AHIP Final examination
2022/2023
1. 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 >>> 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.
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 >>> 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.
3. 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 be- cause 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 >>> You can offer to review the plans
appeal process to help him ask the plan to review the coverage
decision.
4. 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 >>> a. Yes. All SNPs
1 / 10
,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.
= ?????
5. 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
2 / 10
, following must Phiona consider >>> 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.
6. 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 >>>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.
7. 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 >>> 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.
8. 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 >>> Mr. Wu may still qualify
for help in paying Part D costs through his State Pharmaceutical
Assistance Program.
9. 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 >>>
10. 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 >>> a. Due to the provisions of MACRA, his
Part B and D coverage will be combined and covered through a low-
3 / 10
2022/2023
1. 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 >>> 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.
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 >>> 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.
3. 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 be- cause 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 >>> You can offer to review the plans
appeal process to help him ask the plan to review the coverage
decision.
4. 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 >>> a. Yes. All SNPs
1 / 10
,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.
= ?????
5. 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
2 / 10
, following must Phiona consider >>> 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.
6. 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 >>>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.
7. 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 >>> 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.
8. 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 >>> Mr. Wu may still qualify
for help in paying Part D costs through his State Pharmaceutical
Assistance Program.
9. 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 >>>
10. 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 >>> a. Due to the provisions of MACRA, his
Part B and D coverage will be combined and covered through a low-
3 / 10
