AHIP Final Exam 2025

Mrs. Tanner is enrolled in a Medicare Advantage HMO that offers a point of service option. This allows Mrs. Tanner to do which of the following?

Mrs. Tanner can go to non-plan doctors for certain services without receiving prior approval.

You have set up an appointment for an in-home sales presentation with Mrs. Fernandez, who expressed interest in the Medicare plans you represent. In preparation for the sales presentation, what must you do?

Before conducting the presentation, obtain and document having obtained her permission to visit, along with her interest in the specific products you will present.

Mrs. Pierce would like to enroll in a Medicare Cost plan that offers Part D prescription drug coverage. She comes to you for advice about when she can enroll in a plan you have previously discussed. What should you tell her?

Enrollment in Cost plans offering Part D coverage is available only during enrollment periods under the Part D program, and Cost plans must accept enrollments during these periods.

Mr. Liu turns 65 on June 19. He has never previously qualified for Medicare so his first Medicare eligibility date will be June 1. Mr. Liu's ICEP and Part D IEP begin on March 1 and end on September 30. He wants prescription drug coverage with his Part A and Part B benefits. What advice can you provide him?

He can enroll in a MA-PD as long as he enrolls in Part B and is entitled to Part A.

Mr. Ford enrolled in an MA-only plan in mid-November during the Annual Election Period (AEP). On December 1, he calls you up and says that he has changed his mind and would like to enroll in a MA-PD plan. What enrollment rules would apply in this case?

He can make as many enrollment changes as he likes during the Annual Election Period and the last choice made before the end of the period will be the effective one as of January 1.

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?

He 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.

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.

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?

He 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.

Mr. Sanchez 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?

He will have to enroll in Part B.

Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He found a stand-alone Medicare prescription drug plan in his area that offers better coverage than that available through his MA-PD plan and in addition, has a low premium. It won't cost him much more and, because he has the means to do so, he wishes to enroll in the stand-alone prescription drug plan in addition to his MA-PD plan. What should you tell him?

If Mr. Block enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the Medicare Advantage plan.

Mr. Hutchinson has drug coverage through his former employer's retiree plan. He is concerned about the Part D premium penalty if he does not enroll in a Medicare prescription drug plan, but does not want to purchase extra coverage that he will not need. What should you tell him?

If the drug coverage he has is not expected to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay, then he will need to enroll in Medicare Part D during his initial eligibility period to avoid the late enrollment penalty.

Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an automatic monthly withdrawal from his savings account until it is exhausted, and then have his premiums withheld from his Social Security check. What should you tell him?

In general, he must select a single Part D premium payment mechanism that will be used throughout the year.

Mrs. Schmidt is moving and a friend told her she might qualify for a "special election period" to enroll in a new Medicare Advantage plan. She contacted you to ask what a special election period is. What could you tell her?

It is a single period from January 1 - March 31, created by statute, when any Medicare beneficiary who has moved out of the area of their Medicare Advantage or Part D plan can add, drop, or change their Medicare prescription drug coverage.

Who is most likely to benefit from the Medicare Prescription Payment Plan?

Kevin, who suffered a heart attack at the beginning of the year requiring him to take an expensive brand name blood thinner on a daily, as well as an equally expensive injectable cholesterol medication on a bi-weekly basis for which he incurs high out-of-pocket costs.

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. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully 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. 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.

Mr. Carlini has heard that Medicare prescription drug plans are only offered through private companies under a program known as Medicare Advantage (MA), not by the government. He likes Original Medicare and does not want to sign up for an MA product, but he also wants prescription drug coverage. What should you tell him?

Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries.

Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi?

Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription drug plan.

Mr. Wingate is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary, he takes several other medications. These include a prescription drug not on his plan's formulary, over-the-counter medications for colds and allergies, vitamins, and drugs from an Internet-based Canadian pharmacy to promote hair growth and reduce joint swelling. His neighbor recently told him about a concept called TrOOP and he asks you if any of his other medications could count toward TrOOP should he ever reach the Part D catastrophic limit. What should you say.

None of the costs of Mr. Wingate's other medications would currently count toward TrOOP but he may wish to ask his plan for an exception to cover the prescription, not on its formulary.

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. Lee is enrolled in an MA-PD plan but will be moving out of the plan's service area next month. She is worried that she will not be able to enroll in another plan available in her new residence until the Annual Election Period. What should you tell her?

She is eligible for a special election period (SEP) that begins either the month before her permanent move, if the plan is notified in advance, or the month she provides notice of the move, and this period typically lasts an additional two months.

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.

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.

Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know whether he might qualify. What should you tell him?

The extra help is available only to Medicare beneficiaries who are enrolled in Medicaid. He should apply for coverage under his state's Medicaid program to access the extra help with his drug costs.

Mr. Lopez 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?

There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.

One of your colleagues argues that it is better to focus your time and energy exclusively on neighborhoods with single-family homes. He further argues that their older owners are more likely to have higher incomes and purchase the Medicare Advantage products you represent compared to those living in apartment complexes. How should you respond?

This could be considered discriminatory activity and a prohibited practice.

Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you advise her to do before she can enroll in a Medicare Advantage plan?

To join a Medicare Advantage plan, she also must enroll in Part B.

Mr. Barker 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?

You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.

A Medicare beneficiary has walked into your office and requested that you sit down with her and discuss her options under the Medicare Advantage program. Before engaging in such a discussion, what should you do?

You must have her sign a scope of appointment form, indicating which products she wishes to discuss. You may then proceed with the discussion.

Next week you will be participating in your first "educational event" for prospective enrollees. To be sure that you do not violate any of the applicable guidelines, in what activities should you plan to engage?

You should plan to ensure that the educational event is informative and must not conduct a sales presentation or distribute or accept enrollment forms at the event.

You plan to participate in an educational event sponsored by a large regional health care system. One of your colleagues suggests that you do a presentation on one of the Medicare Health plans you market and modify it to include information about preventive screening tests showcased at the event. How should you respond to your colleague's suggestion?

You should tell your colleague no because participation in an educational event may not include a sales presentation.

Richard is a licensed agent who represents Spartan Health Plan and its Medicare Advantage (MA) plans. Richard has several clients who have recently come to him for help who are in their initial coverage election period (ICEP) and are interested in enrolling in one of Spartan Health Plan's MA plans. Alice will soon turn 65 and retire. Alice has coverage through Spartan Health Plan offered by her employer. Bob had health coverage through Spartan but dropped the coverage when he retired early to travel overseas. Bob, who has just turned age 65, is now back in the United States. Charlotte, who will turn 65 next month, has coverage through Athena Health plan - a company Richard also represents. Who qualifies for the opt-in simplified enrollment mechanism?

Alice and Charlotte because each of them currently have health coverage and is in their initial coverage election period (ICEP).

Mr. Lopez, who is fairly well-off financially, would like to enroll in a Medicare prescription drug plan you represent and simply give you a check to cover his premiums for the entire year. What should you tell him?

He will need to mail in his payment with his enrollment form.

Agent Harriet Walker has recently begun marketing Medicare Advantage and related products aimed at meeting the needs of senior citizens. Client Mildred Jones has expressed interest in a Medicare Advantage plan. It is now the beginning of September. If you were in Agent Walker's position, what would you do?

Inquire whether the client qualifies for a special enrollment period, and if not, solicit an enrollment application once the annual open enrollment election period begins on October 15th.

While making an appointment to discuss Medicare Advantage (MA) and Part D plans with a potential enrollee, you are asked to describe other types of insurance products that your client might wish to purchase. What additional types of insurance can you present during the MA and Part D marketing appointments?

You can present only health care related lines of business but must obtain the beneficiary's permission to do so before the presentation occurs and document that you have obtained that permission.

You market many different types of insurance and ordinarily you spend time each evening calling potential clients. To comply with requirements for marketing Medicare Advantage and Part D plans, what must you do about contacting potential clients to market those plansl?

You will have to avoid calling any potential client unless he or she initiates contact with you and specifically asks that you give him or her a call.

Mrs. Mulcahy, age 65, is concerned that she may not qualify for enrollment in a Medicare prescription drug plan because, although she is entitled to Part A, she is not enrolled under Medicare Part B. What should you tell her?

An individual who is entitled to Part A or enrolled under Part B is eligible to enroll in a Medicare prescription drug plan. As long as Mrs. Mulcahy is entitled to Part A, she does not need to enroll under Part B before enrolling in a prescription drug plan.

Mrs. Roswell is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her?

Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90-day transition period.

Which of the following individuals are likely to qualify for a special election period (SEP) for either a MA and/or Part D due to a change of residence? I. Edward (enrolled in MA and Part D) moves to a new home within the same neighborhood in his existing plan's service area. II. Fiona (enrolled in MA and Part D) moves cross-country to an area outside her existing plan's service area. III. Gilbert moves into a plan service area where there is now a Part D plan available to him from a service area where no Part D plan was available. IV. Henry makes a permanent move to a new state providing him with new MA and Part D options.

II, III, and IV only.

Mr. Prentice has many clients who are Medicare beneficiaries. He should review the Centers for Medicare & Medicaid Services (CMS) Communication and Marketing Guidelines to ensure he is compliant with which type of products.

Medicare Advantage (MA) and Prescription Drug (PDP) plans.

Mrs. Wang wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she starts looking at specific plans. What could you tell her?

Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services. It must include a maximum out-of-pocket limit on Part A and Part B services.

Mr. Jacob understands that there is a standard Medicare Part D prescription drug benefit, but when he looks at information on various plans available in his area, he sees a wide range in what they charge for deductibles, premiums, and cost sharing. How can you explain this to him?

Medicare Part D drug plans may have different benefit structures, but on average, they must all be at least as good as the standard model established by the government.

Mr. Chen is enrolled in his employer's group health plan and will be retiring soon. He would like to know his options since he has decided to drop his retiree coverage and is eligible for Medicare. What should you tell him?

Mr. Chen can disenroll from his employer-sponsored coverage to elect a Medicare Advantage or Part D plan within 2 months of his disenrollment.

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.

Scot Fitzwilliam is a Medicare beneficiary who currently takes several prescription drugs daily. He does not suffer, however, from diabetes. He is currently considering enrolling in the PDP you represent. Mr. Fitzwilliam enjoys a comfortable income and therefore is unlikely to qualify for a low-income subsidy. He is careful with his money and asks you about his likely out-of-pocket costs under a standard benefits PDP plan. What do you say?

Mr. Fitzwilliam is likely to be responsible for a deductible of $590 (PY 2025) after which he will be responsible for 25 percent of his prescription drug costs during the initial coverage phase - that is, between the deductible and the initial coverage limit of $2,000 (PY 2025).

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. Anderson is a very organized individual and has filled out and brought to you an enrollment form on October 10 for a new plan available on January 1 next year. He is currently enrolled in Original Medicare. What should you do?

Tell Mr. Anderson that you cannot accept any enrollment forms until the annual election period begins.

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?

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. Kelly wants to know whether he is eligible to sign up for a private fee-for-service (PFFS) plan. What questions would you need to ask to determine his eligibility?

You would need to ask Mr. Kelly if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area.