Mixed Deck — All AHIP Topics Flashcards
100 cards from real AHIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 20 Mixed Deck — All AHIP Topics flashcards as text
Preferred pharmacy networks in Part D are designed to:
Answer: Offer lower cost-sharing when members use designated pharmacies
Preferred pharmacy networks give beneficiaries lower cost-sharing at select pharmacies, incentivizing use of cost-efficient pharmacy partners.
The following benefits are ALL provided to insured workers by workers' compensation policies, EXCEPT
Answer: expenses of running a business until a disabled worker can return to work
Workers' compensation policies are designed to provide benefits directly to employees who suffer work-related injuries or illnesses. These benefits typically include coverage for medical treatment, wage replacement for lost income due to disability, and vocational rehabilitation to help the worker return to employment. However, workers' compensation does not cover the expenses of running a business; these are separate operational costs for the employer, distinct from employee benefits.
Which situation qualifies a North Carolina Medicare beneficiary for a Special Enrollment Period to enroll in a Part D drug plan outside of AEP?
Answer: Losing creditable prescription drug coverage involuntarily
Involuntary loss of creditable prescription drug coverage is a qualifying event that triggers a Part D SEP, allowing enrollment in a PDP or MA-PD plan.
What is the Medicare Advantage Open Enrollment Period (MA OEP)?
Answer: January 1 – March 31
The MA OEP runs January 1–March 31, allowing current MA enrollees to switch plans or return to Original Medicare once.
Which of the following statements about Medicare marketing rules for door-to-door sales is correct?
Answer: Uninvited door-to-door sales contact with Medicare beneficiaries is prohibited
CMS prohibits uninvited door-to-door solicitation of Medicare beneficiaries to protect them from high-pressure sales tactics.
What is a 'creditable coverage' in the context of Medicare Part D?
Answer: Drug coverage at least as good as Medicare's standard benefit
Creditable coverage for Part D means the drug coverage is expected to pay at least as much as Medicare's standard prescription drug benefit.
Under the Mental Health Parity and Addiction Equity Act (MHPAEA), how must plans treat mental health and substance use disorder benefits compared to medical/surgical benefits?
Answer: Financial requirements and treatment limitations must be no more restrictive than those for medical/surgical benefits
MHPAEA requires that financial requirements (like copays) and treatment limitations for mental health and SUD benefits be no more restrictive than the predominant limits applied to medical/surgical benefits.
Which of the following best describes 'reinsurance' as used by health plans?
Answer: A method for spreading risk by ceding a portion of liabilities to another insurer
Reinsurance allows a health plan to transfer a portion of its risk to another insurer (reinsurer) in exchange for a premium, protecting against catastrophic losses.
What is the Part D late enrollment penalty based on?
Answer: 1% of the national base beneficiary premium for each full month without creditable coverage
The Part D late enrollment penalty is 1% of the national base beneficiary premium multiplied by the number of full months without creditable drug coverage.
A health plan's 'administrative expense ratio' is calculated as:
Answer: Administrative expenses divided by total earned premiums
The administrative expense ratio equals administrative expenses divided by earned premiums, indicating what share of premium dollars goes to non-medical costs.
A North Carolina Medicare Part D enrollee has not yet reached the deductible. They purchase a 90-day supply of a Tier 2 drug. How is the cost typically calculated at this stage?
Answer: They pay the full retail price until the deductible is met
Until a Part D beneficiary meets their deductible, they typically pay the full negotiated cost of non-exempt drugs; many plans exempt lower tiers, but this varies by plan.
Which of the following conditions automatically qualifies a person for Medicare regardless of age?
Answer: End-Stage Renal Disease (ESRD)
End-Stage Renal Disease (ESRD) qualifies a person for Medicare at any age.
If a Medicare beneficiary has a Medigap policy and receives Medicare-covered services, in what order do the payers pay?
Answer: Medicare pays first as the primary payer, then the Medigap insurer pays the remaining covered costs
Medicare is always the primary payer and pays first; the Medigap policy then pays its share of the remaining covered costs.
Which star rating system does CMS use to evaluate Medicare Advantage plan quality?
Answer: 1–5 star scale
CMS rates MA plans on a 1 to 5 star scale, where 5 stars represents the highest quality.
A North Carolina Medicare Advantage enrollee disputes a plan's denial of a medical service. What is the first formal step in the appeals process?
Answer: File a redetermination request with the MA plan
The first level of the MA appeals process is a redetermination, which is a formal review of the coverage denial conducted by the MA plan itself.
Which star rating category under CMS's Medicare Advantage 5-Star Rating System carries the most weight in the overall composite score?
Answer: Member experience measures
Member experience measures, including CAHPS survey results, carry the highest weight in the overall MA star rating calculation.
When a health plan calculates its 'completion factors,' what is the purpose?
Answer: To estimate the ultimate cost of claims by accounting for reporting lags
Completion factors adjust paid claims data to estimate the total (ultimate) cost, accounting for the fact that not all incurred claims have been received and processed yet.
What is 'phantom billing' in healthcare fraud?
Answer: Billing for services that were never actually rendered
Phantom billing refers to submitting claims for medical services, supplies, or equipment that were never actually provided to the patient.
In Medicare Part D, 'quantity limits' are a utilization management tool that:
Answer: Restrict the amount of a drug dispensed per fill or time period based on clinical guidelines
Quantity limits restrict how much of a drug can be dispensed at one time or over a period, based on safety guidelines or approved dosing.
Under North Carolina regulations, how must a Medicare Advantage agent document a telephonic enrollment?
Answer: The agent must record the call with the beneficiary's verbal consent
For telephonic enrollments, CMS requires a recorded call confirming the beneficiary's enrollment request, with the recording retained as documentation.