AHIP 2027 Certification Exam |
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Changes, Study Guide, Practice
Questions, Solutions, Answers,
Compliance Tips & How to Pass Easy
Which of the following statements best describes Special Supplemental Benefits for the
Chronically Ill (SSBCI)?
SSBCI generally addresses social determinants of health and includes such items as
groceries, pest control, and non-medical transportation.
Mrs. Waller is a retiree with substantial income. She is enrolled in an MA-PD plan and was
disappointed with 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 would not have to put up with such poor access to
care. What could you tell her?
She could file a grievance with her plan to complain about the lack of timeliness in getting an
appointment.
Mrs. Stark is enrolled in her state's Medicaid program in addition to Medicare. What should she
be aware of when considering enrollment in a Medicare Advantage (MA) plan?
She cannot enroll in an MA Medical Savings Account (MSA) plan.
Mrs. Ramos asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her?
Mrs. Ramos must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.
,Mrs. Lim wants to know generally how the benefits under Original Medicare might compare to
the benefits package of a Medicare Advantage Plan before she starts looking at specific plans.
What could you tell her?
Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such
as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part
A and Part B services.
Avery recently lost her employer's group health and drug coverage and now she wants to
enroll in a PPO that does not include drug coverage. What should you tell her about obtaining
drug coverage?
She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D
prescription drug plan.
Gary Summers is enrolled in Ajax Medicare Advantage plan. Gary has recently faced a series
of health issues leading to substantial out-of-pocket expenses. Gary understands that in
Original Medicare (Parts A and B) there is no annual out-of-pocket maximum. He asks you if
the same is true of his Medicare Advantage plan? How do you respond?
All Medicare Advantage (MA) plans must have a "maximum out-of-pocket" limit (known as
"MOOP") for Part A and Part B benefits. Once the MA plan member pays a specified amount of
cost-sharing that health plan pays 100 percent of the medical services covered.
Mr. Maddox is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him?
In most Medicare Advantage HMOs, Mr. Maddox must generally obtain his services only from
providers within the plan's network (except in an emergency or where care is unavailable
within the network).
Mildred Philps, initially enrolled in Original Medicare when first eligible for Medicare. During
open enrollment Mildred switched to Fairhaven Medicare Advantage. Prior to her enrollment in
Fairhaven, Mildred had begun treatment for a serious illness with a non-network provider. She
asks you whether the treatment from the non-network provider must stop immediately? What
do you say?
,No, when an individual enrolls in a Medicare Advantage (MA) plan after starting a course of
treatment, there is a minimum 90-day transition period during which the MA organization may
not disrupt or require authorization for the active course of treatment.
Mr. Hardin is interested in the Medicare Advantage (MA) PPO plan that you represent. It is one
of three plans operated by the same organization in Mr. Hardin's area. The MA PPO plan does
not include drug coverage, but the other two plans do. Mr. Hardin likes the PPO plan that does
not include drug coverage and intends to obtain his drug coverage through a stand-alone
Medicare prescription drug plan. What should you tell him about this situation?
He could enroll either in one of the MA plans that include prescription drug coverage or
Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but
he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan.
Conrad is 64, retiring soon, and considering enrollment in his employer-sponsored MA retiree
group health plan that includes drug coverage with nominal copays. He heard about a
neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs,
he is considering signing up for it. What should you tell him?
He should compare the benefits in his employer-sponsored retiree group health plan with the
benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage
for his prescription needs.
Which of the following individuals would be eligible to enroll in a Medical Savings Account
(MSA) MA plan?
Abigail, who is age 66, retired and enrolled in Medicare Parts A and B.
Jake is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be the correct description?
Medicare Advantage is a way of covering all the Original Medicare benefits through private
health insurance companies.
Mr. Church notes that a Private Fee-for-Service (PFFS) plan available in his area has an
attractive premium. He wants to know if he must use doctors in a network as his current HMO
plan requires him to do. What should you tell him?
, He may receive health care services from any doctor allowed to bill Medicare, if he shows the
doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment
terms and conditions, which could include balance billing.
Stefan Merritt is turning 65 next month. Stefan legally entered the United States over twenty
years ago, holds a green card, but is not a citizen. Since he entered the country, Stefan has
worked at Smallcap Incorporated and contributed to the Medicare system. Stefan suffers from
diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that
you represent. How would you respond?
Stefan is eligible to enroll in Medicare Advantage if he is entitled to Part A and enrolled in Part
B. Stefan should go to the Social Security website to enroll in Medicare Part A and B if he has
not done so already. Once he is enrolled, he can choose a Medicare Advantage plan.
Peter Miller heads a local association of medical professionals - Better Health. The association
has many members who are retired or approaching retirement age. Peter comes to you for
advice as to whether the association can establish an employer group waiver plan (EGWP) for
these members. What do you say?
No, Better Health is a professional association whose membership is based on their
profession, not an individual employer or former employer.
Lorenzo is a Medicare beneficiary who is considering switching to a Medicare Advantage plan
during this year's open enrollment season. He has read about prior authorization and the need
for referrals in the newspapers and asks you what type of plans can require prior
authorization. What do you say?
HMOs require prior authorization for out-of-network services except for emergency services
and certain other carved-out services. HMOs may also require referrals for in-network
specialist services.
One of your clients, Jasmine Perry, has heard about a Medicare concept from one of her
neighbors called TrOOP. She asks you to explain it. What do you say?
TrOOP stands for true out-of-pocket costs that count toward the Medicare Part D catastrophic
limit and include not only expenses paid by a beneficiary but also, in some instances, amounts
paid by or through qualified State Pharmaceutical Assistance Programs.
Latest Updates, Costs, Module
Changes, Study Guide, Practice
Questions, Solutions, Answers,
Compliance Tips & How to Pass Easy
Which of the following statements best describes Special Supplemental Benefits for the
Chronically Ill (SSBCI)?
SSBCI generally addresses social determinants of health and includes such items as
groceries, pest control, and non-medical transportation.
Mrs. Waller is a retiree with substantial income. She is enrolled in an MA-PD plan and was
disappointed with 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 would not have to put up with such poor access to
care. What could you tell her?
She could file a grievance with her plan to complain about the lack of timeliness in getting an
appointment.
Mrs. Stark is enrolled in her state's Medicaid program in addition to Medicare. What should she
be aware of when considering enrollment in a Medicare Advantage (MA) plan?
She cannot enroll in an MA Medical Savings Account (MSA) plan.
Mrs. Ramos asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her?
Mrs. Ramos must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.
,Mrs. Lim wants to know generally how the benefits under Original Medicare might compare to
the benefits package of a Medicare Advantage Plan before she starts looking at specific plans.
What could you tell her?
Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such
as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part
A and Part B services.
Avery recently lost her employer's group health and drug coverage and now she wants to
enroll in a PPO that does not include drug coverage. What should you tell her about obtaining
drug coverage?
She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D
prescription drug plan.
Gary Summers is enrolled in Ajax Medicare Advantage plan. Gary has recently faced a series
of health issues leading to substantial out-of-pocket expenses. Gary understands that in
Original Medicare (Parts A and B) there is no annual out-of-pocket maximum. He asks you if
the same is true of his Medicare Advantage plan? How do you respond?
All Medicare Advantage (MA) plans must have a "maximum out-of-pocket" limit (known as
"MOOP") for Part A and Part B benefits. Once the MA plan member pays a specified amount of
cost-sharing that health plan pays 100 percent of the medical services covered.
Mr. Maddox is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him?
In most Medicare Advantage HMOs, Mr. Maddox must generally obtain his services only from
providers within the plan's network (except in an emergency or where care is unavailable
within the network).
Mildred Philps, initially enrolled in Original Medicare when first eligible for Medicare. During
open enrollment Mildred switched to Fairhaven Medicare Advantage. Prior to her enrollment in
Fairhaven, Mildred had begun treatment for a serious illness with a non-network provider. She
asks you whether the treatment from the non-network provider must stop immediately? What
do you say?
,No, when an individual enrolls in a Medicare Advantage (MA) plan after starting a course of
treatment, there is a minimum 90-day transition period during which the MA organization may
not disrupt or require authorization for the active course of treatment.
Mr. Hardin is interested in the Medicare Advantage (MA) PPO plan that you represent. It is one
of three plans operated by the same organization in Mr. Hardin's area. The MA PPO plan does
not include drug coverage, but the other two plans do. Mr. Hardin likes the PPO plan that does
not include drug coverage and intends to obtain his drug coverage through a stand-alone
Medicare prescription drug plan. What should you tell him about this situation?
He could enroll either in one of the MA plans that include prescription drug coverage or
Original Medicare with a Medigap plan and standalone Part D prescription drug coverage, but
he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan.
Conrad is 64, retiring soon, and considering enrollment in his employer-sponsored MA retiree
group health plan that includes drug coverage with nominal copays. He heard about a
neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs,
he is considering signing up for it. What should you tell him?
He should compare the benefits in his employer-sponsored retiree group health plan with the
benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage
for his prescription needs.
Which of the following individuals would be eligible to enroll in a Medical Savings Account
(MSA) MA plan?
Abigail, who is age 66, retired and enrolled in Medicare Parts A and B.
Jake is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be the correct description?
Medicare Advantage is a way of covering all the Original Medicare benefits through private
health insurance companies.
Mr. Church notes that a Private Fee-for-Service (PFFS) plan available in his area has an
attractive premium. He wants to know if he must use doctors in a network as his current HMO
plan requires him to do. What should you tell him?
, He may receive health care services from any doctor allowed to bill Medicare, if he shows the
doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment
terms and conditions, which could include balance billing.
Stefan Merritt is turning 65 next month. Stefan legally entered the United States over twenty
years ago, holds a green card, but is not a citizen. Since he entered the country, Stefan has
worked at Smallcap Incorporated and contributed to the Medicare system. Stefan suffers from
diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that
you represent. How would you respond?
Stefan is eligible to enroll in Medicare Advantage if he is entitled to Part A and enrolled in Part
B. Stefan should go to the Social Security website to enroll in Medicare Part A and B if he has
not done so already. Once he is enrolled, he can choose a Medicare Advantage plan.
Peter Miller heads a local association of medical professionals - Better Health. The association
has many members who are retired or approaching retirement age. Peter comes to you for
advice as to whether the association can establish an employer group waiver plan (EGWP) for
these members. What do you say?
No, Better Health is a professional association whose membership is based on their
profession, not an individual employer or former employer.
Lorenzo is a Medicare beneficiary who is considering switching to a Medicare Advantage plan
during this year's open enrollment season. He has read about prior authorization and the need
for referrals in the newspapers and asks you what type of plans can require prior
authorization. What do you say?
HMOs require prior authorization for out-of-network services except for emergency services
and certain other carved-out services. HMOs may also require referrals for in-network
specialist services.
One of your clients, Jasmine Perry, has heard about a Medicare concept from one of her
neighbors called TrOOP. She asks you to explain it. What do you say?
TrOOP stands for true out-of-pocket costs that count toward the Medicare Part D catastrophic
limit and include not only expenses paid by a beneficiary but also, in some instances, amounts
paid by or through qualified State Pharmaceutical Assistance Programs.
