AHIP 2025 Module's 1-5
Mr. Alonso receives some help paying for his two generic prescription drugs from his
employer's retiree coverage, but he wants to compare it to a Part D prescription drug
plan. He asks you what costs he would generally expect to encounter when enrolling into
a standard Medicare Part D prescription drug plan. What should you tell him? - ANS- He
generally would pay a monthly premium, annual deductible, and per-prescription
cost-sharing.
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being
successfully treated for that condition. However, she and her physicians feel that after
her lengthy hospital stay, she will need a month or two of nursing and rehabilitative care.
What should you tell them about Original Medicare's coverage of care in a skilled nursing
facility? - ANS- Medicare will cover Mrs. Shield's skilled nursing services provided
during the first 20 days of her stay, after which she would have a copay until she has
been in the facility for 100 days.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are
provided under Original Medicare. What should you tell Mr. Xi that best describes the
health coverage provided to Medicare beneficiaries? - ANS- Beneficiaries under Original
Medicare have no cost-sharing for most preventive services.
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? - ANS- Most 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.
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease
(ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under
Medicare. What should you tell him? - ANS- He may sign-up for Medicare at any time
however coverage usually begins on the fourth month after dialysis treatments start.
Mr. Patel 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? - ANS- 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.
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? -
ANS- Mrs. 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.
Mr. Diaz continued working with his company and was insured under his employer's
group plan until he reached age 68. He has heard that there is a premium penalty for
those who did not sign up for Part B when first eligible and wants to know how much he
will have to pay. What should you tell him? - ANS- Mr. Diaz will not pay any penalty
because he had continuous coverage under his employer's plan.
Mrs. Paterson is concerned about the deductibles and co-payments associated with
Original Medicare. What can you tell her about Medigap as an option to address this
concern? - ANS- Medigap plans do not cover Original Medicare benefits, but they
coordinate with Original Medicare coverage.
What impact, if any, have recent regulatory changes had on Medigap plans? - ANS- The
Part B deductible is no longer covered for individuals newly eligible for Medicare starting
January 1, 2020.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs.
Park that might be of assistance? - ANS- She 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.
Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin
receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter
informing her that she had been automatically enrolled in Medicare Part B. She wants to
understand what this means. What should you tell Mrs. Quinn? - ANS- Part B primarily
covers physician services. She will be paying a monthly premium and, except for many
preventive and screening tests, generally will have 20% co-payments for these services,
in addition to an annual deductible.
Mrs. Geisler's neighbor told her she should look at her Part D options during the annual
Medicare enrollment period because the features of Part D might have changed. Mrs.
Geisler can't remember what Part D is so she called you to ask what her neighbor was
talking about. What could you tell her? - ANS- Part D covers prescription drugs and she
should look at her premiums, formulary, and cost-sharing among other factors to see if
they have changed.
, 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? - ANS- Beneficiaries
must file an appeal related to Part A or B services within 120 days of the date they get the
MSN in the mail. If a beneficiary disagrees with the Medicare Administrative Contractor's
decision, they have 180 days after getting the decision notice to request a
reconsideration by a Qualified Independent Contractor.
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and
would like to know which of the following services Original Medicare will cover if the
appropriate criteria are met. What could you tell her? - ANS- Original Medicare covers
ambulance services.
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare
Advantage plan. What should you tell him? - ANS- Mr. Singh can enroll in a stand-alone
prescription drug plan and continue to be covered for Part A and Part B services through
Original Fee-for-Service Medicare.
Ms. Brooks has aggressive cancer and would like to know if Medicare will cover hospice
services in case she needs them. What should you tell her? - ANS- Medicare covers
hospice services, and they will be available for her.
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? - ANS- Medicare Part A
provides coverage for inpatient psychiatric care for up to 190 lifetime days.
Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare
Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan.
Anita's older neighbor Mel has told her about the Medigap Plan F in which he is enrolled.
It not only provides foreign travel emergency benefits but also covers his Medicare Part
B deductible. Anita comes to you for advice. What should you tell her? - ANS- You are
sorry to disappoint Anita, but a Medigap F plan is no longer available to those who turn
age 65 after January 1, 2020. Anita might instead consider other Medigap plans that offer
foreign travel benefits but do not cover the Part B deductible.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from
arthritis through massage therapy. She is concerned about whether or not Medicare will
cover these items and services. What should you tell her? - ANS- Medicare does not
cover massage therapy, or, in general, glasses or dentures.
Ms. Gibson recently lost her employer group health and drug coverage and now she
wants to enroll in a PPO that does not include drug coverage. What should you tell her
Mr. Alonso receives some help paying for his two generic prescription drugs from his
employer's retiree coverage, but he wants to compare it to a Part D prescription drug
plan. He asks you what costs he would generally expect to encounter when enrolling into
a standard Medicare Part D prescription drug plan. What should you tell him? - ANS- He
generally would pay a monthly premium, annual deductible, and per-prescription
cost-sharing.
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being
successfully treated for that condition. However, she and her physicians feel that after
her lengthy hospital stay, she will need a month or two of nursing and rehabilitative care.
What should you tell them about Original Medicare's coverage of care in a skilled nursing
facility? - ANS- Medicare will cover Mrs. Shield's skilled nursing services provided
during the first 20 days of her stay, after which she would have a copay until she has
been in the facility for 100 days.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are
provided under Original Medicare. What should you tell Mr. Xi that best describes the
health coverage provided to Medicare beneficiaries? - ANS- Beneficiaries under Original
Medicare have no cost-sharing for most preventive services.
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? - ANS- Most 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.
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease
(ESRD) and will soon begin dialysis. He is wondering if he can obtain coverage under
Medicare. What should you tell him? - ANS- He may sign-up for Medicare at any time
however coverage usually begins on the fourth month after dialysis treatments start.
Mr. Patel 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? - ANS- 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.
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? -
ANS- Mrs. 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.
Mr. Diaz continued working with his company and was insured under his employer's
group plan until he reached age 68. He has heard that there is a premium penalty for
those who did not sign up for Part B when first eligible and wants to know how much he
will have to pay. What should you tell him? - ANS- Mr. Diaz will not pay any penalty
because he had continuous coverage under his employer's plan.
Mrs. Paterson is concerned about the deductibles and co-payments associated with
Original Medicare. What can you tell her about Medigap as an option to address this
concern? - ANS- Medigap plans do not cover Original Medicare benefits, but they
coordinate with Original Medicare coverage.
What impact, if any, have recent regulatory changes had on Medigap plans? - ANS- The
Part B deductible is no longer covered for individuals newly eligible for Medicare starting
January 1, 2020.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs.
Park that might be of assistance? - ANS- She 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.
Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin
receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter
informing her that she had been automatically enrolled in Medicare Part B. She wants to
understand what this means. What should you tell Mrs. Quinn? - ANS- Part B primarily
covers physician services. She will be paying a monthly premium and, except for many
preventive and screening tests, generally will have 20% co-payments for these services,
in addition to an annual deductible.
Mrs. Geisler's neighbor told her she should look at her Part D options during the annual
Medicare enrollment period because the features of Part D might have changed. Mrs.
Geisler can't remember what Part D is so she called you to ask what her neighbor was
talking about. What could you tell her? - ANS- Part D covers prescription drugs and she
should look at her premiums, formulary, and cost-sharing among other factors to see if
they have changed.
, 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? - ANS- Beneficiaries
must file an appeal related to Part A or B services within 120 days of the date they get the
MSN in the mail. If a beneficiary disagrees with the Medicare Administrative Contractor's
decision, they have 180 days after getting the decision notice to request a
reconsideration by a Qualified Independent Contractor.
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and
would like to know which of the following services Original Medicare will cover if the
appropriate criteria are met. What could you tell her? - ANS- Original Medicare covers
ambulance services.
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare
Advantage plan. What should you tell him? - ANS- Mr. Singh can enroll in a stand-alone
prescription drug plan and continue to be covered for Part A and Part B services through
Original Fee-for-Service Medicare.
Ms. Brooks has aggressive cancer and would like to know if Medicare will cover hospice
services in case she needs them. What should you tell her? - ANS- Medicare covers
hospice services, and they will be available for her.
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? - ANS- Medicare Part A
provides coverage for inpatient psychiatric care for up to 190 lifetime days.
Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare
Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan.
Anita's older neighbor Mel has told her about the Medigap Plan F in which he is enrolled.
It not only provides foreign travel emergency benefits but also covers his Medicare Part
B deductible. Anita comes to you for advice. What should you tell her? - ANS- You are
sorry to disappoint Anita, but a Medigap F plan is no longer available to those who turn
age 65 after January 1, 2020. Anita might instead consider other Medigap plans that offer
foreign travel benefits but do not cover the Part B deductible.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from
arthritis through massage therapy. She is concerned about whether or not Medicare will
cover these items and services. What should you tell her? - ANS- Medicare does not
cover massage therapy, or, in general, glasses or dentures.
Ms. Gibson recently lost her employer group health and drug coverage and now she
wants to enroll in a PPO that does not include drug coverage. What should you tell her
