - 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. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan. 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? - ANSWER 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. 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? - ANSWER 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. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various 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? - ANSWER 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? - ANSWER 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. 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? - ANSWER The extra help is available only to Medicare beneficiaries who are enrolled in Medicaid. He should apply for coverage under his state's Medicaid program to access the extra help with his drug costs. 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 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 potential clients to market those plansl? - ANSWER You will have to avoid calling any potential client unless he or she initiates contact with you and specifically asks that you give him or her a call. 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? - ANSWER 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? - ANSWER 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. 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? - ANSWER 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? - ANSWER He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A. 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. - ANSWER II, III, and IV only. 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? - ANSWER 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. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition, has a low premium. It won't cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him? - ANSWER If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan. 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? - ANSWER It is a single period from January 1 - March 31, created by statute, when any Medicare beneficiary who has moved out of the area of their Medicare Advantage or Part D plan can add, drop, or change their Medicare prescription drug coverage. 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? - ANSWER She is eligible for a special election period (SEP) that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months. Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following? - ANSWER Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval. Scot Fitzwilliam is a Medicare beneficiary who currently takes several prescription drugs daily. He does not suffer, however, from diabetes. He is currently considering enrolling in the PDP you represent. Mr. Fitzwilliam enjoys a comfortable income and therefore is unlikely to qualify for a low-income subsidy. He is careful with his money and asks you about his likely out-of-pocket costs under a standard benefits PDP plan. What do you say? - ANSWER Mr. Fitzwilliam is likely to be responsible for a deductible of $590 (PY 2025) after which he will be responsible for 25 percent of his prescription drug costs during the initial coverage phase - that is, between the deductible and the initial coverage limit of $2,000 (PY 2025). Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of BestCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In setting up the enrollment site, which of the following must Phiona consider? - ANSWER II. All data elements required to complete an enrollment request must be captured. III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree" type of button or tool. Ms. Lewis understands that Medicare prescription drug plans may use various methods to control the use of specific drugs. She has heard about a technique called "step therapy" and is wondering if you can explain what that is. What should you tell her? - ANSWER Step therapy involves using one or more lower priced drugs before trying a more expensive drug when all are used to treat the same condition. 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? - ANSWER 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. 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. You have decided to focus on doing in-home presentations to market the Medicare Advantage (MA) plans you represent. Before you conduct such sales presentations, what must you do? - ANSWER 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? - ANSWER a. Due to the provisions of MACRA, his Part B and D coverage will be combined and covered through a low-cost Medigap policy to supplement his Part A coverage. b. Due to his participation in the workforce he will not have to pay premiums for Part A and he will pay the lowest monthly premium rates for Part B and Part D. c. 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. d. Due to his participation in the workforce he will not have to pay premiums for Part A and will pay reduced premiums for Part B and Part D. ????? Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services' communication and Marketing Guidelines to ensure he is compliant for which type of products? - ANSWER Medicare Advantage (MA) and Prescription Drug (PDP) plans Correct Ms. Hernandez has marketed several different types of insurance products in her home state and has typically sought approval of her materials from her State Department of Insurance. What would you advise her regarding seeking such approval for materials she uses to market Medicare Advantage plans? - ANSWER a. States often volunteer to review marketing materials on behalf of the Medicare agency. She should check with her Department of Insurance to see if such a review is available and would satisfy CMS requirements. b. Materials for marketing Medicare health plans to individuals are subject to Medicare's uniform national requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval from the Medicare agency (CMS) for any materials she uses. c. Obtaining approval of her materials from the State Department of Insurance is a good practice and she should continue it with materials for the Medicare health plans she represents. d. Materials need only be reviewed and approved by the company(s) she represents. Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen with respect 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. 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. Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him? - ANSWER 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? - ANSWER Medicare Advantage HMO inpatient hospital stay, after which it converts into a per-day 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 Which of the following statements about Medicare Part D are correct? I. Part D plans must enroll any eligible beneficiary who applies regardless of health status except in limited circumstances. 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 a MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in a MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. - ANSWER I, II AND III ONLY Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain that it is the way for consumers to judge plan performance, what else would you say? - ANSWER ?????? Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in 2013, a Cost plan Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility requirements for Medicare Advantage or Part D plans The SEP is available each year beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2018 can be used from December 8, 2017 through November 30, 2018. Disenroll from an MA plan, PDP or Cost plan or leave Original Medicare Enroll in a 5-star MA plan, PDP or Cost plan Eligible individuals may enroll in a 5-star plan through 1-800-MEDICARE, Medicare.gov, or directly through the 5-star plan. Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan, but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare Cost Plan might fit his needs? - ANSWER Cost plan enrollees can choose to receive Medicare covered services under the plan's benefits by going to plan network providers and paying plan cost sharing, or may receive services from non-network providers and pay cost sharing due under Original Medicare. Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans. This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to continue to receive renewal fees? - ANSWER Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)? - ANSWER Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is concerned about changes in his cost-sharing. What should you tell him? - ANSWER He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him? - ANSWER Formularies must be developed with input from pharmacists,doctors, and other experts. Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation? - ANSWER A meal cannot be provided, but light snacks would be permitted. Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual check-ups for the past 15 years, likes these yearly visits, and would like to continue obtaining these services as a Medicare beneficiary. What should you tell him about annual check-ups? - ANSWER 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? - ANSWER Plans are required to cover out-of network emergency care. Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and Part D due to a change of residence? Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? - ANSWER Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation? - ANSWER This situation is considered a "dual enrollment" and CMS compensation rules are applied to the two plans at once and independently of each other. Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements 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? - ANSWER She qualifies for a special enrollment 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. 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? - ANSWER You are not required to submit copies of disseminated materials to CMS at the time of use, but CMS may request and review copies if employee complains occur. Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her? - ANSWER 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? - ANSWER He may sign-up for Medicare at any time however coverage usually begins on the fourth month after dialysis treatments start. 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? - ANSWER 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. Next week you will be participating in your first "educational event" for prospective enrollees. In order to be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage? Choose one answer. - ANSWER You should plan to ensure that the educational event is a social event, and must not conduct a sales presentation or distribute or accept enrollment forms at the event. Eleanor takes several high-cost prescription drugs. She would like to enroll in a standalone Part D prescription drug plan that is available in her area. In what type of Medicare Health Plan can she enroll if she also wishes to enroll in the standalone Part D plan? - ANSWER