AHIP - Final Examination Questions and Answers
1. Mr. Zachow has a condition for which three drugs are available. He has tried two
but had an allergic reaction to them. Only the third drug works for him and it is not on
his Part D plan's formulary. What could you tell him to do?
Answer Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or
his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan.
2. Mr. Polanski likes the cost of an HMO plan available in his area, but would like to
be able to visit one or two doctors who aren't participating providers. He wants to know
if the Point of Service (POS) option available with some HMOs will be of any help in this
situation. What should you tell him?
Answer The POS option might be a good solution for him as it will allow him to visit out-of-network providers,
generally without prior approval. However,
he should be aware that it is likely he will have to pay higher cost-sharing for services from out-of-network providers.
3. Mr. Barker had surgery recently and expected that he would have certain ser-
vices 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 a number of services and items he thought would be fully covered. He
called you to ask what he could do? What could you tell him?
Answer You can otter to review the plans appeal process to help him ask the plan to review the coverage
decision.
,4. Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is
enrolled in and is interested in that product. She wants to be sure she also has
coverage for prescription drugs. Would she be able to obtain drug coverage if she
enrolled in the SNP?
Answer a. Yes. All SNPs are required to provide Part D coverage for prescription drugs.
b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medicaid program.
c. No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage through a stand-alone
Part D Medicare prescription drug plan that they sign up for independent of their enrollment in the SNP.
d. Maybe. Some SNPs otter Part D coverage for prescription drugs and some do not.
= ?????
5. Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in
charge of BestCare's efforts to facilitate electronic enrollment in its Medicare
Advantage plans. In setting up the enrollment site, which of the following must Phiona
consider?
Answer II. All data elements required to complete an enrollment request must be captured.
III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree"
type of button or tool.
6. Ms. Lewis understands that Medicare prescription drug plans may use var- ious
methods to control the use of specific drugs. She has heard about a technique
called "step therapy" and is wondering if you can explain what that is. What should you
tell her?
, Answer Step therapy involves using one or more lower priced drugs before trying
a more expensive drug when all are used to treat the same condition.
7. 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?
Answer He 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.
8. 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.
9. You have decided to focus on doing in-home presentations to market the
Medicare Advantage (MA) plans you represent. Before you conduct such sales
presentations, what must you do?
Answer
10. Mr. Wong is a single individual. He has had a successful business career
and is now able to retire with a comfortable income. Mr. Wong's taxable income is
in excess of $100,000. Mr. Wong has health coverage through his employer but will
1. Mr. Zachow has a condition for which three drugs are available. He has tried two
but had an allergic reaction to them. Only the third drug works for him and it is not on
his Part D plan's formulary. What could you tell him to do?
Answer Mr. Zachow has a right to request a formulary exception to obtain coverage for his Part D drug. He or
his physician could obtain the standardized request form on the plan's website, fill it out, and submit it to his plan.
2. Mr. Polanski likes the cost of an HMO plan available in his area, but would like to
be able to visit one or two doctors who aren't participating providers. He wants to know
if the Point of Service (POS) option available with some HMOs will be of any help in this
situation. What should you tell him?
Answer The POS option might be a good solution for him as it will allow him to visit out-of-network providers,
generally without prior approval. However,
he should be aware that it is likely he will have to pay higher cost-sharing for services from out-of-network providers.
3. Mr. Barker had surgery recently and expected that he would have certain ser-
vices 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 a number of services and items he thought would be fully covered. He
called you to ask what he could do? What could you tell him?
Answer You can otter to review the plans appeal process to help him ask the plan to review the coverage
decision.
,4. Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is
enrolled in and is interested in that product. She wants to be sure she also has
coverage for prescription drugs. Would she be able to obtain drug coverage if she
enrolled in the SNP?
Answer a. Yes. All SNPs are required to provide Part D coverage for prescription drugs.
b. Yes, but only if she qualifies for Part D prescription drug coverage under her state Medicaid program.
c. No. Medicare beneficiaries who enroll in an SNP must always obtain their drug coverage through a stand-alone
Part D Medicare prescription drug plan that they sign up for independent of their enrollment in the SNP.
d. Maybe. Some SNPs otter Part D coverage for prescription drugs and some do not.
= ?????
5. Phiona works in the IT Department of BestCare Health Plan. Phiona is placed in
charge of BestCare's efforts to facilitate electronic enrollment in its Medicare
Advantage plans. In setting up the enrollment site, which of the following must Phiona
consider?
Answer II. All data elements required to complete an enrollment request must be captured.
III. The process must include a clear and distinct step that requires the applicant to activate an "Enroll Now" or "I Agree"
type of button or tool.
6. Ms. Lewis understands that Medicare prescription drug plans may use var- ious
methods to control the use of specific drugs. She has heard about a technique
called "step therapy" and is wondering if you can explain what that is. What should you
tell her?
, Answer Step therapy involves using one or more lower priced drugs before trying
a more expensive drug when all are used to treat the same condition.
7. 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?
Answer He 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.
8. 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.
9. You have decided to focus on doing in-home presentations to market the
Medicare Advantage (MA) plans you represent. Before you conduct such sales
presentations, what must you do?
Answer
10. Mr. Wong is a single individual. He has had a successful business career
and is now able to retire with a comfortable income. Mr. Wong's taxable income is
in excess of $100,000. Mr. Wong has health coverage through his employer but will
