AHIP Exam Questions And Answers |Latest 2025 |
Guaranteed Pass
1. A Medicare beneficiary is enrolled in Original Medicare (Parts A and B) and a standalone Part
D plan. They are considering switching to a Medicare Advantage (MA) plan during the Annual
Election Period (AEP). Which of the following is a correct statement regarding the interaction
between MA enrollment and Part D coverage?
A. The beneficiary can enroll in the MA plan and keep their standalone Part D plan, as long as the MA plan
does not include drug coverage.
B. Enrolling in an MA plan that does not include prescription drug coverage automatically disenrolls the
beneficiary from their standalone Part D plan.
C. The beneficiary must first disenroll from their standalone Part D plan before enrolling in an MA plan that
includes drug coverage.
D. If the beneficiary enrolls in an MA plan that includes drug coverage, their standalone Part D plan will be
terminated automatically, and they cannot re-enroll in a standalone Part D plan while in the MA plan.
Answer: B
Rationale: If a beneficiary enrolls in an MA plan that does not include drug coverage, they are
automatically disenrolled from any standalone PDP they had because MA plans without drug coverage
cannot be paired with a separate PDP. However, they could join a different MA-PD plan during AEP.
Option D is incorrect because they can disenroll from the MA plan during certain periods and re-enroll
in a PDP.
2. A Medicare Advantage plan is evaluating its star ratings for the upcoming year. Which of the
following measures would have the greatest impact on the plan's overall star rating if it receives a
low score?
A. Member satisfaction survey results
B. Plan's appeals and grievances processing timeliness
C. Compliance with marketing guidelines
D. Diabetes care - blood sugar controlled
Answer: D
Rationale: Clinical quality measures, such as diabetes care, are weighted heavily in the star ratings
system because they directly impact patient outcomes. While member satisfaction and appeals
processing are important, they carry less weight than clinical measures. Marketing compliance is a
separate regulatory requirement but does not directly affect the star rating calculation.
3. A new Medicare beneficiary is turning 65 and is currently covered under their spouse's
employer-sponsored group health plan. They wish to delay enrollment in Medicare Part B without
penalty. Which of the following conditions must be met to qualify for a Special Enrollment Period
(SEP) without incurring a late enrollment penalty?
Page 1
,A. The spouse's employer must have fewer than 20 employees.
B. The beneficiary must be covered under a group health plan based on current employment of the spouse.
C. The beneficiary must enroll in Part B within 6 months of losing coverage.
D. The beneficiary must have had credible prescription drug coverage through the employer plan.
Answer: B
Rationale: To qualify for a SEP without penalty, the beneficiary must be covered under a group health
plan based on current employment (either their own or their spouse's). The size of the employer matters
for Part B, but for Part A, there is no premium, so delay is not penalized. Option C is incorrect because
the SEP window is 8 months after losing coverage. Option D relates to Part D, not Part B.
4. A Medicare Advantage plan is developing its marketing materials for the upcoming Annual
Election Period. Which of the following practices is explicitly prohibited by CMS marketing
guidelines?
A. Using the term 'Medicare-approved' in promotional materials without additional context.
B. Distributing marketing materials that include the plan's star rating prominently.
C. Sending unsolicited emails to beneficiaries who have opted out of electronic communications.
D. Hosting educational events where meal is provided and plan-specific information is discussed.
Answer: C
Rationale: CMS prohibits sending unsolicited electronic communications, including emails, to
beneficiaries who have opted out. Option A is allowed if the plan is indeed Medicare-approved. Option
B is allowed as long as the star rating is accurate. Option D is allowed if the event is educational and
not a sales event, but if the meal is provided, it must be nominal and not conditional on enrollment.
5. A beneficiary enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan enters the
coverage gap (donut hole) during the plan year. Which of the following correctly describes the
cost-sharing for brand-name drugs in the coverage gap in 2025?
A. The beneficiary pays 25% of the drug cost, and the plan pays 75%.
B. The beneficiary pays 25% of the drug cost, and the manufacturer provides a 70% discount on the negotiated
price.
C. The beneficiary pays 25% of the drug cost, and the plan pays 5%, with the manufacturer providing a 70%
discount.
D. The beneficiary pays 25% of the drug cost, and the plan pays 5%, with the manufacturer providing a 70%
discount on the list price.
Answer: C
Rationale: In 2025, for brand-name drugs in the coverage gap, the beneficiary pays 25% of the
negotiated price, the plan pays 5%, and the manufacturer provides a 70% discount on the negotiated
price. Option D is incorrect because the discount is on the negotiated price, not the list price. Options A
and B do not accurately reflect the plan's contribution.
6. A Medicare beneficiary is enrolled in a Medicare Advantage (MA) plan and also has coverage
from the Department of Veterans Affairs (VA). Which of the following statements is true regarding
coordination of benefits?
A. The MA plan is primary payer for all services, and the VA coverage is secondary.
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,B. The VA is primary payer for services provided at VA facilities, and the MA plan is primary for non-VA
services.
C. The beneficiary cannot be enrolled in both an MA plan and VA coverage simultaneously.
D. The MA plan must reimburse the VA for any covered services provided to the beneficiary.
Answer: B
Rationale: When a beneficiary has both MA and VA coverage, the VA pays for services received at VA
facilities, and the MA plan pays for services received from non-VA providers. There is no prohibition on
having both coverages (C is false). The MA plan does not reimburse the VA (D is false). Option A is
incorrect because the VA is primary for its own services.
7. A Medicare beneficiary is considering a Medicare Supplement (Medigap) policy. They are
currently in their Medigap Open Enrollment Period (OEP). Which of the following is true about
this period?
A. The OEP begins on the first day of the month the beneficiary enrolls in Medicare Part B and lasts for 6
months.
B. During the OEP, insurance companies may use medical underwriting to deny coverage or charge higher
premiums.
C. The OEP is a one-time period that applies only to beneficiaries who are 65 or older and enroll in Part B.
D. The OEP allows beneficiaries to switch Medigap policies without underwriting at any time after the initial
enrollment.
Answer: C
Rationale: The Medigap OEP is a one-time, 6-month period that begins when a beneficiary age 65 or
older first enrolls in Part B. During this period, insurers cannot use medical underwriting (B is false).
Option A is incorrect because it starts when Part B is effective, not the first of the month of enrollment.
Option D is false because after the OEP, underwriting may apply.
8. A Medicare Advantage plan is calculating its risk adjustment payments using the CMS-HCC
model. Which of the following conditions would most likely result in the highest risk score
increase?
A. A diagnosis of essential hypertension without complications.
B. A diagnosis of diabetes with chronic kidney disease stage 4.
C. A diagnosis of acute bronchitis during a hospitalization.
D. A diagnosis of hyperlipidemia managed with diet alone.
Answer: B
Rationale: The CMS-HCC model assigns higher risk scores to conditions that are chronic and have
significant cost implications. Diabetes with chronic kidney disease stage 4 is a severe condition that
interacts with other comorbidities, leading to a high risk score. Hypertension without complications (A)
and hyperlipidemia (D) are relatively low risk. Acute bronchitis (C) is acute and not a chronic condition
that affects risk adjustment.
9. A beneficiary is enrolled in a Medicare Advantage plan that has a 5-star overall rating. They
wish to switch to a different MA plan outside of the Annual Election Period. Which of the following
statements is correct?
Page 3
, A. The beneficiary can switch to any MA plan using the 5-star SEP, but only once per year.
B. The beneficiary can switch to a 5-star MA plan using the 5-star SEP, but not to a plan with a lower rating.
C. The beneficiary can switch to any MA plan using the 5-star SEP, regardless of the plan's star rating.
D. The beneficiary cannot use the 5-star SEP to switch plans because they are already in a 5-star plan.
Answer: C
Rationale: The 5-star SEP allows beneficiaries to switch to a 5-star MA plan once per year, but it does
not allow switching from a 5-star plan to a lower-rated plan. However, the beneficiary is already in a
5-star plan, so they cannot use the 5-star SEP to change plans. Option D is correct: the SEP is for
enrolling in a 5-star plan, not for leaving one.
10. A Medicare beneficiary is enrolled in a Medicare Advantage (MA) plan and also has coverage
through an employer-sponsored group health plan due to current employment. The employer has
100 employees. Which payer is primary for the beneficiary's healthcare services?
A. The MA plan is primary because it is the beneficiary's Medicare coverage.
B. The employer group health plan is primary because the employer has 100 or more employees.
C. The MA plan is primary for Part A services, and the employer plan is primary for Part B services.
D. The employer group health plan is primary only if the beneficiary is actively working.
Answer: B
Rationale: For beneficiaries with Medicare and employer group health plan coverage from an employer
with 100 or more employees, the group health plan is primary. This is true regardless of whether the
beneficiary is actively working (D is incorrect because it applies to retirees as well for large employers).
Option A is incorrect because Medicare is secondary when the employer has 100+ employees. Option C
has no basis in law.
11. A health plan is developing a new Medicare Advantage (MA) plan that includes a supplemental
benefit for adult day care services. Under CMS regulations, which of the following conditions must
be met for the plan to offer this benefit as a primarily health-related supplemental benefit?
A. The benefit must be available to all enrollees regardless of health status, and the plan must demonstrate that it
reduces the need for inpatient or post-acute care.
B. The benefit must be targeted only to enrollees with chronic conditions, and the plan must submit actuarial
justification showing it is not a substitute for Part A or B services.
C. The benefit must be uniform for all enrollees, and the plan cannot require prior authorization for its use.
D. The benefit must be offered as a standalone optional supplement with a separate premium, and the plan must
receive state approval.
Answer: A
Rationale: CMS requires that supplemental benefits under MA be primarily health-related, uniform in
availability, and must reduce the need for inpatient or post-acute care. Options B is incorrect because
even targeted benefits must meet the same standard. Option C is incorrect because prior authorization
may be allowed. Option D is incorrect because supplemental benefits are part of the plan's benefit
package, not standalone.
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Guaranteed Pass
1. A Medicare beneficiary is enrolled in Original Medicare (Parts A and B) and a standalone Part
D plan. They are considering switching to a Medicare Advantage (MA) plan during the Annual
Election Period (AEP). Which of the following is a correct statement regarding the interaction
between MA enrollment and Part D coverage?
A. The beneficiary can enroll in the MA plan and keep their standalone Part D plan, as long as the MA plan
does not include drug coverage.
B. Enrolling in an MA plan that does not include prescription drug coverage automatically disenrolls the
beneficiary from their standalone Part D plan.
C. The beneficiary must first disenroll from their standalone Part D plan before enrolling in an MA plan that
includes drug coverage.
D. If the beneficiary enrolls in an MA plan that includes drug coverage, their standalone Part D plan will be
terminated automatically, and they cannot re-enroll in a standalone Part D plan while in the MA plan.
Answer: B
Rationale: If a beneficiary enrolls in an MA plan that does not include drug coverage, they are
automatically disenrolled from any standalone PDP they had because MA plans without drug coverage
cannot be paired with a separate PDP. However, they could join a different MA-PD plan during AEP.
Option D is incorrect because they can disenroll from the MA plan during certain periods and re-enroll
in a PDP.
2. A Medicare Advantage plan is evaluating its star ratings for the upcoming year. Which of the
following measures would have the greatest impact on the plan's overall star rating if it receives a
low score?
A. Member satisfaction survey results
B. Plan's appeals and grievances processing timeliness
C. Compliance with marketing guidelines
D. Diabetes care - blood sugar controlled
Answer: D
Rationale: Clinical quality measures, such as diabetes care, are weighted heavily in the star ratings
system because they directly impact patient outcomes. While member satisfaction and appeals
processing are important, they carry less weight than clinical measures. Marketing compliance is a
separate regulatory requirement but does not directly affect the star rating calculation.
3. A new Medicare beneficiary is turning 65 and is currently covered under their spouse's
employer-sponsored group health plan. They wish to delay enrollment in Medicare Part B without
penalty. Which of the following conditions must be met to qualify for a Special Enrollment Period
(SEP) without incurring a late enrollment penalty?
Page 1
,A. The spouse's employer must have fewer than 20 employees.
B. The beneficiary must be covered under a group health plan based on current employment of the spouse.
C. The beneficiary must enroll in Part B within 6 months of losing coverage.
D. The beneficiary must have had credible prescription drug coverage through the employer plan.
Answer: B
Rationale: To qualify for a SEP without penalty, the beneficiary must be covered under a group health
plan based on current employment (either their own or their spouse's). The size of the employer matters
for Part B, but for Part A, there is no premium, so delay is not penalized. Option C is incorrect because
the SEP window is 8 months after losing coverage. Option D relates to Part D, not Part B.
4. A Medicare Advantage plan is developing its marketing materials for the upcoming Annual
Election Period. Which of the following practices is explicitly prohibited by CMS marketing
guidelines?
A. Using the term 'Medicare-approved' in promotional materials without additional context.
B. Distributing marketing materials that include the plan's star rating prominently.
C. Sending unsolicited emails to beneficiaries who have opted out of electronic communications.
D. Hosting educational events where meal is provided and plan-specific information is discussed.
Answer: C
Rationale: CMS prohibits sending unsolicited electronic communications, including emails, to
beneficiaries who have opted out. Option A is allowed if the plan is indeed Medicare-approved. Option
B is allowed as long as the star rating is accurate. Option D is allowed if the event is educational and
not a sales event, but if the meal is provided, it must be nominal and not conditional on enrollment.
5. A beneficiary enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan enters the
coverage gap (donut hole) during the plan year. Which of the following correctly describes the
cost-sharing for brand-name drugs in the coverage gap in 2025?
A. The beneficiary pays 25% of the drug cost, and the plan pays 75%.
B. The beneficiary pays 25% of the drug cost, and the manufacturer provides a 70% discount on the negotiated
price.
C. The beneficiary pays 25% of the drug cost, and the plan pays 5%, with the manufacturer providing a 70%
discount.
D. The beneficiary pays 25% of the drug cost, and the plan pays 5%, with the manufacturer providing a 70%
discount on the list price.
Answer: C
Rationale: In 2025, for brand-name drugs in the coverage gap, the beneficiary pays 25% of the
negotiated price, the plan pays 5%, and the manufacturer provides a 70% discount on the negotiated
price. Option D is incorrect because the discount is on the negotiated price, not the list price. Options A
and B do not accurately reflect the plan's contribution.
6. A Medicare beneficiary is enrolled in a Medicare Advantage (MA) plan and also has coverage
from the Department of Veterans Affairs (VA). Which of the following statements is true regarding
coordination of benefits?
A. The MA plan is primary payer for all services, and the VA coverage is secondary.
Page 2
,B. The VA is primary payer for services provided at VA facilities, and the MA plan is primary for non-VA
services.
C. The beneficiary cannot be enrolled in both an MA plan and VA coverage simultaneously.
D. The MA plan must reimburse the VA for any covered services provided to the beneficiary.
Answer: B
Rationale: When a beneficiary has both MA and VA coverage, the VA pays for services received at VA
facilities, and the MA plan pays for services received from non-VA providers. There is no prohibition on
having both coverages (C is false). The MA plan does not reimburse the VA (D is false). Option A is
incorrect because the VA is primary for its own services.
7. A Medicare beneficiary is considering a Medicare Supplement (Medigap) policy. They are
currently in their Medigap Open Enrollment Period (OEP). Which of the following is true about
this period?
A. The OEP begins on the first day of the month the beneficiary enrolls in Medicare Part B and lasts for 6
months.
B. During the OEP, insurance companies may use medical underwriting to deny coverage or charge higher
premiums.
C. The OEP is a one-time period that applies only to beneficiaries who are 65 or older and enroll in Part B.
D. The OEP allows beneficiaries to switch Medigap policies without underwriting at any time after the initial
enrollment.
Answer: C
Rationale: The Medigap OEP is a one-time, 6-month period that begins when a beneficiary age 65 or
older first enrolls in Part B. During this period, insurers cannot use medical underwriting (B is false).
Option A is incorrect because it starts when Part B is effective, not the first of the month of enrollment.
Option D is false because after the OEP, underwriting may apply.
8. A Medicare Advantage plan is calculating its risk adjustment payments using the CMS-HCC
model. Which of the following conditions would most likely result in the highest risk score
increase?
A. A diagnosis of essential hypertension without complications.
B. A diagnosis of diabetes with chronic kidney disease stage 4.
C. A diagnosis of acute bronchitis during a hospitalization.
D. A diagnosis of hyperlipidemia managed with diet alone.
Answer: B
Rationale: The CMS-HCC model assigns higher risk scores to conditions that are chronic and have
significant cost implications. Diabetes with chronic kidney disease stage 4 is a severe condition that
interacts with other comorbidities, leading to a high risk score. Hypertension without complications (A)
and hyperlipidemia (D) are relatively low risk. Acute bronchitis (C) is acute and not a chronic condition
that affects risk adjustment.
9. A beneficiary is enrolled in a Medicare Advantage plan that has a 5-star overall rating. They
wish to switch to a different MA plan outside of the Annual Election Period. Which of the following
statements is correct?
Page 3
, A. The beneficiary can switch to any MA plan using the 5-star SEP, but only once per year.
B. The beneficiary can switch to a 5-star MA plan using the 5-star SEP, but not to a plan with a lower rating.
C. The beneficiary can switch to any MA plan using the 5-star SEP, regardless of the plan's star rating.
D. The beneficiary cannot use the 5-star SEP to switch plans because they are already in a 5-star plan.
Answer: C
Rationale: The 5-star SEP allows beneficiaries to switch to a 5-star MA plan once per year, but it does
not allow switching from a 5-star plan to a lower-rated plan. However, the beneficiary is already in a
5-star plan, so they cannot use the 5-star SEP to change plans. Option D is correct: the SEP is for
enrolling in a 5-star plan, not for leaving one.
10. A Medicare beneficiary is enrolled in a Medicare Advantage (MA) plan and also has coverage
through an employer-sponsored group health plan due to current employment. The employer has
100 employees. Which payer is primary for the beneficiary's healthcare services?
A. The MA plan is primary because it is the beneficiary's Medicare coverage.
B. The employer group health plan is primary because the employer has 100 or more employees.
C. The MA plan is primary for Part A services, and the employer plan is primary for Part B services.
D. The employer group health plan is primary only if the beneficiary is actively working.
Answer: B
Rationale: For beneficiaries with Medicare and employer group health plan coverage from an employer
with 100 or more employees, the group health plan is primary. This is true regardless of whether the
beneficiary is actively working (D is incorrect because it applies to retirees as well for large employers).
Option A is incorrect because Medicare is secondary when the employer has 100+ employees. Option C
has no basis in law.
11. A health plan is developing a new Medicare Advantage (MA) plan that includes a supplemental
benefit for adult day care services. Under CMS regulations, which of the following conditions must
be met for the plan to offer this benefit as a primarily health-related supplemental benefit?
A. The benefit must be available to all enrollees regardless of health status, and the plan must demonstrate that it
reduces the need for inpatient or post-acute care.
B. The benefit must be targeted only to enrollees with chronic conditions, and the plan must submit actuarial
justification showing it is not a substitute for Part A or B services.
C. The benefit must be uniform for all enrollees, and the plan cannot require prior authorization for its use.
D. The benefit must be offered as a standalone optional supplement with a separate premium, and the plan must
receive state approval.
Answer: A
Rationale: CMS requires that supplemental benefits under MA be primarily health-related, uniform in
availability, and must reduce the need for inpatient or post-acute care. Options B is incorrect because
even targeted benefits must meet the same standard. Option C is incorrect because prior authorization
may be allowed. Option D is incorrect because supplemental benefits are part of the plan's benefit
package, not standalone.
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