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

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AHIP Final Exam Practice Test

(200 Questions and Answers 100% Correct)

1. 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, SNPs, and MSAs
2. (W) Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be a correct description?- : Medicare Advantage is a way of covering all of the Original Medicare benefits through private health insurance companies.
3. During a sales presentation in Ms. Sullivan's home, she tells you that she has heard about a type of Medicare health plan known as Private Fee-for-Ser- vice (PFFS). She wants to know if this would be available to her. What should you tell her about PFFS plans ANS A PFFS plan is one of various types of Medicare

Advantage plans offered by private entities and she may enroll in one if it is available in her area.

4. (W) 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
5. Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying his Part B premium. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him ANS He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B
6. (W) Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Billings have in regard to her MA plan during the next open enrollment season ANS She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area
7. 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 obtain his services only from providers who have a contractual relationship with the plan (except in an emergency).

8. Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her ANS Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan's preferred providers.

9. 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 10.(W) Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost- sharing amounts and Mr. Greco would like to join that plan. What should you tell him ANS SNPs limit enrollment to certain sub- populations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP. 11.(W) 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 ANS Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a

result of paying monthly premiums. 12.(W) Mr. Bauer is 49 years old, but eighteen months ago he was declared dis- abled 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 ANS After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age. 13.(W) Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug policy ANS No, he cannot purchase a Medicare Advantage or Part D policy because he has not received Social Security or Railroad Retirement disability benefits for 24 months. 14.(W) Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her ANS In order to obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes

15. (W) Mr. Diaz continued working with his company and was insured under his employer's group plan until he reached age
16. 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. 16.(W) Mrs. PeHa is 66 years old, has coverage under an employer plan and will retire next year. She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her ANS She may enroll at any time while she is covered under her employer plan, but she will have a special eight-month enrollment period that differs from the standard general enrollment period, during which she may enroll in Medicare Part B 17.(W) Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enrollment in a Medicare health plan. What should you advise her to do before she will be able to enroll into a Medicare health plan ANS In order to join a Medicare health plan, she also must enroll in Part B 18.Mrs. Park has a low, fixed income. What could you tell her 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 19.(W) Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some type of financial

assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what the assistance could do for him if he qualifies. What could you tell him ANS He might qualify for help with Part D prescription drug costs and help paying Part A and/or Part B premiums, deductibles, and/or cost sharing. 20.(W) Mr. Patel 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 as a result of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original 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 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 21.(W) Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What should you tell Mr. Rainey (or his rep- resentative) about the length of an inpatient psychiatric hospital stay that Medicare will cover ANS Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.

22. 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. Shields' skilled nursing services provided during the first 20 days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days. 23.Mrs. Quinn has just turned 65 and received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn ANS Part B primarily covers physician services. She will be paying a monthly premium and, with the exception of many preventive and screening tests, generally will have 20% co-payments for these services, in addition to an annual deductible. 24.(W) Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening. What should you tell him ANS Medicare covers periodic performance of a range of screening tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests before obtaining them to see if they will be covered. 25.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 26.Mrs. Wolf wears glasses and dentures and has enjoyed considerable pain relief from arthritis through acupuncture. She is concerned about whether or not Medicare will cover these items and services. What should you tell her ANS Medicare does not cover acupuncture, or, in general, glasses or dentures 27.Mr. Singh would like drug coverage, but does not want to be enrolled into a health plan. What should you tell him ANS Mr. Singh can enroll in a stand-alone prescription drug plan and continue to be covered for Part A and Part B services through Original Fee-for- Service Medicare. 28.(W) 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 ex- pect 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

29.Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her ANS Part

D covers prescription drugs and she should look at her premiums, formulary, and cost sharing among other factors to see if they have changed. 30.Mrs. Paterson is concerned about the deductibles and co- payments as- sociated with Original Medicare. What can you tell her about Medigap as an option to address this concern ANS Medigap plans help beneficiaries cover coinsurance, co- payments, and/or deductibles for medically necessary services. 31.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. 32.Mr. Kelly has substantial financial means. He enrolled in Original Medicare and purchased a Medigap policy many years ago that offered prescription drug coverage. The prescription drug coverage has not been comparable to that offered by Medicare Part D for several years and despite notification, Mr. Kelly took no action. Which of the following statements best

describes what will occur if Mr. Kelly now decides to enroll in Medicare Part D ANS He will incur a late enrollment penalty 33.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 ANS 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 34.What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) have upon Medigap plans ANS The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020 35.Mrs. Raskin is a widow who will attain aged 65 and enroll in Medicare in just a few weeks. She concerned about having prescription drug coverage. Which of the following statements provides the best advice ANS Prescription drug coverage can be obtained by enrolling in a Medicare Advantage plan that includes Part D coverage. 36.Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefit package of a

Medicare Health Plan before she starts looking at specific plans. What could you tell her ANS Medicare Health 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

37. Mr. Hernandez is concerned that if he signs up for a Medicare Advantage plan, the health plan may, at some time in the future, reduce his benefits below

what is available in Original Medicare. What should you tell him about his concern ANS Medicare health plans must cover all benefits available under Medicare Part A and Part B. Many also cover Part D prescription drugs 38.Ms. Moore 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 ANS Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end stage renal disease or Lou Gehrig's disease, so she will be eligible for Medicare. 39.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 ANS 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 40.Mr. Meoni's wife has a Medicare Advantage plan, but he wants to under- stand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr.Meoni ANS Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover

41.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 like 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. 42.Mrs. Lee is discussing with you the possibility of enrolling in a Private Fee-for-Service (PFFS) plan. As part of that discussion, what should you be sure to tell her ANS If she uses non-network providers, her doctors and hospital could decide whether to treat her on a visit-by-visit basis 43.Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. What should you tell him ANS Enrollees in a PFFS plan can obtain care from any provider in the U.S. who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan's terms and conditions and agrees to accept them. 44.If Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan's terms and conditions for payment, how will she be paid ANS Generally,

the PFFS plan will pay Dr. Brennan directly the same amount Original Medicare would pay her 45.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

46. 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 ANS 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. 47.Which statement best describes PACE plans ANS It includes comprehensive medical and social service delivery systems using an interdisciplinary team ap- proach in an adult day health center, supplemented by in-home and referral services. 48.Mr. Romero is 64, retiring soon, and considering enrollment

in his employ- er-sponsored retiree group health plan that includes drug coverage with nom- inal 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 Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep 49.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 Health Plan ANS Medicaid will coordinate benefits only with Medicaid par- ticipating providers 50.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

51. Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the year, Mr. Rivera needs dentures, a service only covered under Med-

icaid. What action would you recommend he take in order to have this cost covered ANS He should go to a Medicaid provider or obtain the services through a Medicaid manage care plan if he is enrolled in one

52. 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 in one of the MA plans that include prescription drug coverage or a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan. 53.Mrs. Chou likes a PFFS plan available in her area that does not offer 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. 54.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 55.Mrs. Mulcahy 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 Everyone 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. 56.Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her ANS If a Part D benefit is offered through her plan she may choose in enroll in that plan or a standalone PDP. 57.All plans must cover at least the standard Part D coverage or its actuarial equivalent. What costs would a beneficiary incur for prescription drugs in 2018 under the standard coverage ANS Standard Part D coverage would require payment of an annual deductible, 25% cost-sharing up to the coverage gap, a portion of

costs for both generics and brand-name drugs in the coverage gap, and co-pays or co-insurance after the coverage gap. 58.Mrs. Andrews was preparing a budget for next year because she takes quite a few prescription drugs, she will reach the coverage gap, and wants to be sure she has enough money set aside for those months. She received assistance calculating her projected expenses from her daughter who is a pharmacist, but she doesn't think the calculations are correct because her out- of-pocket expenses would be lower than last year. She calls to ask if you can help. What might you tell her ANS It would not be unusual for her costs to be a bit less because each year until 2020, an enrollee's share of the drug costs in the coverage gap are less 59.Mr. Jacob understands that there is a standard Medicare Part D prescrip- tion 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, premi- ums 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. 60.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 her prescriptions hat 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.

61.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. 62.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 needs. 63.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. 64.Under what conditions can a Medicare prescription drug plan reduce its coverage for a given drug mid-way through the year ANS When a new generic drug for the same condition becomes available or when the FDA or manufacturer withdraws the drug from the market, a brand name drug can be replaced

65. Mrs. Roswell is a new Medicare beneficiary and 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 30 day supply of her existing medications sometime during a 90 day transition period 66.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 67.Mr. Katz reached the Part D coverage gap in August last year. His prescrip- tions have not changed, he is keeping the

same Part D plan and the benefits, cost-sharing, and coverage of his drugs are all the same as last year. He asked what to expect for this year about his out-of-pocket costs. What could you tell him ANS Because he reached the coverage gap last year, he will probably reach it again this year close to the same time 68.Mrs. Grant uses several very expensive drugs and anticipates that she will enter catastrophic coverage at some point during the year. To help her determine when she is likely to qualify for catastrophic coverage, she asked which expenses count toward the out-of-pocket limit that qualifies her for catastrophic coverage. Which one of the following would count ANS Prescription drugs she purchases when in the Part D coverage gap 69.Mr. Shapiro gets by on a very small 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 70.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.