AHIP PRACTICE PAPER 2026 FULL
QUESTIONS AND ANSWERS GRADED A+
◉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.
◉Mr. Barker had surgery recently 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 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 offer to review the plans appeal process to help him
ask the plan to review the coverage decision.
◉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 offer Part D coverage for prescription drugs
and some do not.
= ?????
◉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.
◉Ms. Lewis understands that Medicare prescription drug plans may
use various 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.
◉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.
◉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.
◉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:
◉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 sign-up Medicare Part A,
QUESTIONS AND ANSWERS GRADED A+
◉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.
◉Mr. Barker had surgery recently 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 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 offer to review the plans appeal process to help him
ask the plan to review the coverage decision.
◉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 offer Part D coverage for prescription drugs
and some do not.
= ?????
◉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.
◉Ms. Lewis understands that Medicare prescription drug plans may
use various 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.
◉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.
◉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.
◉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:
◉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 sign-up Medicare Part A,
