AHIP FINAL EXAM
1
AHIP FINAL EXAM QUESTIONS WITH VERIFIED SOLUTIONS
NEWLY UPDATED EXAM 2026 LATEST EXAM
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?
-- ANS >>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? -- ANS >>Mr. Wu may still qualify for help in
paying Part D costs through his State Pharmaceutical Assistance Program.
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? -- ANS
>>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
,AHIP FINAL EXAM
form on the plan's website, fill it out, and submit it to his plan.
,AHIP FINAL EXAM
2
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? -- ANS >> 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?
-- ANS >>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? -- ANS >>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.
, AHIP FINAL EXAM
3
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 Best Care Health Plan. Phiona is placed in
charge of Best Care’s efforts to facilitate electronic enrollment in its Medicare
Advantage plans. In setting up the enrollment site, which of the following must
Phiona consider? -- ANS >>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? -- ANS >>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. 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
1
AHIP FINAL EXAM QUESTIONS WITH VERIFIED SOLUTIONS
NEWLY UPDATED EXAM 2026 LATEST EXAM
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?
-- ANS >>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? -- ANS >>Mr. Wu may still qualify for help in
paying Part D costs through his State Pharmaceutical Assistance Program.
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? -- ANS
>>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
,AHIP FINAL EXAM
form on the plan's website, fill it out, and submit it to his plan.
,AHIP FINAL EXAM
2
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? -- ANS >> 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?
-- ANS >>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? -- ANS >>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.
, AHIP FINAL EXAM
3
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 Best Care Health Plan. Phiona is placed in
charge of Best Care’s efforts to facilitate electronic enrollment in its Medicare
Advantage plans. In setting up the enrollment site, which of the following must
Phiona consider? -- ANS >>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? -- ANS >>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. 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
