AHIP - Final examination with Questions
and Correct Answers 2025
Mr. ,Zachow ,has ,a ,condition ,for ,which ,three ,drugs ,are ,available. ,He ,has ,tried ,two ,but
,had ,an ,allergic ,reaction ,to ,them. ,Only ,the ,third ,drug ,works ,for ,him ,and ,it ,is ,not ,on
,his ,Part ,D ,plan's ,formulary. ,What ,could ,you ,tell ,him ,to ,do? ,- ,CORRECT ,ANSWER-
Mr. ,Zachow ,has ,a ,right ,to ,request ,a ,formulary ,exception ,to ,obtain ,coverage ,for ,his
,Part ,D ,drug. ,He ,or ,his ,physician ,could ,obtain ,the ,standardized ,request ,form ,on ,the
,plan's ,website, ,fill ,it ,out, ,and ,submit ,it ,to ,his ,plan.
Mr. ,Polanski ,likes ,the ,cost ,of ,an ,HMO ,plan ,available ,in ,his ,area, ,but ,would ,like ,to ,be
,able ,to ,visit ,one ,or ,two ,doctors ,who ,aren't ,participating ,providers. ,He ,wants ,to ,know
,if ,the ,Point ,of ,Service ,(POS) ,option ,available ,with ,some ,HMOs ,will ,be ,of ,any ,help ,in
,this ,situation. ,What ,should ,you ,tell ,him? ,- ,CORRECT ,ANSWER-The ,POS ,option
,might ,be ,a ,good ,solution ,for ,him ,as ,it ,will ,allow ,him ,to ,visit ,out-of-network ,providers,
,generally ,without ,prior ,approval. ,However, ,he ,should ,be ,aware ,that ,it ,is ,likely ,he ,will
,have ,to ,pay ,higher ,cost-sharing ,for ,services ,from ,out-of-network ,providers.
Mr. ,Barker ,had ,surgery ,recently ,and ,expected ,that ,he ,would ,have ,certain ,services
,and ,items ,covered ,by ,the ,plan ,with ,minimal ,out-of-pocket ,costs ,because ,his ,MA-PD
,coverage ,has ,been ,very ,good. ,However, ,when ,he ,received ,the ,bill, ,he ,was ,surprised
,to ,see ,large ,charges ,in ,excess ,of ,his ,maximum ,out-of-pocket ,limit ,that ,included ,a
,number ,of ,services ,and ,items ,he ,thought ,would ,be ,fully ,covered. ,He ,called ,you ,to
,ask ,what ,he ,could ,do? ,What ,could ,you ,tell ,him? ,- ,CORRECT ,ANSWER-You ,can
,offer ,to ,review ,the ,plans ,appeal ,process ,to ,help ,him ,ask ,the ,plan ,to ,review ,the
,coverage ,decision.
Ms. ,Stuart ,has ,heard ,about ,a ,special ,needs ,plan ,(SNP) ,that ,one ,of ,her ,friends ,is
,enrolled ,in ,and ,is ,interested ,in ,that ,product. ,She ,wants ,to ,be ,sure ,she ,also ,has
,coverage ,for ,prescription ,drugs. ,Would ,she ,be ,able ,to ,obtain ,drug ,coverage ,if ,she
,enrolled ,in ,the ,SNP? ,- ,CORRECT ,ANSWER-a. ,Yes. ,All ,SNPs ,are ,required ,to
,provide ,Part ,D ,coverage ,for ,prescription ,drugs.
b. ,Yes, ,but ,only ,if ,she ,qualifies ,for ,Part ,D ,prescription ,drug ,coverage ,under ,her ,state
,Medicaid ,program.
, c. ,No. ,Medicare ,beneficiaries ,who ,enroll ,in ,an ,SNP ,must ,always ,obtain ,their ,drug
,coverage ,through ,a ,stand-alone ,Part ,D ,Medicare ,prescription ,drug ,plan ,that ,they
,sign ,up ,for ,independent ,of ,their ,enrollment ,in ,the ,SNP.
d. ,Maybe. ,Some ,SNPs ,offer ,Part ,D ,coverage ,for ,prescription ,drugs ,and ,some ,do ,not.
= ,?????
Phiona ,works ,in ,the ,IT ,Department ,of ,BestCare ,Health ,Plan. ,Phiona ,is ,placed ,in
,charge ,of ,BestCare's ,efforts ,to ,facilitate ,electronic ,enrollment ,in ,its ,Medicare
,Advantage ,plans. ,In ,setting ,up ,the ,enrollment ,site, ,which ,of ,the ,following ,must
,Phiona ,consider? ,- ,CORRECT ,ANSWER-II. ,All ,data ,elements ,required ,to ,complete
,an ,enrollment ,request ,must ,be ,captured.
III. ,The ,process ,must ,include ,a ,clear ,and ,distinct ,step ,that ,requires ,the ,applicant ,to
,activate ,an ,"Enroll ,Now" ,or ,"I ,Agree" ,type ,of ,button ,or ,tool.
Ms. ,Lewis ,understands ,that ,Medicare ,prescription ,drug ,plans ,may ,use ,various
,methods ,to ,control ,the ,use ,of ,specific ,drugs. ,She ,has ,heard ,about ,a ,technique ,called
,"step ,therapy" ,and ,is ,wondering ,if ,you ,can ,explain ,what ,that ,is. ,What ,should ,you ,tell
,her? ,- ,CORRECT ,ANSWER-Step ,therapy ,involves ,using ,one ,or ,more ,lower ,priced
,drugs ,before ,trying ,a ,more ,expensive ,drug ,when ,all ,are ,used ,to ,treat ,the ,same
,condition.
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
,current ,HMO ,plan ,requires ,him ,to ,do. ,What ,should ,you ,tell ,him? ,- ,CORRECT
,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.
Mr. ,Wu ,is ,eligible ,for ,Medicare. ,He ,has ,limited ,financial ,resources ,but ,failed ,to ,qualify
,for ,the ,Part ,D ,low-income ,subsidy. ,Where ,might ,he ,turn ,for ,help ,with ,his ,prescription
,drug ,costs? ,- ,CORRECT ,ANSWER-Mr. ,Wu ,may ,still ,qualify ,for ,help ,in ,paying ,Part ,D
,costs ,through ,his ,State ,Pharmaceutical ,Assistance ,Program.
You ,have ,decided ,to ,focus ,on ,doing ,in-home ,presentations ,to ,market ,the ,Medicare
,Advantage ,(MA) ,plans ,you ,represent. ,Before ,you ,conduct ,such ,sales ,presentations,
,what ,must ,you ,do? ,- ,CORRECT ,ANSWER-
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? ,- ,CORRECT ,ANSWER-a. ,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.
and Correct Answers 2025
Mr. ,Zachow ,has ,a ,condition ,for ,which ,three ,drugs ,are ,available. ,He ,has ,tried ,two ,but
,had ,an ,allergic ,reaction ,to ,them. ,Only ,the ,third ,drug ,works ,for ,him ,and ,it ,is ,not ,on
,his ,Part ,D ,plan's ,formulary. ,What ,could ,you ,tell ,him ,to ,do? ,- ,CORRECT ,ANSWER-
Mr. ,Zachow ,has ,a ,right ,to ,request ,a ,formulary ,exception ,to ,obtain ,coverage ,for ,his
,Part ,D ,drug. ,He ,or ,his ,physician ,could ,obtain ,the ,standardized ,request ,form ,on ,the
,plan's ,website, ,fill ,it ,out, ,and ,submit ,it ,to ,his ,plan.
Mr. ,Polanski ,likes ,the ,cost ,of ,an ,HMO ,plan ,available ,in ,his ,area, ,but ,would ,like ,to ,be
,able ,to ,visit ,one ,or ,two ,doctors ,who ,aren't ,participating ,providers. ,He ,wants ,to ,know
,if ,the ,Point ,of ,Service ,(POS) ,option ,available ,with ,some ,HMOs ,will ,be ,of ,any ,help ,in
,this ,situation. ,What ,should ,you ,tell ,him? ,- ,CORRECT ,ANSWER-The ,POS ,option
,might ,be ,a ,good ,solution ,for ,him ,as ,it ,will ,allow ,him ,to ,visit ,out-of-network ,providers,
,generally ,without ,prior ,approval. ,However, ,he ,should ,be ,aware ,that ,it ,is ,likely ,he ,will
,have ,to ,pay ,higher ,cost-sharing ,for ,services ,from ,out-of-network ,providers.
Mr. ,Barker ,had ,surgery ,recently ,and ,expected ,that ,he ,would ,have ,certain ,services
,and ,items ,covered ,by ,the ,plan ,with ,minimal ,out-of-pocket ,costs ,because ,his ,MA-PD
,coverage ,has ,been ,very ,good. ,However, ,when ,he ,received ,the ,bill, ,he ,was ,surprised
,to ,see ,large ,charges ,in ,excess ,of ,his ,maximum ,out-of-pocket ,limit ,that ,included ,a
,number ,of ,services ,and ,items ,he ,thought ,would ,be ,fully ,covered. ,He ,called ,you ,to
,ask ,what ,he ,could ,do? ,What ,could ,you ,tell ,him? ,- ,CORRECT ,ANSWER-You ,can
,offer ,to ,review ,the ,plans ,appeal ,process ,to ,help ,him ,ask ,the ,plan ,to ,review ,the
,coverage ,decision.
Ms. ,Stuart ,has ,heard ,about ,a ,special ,needs ,plan ,(SNP) ,that ,one ,of ,her ,friends ,is
,enrolled ,in ,and ,is ,interested ,in ,that ,product. ,She ,wants ,to ,be ,sure ,she ,also ,has
,coverage ,for ,prescription ,drugs. ,Would ,she ,be ,able ,to ,obtain ,drug ,coverage ,if ,she
,enrolled ,in ,the ,SNP? ,- ,CORRECT ,ANSWER-a. ,Yes. ,All ,SNPs ,are ,required ,to
,provide ,Part ,D ,coverage ,for ,prescription ,drugs.
b. ,Yes, ,but ,only ,if ,she ,qualifies ,for ,Part ,D ,prescription ,drug ,coverage ,under ,her ,state
,Medicaid ,program.
, c. ,No. ,Medicare ,beneficiaries ,who ,enroll ,in ,an ,SNP ,must ,always ,obtain ,their ,drug
,coverage ,through ,a ,stand-alone ,Part ,D ,Medicare ,prescription ,drug ,plan ,that ,they
,sign ,up ,for ,independent ,of ,their ,enrollment ,in ,the ,SNP.
d. ,Maybe. ,Some ,SNPs ,offer ,Part ,D ,coverage ,for ,prescription ,drugs ,and ,some ,do ,not.
= ,?????
Phiona ,works ,in ,the ,IT ,Department ,of ,BestCare ,Health ,Plan. ,Phiona ,is ,placed ,in
,charge ,of ,BestCare's ,efforts ,to ,facilitate ,electronic ,enrollment ,in ,its ,Medicare
,Advantage ,plans. ,In ,setting ,up ,the ,enrollment ,site, ,which ,of ,the ,following ,must
,Phiona ,consider? ,- ,CORRECT ,ANSWER-II. ,All ,data ,elements ,required ,to ,complete
,an ,enrollment ,request ,must ,be ,captured.
III. ,The ,process ,must ,include ,a ,clear ,and ,distinct ,step ,that ,requires ,the ,applicant ,to
,activate ,an ,"Enroll ,Now" ,or ,"I ,Agree" ,type ,of ,button ,or ,tool.
Ms. ,Lewis ,understands ,that ,Medicare ,prescription ,drug ,plans ,may ,use ,various
,methods ,to ,control ,the ,use ,of ,specific ,drugs. ,She ,has ,heard ,about ,a ,technique ,called
,"step ,therapy" ,and ,is ,wondering ,if ,you ,can ,explain ,what ,that ,is. ,What ,should ,you ,tell
,her? ,- ,CORRECT ,ANSWER-Step ,therapy ,involves ,using ,one ,or ,more ,lower ,priced
,drugs ,before ,trying ,a ,more ,expensive ,drug ,when ,all ,are ,used ,to ,treat ,the ,same
,condition.
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
,current ,HMO ,plan ,requires ,him ,to ,do. ,What ,should ,you ,tell ,him? ,- ,CORRECT
,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.
Mr. ,Wu ,is ,eligible ,for ,Medicare. ,He ,has ,limited ,financial ,resources ,but ,failed ,to ,qualify
,for ,the ,Part ,D ,low-income ,subsidy. ,Where ,might ,he ,turn ,for ,help ,with ,his ,prescription
,drug ,costs? ,- ,CORRECT ,ANSWER-Mr. ,Wu ,may ,still ,qualify ,for ,help ,in ,paying ,Part ,D
,costs ,through ,his ,State ,Pharmaceutical ,Assistance ,Program.
You ,have ,decided ,to ,focus ,on ,doing ,in-home ,presentations ,to ,market ,the ,Medicare
,Advantage ,(MA) ,plans ,you ,represent. ,Before ,you ,conduct ,such ,sales ,presentations,
,what ,must ,you ,do? ,- ,CORRECT ,ANSWER-
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? ,- ,CORRECT ,ANSWER-a. ,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.
