2025-2026 AHIP Final Exam questions
with verified correct detailed solutions
latest updates version
Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but
accepts the plan's terms and conditions for payment. Mary Rodgers
sees Dr. Brennan for treatment. How much may Dr. Brennan charge? -
-- correct precise answer ---Dr. Brennan can charge Mary Rogers no
more than the cost sharing specified in the PFFS plan's terms and
condition of payment which may include balance billing up to 15%of
the Medicare rate.
Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part
B. She is considering enrollment in a Medicare Advantage plan (Part
C). What should you advise her to do before she can enroll in a
Medicare Advantage plan? --- correct precise answer ---To join a
Medicare Advantage plan, she also must enroll in Part B.
Mr. Wells is trying to understand the difference between Original
Medicare and Medicare Advantage. What would be the correct
description? --- correct precise answer ---Medicare Advantage is a
way of covering all the Original Medicare benefits through private
health insurance companies.
,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? --- correct
precise 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.
Mrs. Wang wants to know generally how the benefits under Original
Medicare might compare to the benefits package of a Medicare
Advantage Plan before she starts looking at specific plans. What could
you tell her? --- correct precise answer ---Medicare Advantage Plans
may offer extra benefits that Original Medicare does not offer such as
vision, hearing, and dental services. It must include a maximum out-
of-pocket limit on Part A and Part B services.
Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her
area that does not include drug coverage. She wants to enroll in the
plan and enroll in a stand-alone prescription drug plan. What should
,you tell her? --- correct precise answer ---She could enroll in a PFFS
plan and a stand-alone Medicare prescription drug plan.
Mr. Lopez has heard that he can sign up for a product called
"Medicare Advantage" but is not sure about what type of plan designs
are available through this program. What should you tell him about
the types of health plans that are available through the Medicare
Advantage program? --- correct precise answer ---There are Medicare
health plans such as HMOs, PPOs, PFFS, and MSAs.
Mr. Barker enjoys a comfortable retirement income. He recently had
surgery 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 some services and items he thought
would be fully covered. He called you to ask what he could do? What
could you tell him? --- correct precise answer ---You can offer to
review the plans appeal process to help him ask the plan to review the
coverage decision.
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 Advantage (MA) plan? --- correct precise answer ---She
cannot enroll in an MA Medical Savings Account (MSA) plan.
Mr. Shapiro gets by on a very small amount of fixed income. He has
heard there may be extra help paying for Part D prescription drugs for
Medicare beneficiaries with limited income. He wants to know
whether he might qualify. What should you tell him? --- correct
precise answer ---The extra help is available to beneficiaries whose
income and assets do not exceed annual limits specified by the
government.
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? ---
correct precise 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. Wingate is a newly enrolled Medicare Part D beneficiary and one
of your clients. In addition to drugs on his plan's formulary, he takes
several other medications. These include a prescription drug not on
with verified correct detailed solutions
latest updates version
Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but
accepts the plan's terms and conditions for payment. Mary Rodgers
sees Dr. Brennan for treatment. How much may Dr. Brennan charge? -
-- correct precise answer ---Dr. Brennan can charge Mary Rogers no
more than the cost sharing specified in the PFFS plan's terms and
condition of payment which may include balance billing up to 15%of
the Medicare rate.
Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part
B. She is considering enrollment in a Medicare Advantage plan (Part
C). What should you advise her to do before she can enroll in a
Medicare Advantage plan? --- correct precise answer ---To join a
Medicare Advantage plan, she also must enroll in Part B.
Mr. Wells is trying to understand the difference between Original
Medicare and Medicare Advantage. What would be the correct
description? --- correct precise answer ---Medicare Advantage is a
way of covering all the Original Medicare benefits through private
health insurance companies.
,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? --- correct
precise 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.
Mrs. Wang wants to know generally how the benefits under Original
Medicare might compare to the benefits package of a Medicare
Advantage Plan before she starts looking at specific plans. What could
you tell her? --- correct precise answer ---Medicare Advantage Plans
may offer extra benefits that Original Medicare does not offer such as
vision, hearing, and dental services. It must include a maximum out-
of-pocket limit on Part A and Part B services.
Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her
area that does not include drug coverage. She wants to enroll in the
plan and enroll in a stand-alone prescription drug plan. What should
,you tell her? --- correct precise answer ---She could enroll in a PFFS
plan and a stand-alone Medicare prescription drug plan.
Mr. Lopez has heard that he can sign up for a product called
"Medicare Advantage" but is not sure about what type of plan designs
are available through this program. What should you tell him about
the types of health plans that are available through the Medicare
Advantage program? --- correct precise answer ---There are Medicare
health plans such as HMOs, PPOs, PFFS, and MSAs.
Mr. Barker enjoys a comfortable retirement income. He recently had
surgery 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 some services and items he thought
would be fully covered. He called you to ask what he could do? What
could you tell him? --- correct precise answer ---You can offer to
review the plans appeal process to help him ask the plan to review the
coverage decision.
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 Advantage (MA) plan? --- correct precise answer ---She
cannot enroll in an MA Medical Savings Account (MSA) plan.
Mr. Shapiro gets by on a very small amount of fixed income. He has
heard there may be extra help paying for Part D prescription drugs for
Medicare beneficiaries with limited income. He wants to know
whether he might qualify. What should you tell him? --- correct
precise answer ---The extra help is available to beneficiaries whose
income and assets do not exceed annual limits specified by the
government.
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? ---
correct precise 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. Wingate is a newly enrolled Medicare Part D beneficiary and one
of your clients. In addition to drugs on his plan's formulary, he takes
several other medications. These include a prescription drug not on
