2023 AHIP Final Exam 1
Complete Answers 100% Correct
- 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. - Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her areathat
does not include drug coverage. She wants to enroll in the plan and enroll in a
stand-alone prescription drug plan.What should you tell her?:
Shecould enroll in a PFFS plan and a stand-alone Medicare prescription drug
plan. - Mrs. Roswell is a new Medicare beneficiary who has just retired from retailwork.
She is interested in selecting a Medicare Part D prescription drug plan. She takes
a number of 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 tocover a single one-month fill of her existing
medications sometime during a 90-daytransition period.
- Mr. Robinson was quite ill recently and forgot to pay his monthly premiumfor his MA-PD plan. He is worried that he will lose his coverage now when he needs it
the most. He is certain his plan will disenroll him because that iswhat happened
to a friend of his in a similar type of plan. What can you tell Mr. Robinson about
his situation?:
Plan sponsors have the option to do nothingwhen a plan member does not pay
their premiums or disenroll the member after agrace period and notice. - Mrs. Allen has a rare condition for which two different brand name drugsare
the only available treatment. She is concerned that since no generic prescription
drug is available and these drugs are very high cost, she will notbe able to find a
Medicare Part D prescription drug plan that covers either one of them. What
should you tell her?:
Medicare prescription drug plans are required to cover drugs in each therapeutic
category. She should be able to enrollin a Medicare prescription drug plan that
covers the medications she needs. - One of your clients, Lauren Nichols, has heard about a Medicare conceptfrom
one of her neighbors called TrOOP. She asks you to explain it. What do you
say?:
TrOOP stands for true out-of-pocket expenses that count toward the Medicare
Part D catastrophic limit and include not only expenses paid by a beneficiary but
also in some instances drug manufacturer discounts. - Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage.
She is ready to turn 65 and become Medicare eligible for the first time.What
issues might she consider about whether to enroll in a Medicare prescriptiondrug
plan?:
She could compare the coverage to see if the Medicare Part D planoffers better
benefits and coverage than the FEHB plan for the specific medicationsshe needs
and whether any additional benefits are worth the Part D premium costson top of
her FEHB contribution. - Mrs. Shields is covered by Original Medicare. She sustained a hip fractureand
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
2023 AHIP Final Exam
(ACTUAL TEST ) Questions and Answers
(Solved)
- 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. - Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her areathat
does not include drug coverage. She wants to enroll in the plan and enroll in a
stand-alone prescription drug plan.What should you tell her?:
Shecould enroll in a PFFS plan and a stand-alone Medicare prescription drug
plan. - Mrs. Roswell is a new Medicare beneficiary who has just retired from retailwork.
She is interested in selecting a Medicare Part D prescription drug plan. She takes
a number of 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 tocover a single one-month fill of her existing
medications sometime during a 90-daytransition period.
- Mr. Robinson was quite ill recently and forgot to pay his monthly premiumfor his MA-PD plan. He is worried that he will lose his coverage now when he needs it
the most. He is certain his plan will disenroll him because that iswhat happened
to a friend of his in a similar type of plan. What can you tell Mr. Robinson about
his situation?:
Plan sponsors have the option to do nothingwhen a plan member does not pay
their premiums or disenroll the member after agrace period and notice. - Mrs. Allen has a rare condition for which two different brand name drugsare
the only available treatment. She is concerned that since no generic prescription
drug is available and these drugs are very high cost, she will notbe able to find a
Medicare Part D prescription drug plan that covers either one of them. What
should you tell her?:
Medicare prescription drug plans are required to cover drugs in each therapeutic
category. She should be able to enrollin a Medicare prescription drug plan that
covers the medications she needs. - One of your clients, Lauren Nichols, has heard about a Medicare conceptfrom
one of her neighbors called TrOOP. She asks you to explain it. What do you
say?:
TrOOP stands for true out-of-pocket expenses that count toward the Medicare
Part D catastrophic limit and include not only expenses paid by a beneficiary but
also in some instances drug manufacturer discounts. - Mrs. Fiore is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage.
She is ready to turn 65 and become Medicare eligible for the first time.What
issues might she consider about whether to enroll in a Medicare prescriptiondrug
plan?:
She could compare the coverage to see if the Medicare Part D planoffers better
benefits and coverage than the FEHB plan for the specific medicationsshe needs
and whether any additional benefits are worth the Part D premium costson top of
her FEHB contribution. - Mrs. Shields is covered by Original Medicare. She sustained a hip fractureand
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
2023 AHIP FINAL EXAM 2
| Passed | A+ Rated Guide | New Full Exam
- Insurer vs Insured:
- insurer is a company that provides plan
- insured are the people that buy into the plan
- Group health insurance:
Health coverage provided by employers to membersof a group. - Group health insurance – types of coverage:
You can choose among severalor just one depending on your employer - dental, vision, medical benefits, managed care, fee-for-service insurance
- dental:
- basic/preventative services, restorative services, comprehensive or stand-alone,
ACA (children, some adults) - vision:
- basic exams and prescription glasses, ACA (children, some adults)
^ both are employer-sponsored voluntary group plans
- Premium tax-credit:
a subsidy that reduces the amount that consumers mustpay - tax credit that will lower monthly premium based on income and household info
- advanced premium tax-credit (aptc)
- self employed workers:
can deduct health insurance premiums from theirfederal taxable income –
important tax savings - contracts/health insurance policy: between insurer and insured
- consideration:
specifically termed agreement w/ promise to do something in return for a
valuable benefit (employer/insured premium payments to the insurer) - Covered services:
insurance policy will clearly state their covered services andtheir exlusions - proactive, preventative, and reactive services
- cost-sharing:
a situation where insured individuals pay a portion of the health-care costs, such
as deductibles, coinsurance or co-payments - insured is reimbursed for some but not all of the costs
- reimbursement depends on policy
- Deductible/coinsurance:
Money paid out of pocket before insurance coversthe remaining costs.
% of medical bill that insured pays out of pocket - copay:
a fixed fee you pay for specific medical services - government sponsored plans:
federal and state gov - medicare and medicaid
- medicare –> 65+ or younger w/ disabilities or severe kidney problems
- medicaid –> low-income individuals
- employer sponsored plans:
- employer determines coverage
- company’s HR dept answers employee questions
- excluded services:
services not covered in a medical insurance contract likeexperimental or noncontracted providers, elective or cosmetic surgery - Health Care Philosophy:
- good quality = cost effective
- more expensive does not mean good healthcare
- cost vs care balance
- good benefits priced appropriately
- less cost, more quality
triangle –> cost, access, quality
*more medical care does not mean better outcomes - managed care improves cost/access/quality:
cost: limited provider net- works, inventing new ways to pay physicians,
requiring referrals for specialty care
quality: credentialing providers, evidence-based medical policies, grading
providers on their quality outcomes, comparing providers to their peers
access: reigning in premium increases and reducing unnecessary care to make
additional provider time available - annual increase in premiums:
- result from consumer/government limitationsplaced on managed care
- other factors: higher provider fees, increased use of tech in delivery of care, health
AHIP Final Exam (Latest 2023 – 2024)
| Passed | A+ Rated Guide | New Full Exam
- 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 forhim and it
is not on his Part D plan’s formulary. What could you tell him to do?:
Mr. Zachow has a right to request a formulary exception to obtain coveragefor
his Part D drug. He or his physician could obtain the standardized request formon
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 wouldlike
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 POSoption might be a good solution for him as it will allow him to visit out-ofnetwork 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 be-cause
his MA-PD coverage has been very good. However, when he receivedthe 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 thoughtwould be fully covered.
He called you to ask what he could do? What couldyou tell him?:
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 sureshe also has
coverage for prescription drugs. Would she be able to obtain drug coverage if
she enrolled in the SNP?:
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?:
II. All data elements required to complete anenrollment 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 whatthat is.What should
you tell her?:
Step therapy involves using one or more lowerpriced 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 youtell