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Ahip 2025 Module 2 questions and answers 2015/2016
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Ahip 2025 Module 21. Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan's
terms and conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How
much may Dr. Brennan charge? >ANS>Dr. Brennan can charge Mary Rogers no more
than the cost sharing specified in the PFFS plan's terms and condition of payment which
may include balance billing up to 15%of the Medicare rate.
2. Hank's Fish Store, Inc. is a small company with just 15 employees located in Florida.
Hank, the store owner, has provided excellent health benefits to the store's workforce.
William, one of the store's long-time employees, will soon be reaching age 65 and
eligible for Medicare. William is in good health. He intends to remain an active full-time
employee, working several years after becoming eligible for Medicare. What type(s) of
retiree health benefit will Hank's Fish Store be able to offer William? >ANS>Hank's can
continue to offer William the same employee health benefit plan, or, if William enrolls in
Medicare Part B, it can enroll him in a Medicare Advantage plan that is offered to the
public.
3. Mr. Barker enjoys a comfortable retirement income. He recently had surgery 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 some services and items he thought would
be fully covered. He called you to ask what he could do? What could you tell him?
>ANS>You can offer to review the plans appeal process to help him ask the plan to
review the coverage decision.
4. Mr. Kelly wants to know whether he is eligible to sign up for a private fee-for-service
(PFFS) plan. What questions would you need to ask to determine his eligibility?
>ANS>You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if his
doctor will accept the terms and conditions of payment of the PFFS plan.
5. Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It
is one of three plans operated by the same organization in Mr. Lombardi's area. The MA
PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes
the PPO plan that does not include drug coverage and intends to obtain his drug
coverage through a stand-alone Medicare prescription drug plan. What should you tell
him about this situation? >ANS>He could enroll either in one of the MA plans that
include prescription drug coverage or Original Medicare with a Medigap plan and
standalone Part D prescription drug coverage, but he cannot enroll in the MA-only PPO
plan and a stand-alone prescription drug plan.
6. Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but
is not sure about what type of plan designs are available through this program. What
should you tell him about the types of health plans that are available through the
Medicare Advantage program? >ANS>There are Medicare health plans such as HMOs,
PPOs, PFFS, and MSAs.
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