AHIP FINAL EXAM TEST QUESTIONS AND ANSWERS
(5 DIFFERENT VERSIONS VERIFIED ANSWERS) |ALREADY
GRADED A+
Mr. Romero is 64, retiring soon, and considering enrollment in his
employersponsored retiree group health plan that includes drug coverage with
nominal copays. He heard about a neighbor's MA-PD plan that you represent and
because he takes numerous prescription drugs, he is considering signing up for it.
What should you tell him? ANSWER: Beneficiaries should check with their
employer or union group benefits administrator before changing plans to avoid
losing coverage they want to keep. Mrs. Walters is enrolled in her state's Medicaid
program in addition to Medicare.
What should she be aware of when considering enrollment in a Medicare Health
Plan? ANSWER: Medicaid will coordinate benefits only with Medicaid
participating providers.
Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her
access to services since she receives some assistance for her health care costs from
the State. What should you tell her? ANSWER: Medicaid may provide additional
benefits, but Medicaid will coordinate benefits only with Medicaid participating
providers.
Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and
Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the
year, Mr. Rivera needs dentures, a service only covered under Medicaid. What
action would you recommend he take in order to have this cost covered?
ANSWER: He should go to a Medicaid provider or obtain the services through a
Medicaid manage care plan if he is enrolled in one.
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 in one of the MA plans that include prescription drug coverage or
a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in
the MA-only PPO plan and a stand-alone prescription drug plan.
,Mrs. Chou likes a PFFS plan available in her area that does not offer drug coverage.
She wants to enroll in the plan and enroll in a stand-alone prescription drug plan.
What should you tell her? ANSWER: She could enroll in a PFFS plan and a stand-
alone Medicare prescription drug plan.
Mr. Carlini has heard that Medicare prescription drug plans are only offered
through private companies under a program known as Medicare Advantage (MA),
not by the government. He likes Original Medicare and does not want to sign up
for an MA product, but he also wants prescription drug coverage. What should you
tell him? ANSWER: Mr. Carlini can stay with Original Medicare and also enroll
in a Medicare prescription drug plan through a private company that has contracted
with the government to provide only such drug coverage to eligible Medicare
beneficiaries.
Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare
prescription drug plan because, although she is entitled to Part A, she is not enrolled
under Medicare Part B. What should you tell her? ANSWER: Everyone who is
entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare
prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not
need to enroll under Part B before enrolling in a prescription drug plan.
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost
creditable coverage previously available through her husband's employer. She is
interested in enrolling in a Medicare Part D prescription drug plan (PDP). What
should you tell her? ANSWER: If a Part D benefit is offered through her plan she
may choose in enroll in that plan or a standalone PDP.
All plans must cover at least the standard Part D coverage or its actuarial equivalent.
What costs would a beneficiary incur for prescription drugs in 2018 under the
standard coverage? ANSWER: Standard Part D coverage would require payment
of an annual deductible, 25% cost-sharing up to the coverage
,gap, a portion of costs for both generics and brand-name drugs in the coverage gap,
and co-pays or co- insurance after the coverage gap.
Mrs. Andrews was preparing a budget for next year because she takes quite a few
prescription drugs, she will reach the coverage gap, and wants to be sure she has
enough money set aside for those months. She received assistance calculating her
projected expenses from her daughter who is a pharmacist, but she doesn't think
the calculations are correct because her out-of-pocket expenses would be lower
than last year. She calls to ask if you can help. What might you tell her?
ANSWER: It would not be unusual for her costs to be a bit less because each year
until 2020, an enrollee's share of the drug costs in the coverage gap are less.
Mr. Jacob understands that there is a standard Medicare Part D prescription drug
benefit, but when he looks at information on various plans available in his area, he
sees a wide range in what they charge for deductibles, premiums and cost sharing.
How can you explain this to him? ANSWER: Medicare Part D drug plans may
have different benefit structures, but on average, they must all be at least as good
as the standard model established by the government.
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 her
prescriptions hat 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.
What types of tools can Medicare Part D prescription drug plans use that affect the
way their enrollees can access medications? ANSWER: Part D plans do not have
to cover all medications. As a result, their formularies, or lists of covered drugs,
will vary from plan to plan. In addition, they can use cost containment techniques
such as tiered co-payments and prior authorization.
Mrs. Allen has a rare condition for which two different brand name drugs are the
only available treatment. She is concerned that since no generic prescription drug
is available and these drugs are very high cost, she will not be able to find a
Medicare Part D prescription drug plan that covers either one of them. What
should you tell her? ANSWER: Medicare prescription drug plans are required to
cover drugs in each therapeutic category. She should be able to enroll in a
Medicare prescription drug plan that covers the medications she needs.
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day.
Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to
have their Medicare prescription drug plan cover these drug needs. What should
, you tell them? ANSWER: Medicare prescription drug plans are not permitted to
cover the prescription medications the Vaughns are interested in under Part D
coverage, however, plans may cover them as supplemental benefits and the
Vaughn's could look into that possibility
Under what conditions can a Medicare prescription drug plan reduce its coverage
for a given drug mid- way through the year? ANSWER: When a new generic drug
for the same condition becomes available or when the FDA or manufacturer
withdraws the drug from the market, a brand name drug can be replaced.
Mrs. Roswell is a new Medicare beneficiary and is interested in selecting a
Medicare Part D prescription drug plan. She takes a number of medications and is
concerned that she has not been able to identify a
(5 DIFFERENT VERSIONS VERIFIED ANSWERS) |ALREADY
GRADED A+
Mr. Romero is 64, retiring soon, and considering enrollment in his
employersponsored retiree group health plan that includes drug coverage with
nominal copays. He heard about a neighbor's MA-PD plan that you represent and
because he takes numerous prescription drugs, he is considering signing up for it.
What should you tell him? ANSWER: Beneficiaries should check with their
employer or union group benefits administrator before changing plans to avoid
losing coverage they want to keep. Mrs. Walters is enrolled in her state's Medicaid
program in addition to Medicare.
What should she be aware of when considering enrollment in a Medicare Health
Plan? ANSWER: Medicaid will coordinate benefits only with Medicaid
participating providers.
Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her
access to services since she receives some assistance for her health care costs from
the State. What should you tell her? ANSWER: Medicaid may provide additional
benefits, but Medicaid will coordinate benefits only with Medicaid participating
providers.
Mr. Rivera has QMB-Plus eligibility and is thus covered by both Medicare and
Medicaid. He decides to enroll in a Medicare Advantage (MA) plan. Later in the
year, Mr. Rivera needs dentures, a service only covered under Medicaid. What
action would you recommend he take in order to have this cost covered?
ANSWER: He should go to a Medicaid provider or obtain the services through a
Medicaid manage care plan if he is enrolled in one.
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 in one of the MA plans that include prescription drug coverage or
a Medigap plan and a stand-alone prescription drug plan, but he cannot enroll in
the MA-only PPO plan and a stand-alone prescription drug plan.
,Mrs. Chou likes a PFFS plan available in her area that does not offer drug coverage.
She wants to enroll in the plan and enroll in a stand-alone prescription drug plan.
What should you tell her? ANSWER: She could enroll in a PFFS plan and a stand-
alone Medicare prescription drug plan.
Mr. Carlini has heard that Medicare prescription drug plans are only offered
through private companies under a program known as Medicare Advantage (MA),
not by the government. He likes Original Medicare and does not want to sign up
for an MA product, but he also wants prescription drug coverage. What should you
tell him? ANSWER: Mr. Carlini can stay with Original Medicare and also enroll
in a Medicare prescription drug plan through a private company that has contracted
with the government to provide only such drug coverage to eligible Medicare
beneficiaries.
Mrs. Mulcahy is concerned that she may not qualify for enrollment in a Medicare
prescription drug plan because, although she is entitled to Part A, she is not enrolled
under Medicare Part B. What should you tell her? ANSWER: Everyone who is
entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare
prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not
need to enroll under Part B before enrolling in a prescription drug plan.
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost
creditable coverage previously available through her husband's employer. She is
interested in enrolling in a Medicare Part D prescription drug plan (PDP). What
should you tell her? ANSWER: If a Part D benefit is offered through her plan she
may choose in enroll in that plan or a standalone PDP.
All plans must cover at least the standard Part D coverage or its actuarial equivalent.
What costs would a beneficiary incur for prescription drugs in 2018 under the
standard coverage? ANSWER: Standard Part D coverage would require payment
of an annual deductible, 25% cost-sharing up to the coverage
,gap, a portion of costs for both generics and brand-name drugs in the coverage gap,
and co-pays or co- insurance after the coverage gap.
Mrs. Andrews was preparing a budget for next year because she takes quite a few
prescription drugs, she will reach the coverage gap, and wants to be sure she has
enough money set aside for those months. She received assistance calculating her
projected expenses from her daughter who is a pharmacist, but she doesn't think
the calculations are correct because her out-of-pocket expenses would be lower
than last year. She calls to ask if you can help. What might you tell her?
ANSWER: It would not be unusual for her costs to be a bit less because each year
until 2020, an enrollee's share of the drug costs in the coverage gap are less.
Mr. Jacob understands that there is a standard Medicare Part D prescription drug
benefit, but when he looks at information on various plans available in his area, he
sees a wide range in what they charge for deductibles, premiums and cost sharing.
How can you explain this to him? ANSWER: Medicare Part D drug plans may
have different benefit structures, but on average, they must all be at least as good
as the standard model established by the government.
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 her
prescriptions hat 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.
What types of tools can Medicare Part D prescription drug plans use that affect the
way their enrollees can access medications? ANSWER: Part D plans do not have
to cover all medications. As a result, their formularies, or lists of covered drugs,
will vary from plan to plan. In addition, they can use cost containment techniques
such as tiered co-payments and prior authorization.
Mrs. Allen has a rare condition for which two different brand name drugs are the
only available treatment. She is concerned that since no generic prescription drug
is available and these drugs are very high cost, she will not be able to find a
Medicare Part D prescription drug plan that covers either one of them. What
should you tell her? ANSWER: Medicare prescription drug plans are required to
cover drugs in each therapeutic category. She should be able to enroll in a
Medicare prescription drug plan that covers the medications she needs.
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day.
Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to
have their Medicare prescription drug plan cover these drug needs. What should
, you tell them? ANSWER: Medicare prescription drug plans are not permitted to
cover the prescription medications the Vaughns are interested in under Part D
coverage, however, plans may cover them as supplemental benefits and the
Vaughn's could look into that possibility
Under what conditions can a Medicare prescription drug plan reduce its coverage
for a given drug mid- way through the year? ANSWER: When a new generic drug
for the same condition becomes available or when the FDA or manufacturer
withdraws the drug from the market, a brand name drug can be replaced.
Mrs. Roswell is a new Medicare beneficiary and is interested in selecting a
Medicare Part D prescription drug plan. She takes a number of medications and is
concerned that she has not been able to identify a
