AHIP - FINAL EXAMINATION QUESTIONS WITH VERIFIED
ANSWERS
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
allergic reaction to them. Only the third drug works for him and it is not on his Part D plan's fo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rmulary. What could you tell him to do? - ans- zx zx zx zx zx zx zx zx zx
Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D dr
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ug. He or his physician could obtain the standardized request form on the plan's website, fill
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
it out, and submit it to his plan.
zx zx zx zx zx zx zx
Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to v
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
isit one or two doctors who aren't participating providers. He wants to know if the Point of Se
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rvice (POS) option available with some HMOs will be of any help in this situation. What shou
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ld you tell him? - ans-
zx zx zx zx zx
The POS option might be a good solution for him as it will allow him to visit out-of-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
network providers, generally without prior approval. However, he should be aware that it is l
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ikely he will have to pay higher cost-sharing for services from out-of-network providers.
zx zx zx zx zx zx zx zx zx zx zx zx
Mr. Barker had surgery recently and expected that he would have certain services and item
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
s covered by the plan with minimal out-of-pocket costs because his MA-
zx zx zx zx zx zx zx zx zx zx zx
PD coverage has been very good. However, when he received the bill, he was surprised to
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
see large charges in excess of his maximum out-of-
zx zx zx zx zx zx zx zx
pocket limit that included a number of services and items he thought would be fully covered.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
He called you to ask what he could do? What could you tell him? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
You can offer to review the plans appeal process to help him ask the plan to review the cove
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rage decision. zx
Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
and is interested in that product. She wants to be sure she also has coverage for prescriptio
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
n drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
a. Yes. All SNPs are required to provide Part D coverage for prescription drugs.
zx zx zx zx zx zx zx zx zx zx zx zx zx
b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medica
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
id program.zx
c. No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
through a stand- zx zx
alone Part D Medicare prescription drug plan that they sign up for independent of their enrol
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
lment in the SNP. zx zx zx
d. Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
= ?????
zx
Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of B
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
estCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In settin
zx zx zx zx zx zx zx zx zx zx zx zx
, g up the enrollment site, which of the following must Phiona consider? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx
II. All data elements required to complete an enrollment request must be captured.
zx zx zx zx zx zx zx zx zx zx zx zx
III. The process must include a clear and distinct step that requires the applicant to activate
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
an "Enroll Now" or "I Agree" type of button or tool.
zx zx zx zx zx zx zx zx zx zx
Ms. Lewis understands that Medicare prescription drug plans may use various methods to
zx zx zx zx zx zx zx zx zx zx zx zx zx
control the use of specific drugs. She has heard about a technique called "step therapy" an
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d is wondering if you can explain what that is. What should you tell her? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Step therapy involves using one or more lower priced drugs before trying a more expensive
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
drug when all are used to treat the same condition.
zx zx zx zx zx zx zx zx zx
Mr. Gomez notes that a Private Fee-for-
zx zx zx zx zx zx
Service (PFFS) plan available in his area has an attractive premium. He wants to know if he
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
must use doctors in a network as his current HMO plan requires him to do. What should you
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
tell him? - ans- zx zx zx
He may receive health care services from ANY doctor allowed to bill Medicare, as long as h
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e shows the doctor the plan's identification card and the doctor agrees to accept the PFFS p
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
lan's payment terms and conditions, which could include balance billing.
zx zx zx zx zx zx zx zx zx
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
Part D low-income subsidy. Where might he turn for help with his prescription drug costs? -
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ans-
zx
Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical As
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
sistance Program. zx
You have decided to focus on doing in-
zx zx zx zx zx zx zx
home presentations to market the Medicare Advantage (MA) plans you represent. Before y
zx zx zx zx zx zx zx zx zx zx zx zx
ou conduct such sales presentations, what must you do? - ans-
zx zx zx zx zx zx zx zx zx zx
Mr. Wong is a single individual. He has had a successful business career and is now able to
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
retire with a comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Wong has health coverage through his employer but will sign-
zx zx zx zx zx zx zx zx zx
up Medicare Part A, Part B and Part D when he leaves the workforce. How would you advis
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e him as he budgets for Medicare premiums? - ans-
zx zx zx zx zx zx zx zx zx
a. Due to the provisions of MACRA, his Part B and D coverage will be combined and covere
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d through a low-cost Medigap policy to supplement his Part A coverage.
zx zx zx zx zx zx zx zx zx zx zx
b. Due to his participation in the workforce he will not have to pay premiums for Part A and h
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e will pay the lowest monthly premium rates for Part B and Part D.
zx zx zx zx zx zx zx zx zx zx zx zx zx
c. Due to his participation in the workforce he will not have to pay premiums for Part A but he
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
will pay higher premiums for Part B and Part D due to the amount of his income.
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d. Due to his participation in the workforce he will not have to pay premiums for Part A and w
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ill pay reduced premiums for Part B and Part D.
zx zx zx zx zx zx zx zx zx
?????
Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Center
zx zx zx zx zx zx zx zx zx zx zx zx zx
s for Medicare & Medicaid Services' communication and Marketing Guidelines to ensure he
zx zx zx zx zx zx zx zx zx zx zx zx
ANSWERS
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
allergic reaction to them. Only the third drug works for him and it is not on his Part D plan's fo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rmulary. What could you tell him to do? - ans- zx zx zx zx zx zx zx zx zx
Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D dr
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ug. He or his physician could obtain the standardized request form on the plan's website, fill
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
it out, and submit it to his plan.
zx zx zx zx zx zx zx
Mr. Polanski likes the cost of an HMO plan available in his area, but would like to be able to v
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
isit one or two doctors who aren't participating providers. He wants to know if the Point of Se
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rvice (POS) option available with some HMOs will be of any help in this situation. What shou
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ld you tell him? - ans-
zx zx zx zx zx
The POS option might be a good solution for him as it will allow him to visit out-of-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
network providers, generally without prior approval. However, he should be aware that it is l
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ikely he will have to pay higher cost-sharing for services from out-of-network providers.
zx zx zx zx zx zx zx zx zx zx zx zx
Mr. Barker had surgery recently and expected that he would have certain services and item
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
s covered by the plan with minimal out-of-pocket costs because his MA-
zx zx zx zx zx zx zx zx zx zx zx
PD coverage has been very good. However, when he received the bill, he was surprised to
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
see large charges in excess of his maximum out-of-
zx zx zx zx zx zx zx zx
pocket limit that included a number of services and items he thought would be fully covered.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
He called you to ask what he could do? What could you tell him? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
You can offer to review the plans appeal process to help him ask the plan to review the cove
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
rage decision. zx
Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
and is interested in that product. She wants to be sure she also has coverage for prescriptio
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
n drugs. Would she be able to obtain drug coverage if she enrolled in the SNP? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
a. Yes. All SNPs are required to provide Part D coverage for prescription drugs.
zx zx zx zx zx zx zx zx zx zx zx zx zx
b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medica
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
id program.zx
c. No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
through a stand- zx zx
alone Part D Medicare prescription drug plan that they sign up for independent of their enrol
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
lment in the SNP. zx zx zx
d. Maybe. Some SNPs offer Part D coverage for prescription drugs and some do not.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
= ?????
zx
Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in charge of B
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
estCare's efforts to facilitate electronic enrollment in its Medicare Advantage plans. In settin
zx zx zx zx zx zx zx zx zx zx zx zx
, g up the enrollment site, which of the following must Phiona consider? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx
II. All data elements required to complete an enrollment request must be captured.
zx zx zx zx zx zx zx zx zx zx zx zx
III. The process must include a clear and distinct step that requires the applicant to activate
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
an "Enroll Now" or "I Agree" type of button or tool.
zx zx zx zx zx zx zx zx zx zx
Ms. Lewis understands that Medicare prescription drug plans may use various methods to
zx zx zx zx zx zx zx zx zx zx zx zx zx
control the use of specific drugs. She has heard about a technique called "step therapy" an
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d is wondering if you can explain what that is. What should you tell her? - ans-
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Step therapy involves using one or more lower priced drugs before trying a more expensive
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
drug when all are used to treat the same condition.
zx zx zx zx zx zx zx zx zx
Mr. Gomez notes that a Private Fee-for-
zx zx zx zx zx zx
Service (PFFS) plan available in his area has an attractive premium. He wants to know if he
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
must use doctors in a network as his current HMO plan requires him to do. What should you
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
tell him? - ans- zx zx zx
He may receive health care services from ANY doctor allowed to bill Medicare, as long as h
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e shows the doctor the plan's identification card and the doctor agrees to accept the PFFS p
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
lan's payment terms and conditions, which could include balance billing.
zx zx zx zx zx zx zx zx zx
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
Part D low-income subsidy. Where might he turn for help with his prescription drug costs? -
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ans-
zx
Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical As
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
sistance Program. zx
You have decided to focus on doing in-
zx zx zx zx zx zx zx
home presentations to market the Medicare Advantage (MA) plans you represent. Before y
zx zx zx zx zx zx zx zx zx zx zx zx
ou conduct such sales presentations, what must you do? - ans-
zx zx zx zx zx zx zx zx zx zx
Mr. Wong is a single individual. He has had a successful business career and is now able to
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
retire with a comfortable income. Mr. Wong's taxable income is in excess of $100,000. Mr.
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Wong has health coverage through his employer but will sign-
zx zx zx zx zx zx zx zx zx
up Medicare Part A, Part B and Part D when he leaves the workforce. How would you advis
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e him as he budgets for Medicare premiums? - ans-
zx zx zx zx zx zx zx zx zx
a. Due to the provisions of MACRA, his Part B and D coverage will be combined and covere
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d through a low-cost Medigap policy to supplement his Part A coverage.
zx zx zx zx zx zx zx zx zx zx zx
b. Due to his participation in the workforce he will not have to pay premiums for Part A and h
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e will pay the lowest monthly premium rates for Part B and Part D.
zx zx zx zx zx zx zx zx zx zx zx zx zx
c. Due to his participation in the workforce he will not have to pay premiums for Part A but he
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z
will pay higher premiums for Part B and Part D due to the amount of his income.
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
d. Due to his participation in the workforce he will not have to pay premiums for Part A and w
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
ill pay reduced premiums for Part B and Part D.
zx zx zx zx zx zx zx zx zx
?????
Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Center
zx zx zx zx zx zx zx zx zx zx zx zx zx
s for Medicare & Medicaid Services' communication and Marketing Guidelines to ensure he
zx zx zx zx zx zx zx zx zx zx zx zx
