AHIP - Final Examination (Latest Update 2022)
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? - 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.
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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? -
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, Part B and Part D when he leaves the workforce. How would you advise him as he budgets for
Medicare premiums? - a. Due to the provisions of MACRA, his Part B and D coverage will be combined and covered
through a low-cost Medigap policy to supplement his Part A coverage.
b. Due to his participation in the workforce he will not have to pay premiums for Part A and he will pay the lowest
monthly premium rates for Part B and Part D.
c. Due to his participation in the workforce he will not have to pay premiums for Part A but he will pay higher
premiums for Part B and Part D due to the amount of his income.
d. Due to his participation in the workforce he will not have to pay premiums for Part A and will pay reduced
premiums for Part B and Part D.
?????
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? - 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.
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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? -
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, Part B and Part D when he leaves the workforce. How would you advise him as he budgets for
Medicare premiums? - a. Due to the provisions of MACRA, his Part B and D coverage will be combined and covered
through a low-cost Medigap policy to supplement his Part A coverage.
b. Due to his participation in the workforce he will not have to pay premiums for Part A and he will pay the lowest
monthly premium rates for Part B and Part D.
c. Due to his participation in the workforce he will not have to pay premiums for Part A but he will pay higher
premiums for Part B and Part D due to the amount of his income.
d. Due to his participation in the workforce he will not have to pay premiums for Part A and will pay reduced
premiums for Part B and Part D.
?????
