AHIP Final Exam Test
Questions and Answers
(2024/2025) GRADED A+
Answers Correct/Verified
1: Medicare Advantage Plan
: Maria, a 68-year-old Medicare beneficiary, is interested in enrolling in a Medicare Advantage
Plan. She has diabetes and requires regular medication. She is currently enrolled in Original
Medicare.
Question: What factors should Maria consider before enrolling in a Medicare Advantage Plan,
and how might her diabetes impact her choice?
Answer: Maria should consider the following factors:
● Network of Providers: Ensure that her preferred healthcare providers and specialists
are included in the plan's network.
● Coverage for Medications: Check the plan's formulary to see if her diabetes
medications are covered and at what cost.
● Out-of-Pocket Costs: Compare the plan’s premiums, deductibles, co-pays, and co-
insurance to her current costs under Original Medicare.
● Additional Benefits: Review any extra benefits the Medicare Advantage Plan might
offer, such as wellness programs or dental coverage.
Her diabetes might impact her choice in that she needs to ensure her medications and diabetes-
related treatments are covered adequately. She should also consider whether the plan’s
network includes the specialists she requires for her condition.
2: Compliance Issue
: A health insurance company discovered that one of its agents was providing misleading
information about coverage benefits to potential clients, resulting in several complaints and a
compliance review.
, Question: What steps should the company take to address this compliance issue and prevent it
from recurring?
Answer: The company should:
● Investigate the Issue: Conduct a thorough investigation to understand the extent of the
misleading information and its impact on clients.
● Take Disciplinary Action: If the agent is found to be at fault, appropriate disciplinary
action should be taken according to company policies.
● Implement Training: Provide additional training for all agents on compliance, ethical
behavior, and accurate representation of benefits.
● Review Marketing Materials: Ensure that all marketing materials and communications
are reviewed for accuracy and compliance with regulations.
● Monitor and Audit: Regularly monitor and audit agents' activities to prevent future
compliance issues.
3: Claims Processing
: John, a policyholder, submitted a claim for a procedure that was partially denied by his health
insurance company. He believes the denial was incorrect and wants to appeal the decision.
Question: What steps should John take to appeal the claim denial, and what information might
be necessary for the appeal?
Answer: John should:
● Review the Denial Notice: Carefully read the denial notice to understand the reason for
the denial and the appeal process.
● Gather Documentation: Collect all relevant documentation, including medical records,
bills, and any other evidence supporting the claim.
● Submit an Appeal: Follow the insurance company's appeal process, which typically
involves submitting a written appeal along with supporting documentation.
● Contact Customer Service: Reach out to customer service or a claims representative
for guidance on the appeal process and any additional information that may be required.
1: Eligibility for Medicare
: Linda, 64, is considering Medicare enrollment. She is currently covered under her employer's
health plan.
Question: What factors should Linda consider when deciding to enroll in Medicare at age 65?
Answer: Linda should consider:
● Current Coverage: Evaluate if her employer's health plan provides equivalent or better
coverage than Medicare.
Questions and Answers
(2024/2025) GRADED A+
Answers Correct/Verified
1: Medicare Advantage Plan
: Maria, a 68-year-old Medicare beneficiary, is interested in enrolling in a Medicare Advantage
Plan. She has diabetes and requires regular medication. She is currently enrolled in Original
Medicare.
Question: What factors should Maria consider before enrolling in a Medicare Advantage Plan,
and how might her diabetes impact her choice?
Answer: Maria should consider the following factors:
● Network of Providers: Ensure that her preferred healthcare providers and specialists
are included in the plan's network.
● Coverage for Medications: Check the plan's formulary to see if her diabetes
medications are covered and at what cost.
● Out-of-Pocket Costs: Compare the plan’s premiums, deductibles, co-pays, and co-
insurance to her current costs under Original Medicare.
● Additional Benefits: Review any extra benefits the Medicare Advantage Plan might
offer, such as wellness programs or dental coverage.
Her diabetes might impact her choice in that she needs to ensure her medications and diabetes-
related treatments are covered adequately. She should also consider whether the plan’s
network includes the specialists she requires for her condition.
2: Compliance Issue
: A health insurance company discovered that one of its agents was providing misleading
information about coverage benefits to potential clients, resulting in several complaints and a
compliance review.
, Question: What steps should the company take to address this compliance issue and prevent it
from recurring?
Answer: The company should:
● Investigate the Issue: Conduct a thorough investigation to understand the extent of the
misleading information and its impact on clients.
● Take Disciplinary Action: If the agent is found to be at fault, appropriate disciplinary
action should be taken according to company policies.
● Implement Training: Provide additional training for all agents on compliance, ethical
behavior, and accurate representation of benefits.
● Review Marketing Materials: Ensure that all marketing materials and communications
are reviewed for accuracy and compliance with regulations.
● Monitor and Audit: Regularly monitor and audit agents' activities to prevent future
compliance issues.
3: Claims Processing
: John, a policyholder, submitted a claim for a procedure that was partially denied by his health
insurance company. He believes the denial was incorrect and wants to appeal the decision.
Question: What steps should John take to appeal the claim denial, and what information might
be necessary for the appeal?
Answer: John should:
● Review the Denial Notice: Carefully read the denial notice to understand the reason for
the denial and the appeal process.
● Gather Documentation: Collect all relevant documentation, including medical records,
bills, and any other evidence supporting the claim.
● Submit an Appeal: Follow the insurance company's appeal process, which typically
involves submitting a written appeal along with supporting documentation.
● Contact Customer Service: Reach out to customer service or a claims representative
for guidance on the appeal process and any additional information that may be required.
1: Eligibility for Medicare
: Linda, 64, is considering Medicare enrollment. She is currently covered under her employer's
health plan.
Question: What factors should Linda consider when deciding to enroll in Medicare at age 65?
Answer: Linda should consider:
● Current Coverage: Evaluate if her employer's health plan provides equivalent or better
coverage than Medicare.
