2022 AHIP
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? - ANSHe may sign-up for Medicare at any time however coverage
usually begins on the fourth month after dialysis treatments start.
Juan Perez, who is turning age 65 next month, intends to work for several more years at
Smallcap, Incorporated. Smallcap has a workforce of15 employees and offers
employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to
the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he
enrolls how that will impact his employer-sponsored healthcare coverage. How would you
respond? - ANSJuan is likely to be eligible for Medicare once he turns age 65 and if he enrolls
Medicare would become the primary payor of his healthcare claims and Smallcap does not have
to continue to offer him coverage comparable to those under age 65 under its
employer-sponsored group health plan.
Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage
Medicare Supplemental Insurance provides since his health care needs are different from his
wife's needs. What could you tell Mr. Moy? - ANSMedicare Supplemental Insurance would help
cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS)
Medicare as well as possibly some services that Medicare does not cover.
Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She
heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What
can you tell her? - ANSShe may enroll at any time while she is covered under her employer
plan, but she will have a special eight-month enrollment period after the last month on her
employer plan that differs from the standard general enrollment period, during which she may
enroll in Medicare Part B.
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? -
ANSMost 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. 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? - ANSMrs.
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.
,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? - ANSMedicare does not cover massage therapy,
or, in general, glasses or dentures.
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 as a result of an illness. In general terms, what could you tell
him about his costs for inpatient hospital services
under Original Medicare? - ANSUnder 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.
Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without
paying any premiums, because she has been working for 40 years and paying Medicare taxes.
What should you tell her? - ANSTo obtain Part B coverage, she must pay a standard monthly
premium, though it is higher for individuals with higher incomes.
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 MedicarePart
D prescription drug plan. What should you tell him? - ANSHe generally would pay a monthly
premium, annual deductible, and per-prescription cost-sharing.
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will
have considerable income when she retires. She is concerned that her income will make it
impossible for her to qualify for Medicare. What could you tell her to address her concern? -
ANSMedicare is a program for people age 65 or older and those under age 65 with certain
disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for
Medicare.
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? - ANSBeneficiaries under Original Medicare have no
cost-sharing for most preventive services which include immunizations such as annual flu shots.
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? - ANSMrs. Duarte should file an
appeal of this initial determination within 120 days of the date she received the MSN in the mail.
,Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to
pick up costs not covered by that plan.
What should you tell him? - ANSIt is illegal for you to sell Mr. Capadona a Medigap plan if he is
enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park
that might be of assistance? - ANSShe 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. 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? - ANSMedicare will cover a total of
190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.
Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original
Fee-for-Service (FFS) Medicare? What could you tell him? - ANSPart A, which covers hospital,
skilled nursing facility, hospice, and home health services and Part B, which covers professional
services such as those provided by a doctor are covered under Original Medicare.
Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in
Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan
which he has had for several years. However, the plan does not provide drug benefits. How
would you advise Agent John Miller to proceed? - ANSTell prospect Jerry Smith that he should
consider adding a standalone Part D prescription drug coverage policy to his present coverage.
Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social
Security Administration and has been receiving disability payments. He is wondering whether he
can obtain coverage under Medicare. What should you tell him? - ANSAfter receiving such
disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of
age.
Mr. Buck has several family members who died from different cancers. He wants to know if
Medicare covers cancer screening.
What should you tell him? - ANSMedicare covers the periodic performance of a range of
screening tests that are meant to provide early detection of disease. Mr. Buck will need to check
specific tests before obtaining them to see if they will be covered.
Which of the following statement is/are correct about a Medicare Savings Account (MSA)
Plans?
I. MSAs may have either a partial network, full network, or no network of providers.
II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
, III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500
indexed for inflation.
IV. Non-network providers must accept the same amount that Original Medicare would pay them
as payment in ful - ANSI, II, and IV only
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? -
ANSHe 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.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which
providers she can go to for her health care. What should you tell her? - ANSMrs. Ramos can
obtain care from any provider who participates in Original Medicare, but generally will have a
higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network.
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? - ANSHe should compare the
benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor's
MA-PD plan to determine which one will provide sufficient coverage for his prescription needs.
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? - ANSDr. 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.
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? - ANSHe 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. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be the correct description? - ANSMedicare Advantage is a way of
covering all the Original Medicare benefits through private health insurance companies.
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? - ANSHe may sign-up for Medicare at any time however coverage
usually begins on the fourth month after dialysis treatments start.
Juan Perez, who is turning age 65 next month, intends to work for several more years at
Smallcap, Incorporated. Smallcap has a workforce of15 employees and offers
employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to
the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he
enrolls how that will impact his employer-sponsored healthcare coverage. How would you
respond? - ANSJuan is likely to be eligible for Medicare once he turns age 65 and if he enrolls
Medicare would become the primary payor of his healthcare claims and Smallcap does not have
to continue to offer him coverage comparable to those under age 65 under its
employer-sponsored group health plan.
Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage
Medicare Supplemental Insurance provides since his health care needs are different from his
wife's needs. What could you tell Mr. Moy? - ANSMedicare Supplemental Insurance would help
cover his Part A and Part B deductibles or coinsurance in Original Fee-for-Service (FFS)
Medicare as well as possibly some services that Medicare does not cover.
Mrs. Peňa is 66 years old, has coverage under an employer plan, and will retire next year. She
heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What
can you tell her? - ANSShe may enroll at any time while she is covered under her employer
plan, but she will have a special eight-month enrollment period after the last month on her
employer plan that differs from the standard general enrollment period, during which she may
enroll in Medicare Part B.
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? -
ANSMost 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. 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? - ANSMrs.
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.
,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? - ANSMedicare does not cover massage therapy,
or, in general, glasses or dentures.
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 as a result of an illness. In general terms, what could you tell
him about his costs for inpatient hospital services
under Original Medicare? - ANSUnder 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.
Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without
paying any premiums, because she has been working for 40 years and paying Medicare taxes.
What should you tell her? - ANSTo obtain Part B coverage, she must pay a standard monthly
premium, though it is higher for individuals with higher incomes.
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 MedicarePart
D prescription drug plan. What should you tell him? - ANSHe generally would pay a monthly
premium, annual deductible, and per-prescription cost-sharing.
Ms. Moore plans to retire when she turns 65 in a few months. She is in excellent health and will
have considerable income when she retires. She is concerned that her income will make it
impossible for her to qualify for Medicare. What could you tell her to address her concern? -
ANSMedicare is a program for people age 65 or older and those under age 65 with certain
disabilities, end-stage renal disease, and Lou Gehrig's disease so she will be eligible for
Medicare.
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? - ANSBeneficiaries under Original Medicare have no
cost-sharing for most preventive services which include immunizations such as annual flu shots.
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? - ANSMrs. Duarte should file an
appeal of this initial determination within 120 days of the date she received the MSN in the mail.
,Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to
pick up costs not covered by that plan.
What should you tell him? - ANSIt is illegal for you to sell Mr. Capadona a Medigap plan if he is
enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park
that might be of assistance? - ANSShe 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. 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? - ANSMedicare will cover a total of
190 days of inpatient psychiatric care during Mr. Rainey's entire lifetime.
Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original
Fee-for-Service (FFS) Medicare? What could you tell him? - ANSPart A, which covers hospital,
skilled nursing facility, hospice, and home health services and Part B, which covers professional
services such as those provided by a doctor are covered under Original Medicare.
Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in
Medicare Parts A and B. Jerry has also purchased a Medicare Supplement (Medigap) plan
which he has had for several years. However, the plan does not provide drug benefits. How
would you advise Agent John Miller to proceed? - ANSTell prospect Jerry Smith that he should
consider adding a standalone Part D prescription drug coverage policy to his present coverage.
Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social
Security Administration and has been receiving disability payments. He is wondering whether he
can obtain coverage under Medicare. What should you tell him? - ANSAfter receiving such
disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of
age.
Mr. Buck has several family members who died from different cancers. He wants to know if
Medicare covers cancer screening.
What should you tell him? - ANSMedicare covers the periodic performance of a range of
screening tests that are meant to provide early detection of disease. Mr. Buck will need to check
specific tests before obtaining them to see if they will be covered.
Which of the following statement is/are correct about a Medicare Savings Account (MSA)
Plans?
I. MSAs may have either a partial network, full network, or no network of providers.
II. MSA plans cover Part A and Part B benefits but not Part D prescription drug benefits.
, III. An individual who is enrolled in an MSA plan is responsible for a minimal deductible of $500
indexed for inflation.
IV. Non-network providers must accept the same amount that Original Medicare would pay them
as payment in ful - ANSI, II, and IV only
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? -
ANSHe 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.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which
providers she can go to for her health care. What should you tell her? - ANSMrs. Ramos can
obtain care from any provider who participates in Original Medicare, but generally will have a
higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network.
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? - ANSHe should compare the
benefits in his employer-sponsored retiree group health plan with the benefits in his neighbor's
MA-PD plan to determine which one will provide sufficient coverage for his prescription needs.
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? - ANSDr. 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.
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? - ANSHe 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. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be the correct description? - ANSMedicare Advantage is a way of
covering all the Original Medicare benefits through private health insurance companies.
