, AHIP Final Exam — Questions With Answers and Explanations
Question 1.
Mr. Carlini has heard that Medicare prescription drug plans are only offered through
private companies under a program known as Medicare Advantage (MA), not by the
government. He likes Original Medicare and does not want to sign up for an MA product,
but he also wants prescription drug coverage. What should you tell him?
A. He must enroll in a Medicare Advantage plan to get prescription drug coverage.
B. He can stay with Original Medicare and also enroll in a a Medicare prescription drug plan
through a private company that has contracted with the government to provide only such
drug coverage.
C. He cannot get prescription drug coverage unless he enrolls in a Medicare Advantage
plan.
D. He should wait until he turns 65 to enroll in a prescription drug plan.
Correct Answer: B. He can stay with Original Medicare and also enroll in a
Medicare prescription drug plan through a private company that has contracted
with the government to provide only such drug coverage.
Explanation: Beneficiaries can remain in Original Medicare (Parts A and B) and enroll in a
standalone Medicare Prescription Drug Plan (PDP) offered by a private company that
contracts with CMS. PDPs are available to all Medicare beneficiaries regardless of whether
they are in Original Medicare or a Medicare Advantage plan. Enrolling in a Medicare
Advantage plan is not required to obtain prescription drug coverage. Waiting until age 65
is unnecessary as Medicare eligibility can begin earlier under certain circumstances.
Question 2.
Ms. Ramos is enrolled in a Medicare Advantage plan that includes prescription drug plan
(PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has
lost. How would you advise her?
A. She must return to her home state to fill any prescriptions under her plan.
B. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a
higher cost than paid at an in-network pharmacy.
C. She cannot fill prescriptions outside of her plan's network under any circumstances.
D. She can fill prescriptions at any pharmacy for the same cost as in-network pharmacies.
Correct Answer: B. She may fill prescriptions for covered drugs at non-network
pharmacies, but likely at a higher cost than paid at an in-network pharmacy.
Explanation: Medicare Advantage prescription drug plans typically allow enrollees to fill
prescriptions at non-network pharmacies when traveling, but the cost-sharing is usually
higher than at in-network pharmacies. Plans are not required to cover non-network
pharmacy charges at the same level as in-network pharmacies. This provides flexibility for
travelers while maintaining cost incentives to use network pharmacies. Beneficiaries
should check their specific plan's coverage rules before filling prescriptions away from
home.
,Question 3.
Which of the following requires intent to obtain payment and the knowledge that the
actions are wrong?
A. Waste
B. Abuse
C. Fraud
D. Negligence
Correct Answer: C. Fraud
Explanation: Fraud requires intent to obtain payment and the knowledge that the actions
are wrong. Unlike waste or abuse, which may occur without malicious intent, fraud
involves deliberate deception or misrepresentation made with the knowledge that the
action is improper. Waste involves the overuse of services without intentional wrongdoing,
and abuse involves practices that are inconsistent with accepted medical practices.
Negligence involves a failure to exercise reasonable care without the specific intent to
deceive.
Question 4.
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease
(ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under
Medicare. What should you tell him?
A. He is not eligible for Medicare until age 65 regardless of his condition.
B. He may sign up for Medicare at any time, but coverage usually begins on the fourth
month after dialysis treatments start.
C. He must wait until he has been on dialysis for at least one year before applying.
D. He is eligible for Medicare only if he also has a disability that has lasted 24 months.
Correct Answer: B. He may sign up for Medicare at any time, but coverage
usually begins on the fourth month after dialysis treatments start.
Explanation: Individuals with ESRD are eligible for Medicare regardless of age. Coverage
generally begins on the fourth month after a regular course of dialysis begins. However, if
the individual participates in a home dialysis training program, coverage may begin
sooner. This special eligibility rule allows younger individuals with severe kidney disease to
access Medicare coverage without waiting until age 65.
Question 5.
What types of tools can Medicare Part D prescription drug plans use that affect the way
their enrollees can access medications?
A. Plans must cover all medications without any restrictions.
B. Plans can use formularies, tiered copayments, and step therapy as cost containment
techniques.
C. Plans can only use prior authorization but no other restrictions.
D. Plans cannot use any form of cost containment under CMS regulations.
Correct Answer: B. Plans can use formularies, tiered copayments, and step
therapy as cost containment techniques.
, Explanation: Part D plans are not required to cover all medications and can use
formularies (lists of covered drugs) that vary from plan to plan. They may also employ cost
containment techniques such as tiered copayments, prior authorization, step therapy, and
quantity limits. These tools help manage costs while still providing access to medically
necessary medications. Beneficiaries should review plan formularies carefully to ensure
their medications are covered.
Question 6.
A beneficiary is enrolled in Original Medicare and is considering a Medicare Supplement
(Medigap) policy. Which of the following statements about Medigap is correct?
A. Medigap policies can be used to cover copayments and deductibles in Medicare
Advantage plans.
B. Medigap policies work alongside Original Medicare to cover out-of-pocket costs such as
coinsurance and deductibles.
C. Medigap policies include prescription drug coverage as a standard benefit.
D. Medigap policies are available to all beneficiaries regardless of enrollment in Medicare
Advantage.
Correct Answer: B. Medigap policies work alongside Original Medicare to cover
out-of-pocket costs such as coinsurance and deductibles.
Explanation: Medigap policies are designed to supplement Original Medicare by covering
some or all of the out-of-pocket costs such as coinsurance, copayments, and deductibles.
They do not work with Medicare Advantage plans; beneficiaries cannot use a Medigap
policy to pay Medicare Advantage cost-sharing. Medigap policies do not include
prescription drug coverage as a standard benefit—beneficiaries must enroll in a separate
Part D plan for drug coverage.
Question 7.
Mrs. Esmeralda Avila is a Medicare beneficiary enrolled in an MA-PD plan you represent.
She asks whether the cost of the shingles vaccination will be covered under the plan. What
should you say?
A. No, vaccines are not covered under Medicare Part D.
B. Yes, there is no cost sharing for the shingles vaccine even in the deductible phase
because it is an adult vaccine recommended by the Advisory Committee on Immunization
Practices (ACIP).
C. Yes, but only after she meets her annual deductible.
D. Only if she obtains prior authorization from the plan.
Correct Answer: B. Yes, there is no cost sharing for the shingles vaccine even in
the deductible phase because it is an adult vaccine recommended by the
Advisory Committee on Immunization Practices (ACIP).
Explanation: Under the Inflation Reduction Act, adult vaccines recommended by the ACIP
are covered with no cost sharing under Medicare Part D, even during the deductible phase.
This includes vaccines such as shingles, pneumococcal, and influenza vaccines.
Beneficiaries do not need to meet their deductible or pay copayments for these covered
vaccines. This policy helps improve vaccination rates among Medicare beneficiaries.
Question 1.
Mr. Carlini has heard that Medicare prescription drug plans are only offered through
private companies under a program known as Medicare Advantage (MA), not by the
government. He likes Original Medicare and does not want to sign up for an MA product,
but he also wants prescription drug coverage. What should you tell him?
A. He must enroll in a Medicare Advantage plan to get prescription drug coverage.
B. He can stay with Original Medicare and also enroll in a a Medicare prescription drug plan
through a private company that has contracted with the government to provide only such
drug coverage.
C. He cannot get prescription drug coverage unless he enrolls in a Medicare Advantage
plan.
D. He should wait until he turns 65 to enroll in a prescription drug plan.
Correct Answer: B. He can stay with Original Medicare and also enroll in a
Medicare prescription drug plan through a private company that has contracted
with the government to provide only such drug coverage.
Explanation: Beneficiaries can remain in Original Medicare (Parts A and B) and enroll in a
standalone Medicare Prescription Drug Plan (PDP) offered by a private company that
contracts with CMS. PDPs are available to all Medicare beneficiaries regardless of whether
they are in Original Medicare or a Medicare Advantage plan. Enrolling in a Medicare
Advantage plan is not required to obtain prescription drug coverage. Waiting until age 65
is unnecessary as Medicare eligibility can begin earlier under certain circumstances.
Question 2.
Ms. Ramos is enrolled in a Medicare Advantage plan that includes prescription drug plan
(PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has
lost. How would you advise her?
A. She must return to her home state to fill any prescriptions under her plan.
B. She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a
higher cost than paid at an in-network pharmacy.
C. She cannot fill prescriptions outside of her plan's network under any circumstances.
D. She can fill prescriptions at any pharmacy for the same cost as in-network pharmacies.
Correct Answer: B. She may fill prescriptions for covered drugs at non-network
pharmacies, but likely at a higher cost than paid at an in-network pharmacy.
Explanation: Medicare Advantage prescription drug plans typically allow enrollees to fill
prescriptions at non-network pharmacies when traveling, but the cost-sharing is usually
higher than at in-network pharmacies. Plans are not required to cover non-network
pharmacy charges at the same level as in-network pharmacies. This provides flexibility for
travelers while maintaining cost incentives to use network pharmacies. Beneficiaries
should check their specific plan's coverage rules before filling prescriptions away from
home.
,Question 3.
Which of the following requires intent to obtain payment and the knowledge that the
actions are wrong?
A. Waste
B. Abuse
C. Fraud
D. Negligence
Correct Answer: C. Fraud
Explanation: Fraud requires intent to obtain payment and the knowledge that the actions
are wrong. Unlike waste or abuse, which may occur without malicious intent, fraud
involves deliberate deception or misrepresentation made with the knowledge that the
action is improper. Waste involves the overuse of services without intentional wrongdoing,
and abuse involves practices that are inconsistent with accepted medical practices.
Negligence involves a failure to exercise reasonable care without the specific intent to
deceive.
Question 4.
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease
(ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under
Medicare. What should you tell him?
A. He is not eligible for Medicare until age 65 regardless of his condition.
B. He may sign up for Medicare at any time, but coverage usually begins on the fourth
month after dialysis treatments start.
C. He must wait until he has been on dialysis for at least one year before applying.
D. He is eligible for Medicare only if he also has a disability that has lasted 24 months.
Correct Answer: B. He may sign up for Medicare at any time, but coverage
usually begins on the fourth month after dialysis treatments start.
Explanation: Individuals with ESRD are eligible for Medicare regardless of age. Coverage
generally begins on the fourth month after a regular course of dialysis begins. However, if
the individual participates in a home dialysis training program, coverage may begin
sooner. This special eligibility rule allows younger individuals with severe kidney disease to
access Medicare coverage without waiting until age 65.
Question 5.
What types of tools can Medicare Part D prescription drug plans use that affect the way
their enrollees can access medications?
A. Plans must cover all medications without any restrictions.
B. Plans can use formularies, tiered copayments, and step therapy as cost containment
techniques.
C. Plans can only use prior authorization but no other restrictions.
D. Plans cannot use any form of cost containment under CMS regulations.
Correct Answer: B. Plans can use formularies, tiered copayments, and step
therapy as cost containment techniques.
, Explanation: Part D plans are not required to cover all medications and can use
formularies (lists of covered drugs) that vary from plan to plan. They may also employ cost
containment techniques such as tiered copayments, prior authorization, step therapy, and
quantity limits. These tools help manage costs while still providing access to medically
necessary medications. Beneficiaries should review plan formularies carefully to ensure
their medications are covered.
Question 6.
A beneficiary is enrolled in Original Medicare and is considering a Medicare Supplement
(Medigap) policy. Which of the following statements about Medigap is correct?
A. Medigap policies can be used to cover copayments and deductibles in Medicare
Advantage plans.
B. Medigap policies work alongside Original Medicare to cover out-of-pocket costs such as
coinsurance and deductibles.
C. Medigap policies include prescription drug coverage as a standard benefit.
D. Medigap policies are available to all beneficiaries regardless of enrollment in Medicare
Advantage.
Correct Answer: B. Medigap policies work alongside Original Medicare to cover
out-of-pocket costs such as coinsurance and deductibles.
Explanation: Medigap policies are designed to supplement Original Medicare by covering
some or all of the out-of-pocket costs such as coinsurance, copayments, and deductibles.
They do not work with Medicare Advantage plans; beneficiaries cannot use a Medigap
policy to pay Medicare Advantage cost-sharing. Medigap policies do not include
prescription drug coverage as a standard benefit—beneficiaries must enroll in a separate
Part D plan for drug coverage.
Question 7.
Mrs. Esmeralda Avila is a Medicare beneficiary enrolled in an MA-PD plan you represent.
She asks whether the cost of the shingles vaccination will be covered under the plan. What
should you say?
A. No, vaccines are not covered under Medicare Part D.
B. Yes, there is no cost sharing for the shingles vaccine even in the deductible phase
because it is an adult vaccine recommended by the Advisory Committee on Immunization
Practices (ACIP).
C. Yes, but only after she meets her annual deductible.
D. Only if she obtains prior authorization from the plan.
Correct Answer: B. Yes, there is no cost sharing for the shingles vaccine even in
the deductible phase because it is an adult vaccine recommended by the
Advisory Committee on Immunization Practices (ACIP).
Explanation: Under the Inflation Reduction Act, adult vaccines recommended by the ACIP
are covered with no cost sharing under Medicare Part D, even during the deductible phase.
This includes vaccines such as shingles, pneumococcal, and influenza vaccines.
Beneficiaries do not need to meet their deductible or pay copayments for these covered
vaccines. This policy helps improve vaccination rates among Medicare beneficiaries.
