AHIP 2026 Anthem Certification Exam
Test Bank | Verified Q&As
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.
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. Wu is eligible for Medicare. He has limited financial resources but failed to
qualify for the Part D low-income subsidy. Where might he turn for help with his
prescription drug costs? - answer-Mr. Wu may still qualify for help in paying Part
D costs through his State Pharmaceutical Assistance Program (SPAP).
Mr. Vasquez 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? - 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.
Mr. Trevino notes that a Private Fee-for-Service (PFFS) plan available in his area
has an attractive premium. He wants to know if he must use doctors in a network
as his current HMO plan requires him to do. What should you tell him? - answer-
He may receive health care services from any doctor allowed to bill Medicare, if
he shows the doctor the plan's identification card and the doctor agrees to accept
the PFFS plan's payment terms and conditions, which could include balance
billing.
Mrs. Robles is considering a Medicare Advantage PPO and has questions about
which providers she can go to for her health care. What should you tell her? -
answer-Mrs. Robles can obtain care from any provider who participates in
Original Medicare, but generally will have a higher cost-sharing amount if she sees
a provider who/that is not a part of the PPO network.
Tariq is a Medicare beneficiary who is considering switching to a Medicare
Advantage plan during this year's open enrollment season. He has read about
prior authorization and the need for referrals in the newspapers and asks you
what type of plans can require prior authorization. What do you say? - answer-
HMOs can require prior authorization for out-of-network services except for
emergency services and certain other carved-out services. HMOs may also require
referrals for in-network specialist services.
, Henrietta Ross is an elderly individual enrolled in a fully integrated dual-eligible
(FIDE) special needs plan (SNP). Henrietta's daughter Gladys asks you to explain
what a FIDE-SNP offers her mother. What do you say? - answer-FIDE-SNPs provide
individuals access to Medicare and Medicaid benefits under a single organization
that has both a Medicare Advantage and Medicaid managed care contract with
CMS.
Mrs. Joy, age 65, is entitled to Part A but has not yet enrolled in Part B. She is
considering enrolling in a Medicare Advantage plan (Part C). What should you
advise her to do before she can enroll in a Medicare Advantage plan? - answer-To
join a Medicare Advantage plan, she also must enroll in Part B.
Mr. Barrow has diabetes and heart trouble and is generally satisfied with the care
he has received under Original Medicare, but he would like to know more about
Medicare Advantage Special Needs Plans (SNPs). What could you tell him? -
answer-SNPs have special programs for enrollees with chronic conditions, like Mr.
Barrow, and they provide prescription drug coverage that could be very helpful as
well.
Mrs. Sanchez cares for her frail elderly mother, Maria, who lives in North Carolina.
She is worried that without additional support, her mother will need to go into a
nursing home. Mrs. Sanchez asks you if there is any Medicare plan that might
allow her mother to remain in the community rather than going into a nursing
home. How should you advise Mrs. Sanchez? - answer-There are Programs of All-
Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as
needing a nursing home level of care but are able to live safely in the community
at the time of enrolment.
Dr. Elizabeth Morgan does not contract with the ABC PFFS plan but accepts the
plan's terms and conditions for payment. Mary Rodgers sees Dr. Morgan for
treatment. How much may Dr. Morgan charge? - answer-Dr. Morgan can charge
Test Bank | Verified Q&As
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.
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. Wu is eligible for Medicare. He has limited financial resources but failed to
qualify for the Part D low-income subsidy. Where might he turn for help with his
prescription drug costs? - answer-Mr. Wu may still qualify for help in paying Part
D costs through his State Pharmaceutical Assistance Program (SPAP).
Mr. Vasquez 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? - 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.
Mr. Trevino notes that a Private Fee-for-Service (PFFS) plan available in his area
has an attractive premium. He wants to know if he must use doctors in a network
as his current HMO plan requires him to do. What should you tell him? - answer-
He may receive health care services from any doctor allowed to bill Medicare, if
he shows the doctor the plan's identification card and the doctor agrees to accept
the PFFS plan's payment terms and conditions, which could include balance
billing.
Mrs. Robles is considering a Medicare Advantage PPO and has questions about
which providers she can go to for her health care. What should you tell her? -
answer-Mrs. Robles can obtain care from any provider who participates in
Original Medicare, but generally will have a higher cost-sharing amount if she sees
a provider who/that is not a part of the PPO network.
Tariq is a Medicare beneficiary who is considering switching to a Medicare
Advantage plan during this year's open enrollment season. He has read about
prior authorization and the need for referrals in the newspapers and asks you
what type of plans can require prior authorization. What do you say? - answer-
HMOs can require prior authorization for out-of-network services except for
emergency services and certain other carved-out services. HMOs may also require
referrals for in-network specialist services.
, Henrietta Ross is an elderly individual enrolled in a fully integrated dual-eligible
(FIDE) special needs plan (SNP). Henrietta's daughter Gladys asks you to explain
what a FIDE-SNP offers her mother. What do you say? - answer-FIDE-SNPs provide
individuals access to Medicare and Medicaid benefits under a single organization
that has both a Medicare Advantage and Medicaid managed care contract with
CMS.
Mrs. Joy, age 65, is entitled to Part A but has not yet enrolled in Part B. She is
considering enrolling in a Medicare Advantage plan (Part C). What should you
advise her to do before she can enroll in a Medicare Advantage plan? - answer-To
join a Medicare Advantage plan, she also must enroll in Part B.
Mr. Barrow has diabetes and heart trouble and is generally satisfied with the care
he has received under Original Medicare, but he would like to know more about
Medicare Advantage Special Needs Plans (SNPs). What could you tell him? -
answer-SNPs have special programs for enrollees with chronic conditions, like Mr.
Barrow, and they provide prescription drug coverage that could be very helpful as
well.
Mrs. Sanchez cares for her frail elderly mother, Maria, who lives in North Carolina.
She is worried that without additional support, her mother will need to go into a
nursing home. Mrs. Sanchez asks you if there is any Medicare plan that might
allow her mother to remain in the community rather than going into a nursing
home. How should you advise Mrs. Sanchez? - answer-There are Programs of All-
Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as
needing a nursing home level of care but are able to live safely in the community
at the time of enrolment.
Dr. Elizabeth Morgan does not contract with the ABC PFFS plan but accepts the
plan's terms and conditions for payment. Mary Rodgers sees Dr. Morgan for
treatment. How much may Dr. Morgan charge? - answer-Dr. Morgan can charge
