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AHIP - Final Examination Questions And Answers Latest Test 2022/2023
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AHIP - Final Examination Questions AndAnswer
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 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?
Correct 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 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 Answer: You 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 Answer: a. 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 Answer: II. 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 Answer: Step therapy involves using one
or more lower priced drugs before trying a more expensive drug when all are used to treat the same
condition.
, 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 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.
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 Answer:
Mr. 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
Answer:
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
Answer: a. 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
reduced 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 Answer: Medicare Advantage (MA) and Prescription Drug (PDP)
plans Correct
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 Answer: a. 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.
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