2025 AHIP Medicare Certification
Final Exam: Master Compliance,
Coverage & Ethics
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? - Answer He may sign-up for Medicare at any time
however coverage usually begins on the fourth month after dialysis
treatments start.
Mrs. 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.
One of your clients, Lauren Nichols, has heard about a Medicare concept
from one of her neighbors called TrOOP. She asks you to explain it.
What do you say? - Answer TrOOP stands for true out-of-
pocket costs that count toward the Medicare Part D catastrophic limit
,and include not only expenses paid by a beneficiary but also in some
instances amounts paid by or through qualified State Pharmaceutical
Assistance Programs.
Ms. Edwards 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?
- Answer She may fill prescriptions for covered drugs at non-
network pharmacies, but likely at a higher cost than paid at an in-
network pharmacy.
Mrs. Roswell is a new Medicare beneficiary who has just retired from
retail work. She is interested in selecting a Medicare Part D prescription
drug plan. She takes several medications and is concerned that she has
not been able to identify a plan that covers all of her medications. She
does not want to make an abrupt change to new drugs that would be
covered and asks what she should do. What should you tell her? -
Answer Every Part D drug plan is required to cover a single
one-month fill of her existing medications sometime during a 90-day
transition period.
Mrs. Geisler's neighbor told her she should look at her Part D options
during the annual Medicare enrollment period because the features of
Part D might have changed. Mrs. Geisler can't remember what Part D is
so she called you to ask what her neighbor was talking about. What
could you tell her? - Answer Part D covers prescription drugs
,and she should look at her premiums, formulary, and cost-sharing among
other factors to see if they have changed.
Mr. 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.
Mr. Xi will soon turn age 65 and has come to you for advice as to what
services are provided under Original Medicare. What should you tell Mr.
Xi that best describes the health coverage provided to Medicare
beneficiaries? - Answer Beneficiaries under Original
Medicare have no cost-sharing for most preventive services.
Mr. Singh would like drug coverage but does not want to be enrolled in a
Medicare Advantage plan. What should you tell him? - Answer
Mr. Singh can enroll in a stand-alone prescription drug plan and
continue to be covered for Part A and Part B services through Original
Fee-for-Service Medicare.
Mrs. 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.
Mrs. Quinn recently turned 66 and decided after many years of work to
retire and begin receiving Social Security benefits. Shortly thereafter
Mrs. Quinn received a letter informing her that she had been
automatically enrolled in Medicare Part B. She wants to understand what
this means. What should you tell Mrs. Quinn? - Answer Part
B primarily covers physician services. She will be paying a monthly
premium and, except for many preventive and screening tests, generally
will have 20% co-payments for these services, in addition to an annual
deductible.
Mr. Patel is in good health and is preparing a budget in anticipation of
his retirement when he turns 66. He wants to understand the health care
costs he might be exposed to under Medicare if he were to require
hospitalization because of an illness. In general terms, what could you
tell him about his costs for inpatient hospital services under Original
Medicare? - Answer Under Original Medicare, there is a
single deductible amount due for the first 60 days of any inpatient
hospital stay, after which it converts into a per-day coinsurance amount
through day 90. After day 90, he would pay a daily amount up to 60 days
over his lifetime, after which he would be responsible for all costs.
Final Exam: Master Compliance,
Coverage & Ethics
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? - Answer He may sign-up for Medicare at any time
however coverage usually begins on the fourth month after dialysis
treatments start.
Mrs. 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.
One of your clients, Lauren Nichols, has heard about a Medicare concept
from one of her neighbors called TrOOP. She asks you to explain it.
What do you say? - Answer TrOOP stands for true out-of-
pocket costs that count toward the Medicare Part D catastrophic limit
,and include not only expenses paid by a beneficiary but also in some
instances amounts paid by or through qualified State Pharmaceutical
Assistance Programs.
Ms. Edwards 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?
- Answer She may fill prescriptions for covered drugs at non-
network pharmacies, but likely at a higher cost than paid at an in-
network pharmacy.
Mrs. Roswell is a new Medicare beneficiary who has just retired from
retail work. She is interested in selecting a Medicare Part D prescription
drug plan. She takes several medications and is concerned that she has
not been able to identify a plan that covers all of her medications. She
does not want to make an abrupt change to new drugs that would be
covered and asks what she should do. What should you tell her? -
Answer Every Part D drug plan is required to cover a single
one-month fill of her existing medications sometime during a 90-day
transition period.
Mrs. Geisler's neighbor told her she should look at her Part D options
during the annual Medicare enrollment period because the features of
Part D might have changed. Mrs. Geisler can't remember what Part D is
so she called you to ask what her neighbor was talking about. What
could you tell her? - Answer Part D covers prescription drugs
,and she should look at her premiums, formulary, and cost-sharing among
other factors to see if they have changed.
Mr. 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.
Mr. Xi will soon turn age 65 and has come to you for advice as to what
services are provided under Original Medicare. What should you tell Mr.
Xi that best describes the health coverage provided to Medicare
beneficiaries? - Answer Beneficiaries under Original
Medicare have no cost-sharing for most preventive services.
Mr. Singh would like drug coverage but does not want to be enrolled in a
Medicare Advantage plan. What should you tell him? - Answer
Mr. Singh can enroll in a stand-alone prescription drug plan and
continue to be covered for Part A and Part B services through Original
Fee-for-Service Medicare.
Mrs. 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.
Mrs. Quinn recently turned 66 and decided after many years of work to
retire and begin receiving Social Security benefits. Shortly thereafter
Mrs. Quinn received a letter informing her that she had been
automatically enrolled in Medicare Part B. She wants to understand what
this means. What should you tell Mrs. Quinn? - Answer Part
B primarily covers physician services. She will be paying a monthly
premium and, except for many preventive and screening tests, generally
will have 20% co-payments for these services, in addition to an annual
deductible.
Mr. Patel is in good health and is preparing a budget in anticipation of
his retirement when he turns 66. He wants to understand the health care
costs he might be exposed to under Medicare if he were to require
hospitalization because of an illness. In general terms, what could you
tell him about his costs for inpatient hospital services under Original
Medicare? - Answer Under Original Medicare, there is a
single deductible amount due for the first 60 days of any inpatient
hospital stay, after which it converts into a per-day coinsurance amount
through day 90. After day 90, he would pay a daily amount up to 60 days
over his lifetime, after which he would be responsible for all costs.
