AHIP Final EXAM 2025/2026
Types of Medicare Advantage Plans - answers PPO, HMO, MSA, Cost Plan, PFFS
Medicare-Medicaid plans - answers Serve both Medicare and Medicaid individuals.
Include Part D coverage. Individuals sometimes referred to as dual eligibles
Medicare Cost Plan - answers Type of Medicare health plan. Have Part B to enroll. Can
join anytime plan is accepting new members. A non network provider will can charge
higher coinsurances and deuctibles. Different enrollment/disenrollment periods apply.
Can get Part D Rx coverage if available, or apply for a separate PDP.
Medicare Entitlement/Enrollment - Part A & Part B - answers Individuals with ESRD
may sign up at anytime. Date on which coverage begins is the fourth month after
dialysis begins.
Medicare Enrollment Period - answers Individuals who do not enroll in Part B when first
eligible can enroll during a General Enrollment Period, Jan 1st to Mar 31st each year.
Coverage begins July 1st of that year.
Medicare Enrollment Period - Group Health Coverage - answers Individuals who have
group health coveage through employer may enroll in Part A and/or Part B anytime
while on group coverage during a Special Enrollment Period. Occurs during the 8 month
period following last month of group coverage.
Medicare Part A Premium - answers Free if worked 40 quarters of your life and paid
Medicare taxes. Premium is $240.00 for individuals or spouses who paid Medicare
taxes for 30 - 39 quarters. Premium is $437.00 for less than 30 quarters.
Medicare Part A Penalty - answers Don't enroll in Part A when fist eligible, will pay a late
penalty of up to 10% unless enroll during a Special Enrollment Period.
Medicare Part B Premium - answers In 2019, the standard monthly premium is $135.50
or higher depending on income. Deducted from S.S. check or Railroad Retirement
check. Do not enroll when first eligible, premium is increased 10% for each 12 month
period not enrolled. Deductible for 2019 is $185.00
Part C Medicare Advantage plans - answers Entiled to benefits under Part A AND
enrolled in Part B.
Part D Prescription Drug benefits - answers Entitled to benefits under Part A but not
enrolled in Part B. Must be entitled to Part A AND/OR enrolled in Part B.
,Part D Low Income Subsidy - answers Do not qualify for Part D Low Income Subsidy,
but are of limited means, may qualify for help in Part D costs through State
Pharmaceutical Assistance Program.
Part A Benefits - answers $1364.00 deductible for each benefit period. Days 1 - 60: $0
coinsurance. Days 61 - 90: $341.00 coinsurance per day. days 91 and beyond: $682.00
coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to
60 days over a beneficiarys lifetime. Beyond lifetime reserve days, all costs.
Part A Benefits - answers Blood, hospice, home health care, skilled nursing and
rehabilitative care only after a 3 day hospital stay up to 100 days in a benefit period. In
2019, will pay $170.50 coinsurance for days 21 - 100 each benefit period. In patient
psychiatric care is 190 lifetime days. Does not cover custodial or long term care.
Part D Prescription Drug Coverage - answers Late enrollment penalty of 1% of national
standard premium for every month that beneficiary could have had Part D but didn't
enroll. No penalty for beneficiaries with low income assistance or who join a Part D
within 63 days of losing creditable coverage.
Medigap Prescription Drug Coverage - answers If coverage is not creditable, individual
dropping coverage and enrolling in Part D coverage will pay a late enrollment penalty,
unless they qualify for "ExtraHelp" or enroll in Part D during Special Enrollment Period
for loss of creditable coverage. If informed non Medicare is no longer creditable, will
have an SEP to enroll without penalty.
Medicare Advantage Eligibility - answers Not eligible if have ESRD unless: MA Plan is a
SNP plan for people with ESRD, OR person developed ESRD after enrolling in MA
plan.
Medicare Advantage Special Needs Plans - answers Three types. Chronic Condition
(CSNP) for specific severe or disabling conditions. Dual Eligible (DSNP) for entitlement
to both Medicare and Medicaid. Institutionalized (ISNP) for individuals who need
services in skilled nursing facility for 90 days or longer. All SNP plans include
prescription drug coverage.
MA Plan Types - Coordinated Care Plans - HMO's - answers Some HMO's offer Point
Of Service option. Allows enrollees to go to no plan doctors/hospitals without prior
approval for sertain services. HMO-POS may limit services out of network or put cap on
out of network coverage. Cost sharing is generally higher than from network providers
MA Plan Types - Coordinated Care Plans - PPO's - answers Do not need referral for out
of network providers. May pay higher cost sharing amount.
MA Plan Types - Private Fee For Service plans - PFFS - answers Individuals in PFFS
plan may receive covered services from any provider who is eligible to provide Medicare
services, and agrees to the plans terms and conditions of payment. Enrollees must
,inform provider they are a PFFS member, so the provider can decide whether to accept
terms and conditions. Not permitted to charge more than cost sharing specified in plan.
Cost sharing may include balance billing up to 15%.
MA Plan Types - Medical Savings Account - MSA plan - answers High deductible plan.
Medicare makes contribution to beneficiaries savings account. Max deductible in 2019
is $12,650.00. In 2020, $13,400.00. Do not cover Part D prescription drug benefits.
Must enroll in stand alone Part D PDP.
MA Plan Types - Medical Savings Account - MSA plan - answers May not have
network. May have partial or full network. No network providers must accept amount
Medicare pays them as payment in full.
Medicare Cost Plans - answers May offer Part D drug coverage, but not required to do
so. Must have Part A & B. If only Part B, will not have Part A unless they buy it.
Medicare Cost Plans - answers May enroll in a Cost Plan AND a PDP. May have longer
enrollment periods. Most Cost Plans are open for enrollment all year long.
MA Plan Types - Private Fee For Service plans - PFFS - answers Have option of
providing prescription drug coverage, but not required to do so.
Medicare Advantage & Prescription Drugs - answers If a beneficiary enrolls in an HMO
or PPO plan that does not include prescription drug coverage, CAN NOT join a stand
alone PDP.
Medicare Advantage & Prescription Drugs - answers Individual enrolled in an MA PFFS
plan that does not include a Part D benefit, may enroll in a stand alone PDP. An
individual enrolled in an MA MSA plan must join a stand alone PDP plan if they want
drug benefits. If enrolled in a Cost Plan, can join a stand alone PDP if the Cost Plan
does not offer prescription drug benefits.
Insurer vs Insured - answers - insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance - answers Health coverage provided by employers to members
of a group.
Group health insurance - types of coverage - answers You can choose among several
or just one depending on your employer
* dental, vision, medical benefits, managed care, fee-for-service insurance
- dental:
* basic/preventative services, restorative services, comprehensive or stand-alone, ACA
(children, some adults)
- vision:
* basic exams and prescription glasses, ACA (children, some adults)
, ^ both are employer-sponsored voluntary group plans
Premium tax-credit - answers a subsidy that reduces the amount that consumers must
pay
* tax credit that will lower monthly premium based on income and household info
* advanced premium tax-credit (aptc)
self employed workers - answers can deduct health insurance premiums from their
federal taxable income - important tax savings
contracts/health insurance policy - answers between insurer and insured
- consideration: specifically termed agreement w/ promise to do something in return for
a valuable benefit (employer/insured premium payments to the insurer)
Covered services - answers insurance policy will clearly state their covered services
and their exlusions
- proactive, preventative, and reactive services
cost-sharing - answers a situation where insured individuals pay a portion of the
healthcare costs, such as deductibles, coinsurance or co-payments
- insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
Deductible/coinsurance - answers Money paid out of pocket before insurance covers
the remaining costs.
% of medical bill that insured pays out of pocket
copay - answers a fixed fee you pay for specific medical services
government sponsored plans - answers federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans - answers - employer determines coverage
- company's HR dept answers employee questions
excluded services - answers services not covered in a medical insurance contract like
experimental or non-contracted providers, elective or cosmetic surgery
Health Care Philosophy - answers * good quality = cost effective
- more expensive does not mean good healthcare
* cost vs care balance
- good benefits priced appropriately
Types of Medicare Advantage Plans - answers PPO, HMO, MSA, Cost Plan, PFFS
Medicare-Medicaid plans - answers Serve both Medicare and Medicaid individuals.
Include Part D coverage. Individuals sometimes referred to as dual eligibles
Medicare Cost Plan - answers Type of Medicare health plan. Have Part B to enroll. Can
join anytime plan is accepting new members. A non network provider will can charge
higher coinsurances and deuctibles. Different enrollment/disenrollment periods apply.
Can get Part D Rx coverage if available, or apply for a separate PDP.
Medicare Entitlement/Enrollment - Part A & Part B - answers Individuals with ESRD
may sign up at anytime. Date on which coverage begins is the fourth month after
dialysis begins.
Medicare Enrollment Period - answers Individuals who do not enroll in Part B when first
eligible can enroll during a General Enrollment Period, Jan 1st to Mar 31st each year.
Coverage begins July 1st of that year.
Medicare Enrollment Period - Group Health Coverage - answers Individuals who have
group health coveage through employer may enroll in Part A and/or Part B anytime
while on group coverage during a Special Enrollment Period. Occurs during the 8 month
period following last month of group coverage.
Medicare Part A Premium - answers Free if worked 40 quarters of your life and paid
Medicare taxes. Premium is $240.00 for individuals or spouses who paid Medicare
taxes for 30 - 39 quarters. Premium is $437.00 for less than 30 quarters.
Medicare Part A Penalty - answers Don't enroll in Part A when fist eligible, will pay a late
penalty of up to 10% unless enroll during a Special Enrollment Period.
Medicare Part B Premium - answers In 2019, the standard monthly premium is $135.50
or higher depending on income. Deducted from S.S. check or Railroad Retirement
check. Do not enroll when first eligible, premium is increased 10% for each 12 month
period not enrolled. Deductible for 2019 is $185.00
Part C Medicare Advantage plans - answers Entiled to benefits under Part A AND
enrolled in Part B.
Part D Prescription Drug benefits - answers Entitled to benefits under Part A but not
enrolled in Part B. Must be entitled to Part A AND/OR enrolled in Part B.
,Part D Low Income Subsidy - answers Do not qualify for Part D Low Income Subsidy,
but are of limited means, may qualify for help in Part D costs through State
Pharmaceutical Assistance Program.
Part A Benefits - answers $1364.00 deductible for each benefit period. Days 1 - 60: $0
coinsurance. Days 61 - 90: $341.00 coinsurance per day. days 91 and beyond: $682.00
coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to
60 days over a beneficiarys lifetime. Beyond lifetime reserve days, all costs.
Part A Benefits - answers Blood, hospice, home health care, skilled nursing and
rehabilitative care only after a 3 day hospital stay up to 100 days in a benefit period. In
2019, will pay $170.50 coinsurance for days 21 - 100 each benefit period. In patient
psychiatric care is 190 lifetime days. Does not cover custodial or long term care.
Part D Prescription Drug Coverage - answers Late enrollment penalty of 1% of national
standard premium for every month that beneficiary could have had Part D but didn't
enroll. No penalty for beneficiaries with low income assistance or who join a Part D
within 63 days of losing creditable coverage.
Medigap Prescription Drug Coverage - answers If coverage is not creditable, individual
dropping coverage and enrolling in Part D coverage will pay a late enrollment penalty,
unless they qualify for "ExtraHelp" or enroll in Part D during Special Enrollment Period
for loss of creditable coverage. If informed non Medicare is no longer creditable, will
have an SEP to enroll without penalty.
Medicare Advantage Eligibility - answers Not eligible if have ESRD unless: MA Plan is a
SNP plan for people with ESRD, OR person developed ESRD after enrolling in MA
plan.
Medicare Advantage Special Needs Plans - answers Three types. Chronic Condition
(CSNP) for specific severe or disabling conditions. Dual Eligible (DSNP) for entitlement
to both Medicare and Medicaid. Institutionalized (ISNP) for individuals who need
services in skilled nursing facility for 90 days or longer. All SNP plans include
prescription drug coverage.
MA Plan Types - Coordinated Care Plans - HMO's - answers Some HMO's offer Point
Of Service option. Allows enrollees to go to no plan doctors/hospitals without prior
approval for sertain services. HMO-POS may limit services out of network or put cap on
out of network coverage. Cost sharing is generally higher than from network providers
MA Plan Types - Coordinated Care Plans - PPO's - answers Do not need referral for out
of network providers. May pay higher cost sharing amount.
MA Plan Types - Private Fee For Service plans - PFFS - answers Individuals in PFFS
plan may receive covered services from any provider who is eligible to provide Medicare
services, and agrees to the plans terms and conditions of payment. Enrollees must
,inform provider they are a PFFS member, so the provider can decide whether to accept
terms and conditions. Not permitted to charge more than cost sharing specified in plan.
Cost sharing may include balance billing up to 15%.
MA Plan Types - Medical Savings Account - MSA plan - answers High deductible plan.
Medicare makes contribution to beneficiaries savings account. Max deductible in 2019
is $12,650.00. In 2020, $13,400.00. Do not cover Part D prescription drug benefits.
Must enroll in stand alone Part D PDP.
MA Plan Types - Medical Savings Account - MSA plan - answers May not have
network. May have partial or full network. No network providers must accept amount
Medicare pays them as payment in full.
Medicare Cost Plans - answers May offer Part D drug coverage, but not required to do
so. Must have Part A & B. If only Part B, will not have Part A unless they buy it.
Medicare Cost Plans - answers May enroll in a Cost Plan AND a PDP. May have longer
enrollment periods. Most Cost Plans are open for enrollment all year long.
MA Plan Types - Private Fee For Service plans - PFFS - answers Have option of
providing prescription drug coverage, but not required to do so.
Medicare Advantage & Prescription Drugs - answers If a beneficiary enrolls in an HMO
or PPO plan that does not include prescription drug coverage, CAN NOT join a stand
alone PDP.
Medicare Advantage & Prescription Drugs - answers Individual enrolled in an MA PFFS
plan that does not include a Part D benefit, may enroll in a stand alone PDP. An
individual enrolled in an MA MSA plan must join a stand alone PDP plan if they want
drug benefits. If enrolled in a Cost Plan, can join a stand alone PDP if the Cost Plan
does not offer prescription drug benefits.
Insurer vs Insured - answers - insurer is a company that provides plan
- insured are the people that buy into the plan
Group health insurance - answers Health coverage provided by employers to members
of a group.
Group health insurance - types of coverage - answers You can choose among several
or just one depending on your employer
* dental, vision, medical benefits, managed care, fee-for-service insurance
- dental:
* basic/preventative services, restorative services, comprehensive or stand-alone, ACA
(children, some adults)
- vision:
* basic exams and prescription glasses, ACA (children, some adults)
, ^ both are employer-sponsored voluntary group plans
Premium tax-credit - answers a subsidy that reduces the amount that consumers must
pay
* tax credit that will lower monthly premium based on income and household info
* advanced premium tax-credit (aptc)
self employed workers - answers can deduct health insurance premiums from their
federal taxable income - important tax savings
contracts/health insurance policy - answers between insurer and insured
- consideration: specifically termed agreement w/ promise to do something in return for
a valuable benefit (employer/insured premium payments to the insurer)
Covered services - answers insurance policy will clearly state their covered services
and their exlusions
- proactive, preventative, and reactive services
cost-sharing - answers a situation where insured individuals pay a portion of the
healthcare costs, such as deductibles, coinsurance or co-payments
- insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
Deductible/coinsurance - answers Money paid out of pocket before insurance covers
the remaining costs.
% of medical bill that insured pays out of pocket
copay - answers a fixed fee you pay for specific medical services
government sponsored plans - answers federal and state gov
* medicare and medicaid
- medicare --> 65+ or younger w/ disabilities or severe kidney problems
- medicaid --> low-income individuals
employer sponsored plans - answers - employer determines coverage
- company's HR dept answers employee questions
excluded services - answers services not covered in a medical insurance contract like
experimental or non-contracted providers, elective or cosmetic surgery
Health Care Philosophy - answers * good quality = cost effective
- more expensive does not mean good healthcare
* cost vs care balance
- good benefits priced appropriately
