2022 AHIP Study Guide (including FWA, Discrimination & Compliance)
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.
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.
Mr. 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.
Mrs. 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.
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. 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.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from
arthritis through massage therapy. She is concerned about whether or not Medicare will
cover these items and services. What should you tell her? –
Answer: : Medicare does not cover massage therapy, or, in general, glasses or
dentures.
,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 as a result 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.
Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65,
without paying any premiums, because she has been working for 40 years and paying
Medicare taxes. What should you tell her? –
Answer: : To obtain Part B coverage, she must pay a standard monthly premium,
though it is higher for individuals with higher incomes.
Mr. Alonso receives some help paying for his two generic prescription drugs from his
employer's retiree coverage, but he wants to compare it to a Part D prescription drug
plan. He asks you what costs he would generally expect to encounter when enrolling
into a standard Medicare Part D prescription drug plan. What should you tell him? -
Answer: : He generally would pay a monthly premium, annual deductible, and per-
prescription cost-sharing.
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health
and will have considerable income when she retires. She is concerned that her income
will make it impossible for her to qualify for Medicare. What could you tell her to address
her concern? –
Answer: : Medicare is a program for people age 65 or older and those under age 65
with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will
be eligible for Medicare.
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 which include immunizations such as annual flu shots.
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.
Mr. 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.
Mrs. 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.
, 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. 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.
Mr. 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.
Mr. 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
Mr. 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.
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.
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.
Mr. 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.
Mrs. 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.
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. 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.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from
arthritis through massage therapy. She is concerned about whether or not Medicare will
cover these items and services. What should you tell her? –
Answer: : Medicare does not cover massage therapy, or, in general, glasses or
dentures.
,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 as a result 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.
Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65,
without paying any premiums, because she has been working for 40 years and paying
Medicare taxes. What should you tell her? –
Answer: : To obtain Part B coverage, she must pay a standard monthly premium,
though it is higher for individuals with higher incomes.
Mr. Alonso receives some help paying for his two generic prescription drugs from his
employer's retiree coverage, but he wants to compare it to a Part D prescription drug
plan. He asks you what costs he would generally expect to encounter when enrolling
into a standard Medicare Part D prescription drug plan. What should you tell him? -
Answer: : He generally would pay a monthly premium, annual deductible, and per-
prescription cost-sharing.
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health
and will have considerable income when she retires. She is concerned that her income
will make it impossible for her to qualify for Medicare. What could you tell her to address
her concern? –
Answer: : Medicare is a program for people age 65 or older and those under age 65
with certain disabilities, end-stage renal disease, and Lou Gehrig's disease so she will
be eligible for Medicare.
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 which include immunizations such as annual flu shots.
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.
Mr. 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.
Mrs. 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.
, 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. 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.
Mr. 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.
Mr. 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
Mr. 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.
