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Entertaining AHIP 2025 questions and answers 2015/2016
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Entertaining AHIP 20251. A beneficiary 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? >ANS>She can enroll in a PPO without drug coverage.
However, If a beneficiary enrolls in a MA plan that is an HMO or PPO plan that does not
include Part D coverage, the beneficiary cannot join a standalone Prescription Drug Plan
(PDP).
2. A client 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>Medicare Advantage (MA) plan enrollees have a right to obtain a review (appeal)
to certain decisions about health care payment, coverage of services, or prescription
drug coverage. Medicare health plans must provide enrollees with a written description
of the appeals process.
3. A client is enrolled in her state's Medicaid program in addition to Medicare. What should
she be aware of when considering enrollment in a Medicare Advantage (MA) plan?
>ANS>The client is a dual-eligible. Dual-eligible beneficiaries may enroll in any type of
MA plan except a MA Medical Savings Account (MSA) plan.
4. A potential client calls and asks whether there are any special eligibility requirements for
Medicare Advantage. What should you tell her? >ANS>To be eligible to enroll in
Medicare Advantage, an individual must be entitled (not enrolled) to Part A and enrolled
in Part B.
5. A potential client 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 coordinated care Medicare
Advantage plans that include HMOs and PPOs. There are also Private-Fee-for-Service
(PFFS), Medicare Savings Account (MSA), and Special Needs Plans (SNPs)
6. Benefits of Medicare Prescription Payment Plan >ANS>Expanding benefits, lowering
drug costs, and improving the sustainability of the Medicare program
7. Dolly Pardon is in really good health, uses a single prescription, and lives independently
in her own home. She is attracted by the idea of maintaining control over a Medical
, Savings Account (MSA) but is not sure if the plan associated with the account will fit her
needs. What specific piece of information about a Medicare MSA plan would it be
important for her to know, prior to enrolling in such a plan? >ANS>MSA enrollees must
enroll in a stand-alone prescription drug plan (PDP) if they want prescription drug
benefits.
8. Dr. DoLittle does not contract with the ABC PFFS plan but accepts the plan's terms and
conditions for payment. Mary Rodgers sees Dr. DoLittle for treatment. How much may
Dr. DoLittle charge? >ANS>This doctor 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. Because Dr. DoLittle accepts the plan's
terms and conditions for payment, she is permitted to charge this amount.
9. Drew Looksatme 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? >ANS>The type of Medicare Advantage plans offered vary by employers.
Therefore, beneficiaries should compare their employer's retiree plan with other
available plan options.
10. Dua Lippa cares for her frail elderly mother, Maria, who lives in North Carolina. She is
worried that without additional support, her mother will need to go into a nursing home.
Ms. Lippa asks you if there is any Medicare plan that might allow her mother to remain in
the community rather than going into a nursing home. How should you advise Ms.
Lippa? >ANS>There are Programs of All-Inclusive Care for the Elderly (PACE) for frail
elderly beneficiaries certified as needing a nursing home level of care but are able to live
safely in the community at the time of enrolment.
11. Eleanor Rigby is enrolled in a Medicare Advantage plan that includes prescription drug
plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she
has lost. How would you advise her? >ANS>She may fill prescriptions for covered drugs
at non-network pharmacies, but likely at a higher cost than paid at an in-network
pharmacy.
12. George Clonie has just turned 65 and is entitled to Part A but has not enrolled in Part B
because he has coverage through an employer plan. If he wants to enroll in a Medicare
Advantage plan, what will he have to do? >ANS>To be eligible to enroll in a Medicare
Advantage plan, a beneficiary must be entitled to Part A and enrolled in Part B.
13. Gramcicle is enrolled in a cost plan for her Medicare benefits. She has recently lost
creditable coverage previously available through her husband's employer. She is
interested in enrolling in a Medicare Part D prescription drug plan (PDP). >ANS>She is
enrolled in a Cost plan. This provides her with options as to how she secures Part D
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