AETNA INDIVIDUAL CORE CERTIFICATION
MASTERY TEST - COMPREHENSIVE QUESTION
AND ANSWER GUIDE BY AETNA MEDICARE
TRAINING DEPARTMENT
1. In the context of Medicare Part D, a plan's formulary includes a drug that is classified as a
'specialty tier' drug. Which of the following best describes the cost-sharing structure that a plan
may apply to this drug under CMS rules?
A. Fixed copayment not exceeding $10 per prescription, regardless of the drug's cost
B. Coinsurance of 25% to 33% of the drug's cost, with no upper limit on out-of-pocket spending
C. Copayment or coinsurance that is the same as for non-preferred brand drugs, but with a maximum
out-of-pocket limit
D. Coinsurance or copayment, but the cost-sharing must be actuarially equivalent to a 25% coinsurance rate and
cannot exceed the drug's negotiated price
Answer: D
Rationale: CMS allows Part D plans to apply cost-sharing that is actuarially equivalent to 25%
coinsurance for specialty tier drugs. The cost-sharing cannot exceed the drug's negotiated price. Options
A and B are incorrect because there is no fixed $10 copay or unlimited coinsurance; specialty tier drugs
often have higher cost-sharing but with limits. Option C is incorrect because specialty tier cost-sharing
is typically higher than non-preferred brand drugs.
2. A Medicare Advantage plan is considering implementing a prior authorization requirement for
a specific service that is currently covered without restrictions. Under CMS regulations, which of
the following conditions must the plan meet to adopt this utilization management tool?
A. The plan must demonstrate that the service is subject to widespread fraud and abuse based on national data
B. The plan must obtain approval from the state insurance department and publish a notice in the Federal
Register
C. The plan must ensure that the prior authorization criterion is based on current medical evidence and is
applied uniformly to all enrollees
D. The plan must first implement a step therapy protocol and then transition to prior authorization if the step
therapy fails to control costs
Answer: C
Rationale: CMS requires that utilization management tools like prior authorization be based on current
medical evidence and applied uniformly. Option A is incorrect because widespread fraud is not a
prerequisite. Option B is incorrect because state approval and Federal Register publication are not
required. Option D is incorrect because step therapy is a separate tool and not a prerequisite for prior
authorization.
Page 1
,3. A Medicare beneficiary is enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan.
The beneficiary's drug costs for the year have reached the initial coverage limit. Which of the
following accurately describes the coverage phase the beneficiary enters next, and the associated
cost-sharing?
A. The coverage gap phase, where the beneficiary pays 25% of the cost of brand-name drugs and 25% of the
cost of generic drugs, with manufacturer discounts applying only to brand-name drugs
B. The catastrophic coverage phase, where the beneficiary pays the greater of 5% coinsurance or $3.70 for
generic and $9.20 for brand-name drugs
C. The coverage gap phase, where the beneficiary pays 25% of the cost of brand-name drugs and 75% of the
cost of generic drugs, with manufacturer discounts applying to both brand and generic drugs
D. The catastrophic coverage phase, where the beneficiary pays a fixed copayment of $10 for each prescription,
regardless of drug tier
Answer: A
Rationale: After the initial coverage limit, the beneficiary enters the coverage gap (donut hole). In 2024,
the beneficiary pays 25% of brand-name drug costs (with manufacturer discounts covering the rest) and
25% of generic drug costs. Option B describes catastrophic coverage but with outdated cost-sharing
amounts. Option C incorrectly states 75% for generics and that discounts apply to generics. Option D is
incorrect because catastrophic coverage has coinsurance, not fixed copays.
4. A Medicare beneficiary is considering enrollment in a Medicare Supplement (Medigap) plan.
The beneficiary has End-Stage Renal Disease (ESRD) and is currently under 65 years of age.
Under federal law, which of the following is true regarding the availability of Medigap policies?
A. Medigap policies are guaranteed issue for individuals under 65 with ESRD only if they reside in a state that
mandates such coverage
B. Medigap policies are available to all individuals with ESRD regardless of age, but only during the initial
open enrollment period
C. Medigap policies are not available to individuals under 65 with ESRD, as they are eligible for Medicare due
to ESRD and must enroll in Medicare Advantage
D. Medigap policies are available to individuals under 65 with ESRD, but only if they have been entitled to
Medicare for at least 24 months
Answer: A
Rationale: Federal law does not require Medigap insurers to sell policies to individuals under 65 with
ESRD, but some states have laws that mandate guaranteed issue. Option B is incorrect because there is
no federal guarantee. Option C is incorrect because Medigap is available in some states. Option D is
incorrect because there is no 24-month waiting period for Medigap; the 24-month waiting period
applies to Medicare eligibility for ESRD, but once eligible, Medigap access depends on state law.
5. A Medicare Advantage plan uses a network of providers that includes both in-network and
out-of-network providers, but out-of-network services are covered at a lower rate. This plan type is
known as a:
A. Health Maintenance Organization (HMO) plan with a point-of-service (POS) option
B. Preferred Provider Organization (PPO) plan
C. Private Fee-for-Service (PFFS) plan
D. Special Needs Plan (SNP)
Page 2
,Answer: B
Rationale: A PPO plan allows enrollees to use out-of-network providers at a higher cost-sharing level.
An HMO with POS option also allows out-of-network coverage, but the term 'PPO' specifically
describes a plan with a network and out-of-network coverage. PFFS plans may have network
arrangements but do not necessarily have out-of-network coverage. SNPs are specialized for certain
populations.
6. A Medicare beneficiary is enrolled in Original Medicare and has a standalone Part D
prescription drug plan. The beneficiary's annual income is $150,000 (modified adjusted gross
income). Which of the following best describes the income-related monthly adjustment amount
(IRMAA) that applies to the Part D premium?
A. No IRMAA applies because the beneficiary's income is below the threshold for Part D IRMAA
B. The beneficiary will pay an additional amount that is a percentage of the national base beneficiary premium,
as determined by income brackets
C. The beneficiary will pay the standard Part D premium plus an additional flat fee of $70.80 per month
D. The beneficiary is not subject to IRMAA for Part D because IRMAA only applies to Part B premiums
Answer: B
Rationale: IRMAA applies to both Part B and Part D premiums for beneficiaries with higher incomes. For
2024, individuals with modified adjusted gross income above $103,000 (or couples above $206,000) pay
an income-related adjustment. The adjustment is a percentage of the national base beneficiary premium,
not a flat fee. Option A is incorrect because $150,000 exceeds the threshold for single filers. Option C is
incorrect because the amount varies by income bracket. Option D is incorrect because IRMAA applies to
Part D as well.
7. A Medicare Advantage plan is audited by CMS and found to have a high rate of denied claims
that were subsequently overturned on appeal. Under CMS's compliance and monitoring
framework, which of the following actions is CMS most likely to take?
A. Impose a civil money penalty of $10,000 per denied claim that was overturned
B. Require the plan to submit a corrective action plan and may impose intermediate sanctions, such as
suspending enrollment
C. Terminate the plan's contract immediately without the opportunity for a hearing
D. Refer the matter to the Office of Inspector General for criminal prosecution
Answer: B
Rationale: CMS typically requires plans with compliance issues to submit a corrective action plan and
may impose intermediate sanctions like enrollment suspension. Civil money penalties are possible but
not per claim. Immediate termination without a hearing is not standard; plans have due process rights.
Criminal prosecution is reserved for fraud, not high overturn rates.
8. A Medicare beneficiary is enrolled in a Medicare Advantage plan that includes a Part D benefit.
The beneficiary's drug costs for the year have reached the catastrophic coverage threshold. Which
of the following cost-sharing structures applies during the catastrophic coverage phase in 2024?
A. The beneficiary pays the greater of 5% coinsurance or $4.15 for generic drugs and $10.35 for brand-name
drugs
Page 3
, B. The beneficiary pays a flat copayment of $10 for each prescription, regardless of drug tier
C. The beneficiary pays 25% coinsurance for all drugs, with no cap on out-of-pocket spending
D. The beneficiary pays no cost-sharing for covered drugs during the catastrophic phase
Answer: A
Rationale: In 2024, catastrophic coverage cost-sharing is the greater of 5% coinsurance or $4.15 for
generics and $10.35 for brand-name drugs. Option B is incorrect because it is not a flat copay. Option C
describes the coverage gap phase. Option D is incorrect because there is still cost-sharing, though
reduced.
9. A Medicare beneficiary is enrolled in a Medicare Advantage plan that has a 5-star quality
rating. The beneficiary wants to switch to another Medicare Advantage plan during the year.
Which of the following special enrollment periods (SEPs) applies?
A. The beneficiary may use the 5-star SEP to switch to any Medicare Advantage plan with a 4-star or higher
rating, once per year
B. The beneficiary may use the 5-star SEP to switch to any Medicare Advantage plan, regardless of star rating,
once per year
C. The beneficiary may use the 5-star SEP to switch to any Medicare Advantage plan, but only if the new plan
also has a 5-star rating
D. The beneficiary may use the 5-star SEP to switch to a different Medicare Advantage plan, but only during the
annual open enrollment period
Answer: B
Rationale: The 5-star SEP allows beneficiaries enrolled in a 5-star plan to switch to any Medicare
Advantage plan (any star rating) once per year. Option A incorrectly restricts to 4-star or higher. Option
C incorrectly requires the new plan to be 5-star. Option D is incorrect because the SEP is available
outside the annual open enrollment period.
10. A Medicare beneficiary is enrolled in Original Medicare and has a Medigap policy. The
beneficiary is considering switching to a Medicare Advantage plan. Which of the following is true
regarding the beneficiary's ability to return to Medigap coverage if they disenroll from the
Medicare Advantage plan within the first year?
A. The beneficiary has a guaranteed issue right to purchase any Medigap policy if they disenroll from the
Medicare Advantage plan within the first 12 months of enrollment
B. The beneficiary has a guaranteed issue right to purchase a Medigap policy only if they disenroll during the
Medicare Advantage open enrollment period (January 1 to March 31)
C. The beneficiary has no guaranteed issue rights and may be subject to medical underwriting if they want to
purchase a Medigap policy after disenrolling
D. The beneficiary has a guaranteed issue right to purchase a Medigap policy only if the Medicare Advantage
plan has a star rating below 3.5
Answer: A
Rationale: Under the 'trial period' rules, beneficiaries who enroll in a Medicare Advantage plan for the
first time have a 12-month trial period during which they have guaranteed issue rights to return to a
Medigap policy. Option B is incorrect because the trial period is not limited to the MA OEP. Option C is
incorrect because guaranteed issue rights exist. Option D is incorrect because star rating does not affect
this right.
Page 4
MASTERY TEST - COMPREHENSIVE QUESTION
AND ANSWER GUIDE BY AETNA MEDICARE
TRAINING DEPARTMENT
1. In the context of Medicare Part D, a plan's formulary includes a drug that is classified as a
'specialty tier' drug. Which of the following best describes the cost-sharing structure that a plan
may apply to this drug under CMS rules?
A. Fixed copayment not exceeding $10 per prescription, regardless of the drug's cost
B. Coinsurance of 25% to 33% of the drug's cost, with no upper limit on out-of-pocket spending
C. Copayment or coinsurance that is the same as for non-preferred brand drugs, but with a maximum
out-of-pocket limit
D. Coinsurance or copayment, but the cost-sharing must be actuarially equivalent to a 25% coinsurance rate and
cannot exceed the drug's negotiated price
Answer: D
Rationale: CMS allows Part D plans to apply cost-sharing that is actuarially equivalent to 25%
coinsurance for specialty tier drugs. The cost-sharing cannot exceed the drug's negotiated price. Options
A and B are incorrect because there is no fixed $10 copay or unlimited coinsurance; specialty tier drugs
often have higher cost-sharing but with limits. Option C is incorrect because specialty tier cost-sharing
is typically higher than non-preferred brand drugs.
2. A Medicare Advantage plan is considering implementing a prior authorization requirement for
a specific service that is currently covered without restrictions. Under CMS regulations, which of
the following conditions must the plan meet to adopt this utilization management tool?
A. The plan must demonstrate that the service is subject to widespread fraud and abuse based on national data
B. The plan must obtain approval from the state insurance department and publish a notice in the Federal
Register
C. The plan must ensure that the prior authorization criterion is based on current medical evidence and is
applied uniformly to all enrollees
D. The plan must first implement a step therapy protocol and then transition to prior authorization if the step
therapy fails to control costs
Answer: C
Rationale: CMS requires that utilization management tools like prior authorization be based on current
medical evidence and applied uniformly. Option A is incorrect because widespread fraud is not a
prerequisite. Option B is incorrect because state approval and Federal Register publication are not
required. Option D is incorrect because step therapy is a separate tool and not a prerequisite for prior
authorization.
Page 1
,3. A Medicare beneficiary is enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan.
The beneficiary's drug costs for the year have reached the initial coverage limit. Which of the
following accurately describes the coverage phase the beneficiary enters next, and the associated
cost-sharing?
A. The coverage gap phase, where the beneficiary pays 25% of the cost of brand-name drugs and 25% of the
cost of generic drugs, with manufacturer discounts applying only to brand-name drugs
B. The catastrophic coverage phase, where the beneficiary pays the greater of 5% coinsurance or $3.70 for
generic and $9.20 for brand-name drugs
C. The coverage gap phase, where the beneficiary pays 25% of the cost of brand-name drugs and 75% of the
cost of generic drugs, with manufacturer discounts applying to both brand and generic drugs
D. The catastrophic coverage phase, where the beneficiary pays a fixed copayment of $10 for each prescription,
regardless of drug tier
Answer: A
Rationale: After the initial coverage limit, the beneficiary enters the coverage gap (donut hole). In 2024,
the beneficiary pays 25% of brand-name drug costs (with manufacturer discounts covering the rest) and
25% of generic drug costs. Option B describes catastrophic coverage but with outdated cost-sharing
amounts. Option C incorrectly states 75% for generics and that discounts apply to generics. Option D is
incorrect because catastrophic coverage has coinsurance, not fixed copays.
4. A Medicare beneficiary is considering enrollment in a Medicare Supplement (Medigap) plan.
The beneficiary has End-Stage Renal Disease (ESRD) and is currently under 65 years of age.
Under federal law, which of the following is true regarding the availability of Medigap policies?
A. Medigap policies are guaranteed issue for individuals under 65 with ESRD only if they reside in a state that
mandates such coverage
B. Medigap policies are available to all individuals with ESRD regardless of age, but only during the initial
open enrollment period
C. Medigap policies are not available to individuals under 65 with ESRD, as they are eligible for Medicare due
to ESRD and must enroll in Medicare Advantage
D. Medigap policies are available to individuals under 65 with ESRD, but only if they have been entitled to
Medicare for at least 24 months
Answer: A
Rationale: Federal law does not require Medigap insurers to sell policies to individuals under 65 with
ESRD, but some states have laws that mandate guaranteed issue. Option B is incorrect because there is
no federal guarantee. Option C is incorrect because Medigap is available in some states. Option D is
incorrect because there is no 24-month waiting period for Medigap; the 24-month waiting period
applies to Medicare eligibility for ESRD, but once eligible, Medigap access depends on state law.
5. A Medicare Advantage plan uses a network of providers that includes both in-network and
out-of-network providers, but out-of-network services are covered at a lower rate. This plan type is
known as a:
A. Health Maintenance Organization (HMO) plan with a point-of-service (POS) option
B. Preferred Provider Organization (PPO) plan
C. Private Fee-for-Service (PFFS) plan
D. Special Needs Plan (SNP)
Page 2
,Answer: B
Rationale: A PPO plan allows enrollees to use out-of-network providers at a higher cost-sharing level.
An HMO with POS option also allows out-of-network coverage, but the term 'PPO' specifically
describes a plan with a network and out-of-network coverage. PFFS plans may have network
arrangements but do not necessarily have out-of-network coverage. SNPs are specialized for certain
populations.
6. A Medicare beneficiary is enrolled in Original Medicare and has a standalone Part D
prescription drug plan. The beneficiary's annual income is $150,000 (modified adjusted gross
income). Which of the following best describes the income-related monthly adjustment amount
(IRMAA) that applies to the Part D premium?
A. No IRMAA applies because the beneficiary's income is below the threshold for Part D IRMAA
B. The beneficiary will pay an additional amount that is a percentage of the national base beneficiary premium,
as determined by income brackets
C. The beneficiary will pay the standard Part D premium plus an additional flat fee of $70.80 per month
D. The beneficiary is not subject to IRMAA for Part D because IRMAA only applies to Part B premiums
Answer: B
Rationale: IRMAA applies to both Part B and Part D premiums for beneficiaries with higher incomes. For
2024, individuals with modified adjusted gross income above $103,000 (or couples above $206,000) pay
an income-related adjustment. The adjustment is a percentage of the national base beneficiary premium,
not a flat fee. Option A is incorrect because $150,000 exceeds the threshold for single filers. Option C is
incorrect because the amount varies by income bracket. Option D is incorrect because IRMAA applies to
Part D as well.
7. A Medicare Advantage plan is audited by CMS and found to have a high rate of denied claims
that were subsequently overturned on appeal. Under CMS's compliance and monitoring
framework, which of the following actions is CMS most likely to take?
A. Impose a civil money penalty of $10,000 per denied claim that was overturned
B. Require the plan to submit a corrective action plan and may impose intermediate sanctions, such as
suspending enrollment
C. Terminate the plan's contract immediately without the opportunity for a hearing
D. Refer the matter to the Office of Inspector General for criminal prosecution
Answer: B
Rationale: CMS typically requires plans with compliance issues to submit a corrective action plan and
may impose intermediate sanctions like enrollment suspension. Civil money penalties are possible but
not per claim. Immediate termination without a hearing is not standard; plans have due process rights.
Criminal prosecution is reserved for fraud, not high overturn rates.
8. A Medicare beneficiary is enrolled in a Medicare Advantage plan that includes a Part D benefit.
The beneficiary's drug costs for the year have reached the catastrophic coverage threshold. Which
of the following cost-sharing structures applies during the catastrophic coverage phase in 2024?
A. The beneficiary pays the greater of 5% coinsurance or $4.15 for generic drugs and $10.35 for brand-name
drugs
Page 3
, B. The beneficiary pays a flat copayment of $10 for each prescription, regardless of drug tier
C. The beneficiary pays 25% coinsurance for all drugs, with no cap on out-of-pocket spending
D. The beneficiary pays no cost-sharing for covered drugs during the catastrophic phase
Answer: A
Rationale: In 2024, catastrophic coverage cost-sharing is the greater of 5% coinsurance or $4.15 for
generics and $10.35 for brand-name drugs. Option B is incorrect because it is not a flat copay. Option C
describes the coverage gap phase. Option D is incorrect because there is still cost-sharing, though
reduced.
9. A Medicare beneficiary is enrolled in a Medicare Advantage plan that has a 5-star quality
rating. The beneficiary wants to switch to another Medicare Advantage plan during the year.
Which of the following special enrollment periods (SEPs) applies?
A. The beneficiary may use the 5-star SEP to switch to any Medicare Advantage plan with a 4-star or higher
rating, once per year
B. The beneficiary may use the 5-star SEP to switch to any Medicare Advantage plan, regardless of star rating,
once per year
C. The beneficiary may use the 5-star SEP to switch to any Medicare Advantage plan, but only if the new plan
also has a 5-star rating
D. The beneficiary may use the 5-star SEP to switch to a different Medicare Advantage plan, but only during the
annual open enrollment period
Answer: B
Rationale: The 5-star SEP allows beneficiaries enrolled in a 5-star plan to switch to any Medicare
Advantage plan (any star rating) once per year. Option A incorrectly restricts to 4-star or higher. Option
C incorrectly requires the new plan to be 5-star. Option D is incorrect because the SEP is available
outside the annual open enrollment period.
10. A Medicare beneficiary is enrolled in Original Medicare and has a Medigap policy. The
beneficiary is considering switching to a Medicare Advantage plan. Which of the following is true
regarding the beneficiary's ability to return to Medigap coverage if they disenroll from the
Medicare Advantage plan within the first year?
A. The beneficiary has a guaranteed issue right to purchase any Medigap policy if they disenroll from the
Medicare Advantage plan within the first 12 months of enrollment
B. The beneficiary has a guaranteed issue right to purchase a Medigap policy only if they disenroll during the
Medicare Advantage open enrollment period (January 1 to March 31)
C. The beneficiary has no guaranteed issue rights and may be subject to medical underwriting if they want to
purchase a Medigap policy after disenrolling
D. The beneficiary has a guaranteed issue right to purchase a Medigap policy only if the Medicare Advantage
plan has a star rating below 3.5
Answer: A
Rationale: Under the 'trial period' rules, beneficiaries who enroll in a Medicare Advantage plan for the
first time have a 12-month trial period during which they have guaranteed issue rights to return to a
Medigap policy. Option B is incorrect because the trial period is not limited to the MA OEP. Option C is
incorrect because guaranteed issue rights exist. Option D is incorrect because star rating does not affect
this right.
Page 4
