AHIP - Final Examination (Latest Update 2025) real
exam!!!
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.
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.
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? - 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? - 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.
= ?????
, 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? - 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.
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.
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.
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.
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? -
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-cost
Medigap policy to supplement his Part A coverage.
b. Due to his participation in the workforce he will not have to pay premiums for Part A and he
will pay the lowest monthly premium rates for Part B and Part D.
c. Due to his participation in the workforce he will not have to pay premiums for Part A but he
will pay higher premiums for Part B and Part D due to the amount of his income.
exam!!!
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.
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.
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? - 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? - 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.
= ?????
, 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? - 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.
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.
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.
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.
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? -
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-cost
Medigap policy to supplement his Part A coverage.
b. Due to his participation in the workforce he will not have to pay premiums for Part A and he
will pay the lowest monthly premium rates for Part B and Part D.
c. Due to his participation in the workforce he will not have to pay premiums for Part A but he
will pay higher premiums for Part B and Part D due to the amount of his income.
