AHIP FINAL EXAM
Mr.Gomez notes that a Private Fee for Service (PFFS) plan avaliable in his area has an attractive
preminum. 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? - ANSWER He may
receive health care services from any doctor allowed to bill Medicare as long as 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.
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? - ANSWER
PFFS plans may choose to offer Part D benefits but are not required to do so.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers
she can go to for her health care. What should you tell her? - ANSWER
Mrs. Ramos can obtain care from any provider who participates in Original Medicare but
generally will have a higher cost-sharing amount if she sees a provider who/that is not apart of
the PPO network.
Mr. McTaggert notes that a Private Fee for-Service (PFFS) plan avaliable in his area has an
attractive premium. He wants to know what makes them different from an HMO or a PPO. What
should you tell him? - ANSWER Enrollees in a PFFS plan can obtain
care from any provider in the US 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.
,Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently
stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll
in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? -
ANSWER He is not eligible to enroll in a Medicare Advantage plan until
he re-enrolls in Medicare Part B.
Mr. Sinclar has diabetes and heart trouble and is generally satisified with the care he has just
received under Original Medicare, but he would like to know more about Medicare Advantage
Special Needs Plans (SNPs). What could you tell him? - ANSWER SNPs
have special programs from enrollees with chronic conditions, like Mr. Sinclair and they provide
prescription drug coverage that could be very helpful as well.
Mrs.Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor
recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does
Mrs.Davenport have regarding her MA plan during the next open enrollment season? -
ANSWER She may remain in her ABC MA plan or enroll in a Special Needs
Plan (SNP) for individuals sufferinf from ESRD if one is available in her area.
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
be most appropriate for him? - ANSWER C-SNP
,Mr. Gomez 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 curreny HMO plan
requires him to do. What should you tell him? - ANSWER He may
receive health care services from any doctor allowed to bill Medicare as long as 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.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers
she can go to for her health care. What should you tell her? - ANSWER
Mrs. Ramos can obtain care from any provider who participates in Original Medicare but
generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of
the PPO network.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him? - ANSWER 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 emergency or where care is
unavailable within the network)
Mr.Greco is in excellent health, lives in his own home, and has aa sizeable income from his
investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His
friend has mentioned that the SNP charges very low costs sharing amounts and Mr. Greco
would like to join that plan. What should you tell him? - ANSWER
SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he
is unlikelt to qualify and would not be able to enroll in the SNP.
, Dr. Elizabeth Brennan does not contract with the PFFS plan but she accepts the plan's terms and
conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr.
Brennan charge? - ANSWER Dr. Brennan can charge Mary Rodgers no
more than the cost sharing specified in the PFFS plan's terms and condition of payment which
may include balance billing up to 15 percent of the Medicare rate.
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? - ANSWER 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.
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? - ANSWER
PFFS plans may choose to offer Part D benefits but are not required to do so.
Which of the following statements is correct about 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
Mr.Gomez notes that a Private Fee for Service (PFFS) plan avaliable in his area has an attractive
preminum. 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? - ANSWER He may
receive health care services from any doctor allowed to bill Medicare as long as 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.
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? - ANSWER
PFFS plans may choose to offer Part D benefits but are not required to do so.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers
she can go to for her health care. What should you tell her? - ANSWER
Mrs. Ramos can obtain care from any provider who participates in Original Medicare but
generally will have a higher cost-sharing amount if she sees a provider who/that is not apart of
the PPO network.
Mr. McTaggert notes that a Private Fee for-Service (PFFS) plan avaliable in his area has an
attractive premium. He wants to know what makes them different from an HMO or a PPO. What
should you tell him? - ANSWER Enrollees in a PFFS plan can obtain
care from any provider in the US 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.
,Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently
stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to enroll
in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell him? -
ANSWER He is not eligible to enroll in a Medicare Advantage plan until
he re-enrolls in Medicare Part B.
Mr. Sinclar has diabetes and heart trouble and is generally satisified with the care he has just
received under Original Medicare, but he would like to know more about Medicare Advantage
Special Needs Plans (SNPs). What could you tell him? - ANSWER SNPs
have special programs from enrollees with chronic conditions, like Mr. Sinclair and they provide
prescription drug coverage that could be very helpful as well.
Mrs.Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor
recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does
Mrs.Davenport have regarding her MA plan during the next open enrollment season? -
ANSWER She may remain in her ABC MA plan or enroll in a Special Needs
Plan (SNP) for individuals sufferinf from ESRD if one is available in her area.
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
be most appropriate for him? - ANSWER C-SNP
,Mr. Gomez 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 curreny HMO plan
requires him to do. What should you tell him? - ANSWER He may
receive health care services from any doctor allowed to bill Medicare as long as 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.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers
she can go to for her health care. What should you tell her? - ANSWER
Mrs. Ramos can obtain care from any provider who participates in Original Medicare but
generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of
the PPO network.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him? - ANSWER 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 emergency or where care is
unavailable within the network)
Mr.Greco is in excellent health, lives in his own home, and has aa sizeable income from his
investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His
friend has mentioned that the SNP charges very low costs sharing amounts and Mr. Greco
would like to join that plan. What should you tell him? - ANSWER
SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he
is unlikelt to qualify and would not be able to enroll in the SNP.
, Dr. Elizabeth Brennan does not contract with the PFFS plan but she accepts the plan's terms and
conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr.
Brennan charge? - ANSWER Dr. Brennan can charge Mary Rodgers no
more than the cost sharing specified in the PFFS plan's terms and condition of payment which
may include balance billing up to 15 percent of the Medicare rate.
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? - ANSWER 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.
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? - ANSWER
PFFS plans may choose to offer Part D benefits but are not required to do so.
Which of the following statements is correct about 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
