AHIP Final Exam (2025/2026) : Overview
The AHIP Medicare final exam is a 150-question, multiple-choice, open-book test required for
agents and brokers selling Medicare Advantage and Part D plans. A minimum score of 90% is
required to pass, with up to three attempts allowed. The exam covers Medicare Parts A, B, C,
and D, enrollment periods (AEP, IEP, SEP), CMS compliance and marketing rules (Scope of
Appointment, SOA), plan benefits, cost-sharing, appeals, grievances, and Special Needs Plans
(SNPs). Passing ensures agents are knowledgeable and compliant with federal Medicare
regulations to protect beneficiaries.
Section 1: Medicare Basics and Eligibility
1. What types of Medicare Advantage plans are available to beneficiaries?
A) PPO, HMO, MSA, Cost Plan, PFFS
B) HMO only
C) PPO and MSA only
D) Cost Plan and PFFS only
Correct Answer: A) PPO, HMO, MSA, Cost Plan, PFFS
Rationale: Medicare Advantage (MA) plans, also known as Part C, are offered by private
insurance companies. The primary types include Health Maintenance Organizations (HMOs),
Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Medical Savings
Account (MSA) plans, and Cost Plans (in limited areas). This variety allows beneficiaries to
pg. 1
,choose a plan that best fits their healthcare needs and budget, with each type having different
rules for cost-sharing, network usage, and referrals.
2. Which individuals are eligible for Medicare-Medicaid Plans (MMPs)?
A) Those enrolled in Medicare Part A only
B) Medicare and Medicaid dual eligibles, including Part D coverage
C) Individuals under age 65 without disabilities
D) Those with employer-sponsored plans only
Correct Answer: B) Medicare and Medicaid dual eligibles, including Part D coverage
Rationale: MMPs, often known as Dual Eligible Special Needs Plans (D-SNPs), are specifically
designed for individuals who are entitled to both Medicare and Medicaid. These plans are
required to cover Medicare Part D prescription drugs and coordinate benefits between
Medicare and Medicaid to provide comprehensive coverage and reduce out-of-pocket costs for
this vulnerable population.
3. What is a key feature of a Medicare Cost Plan?
A) Requires only Part A enrollment
B) Allows non-network provider visits with higher coinsurance and deductibles
C) Limits enrollment to HMO periods
D) Excludes Part D prescription drug coverage
Correct Answer: B) Allows non-network provider visits with higher coinsurance and deductibles
Rationale: Medicare Cost Plans are a type of Medicare Advantage plan that allows beneficiaries
to use out-of-network providers, but at a higher cost. They provide a "point of service" option,
meaning you can see any Medicare-participating provider, but your cost-sharing (coinsurance
and deductibles) will be higher than if you used an in-network provider.
4. When can individuals with End-Stage Renal Disease (ESRD) enroll in Medicare?
A) Only during the Annual Enrollment Period (AEP)
B) Anytime, with coverage beginning the fourth month after dialysis starts
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,C) During a Special Enrollment Period (SEP) for employment changes
D) Only at age 65
Correct Answer: B) Anytime, with coverage beginning the fourth month after dialysis starts
Rationale: Individuals with ESRD are eligible for Medicare regardless of age. Enrollment can
occur at any time, and coverage typically begins on the first day of the fourth month of a
regular course of dialysis, or the month of a kidney transplant, whichever is applicable.
5. What are the dates for the General Enrollment Period (GEP) for those not enrolling in Part B
when first eligible?
A) April 1 to June 30
B) January 1 to March 31, with coverage starting July 1
C) October 15 to December 7
D) July 1 to September 30
Correct Answer: B) January 1 to March 31, with coverage starting July 1
Rationale: The General Enrollment Period is for individuals who did not enroll in Medicare Part
B during their Initial Enrollment Period (IEP) and were not eligible for a Special Enrollment
Period (SEP). It runs from January 1st to March 31st each year, with coverage beginning on July
1st of the same year.
6. When can individuals with employer group health coverage enroll in Part A and/or Part B?
A) Only during the Initial Enrollment Period (IEP)
B) Anytime while on group coverage during a Special Enrollment Period (SEP)
C) After age 70
D) During the Annual Election Period (AEP) only
Correct Answer: B) Anytime while on group coverage during a Special Enrollment Period (SEP)
Rationale: A Special Enrollment Period (SEP) allows individuals who are covered under an
employer group health plan based on current employment (their own or a spouse's) to enroll in
Part A and/or Part B without penalty. This SEP is available as long as they have the qualifying
group coverage and for up to eight months after the employment or coverage ends.
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, 7. What is the primary purpose of Medicare Part A?
A) Prescription drug coverage
B) Hospital insurance
C) Medical insurance for doctor visits
D) Preventive care only
Correct Answer: B) Hospital insurance
Rationale: Medicare Part A, also known as "Hospital Insurance," covers inpatient care in
hospitals, skilled nursing facility care, hospice care, and some home health care. Most people
do not pay a premium for Part A if they or their spouse paid Medicare taxes while working.
8. What is the primary purpose of Medicare Part B?
A) Prescription drug coverage
B) Hospital insurance
C) Medical insurance for outpatient care, doctor visits, and preventive services
D) Supplemental insurance for deductibles and coinsurance
Correct Answer: C) Medical insurance for outpatient care, doctor visits, and preventive services
Rationale: Medicare Part B is "Medical Insurance" that covers outpatient care, doctor visits,
durable medical equipment (DME), and many preventive services (like flu shots and cancer
screenings). Part B requires a monthly premium, which is based on the beneficiary's income.
9. What is Medicare Part C?
A) Medicare Supplement Insurance
B) Medicare Advantage Plans
C) Prescription Drug Coverage
D) Inpatient Hospital Coverage
Correct Answer: B) Medicare Advantage Plans
pg. 4
The AHIP Medicare final exam is a 150-question, multiple-choice, open-book test required for
agents and brokers selling Medicare Advantage and Part D plans. A minimum score of 90% is
required to pass, with up to three attempts allowed. The exam covers Medicare Parts A, B, C,
and D, enrollment periods (AEP, IEP, SEP), CMS compliance and marketing rules (Scope of
Appointment, SOA), plan benefits, cost-sharing, appeals, grievances, and Special Needs Plans
(SNPs). Passing ensures agents are knowledgeable and compliant with federal Medicare
regulations to protect beneficiaries.
Section 1: Medicare Basics and Eligibility
1. What types of Medicare Advantage plans are available to beneficiaries?
A) PPO, HMO, MSA, Cost Plan, PFFS
B) HMO only
C) PPO and MSA only
D) Cost Plan and PFFS only
Correct Answer: A) PPO, HMO, MSA, Cost Plan, PFFS
Rationale: Medicare Advantage (MA) plans, also known as Part C, are offered by private
insurance companies. The primary types include Health Maintenance Organizations (HMOs),
Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Medical Savings
Account (MSA) plans, and Cost Plans (in limited areas). This variety allows beneficiaries to
pg. 1
,choose a plan that best fits their healthcare needs and budget, with each type having different
rules for cost-sharing, network usage, and referrals.
2. Which individuals are eligible for Medicare-Medicaid Plans (MMPs)?
A) Those enrolled in Medicare Part A only
B) Medicare and Medicaid dual eligibles, including Part D coverage
C) Individuals under age 65 without disabilities
D) Those with employer-sponsored plans only
Correct Answer: B) Medicare and Medicaid dual eligibles, including Part D coverage
Rationale: MMPs, often known as Dual Eligible Special Needs Plans (D-SNPs), are specifically
designed for individuals who are entitled to both Medicare and Medicaid. These plans are
required to cover Medicare Part D prescription drugs and coordinate benefits between
Medicare and Medicaid to provide comprehensive coverage and reduce out-of-pocket costs for
this vulnerable population.
3. What is a key feature of a Medicare Cost Plan?
A) Requires only Part A enrollment
B) Allows non-network provider visits with higher coinsurance and deductibles
C) Limits enrollment to HMO periods
D) Excludes Part D prescription drug coverage
Correct Answer: B) Allows non-network provider visits with higher coinsurance and deductibles
Rationale: Medicare Cost Plans are a type of Medicare Advantage plan that allows beneficiaries
to use out-of-network providers, but at a higher cost. They provide a "point of service" option,
meaning you can see any Medicare-participating provider, but your cost-sharing (coinsurance
and deductibles) will be higher than if you used an in-network provider.
4. When can individuals with End-Stage Renal Disease (ESRD) enroll in Medicare?
A) Only during the Annual Enrollment Period (AEP)
B) Anytime, with coverage beginning the fourth month after dialysis starts
pg. 2
,C) During a Special Enrollment Period (SEP) for employment changes
D) Only at age 65
Correct Answer: B) Anytime, with coverage beginning the fourth month after dialysis starts
Rationale: Individuals with ESRD are eligible for Medicare regardless of age. Enrollment can
occur at any time, and coverage typically begins on the first day of the fourth month of a
regular course of dialysis, or the month of a kidney transplant, whichever is applicable.
5. What are the dates for the General Enrollment Period (GEP) for those not enrolling in Part B
when first eligible?
A) April 1 to June 30
B) January 1 to March 31, with coverage starting July 1
C) October 15 to December 7
D) July 1 to September 30
Correct Answer: B) January 1 to March 31, with coverage starting July 1
Rationale: The General Enrollment Period is for individuals who did not enroll in Medicare Part
B during their Initial Enrollment Period (IEP) and were not eligible for a Special Enrollment
Period (SEP). It runs from January 1st to March 31st each year, with coverage beginning on July
1st of the same year.
6. When can individuals with employer group health coverage enroll in Part A and/or Part B?
A) Only during the Initial Enrollment Period (IEP)
B) Anytime while on group coverage during a Special Enrollment Period (SEP)
C) After age 70
D) During the Annual Election Period (AEP) only
Correct Answer: B) Anytime while on group coverage during a Special Enrollment Period (SEP)
Rationale: A Special Enrollment Period (SEP) allows individuals who are covered under an
employer group health plan based on current employment (their own or a spouse's) to enroll in
Part A and/or Part B without penalty. This SEP is available as long as they have the qualifying
group coverage and for up to eight months after the employment or coverage ends.
pg. 3
, 7. What is the primary purpose of Medicare Part A?
A) Prescription drug coverage
B) Hospital insurance
C) Medical insurance for doctor visits
D) Preventive care only
Correct Answer: B) Hospital insurance
Rationale: Medicare Part A, also known as "Hospital Insurance," covers inpatient care in
hospitals, skilled nursing facility care, hospice care, and some home health care. Most people
do not pay a premium for Part A if they or their spouse paid Medicare taxes while working.
8. What is the primary purpose of Medicare Part B?
A) Prescription drug coverage
B) Hospital insurance
C) Medical insurance for outpatient care, doctor visits, and preventive services
D) Supplemental insurance for deductibles and coinsurance
Correct Answer: C) Medical insurance for outpatient care, doctor visits, and preventive services
Rationale: Medicare Part B is "Medical Insurance" that covers outpatient care, doctor visits,
durable medical equipment (DME), and many preventive services (like flu shots and cancer
screenings). Part B requires a monthly premium, which is based on the beneficiary's income.
9. What is Medicare Part C?
A) Medicare Supplement Insurance
B) Medicare Advantage Plans
C) Prescription Drug Coverage
D) Inpatient Hospital Coverage
Correct Answer: B) Medicare Advantage Plans
pg. 4
