AHIP 2026/2027 Final Exam - 190 Questions and Answers
Already Graded A+ Premium Exam Tested And Verified
Subject Area AHIP (America's Health Insurance Plans) Certification - Medicare
Advantage, Part D, and Compliance
Description This rigorous final exam assesses mastery of the 2026/2027 AHIP curriculum,
including Medicare Advantage plan design, Part D formularies, risk adjustment,
marketing and enrollment rules, appeals and grievances, and compliance with
CMS regulations. Questions require synthesis of complex regulatory concepts and
application to realistic scenarios.
Expected Grade A+
Total Questions 190
Duration 3 hours
Learning Outcomes 1. Analyze and apply CMS rules for Medicare Advantage and Part D plans.
2. Evaluate risk adjustment methodologies and their impact on plan payments.
3. Demonstrate compliance with marketing, enrollment, and appeals regulations.
4. Interpret formulary design, benefit variations, and cost-sharing structures.
Accreditation This exam meets the standards of the AHIP certification program, recognized by
CMS and top US universities for health insurance education.
Page 1
,1. A Medicare Advantage plan is considering a new benefit package that
includes a $0 monthly premium, $0 primary care copay, and a maximum
out-of-pocket (MOOP) limit of $8,000. However, to meet CMS' actuarial value
requirements, the plan must adjust cost-sharing. Which of the following
adjustments would most likely bring the plan into compliance while
maintaining the $0 premium?
Answer: Increase the MOOP to $9,500 and add a $10 specialist copay
CMS requires that the actuarial value of the benefit package meet a minimum
threshold. Increasing the MOOP to $9,500 (still within the allowed maximum for
2026) and adding a $10 specialist copay raises cost-sharing enough to offset the
$0 premium while keeping the plan attractive. Option B would lower the MOOP
too much, increasing plan costs. Option C's inpatient coinsurance might exceed
allowed limits. Option D's MOOP is too low, making the plan unsustainable
without a premium.
2. During an audit, a Medicare Advantage organization discovers that its risk
adjustment data validation (RADV) process has a 5% error rate in HCC
coding. The organization's risk score for the audited year was 1.20. Assuming
the error rate is applied uniformly, what is the estimated impact on the plan's
risk-adjusted payment?
Answer: Payment will be reduced by 5% of the risk score, resulting in an
effective risk score of 1.14
In RADV audits, errors in HCC coding lead to a proportional reduction in the
risk score. A 5% error rate means that 5% of the conditions are invalid, so the
risk score is reduced by 5% (1.20 * 0.95 = 1.14). This directly lowers the plan's
risk-adjusted payment. Options B, C, and D misrepresent the methodology; the
correction applies to the risk score itself, not a separate penalty or difference.
Page 2
,3. A Medicare Advantage plan offers a Special Supplemental Benefits for the
Chronically Ill (SSBCI) program that provides transportation to non-medical
activities and home-delivered meals. Which of the following conditions must
the plan satisfy to continue offering these benefits under CMS rules?
Answer: The benefits must be targeted to enrollees with specific chronic
conditions and have a reasonable expectation of improving or maintaining
health
SSBCI benefits are specifically designed for enrollees with chronic conditions and
must have a reasonable expectation of improving or maintaining health. They are
not required to be offered to all enrollees (A), can vary by plan and county (C),
and do not require state approval or separate premium (D). The key is targeting
to chronic conditions and health-related rationale.
4. A beneficiary is enrolled in a Medicare Advantage Prescription Drug
(MA-PD) plan. The plan's formulary places a brand-name drug for
hypertension on Tier 3 with a $47 copay. The beneficiary's physician requests a
tiering exception to move the drug to Tier 2 ($20 copay). Which of the
following is a valid basis for granting this exception?
Answer: The drug is the only one in its class that is effective for the
beneficiary
A tiering exception can be granted if the drug is medically necessary and there is
no lower-tier alternative that is equally effective for the beneficiary. Option A
touches on cost but is not a standard criterion. Options C and D are subjective
and not sufficient; the exception requires clinical necessity, not preference or
general belief.
Page 3
, 5. A Medicare Advantage organization plans to market its plans through a
network of independent agents. Under CMS marketing rules, which of the
following agent activities is prohibited during the Annual Enrollment Period
(AEP)?
Answer: Offering a $10 gift card to beneficiaries who attend a sales
presentation
CMS prohibits offering anything of value (including gift cards) to induce
enrollment or attendance at a sales event. Options A and C are permissible as
long as no personal information is collected without consent. Option B is
prohibited only if the beneficiary has not expressed interest; the scenario says
'who has not expressed interest', but the correct answer is D because the gift card
is a clear inducement.
6. A Medicare Part D plan sponsor is evaluating its formulary for the
upcoming year. The plan currently places a brand-name anticoagulant on Tier
4 (non-preferred brand) with a $100 copay. The sponsor wants to move it to
Tier 3 (preferred brand) with a $47 copay to improve adherence. However, the
drug's manufacturer offers a rebate that is lower than the rebate for a
competing drug on Tier 3. Which of the following is the sponsor's primary
consideration under CMS formulary requirements?
Answer: The plan must ensure that the tier placement is based on clinical
value, not solely on rebate amounts
CMS requires that formulary tier placement be based on clinical efficacy, safety,
and value, not solely on rebate amounts. While rebates are considered, the
primary driver must be clinical. Option A is incorrect because the requirement is
for at least two drugs per category, but that is not the primary issue here. Option
C is a general rule but not specific to this decision. Option D is not required.
Page 4
Already Graded A+ Premium Exam Tested And Verified
Subject Area AHIP (America's Health Insurance Plans) Certification - Medicare
Advantage, Part D, and Compliance
Description This rigorous final exam assesses mastery of the 2026/2027 AHIP curriculum,
including Medicare Advantage plan design, Part D formularies, risk adjustment,
marketing and enrollment rules, appeals and grievances, and compliance with
CMS regulations. Questions require synthesis of complex regulatory concepts and
application to realistic scenarios.
Expected Grade A+
Total Questions 190
Duration 3 hours
Learning Outcomes 1. Analyze and apply CMS rules for Medicare Advantage and Part D plans.
2. Evaluate risk adjustment methodologies and their impact on plan payments.
3. Demonstrate compliance with marketing, enrollment, and appeals regulations.
4. Interpret formulary design, benefit variations, and cost-sharing structures.
Accreditation This exam meets the standards of the AHIP certification program, recognized by
CMS and top US universities for health insurance education.
Page 1
,1. A Medicare Advantage plan is considering a new benefit package that
includes a $0 monthly premium, $0 primary care copay, and a maximum
out-of-pocket (MOOP) limit of $8,000. However, to meet CMS' actuarial value
requirements, the plan must adjust cost-sharing. Which of the following
adjustments would most likely bring the plan into compliance while
maintaining the $0 premium?
Answer: Increase the MOOP to $9,500 and add a $10 specialist copay
CMS requires that the actuarial value of the benefit package meet a minimum
threshold. Increasing the MOOP to $9,500 (still within the allowed maximum for
2026) and adding a $10 specialist copay raises cost-sharing enough to offset the
$0 premium while keeping the plan attractive. Option B would lower the MOOP
too much, increasing plan costs. Option C's inpatient coinsurance might exceed
allowed limits. Option D's MOOP is too low, making the plan unsustainable
without a premium.
2. During an audit, a Medicare Advantage organization discovers that its risk
adjustment data validation (RADV) process has a 5% error rate in HCC
coding. The organization's risk score for the audited year was 1.20. Assuming
the error rate is applied uniformly, what is the estimated impact on the plan's
risk-adjusted payment?
Answer: Payment will be reduced by 5% of the risk score, resulting in an
effective risk score of 1.14
In RADV audits, errors in HCC coding lead to a proportional reduction in the
risk score. A 5% error rate means that 5% of the conditions are invalid, so the
risk score is reduced by 5% (1.20 * 0.95 = 1.14). This directly lowers the plan's
risk-adjusted payment. Options B, C, and D misrepresent the methodology; the
correction applies to the risk score itself, not a separate penalty or difference.
Page 2
,3. A Medicare Advantage plan offers a Special Supplemental Benefits for the
Chronically Ill (SSBCI) program that provides transportation to non-medical
activities and home-delivered meals. Which of the following conditions must
the plan satisfy to continue offering these benefits under CMS rules?
Answer: The benefits must be targeted to enrollees with specific chronic
conditions and have a reasonable expectation of improving or maintaining
health
SSBCI benefits are specifically designed for enrollees with chronic conditions and
must have a reasonable expectation of improving or maintaining health. They are
not required to be offered to all enrollees (A), can vary by plan and county (C),
and do not require state approval or separate premium (D). The key is targeting
to chronic conditions and health-related rationale.
4. A beneficiary is enrolled in a Medicare Advantage Prescription Drug
(MA-PD) plan. The plan's formulary places a brand-name drug for
hypertension on Tier 3 with a $47 copay. The beneficiary's physician requests a
tiering exception to move the drug to Tier 2 ($20 copay). Which of the
following is a valid basis for granting this exception?
Answer: The drug is the only one in its class that is effective for the
beneficiary
A tiering exception can be granted if the drug is medically necessary and there is
no lower-tier alternative that is equally effective for the beneficiary. Option A
touches on cost but is not a standard criterion. Options C and D are subjective
and not sufficient; the exception requires clinical necessity, not preference or
general belief.
Page 3
, 5. A Medicare Advantage organization plans to market its plans through a
network of independent agents. Under CMS marketing rules, which of the
following agent activities is prohibited during the Annual Enrollment Period
(AEP)?
Answer: Offering a $10 gift card to beneficiaries who attend a sales
presentation
CMS prohibits offering anything of value (including gift cards) to induce
enrollment or attendance at a sales event. Options A and C are permissible as
long as no personal information is collected without consent. Option B is
prohibited only if the beneficiary has not expressed interest; the scenario says
'who has not expressed interest', but the correct answer is D because the gift card
is a clear inducement.
6. A Medicare Part D plan sponsor is evaluating its formulary for the
upcoming year. The plan currently places a brand-name anticoagulant on Tier
4 (non-preferred brand) with a $100 copay. The sponsor wants to move it to
Tier 3 (preferred brand) with a $47 copay to improve adherence. However, the
drug's manufacturer offers a rebate that is lower than the rebate for a
competing drug on Tier 3. Which of the following is the sponsor's primary
consideration under CMS formulary requirements?
Answer: The plan must ensure that the tier placement is based on clinical
value, not solely on rebate amounts
CMS requires that formulary tier placement be based on clinical efficacy, safety,
and value, not solely on rebate amounts. While rebates are considered, the
primary driver must be clinical. Option A is incorrect because the requirement is
for at least two drugs per category, but that is not the primary issue here. Option
C is a general rule but not specific to this decision. Option D is not required.
Page 4
