AHIP Final Exam - Question and Answers

AHIP Final Exam Test Questions and Answers

1. 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?

2. 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?

3. 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?

4. Mrs. Pe?a 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?

5. 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?

6. 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?

7. 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?

8. 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 servicesunder Original Medicare?

9. 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?

10. 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?

11. 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?

12. 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?

13. 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?

14. 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?

15. Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that might be of assistance?

16. 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?

17. 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?

18. 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?

19. 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?

20. Mr. Buck has several family members who died from different cancers. He wants to know if Medicare covers cancer screening.

21. Which of the following statement is/are

22. 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?

23. 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?

24. 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?

25. 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?

27. 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.

28. 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?

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

30. 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?

31. Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him?

32. 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?

32. Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that plan. What should you tell him?

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

34. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her?

36. Mrs. Davenport enrolled in the ABC Medicare Advantage (MA) plan several years ago. In mid-February of 2021, her doctor confirms a diagnosis of end-stage renal disease (ESRD). What options will Mrs. Davenport have regarding her MA plan during the next open enrollment season?

37. Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him?

38. 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?

39. Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him?

40. 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?

41. 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?

42. 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?

43. Mr. Bickford did not quite qualify for the extra help low-income subsidy under the Medicare Part D Prescription Drug program and he is wondering if there is any other option he has for obtaining help with his considerable drug costs. What should you tell him?

44. Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a prescription for helping to regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them?

45. 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?

 46. Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?

47. Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage previously available through her husband's employer. She is interested in enrolling in a Medicare Part D prescription drug plan (PDP). What should you tell her?

48. Mrs. Allen has a rare condition for which two different brand name drugs are the only available treatment. She is concerned that since no generic prescription drug is available and these drugs are very high cost, she will not be able to find a Medicare Part D prescription drug plan that covers either one of them. What should you tell her?

49. Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision?

50. Mr. Shultz was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has lost his employer group coverage within the last two weeks. How would you advise him

51. 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?

52. What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications

53. All plans must cover at least the standard Part D coverage or its actuarial equivalent. Which of the following statements best describes some of the costs a beneficiary would incur for prescription drugs under the standard coverage

54. 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?

55. 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?

56. Which of the following individuals is most likely to be eligible to enroll in a Part D Plan?correct answersJose, a grandfather who was granted asylum and has worked in the United States for many years.

57. 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?

58. Mrs. McIntire is enrolled in her state's Medicaid plan and has just become eligible for Medicare as well. What can she expect will happen to her drug coverage?

59. Unless she chooses a Medicare Part D prescription drug plan on her own, she will be automatically enrolled in one available in her area.

60. Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this?

61. Which of the following statements about Medicare Part D are correct?

62. 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?

63. You will be holding a sales event soon, at which you would like to offer door prizes to attendees. Under guidelines from the Medicare agency, what types of gifts or prizes would not be allowed in this situation?

64. Another agent working for your agency claims that because you are not employed by the Medicare Advantage plans that you represent, you are not subject to the same marketing requirements as the plans themselves. How should you respond to such a statement?

65. Mrs. Lu is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do?

66. One of your colleagues argues that it is better to focus your time and energy exclusively in 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?

67. 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?

68. Your friend's mother just moved to an assisted living facility and he asked if you could present a program for the residents about the MA-PD plans you market. What could you tell him?

69. Melissa Meadows is a marketing representative for Best Care which has recently introduced a Medicare Advantage plan offering comprehensive dental benefits for $15 per month. Best Care has not submitted any potential posts to CMS for approval.Melissa would like to use the power of social media to reach potential prospects. What advice would you give her?

70. Agent Jennings makes a presentation on Medicare advertised as an educational event. Agent Jennings distributes materials that are solely educational. However, she gives a brief presentation that mentions plan-specific premiums. Is this a prohibited activity at an event that has been advertised as educational?

71. Agent Martinez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her?

72. Miguel Sanchez is a relatively new agent who has come to you for advice as to what he can do during the Medicare Advantage Open Enrollment Period (MA-OEP). What advice should you give Miguel?

73. ABC is a Medicare Advantage (MA) plan sponsor. It would like to use its enrollees' information to market non-health related products such as life insurance and annuities. Which statement best describes ABC's obligation to its enrollees regarding marketing such products?

74. You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns?

75. During a sales presentation, your client asks you whether the Medicare agency recommends that she sign up for your plan or stay in Original Medicare. What should you tell her?

76. Agent Armstrong is employed by XYZ Agency, which is under contract with ABC Health Plan, a Medicare Advantage (MA) plan that offers plans in multiple states. XYZ Agency maintains a website marketing the MA plans with which it has contracts. Agent Armstrong follows up with individuals who request more information about ABC MA plans via the website and tries to persuade them to enroll in ABC plans. What statement best describes the marketing and compliance rules that apply to Agent Armstrong?

77. You have been providing a pre-Thanksgiving meal during sales presentations in November for many years and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do with respect to meals?

78. 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?

79. You are working several plans and community organizations to sponsor an educational event. When putting together advertisements for this event, what should you do?

 80. Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual?

81. You are seeking to represent an individual Medicare Advantage plan and an individual Part D plan in your state. You have completed the required training for each plan, but you did not achieve a passing score on the tests that came after the training. What can you do in this situation?

82. Plan sponsors may undertake the following marketing activities with current Medicare Advantage plan members?

83. Mr. Rockwell, age 67, is enrolled in Medicare Part A, but because he continues to work and is covered by an employer health plan, he has not enrolled in Part B or Part D. He receives a notice on June 1 that his employer is cutting back on prescription drug benefits and that as of July 1 his coverage will no longer be creditable. He has come to you for advice. What advice would you give Mr. Rockwell about special election periods

84. Mrs. Young is currently enrolled in Original Medicare (Parts A and B), but she has been working with Agent Neil Adams in the selection of a Medicare Advantage (MA) plan. It is mid-September, and Mrs. Young is going on vacation. Agent Adams is considering suggesting that he and Mrs. Young complete the application together before she leaves. He will then submit the paper application before the start of the annual enrollment period (AEP). What would you say If you were advising Agent Adams?

85. 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?

86. Mrs. Reeves is newly eligible to enroll in a Medicare Advantage plan and her MA Initial Coverage Election Period (ICEP) has just begun. Which of the following can she not do during the ICEP? 87. Mr. Johannsen is entitled to Medicare Part A and Part B. He gains the Part D low- income subsidy. How does that affect his ability to enroll or disenroll in a Part D plan?

87. Mr. Yoo's employer has recently dropped comprehensive creditable prescription drug coverage that was offered to company retirees. The company told Mr. Yoo that, because he was affected by this change, he would qualify for a Special election period. Mr. Yoo contacted you to find out more about what this means. What can you tell him?

88. 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?

89. Mrs. Margolis contacts you in August because she will become eligible for Medicare for the first time in November. She would like to meet and discuss plan choices with you. What advice should you give her?.

90. 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?

91. Mrs. Kumar would like her daughter, who lives in another state, to meet with you during the Annual Election Period to help her complete her enrollment in a Part D plan. She asked you when she should have her daughter plan to visit. What could you tell her?

92. Mr. Roberts is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Roberts is about to be discharged. What advice would you give him regarding his health coverage options?

93. Mr. White has Medicare Parts A and B with a Part D plan. Last year, he received a notice that his plan sponsor identified him as a "potential at-risk" beneficiary. This month, he started receiving assistance from Medicaid. He wants to find a different Part D plan that's more suitable to his current prescription drug needs. He believes he's entitled to a SEP since he is now a dual eligible. Is he able to change to a different Part D plan during a SEP for dual eligible individuals?

94. Mr. Ziegler is turning 65 next month and has asked you what he can do, and when he must do it, with respect to enrolling in Part D. What could you tell him?

95. A client wants to give you an enrollment application on October 1 before the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him?

96. Mr. Garrett has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time?

97. You are meeting with Ms. Berlin and she has completed an enrollment form for a MA- PD plan you represent. You notice that her handwriting is illegible and as a result, the spelling of her street looks incorrect. She asks you to fill in the corrected street name. What should you do?

98. You have come to Mrs. Midler's home for a sales presentation. At the beginning of the presentation, Mrs. Midler tells you that she has a copy of her medical records available because she thinks this will help you understand her needs. She suggests that you will know which questions to ask her about her health status in order to best assist her in selecting a plan. What should you do?

 99. Mr. and Mrs. Nunez attended one of your sales presentations. They've asked you to come to their home to clear up a few questions. During the presentation, Mrs. Nunez feels tired and tells you that her husband can finish things up. She goes to bed. At the end of your discussion, Mr. Nunez says that he wants to enroll both himself and his wife. What should you do?

100. When Myra first became eligible for Medicare, she enrolled in Original Medicare (Parts A and B). She is now 67 and will turn 68 on July 1. She would now like to enroll in a Medicare Advantage (MA) plan and approaches you about her options. What advice would you give her?

101. Mr. Wendt suffers from diabetes which has gotten progressively worse during the last year. He is currently enrolled in Original Medicare (Parts A and B) and a Part D prescription drug plan and did not enroll in a Medicare Advantage (MA) plan during the last annual open enrollment period (AEP) which has just closed. Mr. Wendt has heard certain MA plans might provide him with more specialized coverage for his diabetes and wants to know if he must wait until the next annual open enrollment period (AEP) before enrolling in such a plan. What should you tell him?

102. Since 2004 Ms. Eisenberg has had a Medigap plan that provides some drug coverage. She has recently received a letter from her Medigap carrier informing her that her drug coverage is not "creditable." She wants to know what this means. What should you tell her?

103. Mr. Cole has been a Medicaid beneficiary for some time, and recently qualified for Medicare as well. He is concerned about changes in his cost-sharing. What should you tell him?

 104. Mrs. Wu was primarily a homemaker and employed in jobs that provided taxable income only sporadically. Her husband worked full-time throughout his long career. She has heard that to qualify for Medicare Part A she has to have worked and paid Medicare taxes for a sufficient time. What should you tell her?

105. 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?

106. Mr. Perry is entitled to Medicare Part A but has not yet enrolled in Part B, even though he is 69 years old. He would like to enroll in a Medicare Part D prescription drug plan but is concerned that he will have to sign up for Part B as well in order to qualify for enrollment in a Part D plan. What should you tell him?

107. Mr. Nguyen understands that Medicare prescription drug plans can use a formulary or list of covered drugs. He is suspicious about how plans establish these formularies. What should you tell him?

108. ACA Section 1557 rules for disability concern

109. Which of the following statements best describes Section 1557 of the Affordable Care Act (ACA)?

110. Which Medicare programs are covered by ACA Section 1557?

111. As a result of violations of ACA Section 1557 nondiscrimination rules,

112. Which of the following statements best describes the scope of operations subject to Section 1557 under the 2020 Final Rule?

113. Section 1557 of the Affordable Care Act applies to

114. Under Section 1557, 2020 Final Rule issued during the Trump Administration sex was initially defined

115. Which of the following would be considered permissible under Section 1557 and the 2020 Final Rule?

116. Auxiliary aids and services must be provided to individuals with disabilities, such as those suffering from vision or hearing impairments, free of charge, and in a timely manner. Auxiliary aids and services include which of the following:

117. Which entity enforces Section 1557 for programs that receive funding from on are administered by HHS?

118. Which of these actions is most likely to be permitted in dealing with a person with limited English proficiency?

119. Under ACA Section 1557, a health plan

120. For a health plan, what are the possible consequences of violations of ACA Section 1557?

121. Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)?

122. Which of the following requires intent to obtain payment and the knowledge the actions are wrong?

123. You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?

124. Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do?

125. You are in charge of paying claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do?

126. A person drops off a prescription for a beneficiary who is a "regular" customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step?

127. Waste includes any misuse of resources, such as the overuse of services or other practices that directly or indirectly result in unnecessary costs to the Medicare Program.

128. Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them.

129. These are examples of issues that should be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical behavior, and employee misconduct.

130. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payme

129. Ways to report potential fraud, waste, and abuse (FWA) include: a. Mail drops

131. Once a corrective action plan is started, the corrective action plan must be monitored annually to ensure they are effective.

131. What are some of the penalties for violating fraud, waste, and abuse (FWA) laws?

132. Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty.

133. Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA), the False Claims Act the Anti-Kickback Statute, and the Health Care Fraud Statute.

134. You can help prevent fraud, waste, and abuse (FWA) by doing all the following: Look for suspicious activity Conduct yourself in an ethical manner Ensure accurate and timely data and billing Ensure you coordinate with other payers Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance Verify all information provided to you

135. You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?

136. You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid Services (CMS) monthly report, you identified multiple individuals not enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't worry about it. This month, you identify the same enrollees on the report again. What should you do?

 137. You discover an unattended email address or fax machine in your office receiving beneficiary appeals requests. You suspect no one is processing the appeals. What should you do?

138. A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR), submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary. What should you do?

139. Ways to report a compliance issue include:

140. Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.

141. What is the policy of non-retaliation?

142. Medicare Parts C and D sponsors are not required to have a compliance program.

143. At a minimum, an effective compliance program includes four core requirements.

144. Correcting non-compliance

145. These are examples of issues that can be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA), potential health privacy violation, and unethical behavior/employee misconduct.

146. Once a corrective action plan begins addressing non-compliance for fraud, waste, and abuse (FWA) committed by a Sponsor's employee or first-tier, downstream, or related entity's (FDR's) employee, ongoing monitoring of the corrective actions is not necessary.

147. Standards of Conduct are the same for every Medicare Parts C and D sponsor.

 148. What are some of the consequences for non-compliance, fraudulent, or unethical behavior?

149. Ms. Levi is considering enrollment in a Medicare Advantage HMO plan offered in her area. Ms. Levi often travels to visit relatives and is concerned that she may need emergency care outside of her plan's service area. What should you tell her about coverage of emergency care?

150. Ms. Morris will turn 65 on June 10th. She has never previously qualified for Medicare. She is entitled to Medicare Part A and intends to enroll in Part B. She wants to know if she is eligible to enroll in a Medicare Advantage plan that includes prescription drug coverage. What do you tell her?

 151. Agent Marvin Millner wants to reach out to his current clients for referrals. What advice would you give to Marvin?

152. Mr. Chen has heard about a Medical Savings Account (MSA) but wants to know if it is just about saving money, or if he will get insurance coverage for his health care expenditures as well. What should you tell him?

153. 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?

154. 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?

155. Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation rules apply to this situation?

156. Mr. Olsen is concerned that a Medicare Advantage plan will not cover the same range of services that would be covered under Original fee-for-service Medicare. What should you tell him?

157. Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On January 15 she comes to you for advice as to what options, if any, she has. What should you say regarding special enrollment periods (SEPs)?

158. Ms. Gardner is currently enrolled in an MA-PD plan. However, she wants to disenroll from the MA-PD plan and instead enroll in a Part D only plan and go back to Original Medicare. According to Medicare's enrollment guidelines, when could she do this?

159. 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?

160. Ms. Jensen has heard about "Original Fee-for-Service Medicare" and "Private Fee-for- Service" plans. She wants to know what the difference is if any. What should you tell her?

161. Ms. Bushman has two homes in different states and is concerned about restrictions on where she can get her medications. What should you tell her?

162. Who is most likely to be eligible to enroll in a Part D prescription drug plan?

163. Mr. Lopez takes several high-cost prescription drugs. He would like to enroll in a standalone Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan can he enroll?

164. If a beneficiary is enrolled in a stand-alone prescription drug plan and wants to keep that plan, what type of Medicare health plan could the individual also enroll in, without being automatically disenrolled from the stand-alone prescription drug plan?

165. Mr. Moreno invited his neighbor, Agent Tom Smith, to discuss Medicare Advantage (MA) and Part D plans that Agent Smith sells at the regular Tuesday brunch the neighbors have for senior citizens. What should Agent Tom Smith tell Mr. Moreno about the kinds of food that can be provided to potential enrollees who attend the sales presentation?

166. Which of the following is/are most likely to be characterized as an involuntary disenrollment from a Medicare Advantage (MA) plan?

167. Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan. What should you tell him

168. Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her?

169. 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?

170. Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can't remember what Part D is so she called you to ask what her neighbor was talking about. What could you tell her?

171. 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?

172. Mrs. Paterson is concerned about the deductibles and co-payments associated with Original Medicare. What can you tell her about Medigap as an option to address this concern?

173. 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?

174. Anita Magri will turn age 65 in August 2022. Anita intends to enroll in Original Medicare Part A and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel has told her about the Medigap Part F plan in which he is enrolled. It not only provides foreign travel emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What should you tell her?

175. Mrs. Quinn recently turned 66 and decided after many years of work to begin receiving Social Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she has been automatically enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs. Quinn?

176. What impact, if any, have recent regulatory changes had upon Medigap plans?

177. 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?

178. Mrs. Willard 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?

179. Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her?

180. 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?

181. 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 will be able to enroll in a Medicare Advantage plan?

182. 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?

183. 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?

184. 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?

185. 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 prescription drug plan?

187. Mrs. Roberts has Original Medicare and would like to enroll in a Private Fee-for-Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Roberts consider before selecting a PFFS plan?

188. Mrs. Walters is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to?

189. Mrs. Fields wants to know whether applying for the Part D low-income subsidy will be worth the time to fill out the paperwork. What could you tell her?

190. One of your clients, Lauren Nichols, has heard about a Medicare concept from one of her neighbors called TrOOP. She asks you to explain it. What do you say?

191. Part D catastrophic limit and include not only expenses paid by a beneficiary but also in some instances drug manufacturer discounts.

192. Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help pa