NEW AHIP FINAL ACTUAL EXAM WITH Q&A
NEWLY MODIFIED EXAM
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? -- ANSWER--It 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.
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 about obtaining drug coverage? -- ANSWER--Medicare Advantage
HMO or PPO may only obtain Part D benefits through their plan. They may not
enroll in a standalone PDP. (Employer group plan enrollees may have additional
choices.)
Able, Baker, and Charles are engaged in the marketing to and enrollment of
beneficiaries into Medicare health plans. Mr. Able is an independent agent paid
directly by a health plan. Ms. Baker is an independent agent paid through a field
marketing organization (FMO). Mr. Charles is an independent agent paid for his
work by a third-party marketing organization (TMO). How do the CMS
compensation rules apply to these three agents? -- ANSWER--Baker and
Charles are subject to CMS compensation rules because they are paid by third
parties. Able is not because she is paid directly by a health plan.
Page 1 of 49
,Agent Willis had several clients who disenrolled from the plans he represents
during the AEP to try new Medicare Advantage plans. Agent Willis believes that
the choices they made are not ideal for them and would like to get their business
back during the Medicare Advantage Open Enrollment Period (MAOEP). What
can agent Willis do? -- ANSWER--He can wait until October and send them
information about the plans he represents.
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? -- ANSWER--SNPs limit enrollment to certain sub
populations of beneficiaries. Given his current situation, he is unlikely to
qualify and would not be able to enroll in the SNP.
Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage
(MAPD) plan. She is new to this type of coverage and asks you what materials,
if any, she should expect to receive. How would you reply? -- ANSWER--1.
Plan ratings information, summary of benefits, and pre-enrollment checklist
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent
health and will have considerable income when she retires. She is concerned
that her income will make it impossible for her to qualify for Medicare. What
Page 2 of 49
,could you tell her to address her concern? -- ANSWER--Medicare is a program
for people age 65 or older and those under age 65 with certain disabilities, end
stage renal disease or Lou Gehrig's disease, so she will be eligible for Medicare.
Another agent working for your agency claims that because you are not
employed by the Medicare Advantage plans that you represent, you are not
subject to the same requirements as the plans themselves. How should you
respond to such a statement? -- ANSWER--Your coworker is not correct.
Marketing on behalf of a plan is considered marketing by the plan and requires
that all contracted and employed agents comply with all Medicare marketing
rules.
This year you have decided to focus your efforts on marketing to employer
group plans. One employer provides you with a list of their retirees and asks
you to contact them to explain the characteristics of the plan they have selected.
What should you do? -- ANSWER--You may go ahead and call them.
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.
Page 3 of 49
, 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.
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.
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
Page 4 of 49
NEWLY MODIFIED EXAM
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? -- ANSWER--It 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.
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 about obtaining drug coverage? -- ANSWER--Medicare Advantage
HMO or PPO may only obtain Part D benefits through their plan. They may not
enroll in a standalone PDP. (Employer group plan enrollees may have additional
choices.)
Able, Baker, and Charles are engaged in the marketing to and enrollment of
beneficiaries into Medicare health plans. Mr. Able is an independent agent paid
directly by a health plan. Ms. Baker is an independent agent paid through a field
marketing organization (FMO). Mr. Charles is an independent agent paid for his
work by a third-party marketing organization (TMO). How do the CMS
compensation rules apply to these three agents? -- ANSWER--Baker and
Charles are subject to CMS compensation rules because they are paid by third
parties. Able is not because she is paid directly by a health plan.
Page 1 of 49
,Agent Willis had several clients who disenrolled from the plans he represents
during the AEP to try new Medicare Advantage plans. Agent Willis believes that
the choices they made are not ideal for them and would like to get their business
back during the Medicare Advantage Open Enrollment Period (MAOEP). What
can agent Willis do? -- ANSWER--He can wait until October and send them
information about the plans he represents.
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? -- ANSWER--SNPs limit enrollment to certain sub
populations of beneficiaries. Given his current situation, he is unlikely to
qualify and would not be able to enroll in the SNP.
Mrs. Patterson is a new enrollee in the HealthBest Medicare Advantage
(MAPD) plan. She is new to this type of coverage and asks you what materials,
if any, she should expect to receive. How would you reply? -- ANSWER--1.
Plan ratings information, summary of benefits, and pre-enrollment checklist
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent
health and will have considerable income when she retires. She is concerned
that her income will make it impossible for her to qualify for Medicare. What
Page 2 of 49
,could you tell her to address her concern? -- ANSWER--Medicare is a program
for people age 65 or older and those under age 65 with certain disabilities, end
stage renal disease or Lou Gehrig's disease, so she will be eligible for Medicare.
Another agent working for your agency claims that because you are not
employed by the Medicare Advantage plans that you represent, you are not
subject to the same requirements as the plans themselves. How should you
respond to such a statement? -- ANSWER--Your coworker is not correct.
Marketing on behalf of a plan is considered marketing by the plan and requires
that all contracted and employed agents comply with all Medicare marketing
rules.
This year you have decided to focus your efforts on marketing to employer
group plans. One employer provides you with a list of their retirees and asks
you to contact them to explain the characteristics of the plan they have selected.
What should you do? -- ANSWER--You may go ahead and call them.
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.
Page 3 of 49
, 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.
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.
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
Page 4 of 49
