2025 – 2026 AHIP FINAL EXAM
QUESTIONS AND ANSWERS LATEST
EDITION.
Mrs. |Shields |is |covered |by |Original |Medicare. |She |sustained |a |hip |fracture |and |is |being |
successfully |treated |for |that |condition. |However, |she |and |her |physicians |feel |that |after |her |
lengthy |hospital |stay, |she |will |need |a |month |or |two |of |nursing |and |rehabilitative |care. |What |
should |you |tell |them |about |Original |Medicare's |coverage |of |care |in |a |skilled |nursing |facility? |- |
ANS |-Medicare |will |cover |Mrs. |Shield's |skilled |nursing |services |provided |during |the |first |20 |
days |of |her |stay, |after |which |she |would |have |a |copay |until |she |has |been |in |the |facility |for |100 |
days.
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? |- |ANS |-Medicare |does |not |cover |massage |
therapy, |or, |in |general, |glasses |or |dentures.
Mrs. |Park |is |an |elderly |retiree. |Mrs. |Park |has |a |low |fixed |income. |What |could |you |tell |Mrs. |
Park |that |might |be |of |assistance? |- |ANS |-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. |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? |- |ANS |-He |
generally |would |pay |a |monthly |premium, |annual |deductible, |and |per-prescription |cost-sharing.
,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? |- |ANS
|-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.
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? |- |ANS |-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? |- |ANS |-Mrs. |Duarte |should |
file |an |appeal |of |this |initial |determination |within |120 |days |of |the |date |she |received |the |MSN |
in |the |mail.
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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |
ANS |-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.
What |impact, |if |any, |have |recent |regulatory |changes |had |on |Medigap |plans? |- |ANS |-The |Part |B
|deductible |is |no |longer |covered |for |individuals |newly |eligible |for |Medicare |starting |January |1, |
2020.
QUESTIONS AND ANSWERS LATEST
EDITION.
Mrs. |Shields |is |covered |by |Original |Medicare. |She |sustained |a |hip |fracture |and |is |being |
successfully |treated |for |that |condition. |However, |she |and |her |physicians |feel |that |after |her |
lengthy |hospital |stay, |she |will |need |a |month |or |two |of |nursing |and |rehabilitative |care. |What |
should |you |tell |them |about |Original |Medicare's |coverage |of |care |in |a |skilled |nursing |facility? |- |
ANS |-Medicare |will |cover |Mrs. |Shield's |skilled |nursing |services |provided |during |the |first |20 |
days |of |her |stay, |after |which |she |would |have |a |copay |until |she |has |been |in |the |facility |for |100 |
days.
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? |- |ANS |-Medicare |does |not |cover |massage |
therapy, |or, |in |general, |glasses |or |dentures.
Mrs. |Park |is |an |elderly |retiree. |Mrs. |Park |has |a |low |fixed |income. |What |could |you |tell |Mrs. |
Park |that |might |be |of |assistance? |- |ANS |-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. |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? |- |ANS |-He |
generally |would |pay |a |monthly |premium, |annual |deductible, |and |per-prescription |cost-sharing.
,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? |- |ANS
|-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.
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? |- |ANS |-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? |- |ANS |-Mrs. |Duarte |should |
file |an |appeal |of |this |initial |determination |within |120 |days |of |the |date |she |received |the |MSN |
in |the |mail.
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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |ANS |-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? |- |
ANS |-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.
What |impact, |if |any, |have |recent |regulatory |changes |had |on |Medigap |plans? |- |ANS |-The |Part |B
|deductible |is |no |longer |covered |for |individuals |newly |eligible |for |Medicare |starting |January |1, |
2020.
