2023 AHIP QUESTIONS & ANSWERS(LATEST
UPDATE)
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? -
ANSWER He may sign-up for Medicare at any time however coverage usually begins on the fourth month
after dialysis treatments start.
Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap,
Incorporated. Smallcap has a workforce of15 employees and offers employer-sponsored healthcare
coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years.
Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer-
sponsored healthcare coverage. How would you respond? - ANSWER Juan is likely to be eligible for
Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his
healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those
under age 65 under its employer-sponsored group health plan.
Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare
Supplemental Insurance provides since his health care needs are different from his wife's needs. What
could you tell Mr. Moy? - ANSWER Medicare Supplemental Insurance would help cover his Part A and
Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some
services that Medicare does not cover.
Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must
enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? -
ANSWER She may enroll at any time while she is covered under her employer plan, but she will have a
special eight-month enrollment period after the last month on her employer plan that differs from the
standard general enrollment period, during which she may enroll in Medicare Part B.
Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes
during that entire period. She is concerned that she will not qualify for coverage under part A because
she was not born in the United States. What should you tell her? - ANSWER Most individuals who are
citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while
working, though some may be covered as a result of paying monthly premiums.
, Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug
coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one
that provides drug coverage. What should you tell her? - ANSWER Mrs. Gonzalez cannot purchase a
Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D
prescription drug plan.
Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary
Notice (MSN) and disagrees with a determination that partially denied one of her claims for services.
What advice would you give her? - ANSWER Mrs. Duarte should file an appeal of this initial
determination within 120 days of the date she received the MSN in the mail.
Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs
not covered by that plan.
What should you tell him? - ANSWER It is illegal for you to sell Mr. Capadona a Medigap plan if he is
enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be
of assistance? - ANSWER She should contact her state Medicaid agency to see if she qualifies for one of
several programs that can help with Medicare costs for which she is responsible.
Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What
should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital
stay that Medicare will cover? - ANSWER Medicare will cover a total of 190 days of inpatient psychiatric
care during Mr. Rainey's entire lifetime.
Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-
Service (FFS) Medicare? What could you tell him? - ANSWER Part A, which covers hospital, skilled nursing
facility, hospice, and home health services and Part B, which covers professional services such as those
provided by a doctor are covered under Original Medicare.
Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare
Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for
several years. However, the plan does not provide drug benefits. How would you advise Agent John
Miller to proceed? - ANSWER Tell prospect Jerry Smith that he should consider adding a standalone Part
D prescription drug coverage policy to his present coverage.
, Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security
Administration and has been receiving disability payments. He is wondering whether he can obtain
coverage under Medicare. What should you tell him? - ANSWER After receiving such disability payments
for 24 months, he will be automatically enrolled in Medicare, regardless of age.
Buck has several family members who died from different cancers. He wants to know if Medicare covers
cancer screening.
What should you tell him? - ANSWER Medicare covers the periodic performance of a range of screening
tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests
before obtaining them to see if they will be covered.
Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans?
I. MSAs may have either a partial network, full network, or no network of providers.
II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed
for inflation.
IV. Non-network providers must accept the same amount that Original Medicare would pay them as
payment in full. - ANSWER I, II, and IV only
Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three
plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include drug
coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug
coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug
plan. What should you tell him about this situation? - ANSWER He could enroll either in one of the MA
plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone
Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone
prescription drug plan.
Ramos 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? - ANSWER Mrs. Ramos 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.
UPDATE)
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? -
ANSWER He may sign-up for Medicare at any time however coverage usually begins on the fourth month
after dialysis treatments start.
Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap,
Incorporated. Smallcap has a workforce of15 employees and offers employer-sponsored healthcare
coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years.
Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer-
sponsored healthcare coverage. How would you respond? - ANSWER Juan is likely to be eligible for
Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his
healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those
under age 65 under its employer-sponsored group health plan.
Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare
Supplemental Insurance provides since his health care needs are different from his wife's needs. What
could you tell Mr. Moy? - ANSWER Medicare Supplemental Insurance would help cover his Part A and
Part B deductibles or coinsurance in Original Fee-for-Service (FFS) Medicare as well as possibly some
services that Medicare does not cover.
Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She heard she must
enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell her? -
ANSWER She may enroll at any time while she is covered under her employer plan, but she will have a
special eight-month enrollment period after the last month on her employer plan that differs from the
standard general enrollment period, during which she may enroll in Medicare Part B.
Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid taxes
during that entire period. She is concerned that she will not qualify for coverage under part A because
she was not born in the United States. What should you tell her? - ANSWER Most individuals who are
citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while
working, though some may be covered as a result of paying monthly premiums.
, Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug
coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one
that provides drug coverage. What should you tell her? - ANSWER Mrs. Gonzalez cannot purchase a
Medigap plan that covers drugs, but she could keep her Medigap policy and enroll in a Part D
prescription drug plan.
Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary
Notice (MSN) and disagrees with a determination that partially denied one of her claims for services.
What advice would you give her? - ANSWER Mrs. Duarte should file an appeal of this initial
determination within 120 days of the date she received the MSN in the mail.
Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs
not covered by that plan.
What should you tell him? - ANSWER It is illegal for you to sell Mr. Capadona a Medigap plan if he is
enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be
of assistance? - ANSWER She should contact her state Medicaid agency to see if she qualifies for one of
several programs that can help with Medicare costs for which she is responsible.
Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized. What
should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric hospital
stay that Medicare will cover? - ANSWER Medicare will cover a total of 190 days of inpatient psychiatric
care during Mr. Rainey's entire lifetime.
Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-
Service (FFS) Medicare? What could you tell him? - ANSWER Part A, which covers hospital, skilled nursing
facility, hospice, and home health services and Part B, which covers professional services such as those
provided by a doctor are covered under Original Medicare.
Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare
Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan which he has had for
several years. However, the plan does not provide drug benefits. How would you advise Agent John
Miller to proceed? - ANSWER Tell prospect Jerry Smith that he should consider adding a standalone Part
D prescription drug coverage policy to his present coverage.
, Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security
Administration and has been receiving disability payments. He is wondering whether he can obtain
coverage under Medicare. What should you tell him? - ANSWER After receiving such disability payments
for 24 months, he will be automatically enrolled in Medicare, regardless of age.
Buck has several family members who died from different cancers. He wants to know if Medicare covers
cancer screening.
What should you tell him? - ANSWER Medicare covers the periodic performance of a range of screening
tests that are meant to provide early detection of disease. Mr. Buck will need to check specific tests
before obtaining them to see if they will be covered.
Which of the following statement is/are correct about a Medicare Savings Account (MSA) Plans?
I. MSAs may have either a partial network, full network, or no network of providers.
II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500 indexed
for inflation.
IV. Non-network providers must accept the same amount that Original Medicare would pay them as
payment in full. - ANSWER I, II, and IV only
Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three
plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include drug
coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug
coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug
plan. What should you tell him about this situation? - ANSWER He could enroll either in one of the MA
plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone
Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone
prescription drug plan.
Ramos 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? - ANSWER Mrs. Ramos 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.
