AHIP ACTUAL FINALS QUESTIONS AND ANSWERS
SET A+
✔✔Mrs. Robles 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? - ✔✔Mrs.
Robles 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.
✔✔Tariq 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 can 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.
✔✔Henrietta Ross is an elderly individual enrolled in a fully integrated dual-eligible
(FIDE) special needs plan (SNP). Henrietta's daughter Gladys asks you to explain what
a FIDE-SNP offers her mother. What do you say? - ✔✔FIDE-SNPs provide individuals
access to Medicare and Medicaid benefits under a single organization that has both a
Medicare Advantage and Medicaid managed care contract with CMS.
✔✔Mrs. Joy, age 65, is entitled to Part A but has not yet enrolled in Part B. She is
considering enrolling in a Medicare Advantage plan (Part C). What should you advise
her to do before she can enroll in a Medicare Advantage plan? - ✔✔To join a Medicare
Advantage plan, she also must enroll in Part B.
✔✔Mr. Barrow has diabetes and heart trouble and is generally satisfied with the care he
has received under Original Medicare, but he would like to know more about Medicare
Advantage Special Needs Plans (SNPs). What could you tell him? - ✔✔SNPs have
special programs for enrollees with chronic conditions, like Mr. Barrow, and they provide
prescription drug coverage that could be very helpful as well.
,✔✔Mrs. Sanchez cares for her frail elderly mother, Maria, who lives in North Carolina.
She is worried that without additional support, her mother will need to go into a nursing
home. Mrs. Sanchez asks you if there is any Medicare plan that might allow her mother
to remain in the community rather than going into a nursing home. How should you
advise Mrs. Sanchez? - ✔✔There are Programs of All-Inclusive Care for the Elderly
(PACE) for frail elderly beneficiaries certified as needing a nursing home level of care
but are able to live safely in the community at the time of enrolment.
✔✔Dr. Elizabeth Morgan does not contract with the ABC PFFS plan but accepts the
plan's terms and conditions for payment. Mary Rodgers sees Dr. Morgan for treatment.
How much may Dr. Morgan charge? - ✔✔Dr. Morgan can charge Mary Rogers 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% of the Medicare rate.
✔✔Mr. Pham is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare
Advantage HMO. Shortly thereafter, Mr. Pham visits his primary care provider (PCP),
Dr. Maria Sanchez. Mr. Pham complains of a bad cold and receives care - a Medicare-
covered service. The normal copayment is $40. How much may Dr. Sanchez collects? -
✔✔The minimal copayment that would apply under Medicaid, regardless of what the
plan requires of other enrollees.
✔✔Raymond 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? - ✔✔C-SNP
✔✔Mrs. Nelson likes a Private Fee-for-Service (PFFS) plan available in her area that
does not include drug coverage. She wants to enroll in the plan and enroll in a stand-
alone prescription drug plan. What should you tell her? - ✔✔She could enroll in a PFFS
plan and a stand-alone Medicare prescription drug plan.
✔✔Mrs. Nguyen is a retired federal worker with coverage under a Federal Employee
Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn
65 and become Medicare eligible for the first time. What issues might she consider
about whether to enroll in a Medicare prescription drug plan? - ✔✔She could compare
the coverage to see if the Medicare Part D plan offers better benefits and coverage than
the FEHB plan for the specific medications she needs and whether any additional
benefits are worth the Part D premium costs on top of her FEHB contribution.
✔✔Mrs. Duran is enrolled in a prescription drug plan. She has heard about something
called True-Out-Pocket costs or "TrOOP" and asks you if any of the following count
toward reaching the catastrophic coverage phase. What do you say?
I. Her annual PDP deductible
II. Supplemental coverage provided by an employer group waiver plan
, III. The off formulary drug her doctor prescribed but she pays for because the plan
denied her exception request
IV. Her over-the-counter (OTC) allergy medication. - ✔✔I and II only
✔✔Mrs. Castro has just turned 65, is in excellent health and has a relatively high
income. She uses no medications and sees no reason to spend money on a Medicare
prescription drug plan if she does not need the coverage. She currently does not have
creditable coverage. What could you tell her about the implications of such a decision? -
✔✔If she does not sign up for a Medicare prescription drug plan as soon as she is
eligible to do so, and if she does sign up at a later date, her premium will be
permanently increased by 1% of the national average premium for every month that she
was not covered.
✔✔Which of the following individuals is most likely to be eligible to enroll in a Part D
Plan? - ✔✔Jose, a grandfather who was granted asylum and has worked in the United
States for many years.
✔✔Mrs. Esmeralda Avila is a Medicare beneficiary enrolled in a MA-PD plan you
represent. Her neighbor recently suffered from a painful case of shingles. Mrs. Avila
hopes to avoid such an illness through vaccination. She asks you whether the cost of
the shingles vaccination will be covered under the plan you represent. What should you
say? - ✔✔Yes, there is no cost sharing for the shingles vaccine even in the deductible
phase of her prescription drug plan because it is an adult vaccine recommended by the
Advisory Committee on Immunization Practices (AICP).
✔✔Mrs. Russo is entitled to Part A and has medical coverage without drug coverage
through an employer retiree plan. She is not enrolled in Part B. Since the employer plan
does not cover prescription drugs, she wants to enroll in a Medicare prescription drug
plan. Will she be able to? - ✔✔Yes. Mrs. Russo must be entitled to Part A and/or
enrolled in Part B to be eligible for coverage under the Medicare prescription drug
program.
✔✔Mrs. Willis has a rare condition for which two different brand name drugs are the
only available treatment. She is concerned that since no generic prescription drugs are
available and these drugs are very high cost, she will not be able to find a Medicare Part
D prescription drug plan that covers either one of them. What should you tell her? -
✔✔Medicare prescription drug plans are required to cover drugs in each therapeutic
category. She should be able to enroll in a Medicare prescription drug plan that covers
the medications she needs.
✔✔Mrs. McFarren is enrolled in her state's Medicaid plan and has just become eligible
for Medicare as well. What can she expect will happen to her drug coverage? -
✔✔Unless she chooses a Medicare Part D prescription drug plan on her own, she will
be automatically enrolled in one available in her area.
SET A+
✔✔Mrs. Robles 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? - ✔✔Mrs.
Robles 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.
✔✔Tariq 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 can 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.
✔✔Henrietta Ross is an elderly individual enrolled in a fully integrated dual-eligible
(FIDE) special needs plan (SNP). Henrietta's daughter Gladys asks you to explain what
a FIDE-SNP offers her mother. What do you say? - ✔✔FIDE-SNPs provide individuals
access to Medicare and Medicaid benefits under a single organization that has both a
Medicare Advantage and Medicaid managed care contract with CMS.
✔✔Mrs. Joy, age 65, is entitled to Part A but has not yet enrolled in Part B. She is
considering enrolling in a Medicare Advantage plan (Part C). What should you advise
her to do before she can enroll in a Medicare Advantage plan? - ✔✔To join a Medicare
Advantage plan, she also must enroll in Part B.
✔✔Mr. Barrow has diabetes and heart trouble and is generally satisfied with the care he
has received under Original Medicare, but he would like to know more about Medicare
Advantage Special Needs Plans (SNPs). What could you tell him? - ✔✔SNPs have
special programs for enrollees with chronic conditions, like Mr. Barrow, and they provide
prescription drug coverage that could be very helpful as well.
,✔✔Mrs. Sanchez cares for her frail elderly mother, Maria, who lives in North Carolina.
She is worried that without additional support, her mother will need to go into a nursing
home. Mrs. Sanchez asks you if there is any Medicare plan that might allow her mother
to remain in the community rather than going into a nursing home. How should you
advise Mrs. Sanchez? - ✔✔There are Programs of All-Inclusive Care for the Elderly
(PACE) for frail elderly beneficiaries certified as needing a nursing home level of care
but are able to live safely in the community at the time of enrolment.
✔✔Dr. Elizabeth Morgan does not contract with the ABC PFFS plan but accepts the
plan's terms and conditions for payment. Mary Rodgers sees Dr. Morgan for treatment.
How much may Dr. Morgan charge? - ✔✔Dr. Morgan can charge Mary Rogers 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% of the Medicare rate.
✔✔Mr. Pham is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare
Advantage HMO. Shortly thereafter, Mr. Pham visits his primary care provider (PCP),
Dr. Maria Sanchez. Mr. Pham complains of a bad cold and receives care - a Medicare-
covered service. The normal copayment is $40. How much may Dr. Sanchez collects? -
✔✔The minimal copayment that would apply under Medicaid, regardless of what the
plan requires of other enrollees.
✔✔Raymond 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? - ✔✔C-SNP
✔✔Mrs. Nelson likes a Private Fee-for-Service (PFFS) plan available in her area that
does not include drug coverage. She wants to enroll in the plan and enroll in a stand-
alone prescription drug plan. What should you tell her? - ✔✔She could enroll in a PFFS
plan and a stand-alone Medicare prescription drug plan.
✔✔Mrs. Nguyen is a retired federal worker with coverage under a Federal Employee
Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn
65 and become Medicare eligible for the first time. What issues might she consider
about whether to enroll in a Medicare prescription drug plan? - ✔✔She could compare
the coverage to see if the Medicare Part D plan offers better benefits and coverage than
the FEHB plan for the specific medications she needs and whether any additional
benefits are worth the Part D premium costs on top of her FEHB contribution.
✔✔Mrs. Duran is enrolled in a prescription drug plan. She has heard about something
called True-Out-Pocket costs or "TrOOP" and asks you if any of the following count
toward reaching the catastrophic coverage phase. What do you say?
I. Her annual PDP deductible
II. Supplemental coverage provided by an employer group waiver plan
, III. The off formulary drug her doctor prescribed but she pays for because the plan
denied her exception request
IV. Her over-the-counter (OTC) allergy medication. - ✔✔I and II only
✔✔Mrs. Castro has just turned 65, is in excellent health and has a relatively high
income. She uses no medications and sees no reason to spend money on a Medicare
prescription drug plan if she does not need the coverage. She currently does not have
creditable coverage. What could you tell her about the implications of such a decision? -
✔✔If she does not sign up for a Medicare prescription drug plan as soon as she is
eligible to do so, and if she does sign up at a later date, her premium will be
permanently increased by 1% of the national average premium for every month that she
was not covered.
✔✔Which of the following individuals is most likely to be eligible to enroll in a Part D
Plan? - ✔✔Jose, a grandfather who was granted asylum and has worked in the United
States for many years.
✔✔Mrs. Esmeralda Avila is a Medicare beneficiary enrolled in a MA-PD plan you
represent. Her neighbor recently suffered from a painful case of shingles. Mrs. Avila
hopes to avoid such an illness through vaccination. She asks you whether the cost of
the shingles vaccination will be covered under the plan you represent. What should you
say? - ✔✔Yes, there is no cost sharing for the shingles vaccine even in the deductible
phase of her prescription drug plan because it is an adult vaccine recommended by the
Advisory Committee on Immunization Practices (AICP).
✔✔Mrs. Russo is entitled to Part A and has medical coverage without drug coverage
through an employer retiree plan. She is not enrolled in Part B. Since the employer plan
does not cover prescription drugs, she wants to enroll in a Medicare prescription drug
plan. Will she be able to? - ✔✔Yes. Mrs. Russo must be entitled to Part A and/or
enrolled in Part B to be eligible for coverage under the Medicare prescription drug
program.
✔✔Mrs. Willis has a rare condition for which two different brand name drugs are the
only available treatment. She is concerned that since no generic prescription drugs are
available and these drugs are very high cost, she will not be able to find a Medicare Part
D prescription drug plan that covers either one of them. What should you tell her? -
✔✔Medicare prescription drug plans are required to cover drugs in each therapeutic
category. She should be able to enroll in a Medicare prescription drug plan that covers
the medications she needs.
✔✔Mrs. McFarren is enrolled in her state's Medicaid plan and has just become eligible
for Medicare as well. What can she expect will happen to her drug coverage? -
✔✔Unless she chooses a Medicare Part D prescription drug plan on her own, she will
be automatically enrolled in one available in her area.
