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AHIP Final Exam (Version-1, 50 Q & A, Latest-2022) | 100% Verified and Correct Answers, Exams of Nursing

A set of questions and answers related to Medicare Advantage (MA) and Medicare prescription drug plans. The questions cover topics such as eligibility, enrollment, special enrollment periods, marketing requirements, and coverage options. The answers are multiple-choice and provide detailed explanations of the correct option. useful for students studying health insurance, Medicare, and related topics.

Typology: Exams

2022/2023

Available from 05/18/2023

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Download AHIP Final Exam (Version-1, 50 Q & A, Latest-2022) | 100% Verified and Correct Answers and more Exams Nursing in PDF only on Docsity! AHIP Final Exam (Version-1, 50 Q & A, Latest-2022) | 100% Verified and Correct Answers 2 Marks: 1 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? Choose one a. Everyone who is entitled to Part A or enrolled under Part B is eligible to enroll in a answer. 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. b. To qualify for enrollment into a Medicare prescription drug plan, Mrs. Mulcahy mustbe entitled to Part A and enrolled under Part B. She should contact her local Social Security office and make arrangements to enroll in Part B prior to selecting a prescription drug plan. c. Like all Medicare beneficiaries, Mrs. Mulcahy will be automatically enrolled in aMedicare prescription drug plan when she turns 65. She will have a six-month window during which she can select a plan other than the one into which she has been automatically enrolled. d. As long as Mrs. Mulcahy is 65, eligibility for a Medicare prescription drug plan is notdependent on entitlement to Part A or enrollment under Part B, so she should not be concerned. 3 Marks: 1 1 Marks: 1 Choose one answer. a . Agent Higgins entire compensation must be recouped because Mrs. Oā€™Malley has disenrolled within 3 months of enrollment. b . AB MA plan must recoup a pro rata amount of Agent Higginsā€™ compensation if Mrs. Oā€™Malley subsequently enrolls in Original Medicare and Part D c . AB MA plan does not have to recoup Agent Higginsā€™ compensation because she has moved away from its service area. d . AB MA plan must recoup a pro rata amount of Agent Higginsā€™ compensation and pay him only for the month of January. Agent Higgins helps Mrs. O'Malley to enroll in AB Medicare Advantage (MA) plan during the Annual Open Enrollment Period. Mrs. O'Malley's effective enrollment date is January 1st. Subsequently, Mrs. O'Malley disenrolls on February 12th following a move outside the plan's service area. What impact will this have on Agent Higgins compe nsation? Final Exam - Attempt 1 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)? Choose one a. She is unlikely to qualify for a SEP but will be automatically covered by Original answer. Medicare and a standalone Part D prescription drug plan. b. She is likely to qualify for a SEP. She can choose an effective date of up to sixmonths after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than 30 days prior to the date of her move. c. She is unlikely to qualify for a SEP and should remain on her current plan, relyingon her current planā€™s out-of-network benefits. d. She is likely to qualify for a SEP. She can choose an effective date of up to threemonths after the month in which the enrollment form is received by the new plan, but the effective date may not be earlier than the date of her permanent move. 5 Marks: 1 describes the respons Choose one answer. Ms. Lopez is an independent agent under contract with MarketCo, a third-party marketing organization. MarketCo has a contract with BestCare health plan, a Medicare Advantage (MA) organization, to offer marketing services through its contracted agents and agencies. Ms. Lopez returns calls to individuals who contact MarketCo in response to its mailers promoting BestCare health plan. Which of the following best ibilities of Ms. Lopez? a. Ms. Lopez is considered a marketing representative of BestCare and thus isobligated to comply with CMS marketing requirements, including those regarding using only approved call scripts. b. Ms. Lopez no longer needs to be concerned about state licensure since she ismarketing an MA product subject to federal rules. c. Ms. Lopez is considered a marketing representative of BestCare but is exempt fromthe marketing rules regarding approved call scripts because she works directly for MarketCo. d. Ms. Lopez needs to maintain state licensure, but because she is working for a third-party marketing organization she is exempt from CMS training requirements that apply to BestCare captive agents. 4 Marks: 1 Choose one answer. a . Yes, but Mrs. Walters must drop the employer coverage prior to enrolling in a Medicare prescription drug plan. b . No. Mrs. Walters will have to enroll in Part B in order to qualify for enrollment into the Medicare prescription drug program. c . Yes. Mrs. Walters must be entitled to Part A or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. d . No. As long as her employer offers coverage that is equivalent to that available through Medicare, Mrs. Walters cannot enroll in a Medicare prescription drug plan. 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? 11 Marks: 1 Choose one answer. a . Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not. b . Yes, but only if she qualifies for Part D prescription drug coverage under her state Medicaid program. c . Yes. All SNPs are required to provide Part D coverage for prescription drugs. d . No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage through a stand-alone Part D Medicare prescription drug plan that they sign up for independent of their enrollment in the SNP. Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and is interested in that product. She wants to be sure she also has coverage for prescription drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? 12 Marks: 1 Choose one answer. a . If offered, beneficiaries can select a stand-alone Part D prescription drug plan ( PDP) with an HMO or a PPO, but not with a PFFS plan. b . 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 planā€™s terms and conditions and agrees to accept them. c . PFFS plans are the same as Medicare supplement plans and he may obtain care from any provider in the U.S. d . If a PFFS enrollee shows his/her card when obtaining services from a provider who participates in Original Medicare, then that provider is required to accept the planā€™s terms and conditions. Mr. McTaggert notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants t o know what makes them different from an HMO or a PPO. What should you tell him? 13 Marks: 1 Choose one answer. a . She may only enroll in Part B during the general enrollment period whether she is retired or not. b . 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. c . She must wait at least 30 days after her employment terminates before she may enroll in Medicare Part B. d . She may not enroll in Part B while covered under an employer group health plan and must wait until the standard general enrollment period after she retires. Mrs. Peňa 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? 16 Marks: 1 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? Choose one a. This situation is considered a ā€œdual enrollment,ā€ and CMS compensation rules are answer. applied to the two plans at once and independently of each other. b. MSA Medicare health plans are subject to special rules limiting initial yearcompensation to 50 percent of the fair market value (FMV) published annually by CMS. Regular initial year enrollment rules apply to the PDP. c. When an MSA Medicare health plan is combined with a PDP, initial and renewalyear(s) compensation is paid only for the MSA enrollment in order to recompense CMS for contributions made to the enrolleeā€™s MSA account. d. Regular CMS and renewal compensation rules apply to the PDP enrollment, butcompensation is limited to $100 for the MSA health plan enrollment in order to recompense CMS for contributions made to the enrolleeā€™s MSA account. 14 Marks: 1 Choose one answer. a . Mrs. Duarte has no right to appeal this determination since her claim has been partially paid. b . Mrs. Duarte should file an appeal of this initial determination within 90 days of the date she received the MSN in the mail. If she still disagrees with Medicare Administrative Contractor's (MAC's) further decision she should request a reconsideration by a qualified independent party within 10 days. c . Mrs. Duarte should request a reconsideration of the decision by a qualified independent party within 60 days of the date she received the MSN in the mail. d . Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail. Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services. What advice would you give her? 15 Marks: 1 Choose one answer. a . He will have to enroll in Part B. b . As long as his employer offers coverage that is equivalent to Medicareā€™s, he cannot enroll in Part B. c . He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan. d . He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan. Mr. Sanchez 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? 17 Marks: 1 plan. How would you Choose one answer. Mr. Landry is approaching his 65th birthday. He has signed up for Medicare Part A, but he did not enroll in Part B because he has employer-sponsored coverage and intends to keep working for several more years. But he is considering enrolling in Part D prescription drug coverage because he believes it is superior to his employer advise him? a. Mr. Landry is eligible for Part D since he has Part A, and his initial enrollment period(IEP) for Part D will continue for three months after his 65th birthday. b. Mr. Landry must enroll in Part B to enroll in Part D, but his initial enrollment periodfor Part B lapsed when he enrolled in Part A. c. Mr. Landry must wait until the next annual open enrollment period because his initialenrollment period for Part D lapsed when he enrolled in Part A. d. Mr. Landry must enroll in Part B to enroll in Part D, and he still has time to do so. 18 Marks: 1 Dr. Elizabeth Brennan does not contract with the PFFS plan but accepts the planā€™s terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan charge? Choose one a. Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the answer. PFFS planā€™s terms and condition of payment which may include balance billing up to 15 percent of the Medicare rate. b. Dr. Brennan can charge Mary Rodgers more than the cost sharing specified in thePFFS planā€™s terms and conditions as long as she treats all beneficiaries the same. c. Dr. Brennan can charge the beneficiary the same costsharing as Original Medicareas long as she sends the claim to Medicare and not the plan. d. Dr. Brennan can charge Mary no more than the cost sharing specified in the PFFSplanā€™s terms and conditions of payment which may include balance billing up to 25 percent of the Medicare rate. 19 Marks: 1 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? Choose one a. States often volunteer to review marketing materials on behalf of the Medicare answer. 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 toMedicareā€™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. Materials need only be reviewed and approved by the company(s) she represents. 26 Marks: 1 Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to visit one or two doctors who arenā€™t participating providers. He wants to know if the Point of Service (POS) option available with some HMOs will be of any help in this situation. What should you tell him? Choose one a. The POS option is only to allow him to visit in-network specialists without a referral. answer. He will have no coverage if he goes out-of-network. b. The POS option will allow him to visit out-of-network providers and generally the plan must provide the same level of cost sharing as if he went to in-network providers. c. The POS option refers to a method of processing claims in real time so that Mr. Polanski will be able to finalize his bill at the point of service with the provider, rather than waiting for the plan to mail him statements several weeks later. It does not have anything to do with his ability to access out-of-network providers. d. The POS option might be a good solution for him as it will allow him to visit out- ofnetwork providers, generally without prior approval. However, he should be aware that it is likely he will have to pay higher cost-sharing for services from out-of-network providers. 27 Marks: 1 Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a meeting so that she can learn about Medicare and the products you represent. How should you respond? Choose one a. Tell Julia that she must first complete a questionnaire providing her health history so answer. that you can recommend an appropriate product before submitting an enrollment application, since she qualifies for a special enrollment period. b. Tell Julia that you will meet with her at a time of her convenience within the nextweek, when you can accept a completed enrollment application to be submitted after October 15th. 25 Marks: 1 Choose one answer. a . Plans are required to cover out-of-network emergency care only if she has the ambulance driver or ER doctor call her plan for approval prior to receiving emergency services. b . Plans are required to cover out-of-network emergency care. c . Plans are required to cover all charges for in-network emergency care, but coverage of out-of-network emergency care is not required. d . Plans are required to cover at least 20% of the cost of out-of-network emergency care. 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 planā€™s service area. What should you tell her about coverage of emergency care? c. Tell Julia that you are happy to meet with her once this yearā€™s open enrollmentbegins on October 15th. d. Tell Julia that you will meet with her to explain Medicare and should she beinterested you can accept and submit an enrollment request, since this is an initial enrollment qualifying her for a special enrollment period. 28 Marks: 1 Mrs. Disraeli is enrolled in Original Medicare (Parts A and B) and a standalone Part D prescription drug plan. She has recently developed diabetes and has suffered from heart disease for several years. She has also recently learned that her area is served by a SNP for individuals suffering from such a combination of chronic diseases (C-SNP). Mrs. Disraeli is concerned however, that she will have few rights or protections if she enrolls in a C-SNP. How would you respond? Choose one a. Enrollees, while able to select their primary care provider (PCP), do have answer. substantial restrictions and financial responsibilities regarding emergency care whether obtained at in-network or out-of-network facilities. b. Enrollees in SNPs must have access to provider networks that include enoughdoctors, specialists, and hospitals to provide all covered services necessary to meet enrollee needs within reasonable travel time. c. The SNP would select her primary care provider (PCP) but she could file agrievance within 90 days if the PCP proved incapable. d. Mrs. Disraeli would have substantial restrictions on obtaining emergency care andmust use network facilities or be responsible for most emergency care costs. 29 Marks: 1 Richard is a licensed agent who represents Spartan Health Plan and its Medicare Advantage (MA) plans. Richard has several clients who have recently come to him for help who are in their initial coverage election period (ICEP) and are interested in enrolling in one of Spartan Health Plan's MA plans. Alice will soon turn 65 and retire. Alice has coverage through Spartan Health Plan offered by her employer. Bob had health coverage through Spartan but dropped the coverage when he retired early to travel overseas. Bob, who has just turned age 65, is now back in the United States. Charlotte, who will turn 65 next month, has coverage through Athena Health plan ā€“ a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism? Choose one a. Alice and Charlotte because each of them currently have health coverage and is in answer. their initial coverage election period (ICEP). b. Alice because she will not have a break between her non-Medicare and Medicarecoverage through Spartan Health Plan. c. Alice and Bob because each of them has had coverage through Spartan HealthPlan. d. Alice, Bob, and Charlotte because electronic health record interoperability will allowRichard to access any needed information for their applications. 31 Marks: 1 What should you tell Choose one answer. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. him? a. In Medicare Advantage HMO plans, services provided by primary care physiciansare covered at 100%, but those of specialists are covered at 80%. b. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his servicesonly from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network). c. Mr. Kumar will be able to obtain routine care outside of the planā€™s service area, butwill pay a higher co-payment (except in an emergency). d. With any Medicare Advantage HMO, Mr. Kumar will be able to see any provider he likes, so long as that provider participates in Original Medicare. 30 Marks: 1 Choose one answer. a . Medicare does not cover hospice services. Hospice services are only available through state Medicaid programs, if the state offers such coverage. b . Hospice services are currently only offered under a limited demonstration project. Whether they will eventually become available nationally depends on the outcomes of the demonstration. c . Medicare covers hospice services and they will be available for her. d . The Federal government facilitates competition between hospice programs to lower the price of their services for Medicare beneficiaries, but does not offer coverage for hospice services through the Medicare program. Ms. Brooks has an aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? 32 Marks: 1 Choose one answer. a . Your coworker is correct because employed agents have to follow a stricter set of rules than do independent agents, such as yourself. b . Your coworker is correct. You may use any marketing techniques that do not involve providing misinformation to potential enrollees. c . Your coworker is correct. You are subject only to requirements issued by your state department of insurance. d . Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all contracted and employed agents comply with all Medicare marketing rules. Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same requirements as the plans themselves. How should you respond to such a statement? 38 Marks: 1 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? Choose one a. The Part D standard modelā€™s importance is that it is the only type of plan into which answer. low-income beneficiaries can enroll and still receive any extra help for which they may qualify. b. 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. c. The government bases its payments to Part D plans on the standard benefit model.For Part D plans to receive the full government payment, they must offer the standard model, however, they can take a risk and revise their benefit structure to attract more beneficiaries. d. The government allows Part D plans to adopt any benefit structure as long as thelist of covered drugs meets their approval. 40 Marks: 1 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? Choose one a. The extra help is available to beneficiaries whose income and assets do not exceed answer. annual limits specified by the government. b. He must apply for the extra help at the same time he applies for enrollment in a PartD plan. If he missed this opportunity, he will not be able to apply for the extra help again until the next annual enrollment period. c. The extra help is available only to Medicare beneficiaries who are enrolled inMedicaid. He should apply for coverage under his stateā€™s Medicaid program to access the extra help with his drug costs. 39 Marks: 1 Choose one answer. a . SNPs offer care from any doctor or hospital Mr. Sinclair would like to use and his costs will always be lower than in Original Medicare. b . SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. c . 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. d . Since SNPs donā€™t cover prescription drugs Mr. Sinclair should consider a different option. 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? d. The government pays a per-beneficiary dollar amount to the Medicare Part Dprescription drug plans, to offset premiums for their low-income enrollees in accordance with the planā€™s set criteria. Mr. Shapiro should check with his plan to see if he qualifies. 43 Marks: 1 Mrs. Goodman enrolled in an MA-PD plan during the Annual Election Period. In mid-January of the following year, she wants to switch back to Original Medicare and enroll in a stand-alone prescription drug plan. What should you tell her? Choose one a. During the MA Open Enrollment Period, from January 1 ā€“ March 31, she may only answer. add or drop Part D coverage, so she cannot switch back to Original Medicare. b. During the MA Open Enrollment Period, from January 1 ā€“ March 31, she maydisenroll from the MA-PD plan into Original Medicare and also may add a stand- alone prescription drug plan. 41 Marks: 1 Choose one answer. a . She should expect to receive a hard copy of the provider directory in and a separate notice describing where she can find monthly periodic updates online and how to request hardcopies. b . She should expect to receive Evidence of Coverage (EOC) within 21 days of confirmation of enrollment. c . She should expect either the pharmacy directory in hard copy or a distinct and separate notice (in hard copy) describing where she can find the pharmacy directory online and how to request a hard copy. d . She should expect to receive hard copies of both the provider and pharmacy directories automatically within 30 days of confirmation of enrollment. Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage (MA-PD) plan. She is new to this type of coverage and asks you what materials, if any, she should expect to receive. How would you reply? 42 Marks: 1 Choose one answer. a . Plan sponsors can use any marketing representative, as long as they are licensed in at least one state. b . State licensure laws are pre-empted and do not apply to marketing representatives marketing MA and Part D plans c . Medicare health plans must comply with requests for information from state insurance departments investigating complaints about a marketing representative. d . Plans must contract only with marketing representatives who reside in the state where they intend to work. Which of the following is a correct statement about state laws as they pertain to marketing representatives? c. During the MA Open Enrollment Period, from January 1 ā€“ March 31, she may dropa MA or MA-PD plan and go back to Original Medicare, but she may only enroll in a stand-alone prescription drug plan if she also purchases a Medigap policy. d. During the MA Open Enrollment Period, from January 1 ā€“ March 31, she may onlydisenroll from a MA or MA-PD plan, but cannot enroll in a stand-alone Part D plan. 46 Marks: 1 Mr. Jenkins is interested in enrolling in a Medicare cost plan and has sought your advice. What would you tell him? Choose onea. Cost plans are required to be open to enrollment at least 30 days per year, and answer.many are open for enrollment all year. So open enrollment will be dependent on the plan he chooses. b. Cost plans that offer an optional supplemental Part D benefit are required to beopen to enrollment at least 90 days per year in addition to accepting Part D enrollments during the annual enrollment period. 44 Marks: 1 Choose one answer. a . Determine whether the beneficiaries present are healthy enough for the plan. b . Make sure that those present provide leads. c . Explain, in your own words, how the plan you represent compares to other companiesā€™ plans. d . Clearly state that no obligation exists to enroll if a gift or prize is being provided. You are scheduled to give a sales presentation at a local senior center. At the beginning of the presentation, which of the following must you do? 45 Marks: 1 Choose one answer. a . Ms. Adams, a healthy early retiree who has just begun to collect Social Security at age 62. b . Ms. Davis who recently turned age 65 and is eligible for Part A and has just enrolled in Part B. c . Ms. Bradley is currently living abroad for a multi-year job assignment. d . Mr. Charles, an undocumented immigrant, entered the country illegally. be eligible to enroll in a Part D prescription drug plan? Who is most likely to