Test Bank For AHIP Multi – Versions Latest Updated 2024
Mr. Albert has heard about something called the Star Rating system for Medicare Advantage plans. He asks you to
explain it to him since he is interested in enrolling in a plan that is newly available in his area. After you explain
that it is the way for consumers to judge plan performance, what else would you say? - correct answers??????
Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in
2013, a Cost plan
Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility
requirements for Medicare Advantage or Part D plans
The SEP is available each year beginning on December 8 and may be used once through November 30 of the
following year. For example, the SEP for calendar year 2018 can be
used from December 8, 2017 through November 30, 2018.
Disenroll from an MA plan, PDP or Cost plan or
leave Original Medicare
Enroll in a 5-star MA plan, PDP or Cost plan
Eligible individuals may enroll in a 5-star plan
through 1-800-MEDICARE, Medicare.gov, or
directly through the 5-star plan.
Mr. Davies is turning 65 next month. He would like to enroll in a Medicare health plan, but does not want to be
limited in terms of where he obtains his care. What should you tell him about how a Medicare Cost Plan might fit
his needs? - correct answersCost plan enrollees can choose to receive Medicare covered services under the plan's
benefits by going to plan network providers and paying plan cost sharing, or may receive services
from non-network providers and pay cost sharing due under Original Medicare.
Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage (MA) health plans.
This year she has decided to focus on non-MA products. What advice would you give Melanie if she wishes to
continue to receive renewal fees? - correct answers
Alice is enrolled in a MA-PD plan. She makes a permanent move across the country and wonders what her options
are for continuing MA-PD coverage. What would you say to her in regard to a special enrollment period (SEP)? -
correct answers
Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is
concerned about changes in his cost-sharing. What should you tell him? - correct answersHe should know that
Medicaid will pay cost sharing only for services provided by Medicaid participating providers.
Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is
suspicious about how plans establish these formularies. What should you tell him? - correct answersFormularies
must be developed with input from pharmacists,doctors, and other experts.
Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that
Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom
Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales
presentation? - correct answersA meal cannot be provided, but light
snacks would be permitted.
Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual check-ups for the past 15
years, likes these yearly visits, and would like to continue obtaining these services as a Medicare beneficiary. What
should you tell him about annual check-ups? - correct answers
Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. Ms. Levi often travels
to visit relatives and is concerned that she may need emergency care outside of her plan's service area. What should
,you tell her about coverage of emergency care? - correct answersPlans are required to cover out-of network
emergency care.
Which of the following individuals are likely to qualify for a special enrollment period (SEP) for both MA and Part
D due to a change of residence?
I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's
service area.
II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area.
III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area
where no Part D plan was available.
IV. Henry makes a permanent move providing him with new MA and Part D options. - correct answersII, III, and
IV only
Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted with regard to the
marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise
him concerning the type of scrutiny he will be under? - correct answersOrganizations sponsoring Medicare
health plans are responsible for the behavior of their contracted representatives and will be conducting
monitoring activities to ensure compliance with all applicable Federal
law and guidance and plan policies.
Furthermore, state agent licensure laws are not preempted and he must abide by their requirements.
Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an
excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you
for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)? -
correct answersMrs. Wellington is eligible for a SEP
that may be used once until November 30 to enroll in the fivestar plan.
Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in
a stand-alone Medicare prescription drug plan. Under what circumstances can she do this? - correct answersIf the
Medicare Advantage plan is a
Private Fee-for-Service (PFFS) plan
that does not offer drug coverage or a
Medical Savings Account, Mrs. Berkowitz can do this.
Julia Harris is turning 66 in July, at which time she will retire. She has contacted your office and requested a
meeting so that she can learn about Medicare and the products you represent. How should you respond? - correct
answers
Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan
that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and
because he takes numerous prescription drugs, he is considering signing up for it. What should you tell him? -
correct answersBeneficiaries should check with their employer or union group benefits administrator before
changing plans to avoid losing coverage they want to keep.
Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of misusing or abusing
frequently abused drugs?
I. Identifying at risk individuals by using criteria that includes the number of opioid prescriptions the beneficiary
has and the number of prescribers who have written those prescriptions.
II. Locking an at-risk beneficiary into one pharmacy.
III. Locking an at-risk beneficiary into one prescriber.
IV. Increasing deductibles and copays for at-risk beneficiaries. - correct answersI, II and III only.
Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would
be the correct description? - correct answersMedicare Advantage is a way of covering all the Original Medicare
benefits through private health insurance
,companies.
Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA
plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone
prescription drug plan (PDP). What CMS compensation rules apply to this situation? - correct answersThis situation
is considered a "dual
enrollment" and CMS compensation rules are applied to the two plans at once and independently of each other.
Mrs. Ridgeway enrolled in Original Medicare and Medigap coverage following her retirements several years ago.
Four months ago, Mrs. Ridgeway dropped her Medigap policy to enroll in a Medicare Advantage (MA) plan for the
first time. Unfortunately, Mrs. Ridgeway has found that many of her providers are not in the MA plan's network.
She has come to you for advice? What should you tell her? - correct answersShe qualifies for a special enrollment
period (SEP) that will allow her to make a one-time election to return to Original
Medicare and she also has a guaranteed eligibility period to rejoin her Medigap plan.
This year you decide to focus your efforts on marketing to employer and union groups. Which of the following
statements best describes what you can and cannot do in order to stay in compliance? - correct answersYou are not
required to submit
copies of disseminated materials to CMS
at the time of use, but CMS may request and review copies if employee complains occur.
Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a
letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what
this means. What should you tell her? - correct answers
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? - correct answersHe 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? - correct answersMr. 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? - correct answers
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? - correct answersa. 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 reduce d
premiums for Part B and Part D.
?????
Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare &
Medicaid Services' communication and Marketing Guidelines to ensure he is compliant for which type of products?
- correct answersMedicare Advantage (MA) and Prescription Drug (PDP) plans Correct
, 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?
- correct answersMr. 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? - correct answersThe 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? - correct answersYou 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? - correct answersa. 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? - correct answersII. 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? - correct answersStep therapy involves using one or more lower priced drugs before trying a
more expensive drug when all are used to treat the same condition.
Ms. Hernandez has marketed several different types of insurance products in her home state and has typically
sought approval of her materials from her State Department of Insurance. What would you advise her regarding
seeking such approval for materials she uses to market Medicare Advantage plans? - correct answersa. States often
volunteer to review marketing materials on behalf of the Medicare agency. She should check with her Department
of Insurance to see if such a review is available and would satisfy CMS requirements.
b. Materials for marketing Medicare health plans to individuals are subject to Medicare's uniform national
requirements. They do not need to be reviewed by the state, but the company she represents must obtain approval
from the Medicare agency (CMS) for any materials she uses.
c. Obtaining approval of her materials from the State Department of Insurance is a good practice and she should
continue it with materials for the Medicare health plans she represents.
d. Materials need only be reviewed and approved by the company(s) she represents.
Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can
