AHIP - Final examination/ Questions &
Answers Updated 2024-2025
Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for
Medicare as well. He is concerned about changes in his cost-sharing. What should you
tell him? - CORRECT ANSWERS-He should know that Medicaid will pay cost sharing
only for services provided by Medicaid participating providers.
Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or
list of covered drugs. He is suspicious about how plans establish these formularies.
What should you tell him? - CORRECT ANSWERS-Formularies must be developed
with input from pharmacists, doctors, and other experts.
Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage
(MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the
neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about
the kinds of food that can be provided to potential enrollees who attend the sales
presentation? - CORRECT ANSWERS-A meal cannot be provided, but light
snacks would be permitted.
Mr. Jackson just turned 65. He has been seeing the same general practitioner for
annual check-ups for the past 15 years, likes these yearly visits, and would like to
continue obtaining these services as a Medicare beneficiary. What should you tell him
about annual check-ups? - CORRECT ANSWERS-
Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her
area. Ms. Levi often travels to visit relatives and is concerned that she may need
emergency care outside of her plan's service area. What should you tell her about
coverage of emergency care? - CORRECT ANSWERS-Plans are required to cover out-
of network emergency care.
Which of the following individuals are likely to qualify for a special enrollment period
(SEP) for both MA and Part D due to a change of residence?
I. Edward (enrolled in MA and Part D) moves to a new home within the same
neighborhood in his existing plan's service area.
II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her
existing plan's service area.
III. Gilbert moves into a plan service area where there is now a Part D plan available to
him from a service area where no Part D plan was available.
IV. Henry makes a permanent move providing him with new MA and Part D options. -
CORRECT ANSWERS-II, III, and IV only
, Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted
with regard to the marketing of Medicare health plans, he doesn't have much to worry
about. What might you, as his colleague, advise him concerning the type of scrutiny he
will be under? - CORRECT ANSWERS-Organizations sponsoring Medicare
health plans are responsible for the behavior of their contracted representatives and will
be conducting
monitoring activities to ensure compliance with all applicable Federal
law and guidance and plan policies.
Furthermore, state agent licensure laws are not preempted and he must abide by their
requirements.
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? - CORRECT ANSWERS-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.
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? - CORRECT ANSWERS-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.
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? - CORRECT ANSWERS-You can offer to review the
plans appeal process to help him ask the plan to review the coverage decision.
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? - CORRECT ANSWERS-a. Yes. All SNPs 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.
= ?????
Answers Updated 2024-2025
Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for
Medicare as well. He is concerned about changes in his cost-sharing. What should you
tell him? - CORRECT ANSWERS-He should know that Medicaid will pay cost sharing
only for services provided by Medicaid participating providers.
Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or
list of covered drugs. He is suspicious about how plans establish these formularies.
What should you tell him? - CORRECT ANSWERS-Formularies must be developed
with input from pharmacists, doctors, and other experts.
Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage
(MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the
neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about
the kinds of food that can be provided to potential enrollees who attend the sales
presentation? - CORRECT ANSWERS-A meal cannot be provided, but light
snacks would be permitted.
Mr. Jackson just turned 65. He has been seeing the same general practitioner for
annual check-ups for the past 15 years, likes these yearly visits, and would like to
continue obtaining these services as a Medicare beneficiary. What should you tell him
about annual check-ups? - CORRECT ANSWERS-
Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her
area. Ms. Levi often travels to visit relatives and is concerned that she may need
emergency care outside of her plan's service area. What should you tell her about
coverage of emergency care? - CORRECT ANSWERS-Plans are required to cover out-
of network emergency care.
Which of the following individuals are likely to qualify for a special enrollment period
(SEP) for both MA and Part D due to a change of residence?
I. Edward (enrolled in MA and Part D) moves to a new home within the same
neighborhood in his existing plan's service area.
II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her
existing plan's service area.
III. Gilbert moves into a plan service area where there is now a Part D plan available to
him from a service area where no Part D plan was available.
IV. Henry makes a permanent move providing him with new MA and Part D options. -
CORRECT ANSWERS-II, III, and IV only
, Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted
with regard to the marketing of Medicare health plans, he doesn't have much to worry
about. What might you, as his colleague, advise him concerning the type of scrutiny he
will be under? - CORRECT ANSWERS-Organizations sponsoring Medicare
health plans are responsible for the behavior of their contracted representatives and will
be conducting
monitoring activities to ensure compliance with all applicable Federal
law and guidance and plan policies.
Furthermore, state agent licensure laws are not preempted and he must abide by their
requirements.
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? - CORRECT ANSWERS-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.
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? - CORRECT ANSWERS-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.
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? - CORRECT ANSWERS-You can offer to review the
plans appeal process to help him ask the plan to review the coverage decision.
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? - CORRECT ANSWERS-a. Yes. All SNPs 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.
= ?????
