AHIP Test Review Questions with Verified answers (2025) GRADED A+, Exercises of Nursing

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2025 OVERVIEW OF MEDICARE PROGRAM BASICS: CHOICE,

ELIGIBILTY, AND BENEFITS

MODULE 1 QUESTIONS WITH

CORRECT SOLUTIONS GRADED A+

1. Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health andwill 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? a. Medicare is a program for people of all ages with specific mental health disabilities. Since she is in excellent health, she would not qualify, but should instead look into her state’s Medicaid program if she wants further coverage. Incorrect b. Eligibility for Medicare is based on whether or not a person has ever been employed by the federal government. If she or her husband were ever employed by the federal government, she can enroll in Medicare. Incorrect c. Medicare is a program for people age 65 or older and those under age 65 with certain disabilities, end- stage renal disease, and Lou Gehrig’s disease so she will be eligible for Medicare. Correct d. Medicare is a program for people who have incomes and assets below specific limits, so you will have to find out her exact financial situation before telling her whether she can obtain Medicare coverage. Incorrect 2. Mrs. Park is an elderly retiree. She has a low, fixed income. What could you tell Mrs. Park thatmight be of assistance? a. She should not sign up for a Medigap or Medicare Advantage plan. Incorrect b. She should only seek help from private organizations to cover her Medicare costs. Incorrect c. She can apply to the Medicare agency for lower premiums and cost-sharing. Incorrect d. 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. Correct 3. Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for thePart D low-income subsidy. Where might he turn for help with his prescription drug costs? a. Mr. Wu may still qualify for help in paying for Part D costs through the local Office of the Aging. Incorrect b. Mr. Wu has no alternative but to liquidate his remaining assets and apply for coverage through his state’s Medicaid program. Incorrect c. Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program. Correct

d. Mr. Wu may still qualify for help in paying for Part D costs through the Federal Pharmaceutical Assistance Program. Incorrect

4. Mr. Schmidt would like to plan for retirement and has asked you what is covered underOriginal Fee-for-Service (FFS) Medicare? What could you tell him? a. 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. Correct b. Part C, which always covers dental and vision services, is covered under Original Medicare. Incorrect c. Part A, which covers long term custodial care services, is covered under Original Medicare. Incorrect d. Part D, which covers prescription drug services, is covered under Original Medicare. Incorrect 5. Mr. Buck has several family members who died from different cancers. He wants to know ifMedicare covers cancer screening. What should you tell him? a. Medicare covers the 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. Correct b. Medicare covers all screening tests that have been approved by the FDA on a frequency determined by the treating physician. Incorrect c. Medicare covers some screening tests that must be performed within the first year after enrollment. Beyond that point expenses for screening tests is the responsibility of the beneficiary. Incorrect d. Medicare covers treatments for existing disease, injury and malformed limbs or body parts. As such, it does not cover any screening tests and these must be paid for by the beneficiary out of pocket. Incorrect 6. Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when heturns 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? a. Under Original Medicare, the inpatient hospital co-payment is a flat per-day amount that remains the same throughout the first 60 days of a beneficiary’s stay. After day 60 the amount gradually increases until day 90. After 90 days he would pay the full amount of all costs. Incorrect b. 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 Correct c. Under Original Medicare, the inpatient hospital co-payment is a percentage of allowed charges. The percentage increases after 60 days and again after 90 days. Incorrect

d. Under Original Medicare, if the inpatient hospital service is provided by a participating Medicare provider, the co-payment is waived. Co-payments are only charged when a beneficiary opts to receive care from a non-participating provider. Incorrect

7. 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 canobtain coverage under Medicare. What should you tell him? a. Individuals who become eligible for such disability payments only have to wait 12 months before they can apply for coverage under Medicare. Incorrect b. He became eligible for Medicare when his disability eligibility determination was first made. Incorrect c. After receiving such disability payments for 24 months he will be automatically enrolled in Medicare, regardless of age. Correct d. Individuals receiving such disability payments from the Social Security Administration continue to receive those payments, but only become eligible for Medicare upon reaching age 65. Incorrect 8. Mrs. Roberts has just received a new Medicare identity card in the mail. She is concerned thatit is a forgery since it does not have her Social Security number on it. What should you tell her? a. The card is indeed a forgery since all identity cards are being phased out in favor of a new electronic identity system developed by the Social Security Administration. Incorrect b. The card she received is valid but she should keep her old card for at least two years and present it whenever she receives health care. Incorrect c. The card she received is valid, the change has been made to protect Medicare beneficiaries from identity theft, and she should now destroy her old card. Correct d. The card is indeed a forgery since newly issued Medicare cards will have both a beneficiary’s Social Security number and date of birth imprinted on them. Incorrect 9. Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare health plan (Part C). What should you advise her to do before she will be ableto enroll in a Medicare health plan? a. To enroll in a Medicare health plan, she need only be entitled to Part A, so she does not need to take any further steps. Incorrect b. In order to join a Medicare health plan, she must be enrolled in Parts A, B, and D. Incorrect c. Since she is age 65 she may enroll in any Medicare health plan, regardless of whether she is entitled to Part A or Part B coverage. Incorrect d. In order to join a Medicare health plan, she also must enroll in Part B. Correct

10. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverageMedicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? a. Medicare Supplemental Insurance would cover his dental, vision and hearing services only. Incorrect b. Medicare Supplemental Insurance would cover all of his IRS approved health care expenditures not covered under Original Fee-for-Service (FFS) Medicare. Incorrect d. Medicare Supplemental Insurance would cover his long-term care services. Incorrect

MEDICARE

HEALTH PLANS

PART 2

1. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability toaccess providers. What should you tell him? a. Mr. Kumar will be able to obtain routine care outside of the plan’s service area, but will pay a higher co-payment (except in an emergency). Incorrect b. In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers who have a contractual relationship with the plan (except in an emergency or where care is unavailable within the network). Correct c. In Medicare Advantage HMO plans, services provided by primary care physicians are covered at 100%, but those of specialists are covered at 80%. Incorrect 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. Incorrect

2. Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her? a. Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage. Correct b. Even if Mrs. Radford has end-stage renal disease, she will be able to enroll in any Medicare Advantage plan in her service area. Incorrect c. Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, prior to being accepted and enrolled. Incorrect d. Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States. for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover. Correct c. Medicare Supplemental Insurance would help cover his Part A and Part B cost sharing in Original Fee-

Incorrect

3. Mr. Wells is trying to understand the difference between Original Medicare and MedicareAdvantage. What would be the correct description? a. Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare. Incorrect b. Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. Incorrect c. Medicare Advantage is a new name for the Original Medicare program. Incorrect d. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. Correct 4. 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 SpecialNeeds Plans (SNPs). What could you tell him? a. SNPs are essentially the same as Original Medicare and are not likely to have a noticeable impact on how Mr. Sinclair receives his care. Incorrect b. Since SNPs don’t cover prescription drugs Mr. Sinclair should consider a different option. Incorrect c. 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. Incorrect d. 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. Correct 5. Mrs. Walters is enrolled in her state’s Medicaid program in addition to Medicare. What shouldshe be aware of when considering enrollment in a Medicare Advantage plan? a. She can submit any bills she has for co-payments under Medicare to the state’s Medicaid program and they will always be fully covered. Incorrect b. If a provider accepts her Medicare Advantage plan coverage, that provider is legally obligated to also accept her Medicaid coverage, so she does not need to worry about finding providers who participate in both Medicare and Medicaid. Incorrect c. State Medicaid programs do not coordinate any of their coverage with Medicare Advantage plans. Incorrect d. She can enroll in any type of Medicare Advantage (MA) plan except an MA Medical Savings Account (MSA) plan. Correct 6. Daniel 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 bemost appropriate for him? a. FIDE-SNP Incorrect

b. C-SNP Correct c. I-SNP Incorrect d. D-SNP Incorrect

7. 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? a. PFFS plans are not permitted to provide any benefits beyond what is covered under Original Medicare. Incorrect b. If she uses non-network providers, she would not be permitted to obtain care outside of her plan’s service area. Incorrect c. If she uses non-network providers, her cost sharing would be the same under a PFFS plan as it would be under Original Medicare. Incorrect d. PFFS plans may choose to offer Part D benefits but are not required to do so. Correct 8. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. Herdoctor recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Davenport have in regard to her MA plan during the next open enrollment season? a. She must immediately drop her ABC MA plan and enroll in Original Medicare. Incorrect b. 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. Correct c. She must immediately drop her ABC MA plan and enroll in a Special Needs Plan (SNP) for individuals suffering from ESRD if one is available in her area. Incorrect d. She must remain enrolled in her ABC MA plan unless the plan terminates. Incorrect 9. Mr. McTaggart 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 shouldyou tell him? a. 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 plan’s terms and conditions. Incorrect b. 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. Incorrect c. 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. Correct d. PFFS plans are the same as Medicare supplement plans and he may obtain care from any provider in the U.S. Incorrect

10. Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from hisinvestments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend hasmentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him? a. SNPs only serve individuals in long-term care facilities, so he cannot enroll. Incorrect b. SNPs only serve individuals eligible for both Medicaid and Medicare, so he cannot enroll. Incorrect c. 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. Correct d. SNPs do not provide Part D prescription drug coverage, so if he does enroll, he should be aware that he will not have coverage for any medications he may need now or in the future. Incorrect

MEDICARE PART D: PRESCRIPTION

DRUG COVERAGE

PART 3

1. Mrs. Sanchez lives in a state located near Canada. She has recently become eligible for Medicare and is considering enrollment in Part D prescription drug coverage. One of her friends has toldher that she needs to be aware of something called TrOOP. What should you tell her when she asks youabout TrOOP? a. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include, in addition to the annual deductible, costs for drugs not on the Part D plan's formulary and drugs purchased outside the United States. Incorrect b. TrOOP is calculated on a cumulative basis and consists of the sum of an enrollee's out-of-pocket deductibles from the date of his or her enrollment in Part D plus outlays for over-the-counter drugs. Incorrect c. TrOOP are out-of-pocket costs that count toward the annual out-of-pocket threshold to move into catastrophic coverage and generally include the annual deductible(s) and costs for drugs on the plan's formulary purchased at a plan's participating pharmacy. In some instances, amounts not directly paid by the enrollee (like manufacturer discounts) count toward TrOOP. Correct d. TrOOP is calculated on an annual basis and consists of an enrollee's out-of-pocket deductible plus any amounts paid on behalf of an enrollee by Medicaid. Incorrect 2. Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, butwhen 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? a. 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. Incorrect

b. The Part D standard model’s importance is that it is the only type of plan into which low-income beneficiaries can enroll and still receive any extra help for which they may qualify. Incorrect c. 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. Correct d. The government allows Part D plans to adopt any benefit structure as long as the list of covered drugs meets their approval. Incorrect

3. Mrs. McIntire is enrolled in her state’s Medicaid plan and has just become eligible forMedicare as well. What can she expect will happen with respect to her drug coverage? a. She will continue to obtain her drug coverage through Medicaid. Incorrect b. Medicaid will cover all drugs not covered under the Medicare Part D prescription drug plan into which Mrs. McIntire is enrolled. Incorrect c. She can change Medicare Part D prescription drug plans only during the annual election period. Incorrect d. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area. Correct 4. Ms. Edwards 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 wouldyou advise her? a. She should wait to fill her prescriptions until she is back home since only her local pharmacy is likely to be in her plan’s network. Incorrect b. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy. Correct c. She may fill one prescription out-of-network per year and it will be fully covered. Her second prescription will require her to pay the full cost out-of-pocket. Incorrect d. She may fill both prescriptions and they will be fully covered at in-network pricing due to the fact that she is traveling. Incorrect 5. Mr. Rice has coverage for medical services and medications through his employer’s retiree plan. He is considering switching to a Medicare prescription drug plan because his retiree plan does notcover two important medications. What should he consider before making a change? a. If his drug coverage through the retiree plan is “creditable” he should not switch, even though it is possible to do so. Incorrect b. Mr. Rice can only receive his prescription drug coverage through a Medicare Advantage prescription drug plan so he should drop his employer coverage. Incorrect c. If Mr. Rice drops his drug coverage through the retiree plan, he may not be able to get it back and he also may lose his medical health coverage. Correct

d. Mr. Rice’s retiree plan is required to take him back if, within 63 days of having voluntarily quit the employer’s plan, he decides that he prefers it to his Medicare Part D plan. Incorrect

6. All plans must cover at least the standard Part D coverage or its actuarial equivalent. Whatcosts would a beneficiary incur for prescription drugs in 2020 under the standard coverage? a. Standard Part D coverage would require payment of an annual deductible, fixed per-prescription co- payments, 35% of the costs in the coverage gap, and once catastrophic coverage begins, the plan covers 100% of all costs. Incorrect b. Standard Part D coverage would require payment of fixed per-prescription co-payments and 75% of the costs in the coverage gap. Incorrect c. Standard Part D coverage would require payment of only fixed per-prescription co-payments. Incorrect 7. 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? a. He will need to enroll in a Medicare prescription drug plan upon becoming eligible for the program in order to avoid a premium penalty. To reduce his expenses, he should look for a plan with a zero premium. Incorrect b. He should drop the employer coverage and enroll in a Medicare prescription drug plan. Employer plans are almost always more costly for beneficiaries and most do not cover the same range of drugs available from a Medicare prescription drug plan. Incorrect c. As long as he has any sort of employer coverage, regardless of the level of coverage, he will incur no penalty if he does not enroll in a Part D plan when first eligible. Incorrect d. 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. Correct 8. 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 coverseither one of them. What should you tell her? a. Medicare prescription drug plans are allowed to restrict their coverage to generic drugs. She will need to pay for her brand name medications out of pocket. Incorrect be able to enroll in a Medicare prescription drug plan that covers the medications she needs. Correct between $435 and $4,020, and once through the catastrophic coverage threshold the beneficiary pays either co-pays for generic and brand name drugs or co-insurance of 5%, whichever is greater. Correct d. Standard Part D coverage would require payment of an annual deductible of $435, 25% cost-sharing b. Medicare prescription drug plans are required to cover drugs in each therapeutic category. She should

c. When medication costs exceed a certain threshold amount, which rises each year, a Medicare prescription drug plan is permitted to exclude coverage for all but the least expensive of the medications in a given category. Mrs. Allen will need to encourage her physician to prescribe the least expensive of the two alternatives. d. Medicare prescription drug plans are required to include only a certain percentage of brand name drugs among those they cover. It may be possible that plans available in her area have opted not to include in their formularies the brand name drugs she needs. She may need to pay for this particular medication out of pocket. Incorrect

9. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughntakes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescriptiondrug plan cover these drug needs. What should you tell them? a. Medicare prescription drug plans are permitted to cover vitamins, but not drugs for cosmetic purposes. Incorrect b. 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. Correct c. The vitamins the Vaughns are taking will be covered under Part D because their physician suggested they should take vitamins, but the hair loss medication cannot be covered. Incorrect d. Mr. Vaughn’s hair growth medication would only be covered under Part D if his balding resulted from an illness or was a side effect of a treatment such as chemotherapy. Incorrect 10. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband’s employer. She is interested in enrolling ina Medicare Part D prescription drug plan (PDP). What should you tell her? a. Mrs. Lopez must first seek COBRA benefits under her husband’s plan before she can apply for Part D coverage. Incorrect b. Mrs. Lopez must enroll in either a HMO or PPO Medicare Advantage plan in order to obtain Part D coverage. Incorrect c. If a Part D benefit is offered through her plan she may choose to enroll in that plan or a standalone PDP. Correct d. If a Part D benefit is offered through her plan she must enroll in this plan. Incorrect

MARKETING MEDICARE ADVANTAGE AND

PART D PLANS PART 4

1. Medicare health plans establish provisions in marketing representative contracts to ensurecompliance with applicable laws and policies. If non-compliance occurs, CMS can penalize a plan in which of the following ways? a. CMS requires the dismissal of senior plan management. Incorrect b. CMS requires plan sponsors to create and complete a corrective action plan and may terminate a sponsor’s contract. Correct c. CMS cannot penalize the plan sponsor for marketing representative non-compliance. That is the role of the state. Incorrect d. CMS requires plan sponsors to publish in local newspapers the names and misdeeds of the marketing representatives who have not complied with the terms of their contracts, so that potential clients can know whom to avoid. Incorrect 2. ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' protected health information (PHI) to market non-health related products such as life insurance and annuities. To do so it must obtain authorization from the enrollees. Which statement best describes the authorizationprocess? a. It is not necessary for ABC to obtain an authorization to simply explain pending state or federal legislation since there is no anticipation of selling a non-health related product in these circumstances. Incorrect c. The request for authorization may include a brief synopsis of non-health related content. Incorrect d. Once a plan sends out a written request for consent, a beneficiary can authorize consent by simply failing to reply within 21 days. Incorrect 3. Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted withregard to 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? a. The state sets most requirements for marketing Medicare health plans, but each plan has different policies that he must adhere to. Incorrect b. 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. Correct c. Organizations sponsoring Medicare health plans are not responsible for enforcing compliance with applicable law and guidance. This job belongs solely to the Medicare agency. Incorrect d. The Medicare agency conducts only complaint-based oversight and he can market the products he represents as he sees fit, as long as he does so in a manner that would be considered ethical by a reasonable lay person. Incorrect the website includes a mechanism for an electronic signature that is valid under applicable law. Correct b. Authorization may be obtained by directing a beneficiary to a website to provide consent as long as

4. You are mailing invitations to new Medicare beneficiaries for a marketing event. You want anidea of how many people to expect, so you would like to request RSVPs. What should you keep in mind a. You are not permitted to request RSVPs, so you will need to find a different way to estimate how many people are coming. Incorrect b. You may not require RSVPs, but when people arrive, you may require completion of contact information on a sign-up sheet. Incorrect c. You may require RSVPs and an e-mail address so you can follow up in the event of a cancellation. Incorrect d. You may request RSVPs, but you are not permitted to require contact information. Correct 5. You work for a company that has marketed Medigap products for many years. The company has added Medicare Advantage and Part D plans and you will begin marketing those plans this fall. You are planning what materials to use to easily show the differences in benefits, premiums and cost sharingfor each of the products. What do you need to do with your materials before using them for marketing purposes? a. You do not need to get CMS approval of the materials, so long as the materials are not misleading or materially inaccurate. Incorrect b. You must submit your materials to the plan you represent, so CMS can review and approve the materials to ensure they are accurate. Correct c. Only scripts and marketing practices must be approved by CMS, so you do not need to do anything further with your marketing materials, as long as you make them available to anyone who attends the marketing event Incorrect d. You need to include a statement that the plans you are marketing are approved by the Centers for Medicare & Medicaid Services and the Department of Health and Human Services. Incorrect 6. You are scheduled to give a sales presentation at a local senior center. At the beginning of thepresentation, which of the following must you do? a. Make sure that those present provide leads. Incorrect b. Explain, in your own words, how the plan you represent compares to other companies’ plans. Incorrect c. Determine whether the beneficiaries present are healthy enough for the plan. Incorrect d. Clearly state that no obligation exists to enroll if a gif t or prize is being provided. Correct 7. 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 youplan to engage? a. You should plan to answer questions and accept enrollment forms. Incorrect

b. 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. Correct c. You should plan to conduct sales presentations but must not accept enrollment forms. Incorrect d. You should plan to conduct sales presentations and accept enrollment forms Incorrect

8. Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, aMedicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong? a. Agent Armstrong needs to be licensed and appointed only in the state where ABC Health Plan is headquartered. Incorrect b. Agent Armstrong needs to be licensed and appointed in every state in which beneficiaries to whom he markets ABC MA plans are located. Correct c. Agent Armstrong needs to be licensed and appointed only in the state where XYZ Agency is headquartered. Incorrect d. Agent Armstrong needs to be licensed and appointed only in his state of residence. Incorrect 9. Another agent working for your agency claims that because you are not employed by theMedicare Advantage plans that you represent, you are not subject to the same requirements as theplans themselves. How should you respond to such a statement? a. Your coworker is correct. You may use any marketing techniques that do not involve providing misinformation to potential enrollees. Incorrect requires that all contracted and employed agents comply with all Medicare marketing rules. Correct c. Your coworker is correct. You are subject only to requirements issued by your state department of insurance. Incorrect d. Your coworker is correct because employed agents have to follow a stricter set of rules than do independent agents, such as yourself. Incorrect 10. You market many different types of insurance and ordinarily you spend time each eveningcalling potential clients. To be in compliance with requirements for marketing Medicare Advantage andPart D plans, what must you do about contacting potential clients to market those plans? a. As long as you market only health-related products, you can make an initial call to any beneficiary, but then must honor "do not call again" requests. Incorrect b. You only need to comply with the requirements of federal and state “Do Not Call” registries. Incorrect b. Your coworker is not correct. Marketing on behalf of a plan is considered marketing by the plan and

c. 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. Correct d. Because the Medicare health plans are important federal programs for beneficiaries, federal law regarding the "Do Not Call" registry is waived so you will be able to call and enroll beneficiaries over the telephone. Incorrect

ENROLLMENT GUIDANCE MEDICARE

ADVANTAGE AND PART D

PLANS PART 5

1. You are visiting with Mr. Tully and his daughter at her request. He has advanced Alzheimer’sand is incapable of understanding the implications of choosing a Medicare Advantage or prescription drug plan. Can his daughter fill out the enrollment form and sign it for him? a. Mr. Tully’s daughter can do so only, if she is authorized under state law as a court-appointed legal guardian, has a durable power of attorney for health care decisions, or is authorized under state surrogate consent laws to make health decisions. Correct b. Mr. Tully’s daughter can do so because she is an immediate family member who has taken responsibility for her father’s care. Incorrect c. A signature is not necessary since Mr. Tully is not physically or mentally capable of filling out and signing the form. Incorrect d. If the enrollment form is countersigned by one of Mr. Tully’s treating physicians, she can sign it for him. Incorrect 2. Mrs. Burton is in an MA-PD plan and was disappointed in the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she wouldn’t continue to have to put up with such poor access to care. What could you tell her? a. She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment. Correct b. She should call the doctor’s office to complain since the plan cannot do anything about the doctor’s schedule. Incorrect c. She must write to the plan and wait for a response and then she could file a grievance if she is still dissatisfied. Incorrect d. She should not expect to get in to see her doctor any more quickly since she is a Medicare patient. Incorrect 3. You have come to Mrs. Midler’s home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical record available because she thinks this will help you understand her needs. She suggests that you will know which questions to

askher about her health status in order to best assist her in selecting a plan. What should you do? a. You cannot, under any circumstances, ask Mrs. Midler any health-related questions. Incorrect b. You can initiate a detailed discussion of all of Mrs. Midler's health conditions only to better understand her situation and to advise her to choose a different plan if she is experiencing significant health problems. Incorrect c. You can only ask Mrs. Midler questions about conditions that affect eligibility, specifically, whether she has end-stage renal disease or one of the conditions that would qualify her for a special needs plan. Correct d. If she brings up the topic of her health, you can ask Mrs. Midler as many questions as she is willing to answer, so you can determine which plan is most suitable for her health needs. Incorrect

4. You are meeting with Ms. Berlin and she has completed an enrollment form for a MA-PD planyou represent. You notice that her handwriting is illegible and as a result, the spelling of her street looksincorrect. She asks you to fill in the corrected street name. What should you do? a. You may correct the information since it was a simple mistake. You do not need to do anything further to the application form. Incorrect b. Under no circumstances may you make corrections to information a beneficiary has provided. Review of enrollment forms is the sole responsibility of the plan sponsor. Incorrect c. You may correct the information, but she will need to write a brief statement indicating she authorized you to make the change. Incorrect d. You may correct this information as long as you add your initials and date next to the correction Correct 5. Mrs. Johnson calls to tell you she has not received her new plan ID card yet, but she needs tosee a doctor. What can she expect to receive from the plan after the plan has received her enrollment form? a. A $20 gift certificate thanking her for enrolling. Incorrect b. Evidence of plan membership, information on how to obtain services, and the effective date of coverage. Correct c. A solicitation for friends who might be interested in enrolling in the plan, with a postcard for her to list their names, addresses, and phone numbers. Incorrect d. She will not receive anything from the plan until her ID card arrives, so she should not expect the plan to cover her medical needs until then. Incorrect

6. Mr. Garcia was told he qualifies for a Special Enrollment Period (SEP), but he lost the paper that explains what he could do during the SEP. What can you tell him? a. If the SEP is for MA coverage, he will generally have one opportunity to change his MA coverage. Correct b. If the SEP is for Part D coverage, he may only drop, but not add or change, his Part D coverage one

time before the SEP expires. Incorrect c. He may only use the SEP to disenroll from his MA plan and return to Original Medicare. Incorrect d. If the SEP is for MA coverage, he may make as many changes to his MSA enrollment as he wants and the last choice made before the end of the SEP period will be the effective one. Incorrect

7. Mr. and Mrs. Nunez attended one of your sales presentations. They’ve asked you to come totheir home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do? a. Legal spouses can sign enrollment forms for one another under federal law. You may enroll both Mr. and Mrs. Nunez, as long as her husband signs on her behalf Incorrect b. You can countersign Mrs. Nunez’ application, along with her husband, indicating that she approved this choice verbally. This witness signature is sufficient to make the enrollment valid. Incorrect c. You should sign the form for Mrs. Nunez yourself, since she informed you, as the plan’s representative, that she wanted to enroll. Incorrect d. As long as she is able to do so, only Mrs. Nunez can sign her enrollment form. Mrs. Nunez will have to wake up to sign her form or do so at another time. Correct 8. Mrs. Valentino is currently enrolled in a Medicare Cost plan. This plan is no longer meeting her needs, but it is now mid-year and past the annual election period (AEP). What would you say to Mrs.Valentino regarding her options? a. Mrs. Valentino must remain enrolled in the Medicare Cost plan until the next AEP. Incorrect b. Mrs. Valentino can call Medicare, request to be disenrolled from the Cost plan, and enroll in Original Medicare. Incorrect c. Mrs. Valentino qualifies for a special enrollment period, which will allow her to immediately enroll in a MA-PD plan of her choice. Incorrect d. Mrs. Valentino can submit a written request to Medicare to be disenrolled from the Cost plan and enroll in Original Medicare. Correct 9. 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 fromsuch 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? a. The SNP would select her primary care provider (PCP) but she could file a grievance within 90 days if the PCP proved incapable. Incorrect b. Enrollees in SNPs must have access to provider networks that include enough doctors, specialists, and hospitals to provide all covered services necessary to meet enrollee needs within reasonable travel time. Correct

c. Enrollees, while able to select their primary care provider (PCP), do have substantial restrictions and financial responsibilities regarding emergency care whether obtained at in-network or out-of-network facilities. Incorrect d. Mrs. Disraeli would have substantial restrictions on obtaining emergency care and must use network facilities or be responsible for most emergency care costs.

10. If Mr. Johannsen gains the Part D low-income subsidy, how does that affect his ability to enroll ordisenroll in a Part D plan? a. He qualifies for a special enrollment period and can enroll in or disenroll from a Part D plan and the subsidy will apply to the plan he chooses. Correct b. The subsidy will become effective next year when he can enroll in a different plan or disenroll from his current plan during the next Annual Election Period. Incorrect c. He can only enroll in or disenroll from an MA-PD plan. Incorrect d. He can apply the subsidy amount to his existing plan immediately, but he cannot enroll in a different plan. Incorrect Question 1 Marks: 1 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? Choose one answer. a. As long as he fills out the paperwork to begin withholding from his Social Security check at least 63 days before such withholding should begin, he can change his method of Part D premium payment and withholding will begin the month after his savings account is exhausted. b. During 2017, many people experienced significant problems with deductions from their Social Security check for their Part D premium. As a result, this method of payment is no longer an option for Part D premium payments c. In general, to pay his Part D premium, he only can have automatic withdrawals made from a checking account, so he will need to transfer the funds prior to beginning such withdrawals. d. In general, he must select a single Part D premium payment mechanism that will be used throughout the year. Question

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 answer. a. The government pays a per-beneficiary dollar amount to the Medicare Part D prescription drug plans, to offset premiums for their low-income enrollees in accordance with the plan’s set criteria. Mr. Shapiro should check with his plan to see if he qualifies. b. He must apply for the extra help at the same time he applies for enrollment in a Part D 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 to beneficiaries whose income and assets do not exceed annual limits specified by the government. d. 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. Question Marks: 1 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? Choose one answer. a. Medigap policies designed to cover costs not paid for by an MA plan can be purchased, but only if the MA plan’s design is considered to be the “defined standard benefit.” b. Medigap plans that cover costs not paid for by an MA plan are available only in Massachusetts, Minnesota, and Wisconsin. c. Medigap plans are a form of Medicare Advantage, so purchasing both would be redundant coverage. d. 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. Question Marks: 1

Mrs. Lyons is in good health, uses a single prescription, and lives independently 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? Choose one answer. a. All beneficiaries enrolled in an MSA pay a plan premium in addition to their Part B premium. b. 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. c. For enrollees in an MSA, after the annual deductible is met, the MSA plan generally pays 75% of covered services. d. MSA enrollees may only receive covered health care services from a limited panel of network providers because otherwise some providers may charge more than Original Medicare rates. Question Marks: 1 You have sought permission from a hospital to place brochures for your product in their gift shop and cafeteria. The hospital administration expresses some hesitation about allowing marketing in a health care facility. What should you tell them? Choose one answer. a. Marketing in health care facilities is an acceptable practice, regardless of where it takes place. b. So long as the hospital or its physician staff don’t object, marketing anywhere in the hospital is an acceptable practice. c. Marketing in health care facilities is an acceptable practice, as long as it takes place in common areas where patients are not receiving or waiting to receive health care. d. As long as the marketing activities are conducted in a way that does not target healthy beneficiaries, it does not matter where in the hospital these activities are carried out. Question 6 Marks: 1 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. a. You should plan to conduct sales presentations but must not accept enrollment forms. b. 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. c. You should plan to conduct sales presentations and accept enrollment forms d. You should plan to answer questions and accept enrollment forms. Question Marks: 1 Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her medications. What should you tell her? Choose one answer. a. Part D prescription drug plans focus almost entirely on mail order with fairly limited access to retail pharmacies, so as long as she orders all of her medications through the mail, she will be fine. b. Part D prescription drug plans generally contract with every pharmacy in the country, so she should be able to obtain her drugs in both states with no problem. c. Part D prescription drug plans are restricted to local service areas. She will have to use mail order to fill all of her prescriptions. d. Part D prescription drug plans use networks of pharmacies within their service areas. She could look for a plan that maintains a network in both states. Question 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 – a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism? Choose one answer. a. Alice and Charlotte because each of them currently have health coverage and is in their initial coverage election period (ICEP).

b. Alice because she will not have a break between her non-Medicare and Medicare coverage through Spartan Health Plan. c. Alice, Bob, and Charlotte because electronic health record interoperability will allow Richard to access any needed information for their applications. d. Alice and Bob because each of them has had coverage through Spartan Health Plan. Question9 Marks: 1 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? 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. Question10 Marks: 1 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? Choose one answer. a. Medicaid will cover his cost-sharing, regardless of from which physician or hospital he receives his Medicare-covered services. b. He should know that Medicaid will pay cost sharing only for services provided by Medicaid participating providers. c. Medicaid will no longer pay any cost sharing once he is eligible for Medicare, so he will need to rely only on Medicare providers.

d. For Medicaid beneficiaries, Medicare reduces its cost-sharing amounts to match those charged by the state Medicaid program so there will be no change in his cost-sharing amounts. Question11 Marks: 1 Which of the following statement is correct about a Medicare Savings Account (MSA) Plans? I. MSAs may have either a partial network, full network, or no network of providers. II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits. III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed for inflation. IV. Non-network providers must accept the same amount that Original Medicare would pay them as payment in full. Choose one answer. a. II and III only b. I, II, and IV only c. I, II, and III only d. I and II only Question12 Marks: 1 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? Choose one answer. a. 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.

b. Medicare does not cover hospice services. Hospice services are only available through state Medicaid programs, if the state offers such coverage. c. 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. d. Medicare covers hospice services and they will be available for her. Question13 Marks: 1 Mr. Kelly 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? Choose one answer. a. You would need to ask Mr. Kelly if he is enrolled in Part A and Part B, if he is healthy, and how often he expects to visit a doctor. b. You would need to ask Mr. Kelly if he is enrolled in Part A and Part D and if he needs drug coverage. c. You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if he lives in the PFFS plan’s service area. d. You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if his doctor will accept the terms and conditions of payment of the PFFS plan Question14 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? a. 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. 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 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. Question15

Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? a. He will have one opportunity to enroll in a Medicare Advantage plan. b. He will have a three month period during which he may enroll in as many Medicare Advantage plans as he chooses, with the last enrollment being the effective one. c. He may change or drop MA plans, but may not drop drug coverage. d. If he has a disability, he may enroll in Original Fee-for-Service Medicare during the MA Initial Coverage Election Period. Question16 Marks: 1 Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description? Choose one answer. a. Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies. b. Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare. c. Medicare Advantage is a new name for the Original Medicare program. d. Medicare Advantage is a health insurance program operated jointly by the states with the Federal government. Question17 Marks: 1 Able, Baker, and Charles are engaged in the marketing to and enrollment of beneficiaries into Medicare health plans. Mr. Able is an independent agent paid directly by a health plan. Ms. Baker is an independent agent paid through a field marketing organization (FMO). Mr. Charles is an independent agent paid for his work by a third-party marketing organization (TMO). How do the CMS compensation rules apply to these three agents? Choose one answer. a. Baker and Charles are subject to CMS compensation rules because they are paid by third parties. Able is not because he is paid directly by a health plan.

b. Charles is subject to CMS compliance rules because he works for a TMO and CMS applies an extra layer of scrutiny to such organizations. Able and Baker are not. c. All three are treated as independent agents under CMS compensation rules. d. Able is subject to CMS compensation rules because he is paid directly by a health plan. Agents Baker and Charles are not because they are paid by third parties. Question18 Marks: 1 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? Choose one answer. a. You can make unsolicited contacts but you cannot cross-sell other products. b. You are not required to submit communication and marketing materials specific only to those employer plans to CMS at the time of use, but CMS may request and review copies if employee complaints occur. c. You do not need to take an annual test, but you must not provide potential enrollees with more than light snacks at presentations. d. You do not need to complete a scope of appointment, but CMS can ask you to reconstruct one if there is a subsequent employee complaint. Question19 Marks: 1 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? Choose one answer. a. A meal cannot be provided, but light snacks would be permitted. b. Any type of meal or food is allowed, as long as it is available to the general public and not just those who are eligible to enroll in the plans. c. Any meal is allowed, as long as it is valued at less than $15. d. Nothing may be provided to eat or drink during the sales presentation. Question20