AHIP Final Examination Questions and Answers
(2023) (Verified Answers)
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 ANS
Mr.Zachow has a right to request a formulary exception to obtain coverage for his
PartD drug. He or his physician could obtain the standardized request form on the
plan'swebsite, 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 ANS The POS
optionmight 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 willhave 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
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
theplan 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 ANS a. Yes. All SNPs are required to
providePart 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
following must Phiona consider ANS II. All data elements required to complete
anenrollment 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 ANS Step therapy involves using one or more
lowerpriced 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 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.
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 ANS Mr. Wu may still qualify for help in paying Part
D costs through his State Pharmaceutical Assistance Program.
(2023) (Verified Answers)
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 ANS
Mr.Zachow has a right to request a formulary exception to obtain coverage for his
PartD drug. He or his physician could obtain the standardized request form on the
plan'swebsite, 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 ANS The POS
optionmight 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 willhave 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
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
theplan 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 ANS a. Yes. All SNPs are required to
providePart 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
following must Phiona consider ANS II. All data elements required to complete
anenrollment 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 ANS Step therapy involves using one or more
lowerpriced 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 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.
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 ANS Mr. Wu may still qualify for help in paying Part
D costs through his State Pharmaceutical Assistance Program.
