AHIP FINAL EXAM WITH 100% VERIFIED
QUESTIONS AND ANSWERS LATEST 2023/2024
GRADED A+
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 answersDr. 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.
Mr. Gomez 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?
correct answersHe may receive health care services from any doctor allowed to bill
Medicare, as long as 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.
Mr. Wells is trying to understand the difference between Original Medicare and
Medicare Advantage. What would be the correct description?
correct answersMedicare Advantage is a way of covering all the Original Medicare
benefits through private health insurance companies.
Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She
wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also
wants to have prescription drug coverage since her doctor recently prescribed several
expensive medications. Currently, she is enrolled in Original Medicare and a standalone
Part D plan. How would you advise Mrs. Chi?
correct answersMrs. Chi may enroll in a MA MSA plan and remain in her current
standalone Part D prescription drug plan.
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him
at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of
SNP is likely to be most appropriate for him? correct answers.
C-SNP
Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and
was disappointed with the service she received from her primary care physician
because she was told she would have to wait five weeks to get an appointment when
she was feeling ill. She called you to ask what she could do so she would not have to
put up with such poor access to care. What could you tell her?
correct answers She could file a grievance with her plan to complain about the lack of
timeliness in getting an appointment.
Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from
his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan
,(SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts
and Mr. Greco would like to join that plan. What should you tell him? correct answers
SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current
situation, he is unlikely to qualify and would not be able to enroll in the SNP.
Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her? correct answersMrs. Radford must be entitled to
Part A and enrolled in Part B to enroll in Medicare Advantage.
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?correct answersMedicaid may provide additional benefits, but
Medicaid will coordinate benefits only with Medicaid participating providers.
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has
recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He
would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A.
What should you tell him?
correct answers He is not eligible to enroll in a Medicare Advantage plan until he re-
enrolls in Medicare Part B.
Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago.
In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease
(ESRD). What options will Mrs. Davenport have regarding her MA plan during the next
open enrollment season?correct answersShe may remain in her ABC MA plan, enroll in
another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for
individuals suffering from ESRD if one is available in her area.
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?
correct answersMrs. 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.
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?
correct answersMost 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.
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?
correct answersTell prospect Jerry Smith that he should consider adding a standalone
Part D prescription drug coverage policy to his present coverage.
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?
correct answersMrs. Duarte should file an appeal of this initial determination within 120
days of the date she received the MSN in the mail.
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?
correct answersIt 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.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell
Mrs. Park that might be of assistance?
correct answersShe 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. 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?
correct answersMedicare will cover a total of 190 days of inpatient psychiatric care
during Mr. Rainey's entire lifetime.
Mr. Schmidt would like to plan for retirement and has asked you what is covered under
Original Fee-for-Service (FFS) Medicare? What could you tell him?
correct answersPart A, which covers hospital, skilled nursing facility, hospice, and home
health services and Part B, which covers professional services such as those provided
by a doctor are covered under Original Medicare.
Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the
Social Security Administration and has been receiving disability payments. He is
wondering whether he can obtain coverage under Medicare. What should you tell
him?correct answersAfter receiving such disability payments for 24 months, he will be
automatically enrolled in Medicare, regardless of age.
Mr. Buck has several family members who died from different cancers. He wants to
know if Medicare covers cancer screening.
QUESTIONS AND ANSWERS LATEST 2023/2024
GRADED A+
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 answersDr. 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.
Mr. Gomez 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?
correct answersHe may receive health care services from any doctor allowed to bill
Medicare, as long as 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.
Mr. Wells is trying to understand the difference between Original Medicare and
Medicare Advantage. What would be the correct description?
correct answersMedicare Advantage is a way of covering all the Original Medicare
benefits through private health insurance companies.
Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She
wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also
wants to have prescription drug coverage since her doctor recently prescribed several
expensive medications. Currently, she is enrolled in Original Medicare and a standalone
Part D plan. How would you advise Mrs. Chi?
correct answersMrs. Chi may enroll in a MA MSA plan and remain in her current
standalone Part D prescription drug plan.
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him
at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of
SNP is likely to be most appropriate for him? correct answers.
C-SNP
Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and
was disappointed with the service she received from her primary care physician
because she was told she would have to wait five weeks to get an appointment when
she was feeling ill. She called you to ask what she could do so she would not have to
put up with such poor access to care. What could you tell her?
correct answers She could file a grievance with her plan to complain about the lack of
timeliness in getting an appointment.
Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from
his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan
,(SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts
and Mr. Greco would like to join that plan. What should you tell him? correct answers
SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current
situation, he is unlikely to qualify and would not be able to enroll in the SNP.
Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her? correct answersMrs. Radford must be entitled to
Part A and enrolled in Part B to enroll in Medicare Advantage.
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?correct answersMedicaid may provide additional benefits, but
Medicaid will coordinate benefits only with Medicaid participating providers.
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has
recently stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He
would like to enroll in a Medicare Advantage (MA) plan and is still covered by Part A.
What should you tell him?
correct answers He is not eligible to enroll in a Medicare Advantage plan until he re-
enrolls in Medicare Part B.
Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago.
In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease
(ESRD). What options will Mrs. Davenport have regarding her MA plan during the next
open enrollment season?correct answersShe may remain in her ABC MA plan, enroll in
another MA plan in her service area, or enroll in a Special Needs Plan (SNP) for
individuals suffering from ESRD if one is available in her area.
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?
correct answersMrs. 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.
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?
correct answersMost 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.
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?
correct answersTell prospect Jerry Smith that he should consider adding a standalone
Part D prescription drug coverage policy to his present coverage.
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?
correct answersMrs. Duarte should file an appeal of this initial determination within 120
days of the date she received the MSN in the mail.
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?
correct answersIt 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.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell
Mrs. Park that might be of assistance?
correct answersShe 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. 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?
correct answersMedicare will cover a total of 190 days of inpatient psychiatric care
during Mr. Rainey's entire lifetime.
Mr. Schmidt would like to plan for retirement and has asked you what is covered under
Original Fee-for-Service (FFS) Medicare? What could you tell him?
correct answersPart A, which covers hospital, skilled nursing facility, hospice, and home
health services and Part B, which covers professional services such as those provided
by a doctor are covered under Original Medicare.
Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the
Social Security Administration and has been receiving disability payments. He is
wondering whether he can obtain coverage under Medicare. What should you tell
him?correct answersAfter receiving such disability payments for 24 months, he will be
automatically enrolled in Medicare, regardless of age.
Mr. Buck has several family members who died from different cancers. He wants to
know if Medicare covers cancer screening.
