2025 AHIP – Module 2 Final Review

Question 1

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 do not necessarily have to cover all of the Original Medicare Part A and Part B services but must include a maximum out-of-pocket limit.

All Medicare Advantage Plans offer cost-sharing that is lower than Original Medicare for all Part A and Part B covered services, but the maximum out-of-pocket limit is higher than in Original Medicare.

Medicare Advantage Plans are not permitted to offer any benefits beyond those available under the Original Medicare program and must have the same maximum out-of-pocket limit on Part A and Part B services as Original FFS Medicare.

Hearing Aid co-pays through TruHearing

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.

Question 2

Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What should you tell her?

Mrs. Radford must be enrolled in both Medigap and Part A to enroll in a Medicare Advantage plan.

Mrs. Radford must apply to the Medicare Advantage plan, which will include a medical review, before being accepted and enrolled.

Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.

Mrs. Radford can enroll in any Medicare Advantage plan that operates within the United States.

Question 3

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 Medigap Supplemental plans that fill in the gaps not covered by Medicare.

There are major medical policies but are only for low-income beneficiaries with Medicare.

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

There are custodial long-term care plans for people with Medicare.

Question 4

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?

When possible, it is always the best option to have both the employer’s plan and the MA-PD, so he would have no out-of-pocket expenses.

Generally, employers prefer retirees to have both the retiree group plan and the MA-PD plan to fill in the gaps, but he would be better off with just the MA-PD plan.

Generally, employers prefer retirees to enroll in a stand-alone PDP, so he should consider that instead of the MA-PD.

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.

Question 5

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 could suggest he call the doctor who performed the surgery to complain about the costs and ask for a discount on the charges.

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

You could reassure him that such charges are typical, but if he needs assistance in paying, he should apply to the state for Medicaid assistance.

You could remind him that he cannot do anything until the next Annual Election Period when he will have an opportunity to change plans.

Question 6

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.

As long as his employer offers coverage that is equivalent to Medicare’s, he cannot enroll in Part B.

He will not need to do anything. His entitlement to Part A makes him eligible to enroll in any Medicare Advantage plan.

He must wait until the next Annual Election Period, at which time he can enroll in a Medicare Advantage plan.

Question 7

Which of the following statement(s) 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 full.

I, II, and III only

II and III only

I and II only

I, II, and IV only

Question 8

Hank’s Fish Store, Inc. is a small company with just 15 employees located in Florida. Hank, the store owner, has provided excellent health benefits to the store’s workforce. William, one of the store’s long-time employees, will soon be reaching age 65 and eligible for Medicare. William is in good health. He intends to remain an active full-time employee, working several years after becoming eligible for Medicare. What type(s) of retiree health benefit will Hank’s Fish Store be able to offer William?

Hank’s can continue to offer William the same employee health benefit plan, or, if William enrolls in Medicare Part B, it can enroll him in a Medicare Advantage plan that is offered to the public.

A MSA plan that includes prescription drug coverage.

A PACE plan.

Hank’s can only offer the same plan it provides to its employees who are not Medicare eligible.

Question 9

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 enrolled in Part A and Part D if he needs drug coverage.

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.

You would need to ask Mr. Kelly if he is enrolled in Part A and Part B and if his doctor will accept the terms and conditions of payment of the PFFS plan.

You would need to ask Mr. Kelly if he is enrolled in Part A and Part B, if he is healthy, and how often he expects to visit a doctor.

Question 10

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 but if she wishes prescription drug coverage she must also enroll in a Medicare Supplement Plan (Medigap) F plan that covers the Medicare Part B deductible and includes drug coverage.

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

Mrs. Chi is ineligible for a MA MSA plan because she is ineligible for Medicaid due to her income level.

Mrs. Chi may enroll in a MA MSA plan but if she wishes prescription drug coverage it must be a MSA-PD plan that includes drug coverage.

Question 11

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?

Dr. Brennan can charge the beneficiary the same cost-sharing as Original Medicare as long as she sends the claim to Medicare and not the plan.

Dr. Brennan can charge Mary Rodgers no more than the cost sharing specified in the PFFS plan’s terms and conditions of payment which may include balance billing up to 25% of the Medicare rate.

Dr. 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.

Dr. Brennan can charge Mary Rodgers more than the cost sharing specified in the PFFS plan’s terms and conditions as long as she treats all beneficiaries the same.

Question 12

Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that 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?

She could enroll in the PFFS plan and a Medigap plan that offers drug coverage, but not in a stand-alone Medicare prescription drug plan.

She could enroll in a PFFS plan, but not in a stand-alone drug plan.

She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan.

If she wants drug coverage and a PFFS plan, she could only enroll in a PFFS plan that includes Medicare prescription drug coverage.

Question 13

Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you tell her about obtaining drug coverage?

She can enroll in the PPO and purchase drug coverage through a Medigap plan.

She can enroll in the PPO and if she decides that she wants drug coverage, she will be able to drop her PPO at any time in favor of a Medicare Advantage plan that includes such drug coverage.

She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan.

She can enroll in the PPO and purchase drug coverage through a stand-alone Medicare Part D prescription drug plan.

Question 14

Mrs. Walters is enrolled in her state’s Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Advantage (MA) plan?

Once she enrolls in an MA plan she will be automatically disenrolled from Medicaid.

She cannot enroll in an MA Medical Savings Account (MSA) plan.

As a Medicaid beneficiary, she will be eligible for a low-deductible MSA health plan.

If she enrolls in an MSA plan, she will be paying a monthly premium to the MSA plan that will cover her Part B premium obligation.

Question 15

Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was disappointed with the service she received from her primary care physician because she was told she would have to wait five weeks to get an appointment when she was feeling ill. She called you to ask what she could do so she would not have to put up with such poor access to care. What could you tell her?

She should call the doctor’s office to complain since the plan cannot do anything about the doctor’s schedule.

She must write to the plan and wait for a response and then, if she is still dissatisfied, she could file an appeal with her state Medicaid office requesting transfer to one of its managed care plans.

She should not expect to get in to see her doctor any more quickly since she is a Medicare patient.

She could file a grievance with her plan to complain about the lack of timeliness in getting an appointment.

Question 16

Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan?

For enrollees in an MSA, after the annual deductible is met, the MSA plan generally pays 75% of covered services.

MSA enrollees may only receive covered health care services from a limited panel of network providers because otherwise, some providers may charge more than Original Medicare rates.

All beneficiaries enrolled in an MSA set-aside the MSA funds on a pre-tax basis in addition to paying their Part B premium.

All MSAs cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by also enrolling in a separate prescription drug plan.

Question 17

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.

Since she is age 65 she may enroll in any Medicare Advantage plan, regardless of whether she is entitled to Part A or Part B coverage.

To enroll in a Medicare Advantage plan, she need only be entitled to Part A, so she does not need to take any further steps.

To join a Medicare Advantage plan, she must be enrolled in Parts A, B, and D

Question 18

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 cannot enroll in a stand-alone prescription drug plan because you do not represent such a plan.

He could enroll in the MA-only plan and purchase a Medigap plan with drug coverage.

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.

He could enroll in the MA-only PPO plan and a stand-alone Medicare prescription drug plan.

Question 19

Mrs. Velasquez cares for her frail elderly mother, Maria, who lives in North Carolina. She is worried that without additional support, her mother will need to go into a nursing home. Mrs. Velasquez asks you if there is any Medicare plan that might allow her mother to remain in the community rather than going into a nursing home. How should you advise Mrs. Velasquez?

There are Medicare Private Fee-for-Service (PFFS) plans that are not Medicare Advantage plans and are specifically designed for the frail elderly.

There are Medicare-Medicaid Plans (MMPs) that are available in all states and are designed for the frail elderly.

There are Medicare Cost Plans that are widely available nationwide that are designed for the frail elderly.

There are Programs of All-Inclusive Care for the Elderly (PACE) for frail elderly beneficiaries certified as needing a nursing home level of care but are able to live safely in the community at the time of enrolment.

Question 20

Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage. What would be the correct description?

Medicare Advantage is a way of covering all the Original Medicare benefits through private health insurance companies.

Medicare Advantage is designed to pick up where Original Medicare leaves off, covering those health care services that would not normally be covered by Original Medicare.

Medicare Advantage is a health insurance program operated jointly by the states with the Federal government.

Medicare Advantage is a new name for the Original Medicare program.

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