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2025 AHIP Final Exam
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2025 AHIP FINAL EXAM COMPLETEDETAILED CASE STUDY
treated for that condition. However, she and her physicians feel that after her lengthy hospital stay, she
will need a month or two of nursing and rehabilitative care. What should you tell them about Original
Medicare's coverage of care in a skilled nursing facility? - Medicare will cover Mrs. Shield's skilled nursing
services provided during the first 20 days of her stay, after which she would have a copay until she has
been in the facility for 100 days.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis through
massage therapy. She is concerned about whether or not Medicare will cover these items and services.
What should you tell her? - Medicare does not cover massage therapy, or, in general, glasses or
dentures.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might
be of assistance? - She should contact her state Medicaid agency to see if she qualifies for one of several
programs that can help with Medicare costs for which she is responsible.
Mr. Alonso receives some help paying for his two generic prescription drugs from his employer's retiree
coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what costs he
would generally expect to encounter when enrolling into a standard Medicare Part D prescription drug
plan. What should you tell him? - He generally would pay a monthly premium, annual deductible, and
per-prescription cost-sharing.
Mrs. Gonzalez is enrolled in Original Medicare and has a Medigap policy as well, but it provides no drug
coverage. She would like to keep the coverage she has but replace her existing Medigap plan with one
that provides drug coverage. What should you tell her? - Mrs. Gonzalez cannot purchase a Medigap plan
that covers drugs, but she could keep her Medigap policy and enroll in a Part D prescription drug plan.
Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and will
soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell
him? - He may sign-up for Medicare at any time however coverage usually begins on the fourth month
after dialysis treatments start.
,Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare
Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for
services. What advice would you give her? - Mrs. Duarte should file an appeal of this initial
determination within 120 days of the date she received the MSN in the mail.
Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare
enrollment period because the features of Part D might have changed. Mrs. Geisler can't remember
what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? -
Part D covers prescription drugs and she should look at her premiums, formulary, and cost-sharing
among other factors to see if they have changed.
Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized.
What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric
hospital stay that Medicare will cover? - Medicare will cover a total of 190 days of inpatient psychiatric
care during Mr. Rainey's entire lifetime.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under
Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to
Medicare beneficiaries? - Beneficiaries under Original Medicare have no cost-sharing for most preventive
services.
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan.
What should you tell him? - Mr. Singh can enroll in a stand-alone prescription drug plan and continue to
be covered for Part A and Part B services through Original Fee-for-Service Medicare.
Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid
taxes during that entire period. She is concerned that she will not qualify for coverage under part A
because she was not born in the United States. What should you tell her? - Most individuals who are
citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes while
working, though some may be covered as a result of paying monthly premiums.
Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin receiving Social
Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she had been
automatically enrolled in Medicare Part B. She wants to understand what this means. What should you
tell Mrs. Quinn? - Part B primarily covers physician services. She will be paying a monthly premium and,
except for many preventive and screening tests, generally will have 20% co-payments for these services,
in addition to an annual deductible.
, Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns 66.
He wants to understand the health care costs he might be exposed to under Medicare if he were to
require hospitalization because of an illness. In general terms, what could you tell him about his costs for
inpatient hospital services under Original Medicare? - Under Original Medicare, there is a single
deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a
per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days
over his lifetime, after which he would be responsible for all costs.
What impact, if any, have recent regulatory changes had on Medigap plans? - The Part B deductible is no
longer covered for individuals newly eligible for Medicare starting January 1, 2020.
Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare.
What can you tell her about Medigap as an option to address this concern? - Medigap plans do not cover
Original Medicare benefits, but they coordinate with Original Medicare coverage.
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know
which of the following services Original Medicare will cover if the appropriate criteria are met. What
could you tell her? - Original Medicare covers ambulance services.
Ms. Brooks has aggressive cancer and would like to know if Medicare will cover hospice services in case
she needs them. What should you tell her? - Medicare covers hospice services, and they will be available
for her.
Mr. Diaz continued working with his company and was insured under his employer's group plan until he
reached age 68. He has heard that there is a premium penalty for those who did not sign up for Part B
when first eligible and wants to know how much he will have to pay. What should you tell him? - Mr. Diaz
will not pay any penalty because he had continuous coverage under his employer's plan.
Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare Part A and Part
B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has
told her about the Medigap Plan F in which he is enrolled. It not only provides foreign travel emergency
benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you
tell her? - You are sorry to disappoint Anita, but a Medigap F plan is no longer available to those who
turn age 65 after January 1, 2020. Anita might instead consider other Medigap plans that offer foreign
travel benefits but do not cover the Part B deductible.
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