AHIP - Final examination
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? - ANSMr. 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? - ANSThe 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? -
ANSYou 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? - ANSa. 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? - ANSII. 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? - ANSStep 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? - 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. 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? -
ANSMr. 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? -
ANS
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? - ANSa. 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? - ANSMedicare 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
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? - ANSMr. 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? - ANSThe 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? -
ANSYou 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? - ANSa. 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? - ANSII. 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? - ANSStep 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? - 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. 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? -
ANSMr. 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? -
ANS
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? - ANSa. 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? - ANSMedicare 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
