AHIP Final Exam 2025/2026 | Complete Test Questions with Verified
Correct Answers
1. Mr. Hidalgo complains to you that because he takes multiple expensive drugs, he has
trouble paying his cost sharing for his prescription drugs, particularly at the beginning of the
year during the deductible phase. He is happy with his plan and does not want to change.
However, he said he had heard about a new program called the Medicare Prescription
Payment Plan and asked whether it might help. What do you tell him?
A) The Medicare Prescription Payment Plan eliminates all out-of-pocket costs for prescription
drugs.
B) The Medicare Prescription Payment Plan helps spread out beneficiary cost-sharing payments
but does not decrease the total amount owed.
C) The Medicare Prescription Payment Plan is only available to beneficiaries who are also
enrolled in Medicaid.
D) The Medicare Prescription Payment Plan replaces his current Part D plan with a new one that
has no deductible.
Correct Answer: B – The Medicare Prescription Payment Plan allows beneficiaries to spread
their out-of-pocket prescription drug costs over the calendar year, but it does not reduce the
total amount they owe. It is a payment option, not a discount program.
2. 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?
A) He can switch payment methods at any time during the year without restriction.
B) He must select a single Part D premium payment mechanism that will be used throughout
the year.
C) He can split his premium payments between multiple methods as long as he notifies the plan
in writing.
D) He can only pay Part D premiums through Social Security withholding.
Correct Answer: B – Beneficiaries must select a single payment method for their Part D
premiums and generally cannot change it mid-year unless they experience a qualifying event.
3. 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?
A) TrOOP is the total amount of out-of-pocket costs that a beneficiary pays before Medicare
begins covering services.
B) TrOOP stands for true out-of-pocket costs that count toward the Medicare Part D catastrophic
limit and include not only expenses paid by a beneficiary but also in some instances amounts
paid by or through qualified State Pharmaceutical Assistance Programs.
C) TrOOP is a program that provides free prescription drugs to low-income beneficiaries.
,D) TrOOP is the annual deductible that must be met before Part D coverage begins.
Correct Answer: B – TrOOP (true out-of-pocket costs) includes expenses paid by the beneficiary
and, in some cases, amounts paid by qualified State Pharmaceutical Assistance Programs
(SPAPs) that count toward the catastrophic coverage threshold.
4. 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?
A) Medicare will cover all skilled nursing facility care for up to 100 days with no cost-sharing.
B) Medicare will cover Mrs. Shields's skilled nursing services provided during the first 20 days of
her stay, after which she would have a copay until she has been in the facility for 100 days.
C) Medicare does not cover skilled nursing facility care under any circumstances.
D) Medicare will cover skilled nursing facility care only if she has a Medigap policy.
Correct Answer: B – Original Medicare covers the first 20 days of skilled nursing facility care in
full, with a copayment required for days 21 through 100.
5. 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?
A) Medicare covers glasses, dentures, and massage therapy if ordered by a physician.
B) Medicare covers glasses and dentures but not massage therapy.
C) Medicare does not cover massage therapy, or, in general, glasses or dentures.
D) Medicare covers massage therapy but not glasses or dentures.
Correct Answer: C – Original Medicare generally does not cover glasses, dentures, or massage
therapy. These are considered non-covered services and items.
6. Mrs. Park is an elderly retiree with a low fixed income. What could you tell Mrs. Park that
might be of assistance?
A) She should apply for a Medicare Advantage plan which will eliminate all her out-of-pocket
costs.
B) She should contact her state Medicaid agency to see if she qualifies for one of several
programs that can help with Medicare costs for which she is responsible.
C) She should purchase a Medigap policy to cover all her Medicare cost-sharing.
D) She should switch to a private insurance plan outside of Medicare.
Correct Answer: B – Low-income beneficiaries may qualify for Medicare Savings Programs
(MSPs) through their state Medicaid agency, which can help pay Medicare premiums,
deductibles, and coinsurance.
7. 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
,Medicare Part D prescription drug plan. What should you tell him?
A) He would generally pay only a monthly premium with no other costs.
B) He would generally pay a monthly premium, annual deductible, and per-prescription cost-
sharing.
C) He would generally pay only the cost of the drugs themselves at the pharmacy.
D) He would generally pay an enrollment fee and a monthly premium.
Correct Answer: B – Standard Part D plans typically include a monthly premium, an annual
deductible, and cost-sharing (copayments or coinsurance) for each prescription.
8. 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?
A) She can purchase a new Medigap plan that covers prescription drugs and drop her current
policy.
B) Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her
Medigap policy and enroll in a Part D prescription drug plan.
C) She must drop her Medigap policy and enroll in a Medicare Advantage plan to get drug
coverage.
D) She can add a drug rider to her existing Medigap policy at any time.
Correct Answer: B – Medigap plans sold after January 1, 2006, are not permitted to cover
prescription drugs. Beneficiaries who need drug coverage should enroll in a standalone Part D
plan while keeping their Medigap policy.
9. 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?
A) He is not eligible for Medicare because he is under age 65.
B) He may sign up for Medicare at any time; however, coverage usually begins on the fourth
month after dialysis treatments start.
C) He must wait until he turns 65 to enroll in Medicare.
D) He is eligible for Medicare only if he also has a disability that has lasted at least 24 months.
Correct Answer: B – Individuals with ESRD are eligible for Medicare regardless of age. Coverage
typically begins the fourth month after dialysis treatments start, though there is a three-month
waiting period.
10. 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?
A) Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she
received the MSN in the mail.
B) Mrs. Duarte should pay the denied amount and not challenge the determination.
C) Mrs. Duarte should contact her Medicare Advantage plan directly.
, D) Mrs. Duarte should file a complaint with the state insurance department.
Correct Answer: A – Beneficiaries have the right to appeal Medicare claim denials. For Original
Medicare, the appeal must be filed within 120 days of receiving the Medicare Summary Notice.
11. Mrs. Geisler's neighbor told her she should look at her Part D options during the annual
Medicare enrollment period because the 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?
A) Part D covers hospital insurance and she should look at her premiums and deductibles.
B) Part D covers prescription drugs and she should look at her premiums, formulary, and cost-
sharing among other factors to see if they have changed.
C) Part D covers dental and vision services.
D) Part D is the same as Medicare Advantage.
Correct Answer: B – Medicare Part D provides prescription drug coverage. Beneficiaries should
review their plan's premiums, formulary (list of covered drugs), and cost-sharing each year
during the Annual Enrollment Period to see if changes have been made.
12. Which of the following is an example of waste in the Medicare program?
A) Knowingly submitting a claim for services not rendered.
B) Overuse of services or other practices that directly or indirectly result in unnecessary costs to
the Medicare Program.
C) Offering kickbacks to physicians for referrals.
D) Failing to maintain patient privacy.
Correct Answer: B – Waste includes the overuse of services and other practices that result in
unnecessary costs to the Medicare program. Unlike fraud, waste is not typically intentional.
13. Once a corrective action plan is started, the corrective action plan must be monitored
annually to ensure it is effective. Is this statement true or false?
A) True
B) False
Correct Answer: B – Corrective action plans must be monitored more frequently than annually
to ensure they are effective. Annual monitoring alone is insufficient.
14. Which of the following should be reported to a Compliance Department?
A) Suspected fraud, waste, and abuse (FWA)
B) Potential health privacy violations
C) Unethical behavior and employee misconduct
D) All of the above
Correct Answer: D – All of these issues—suspected FWA, potential health privacy violations,
unethical behavior, and employee misconduct—should be reported to a Compliance
Department.
Correct Answers
1. Mr. Hidalgo complains to you that because he takes multiple expensive drugs, he has
trouble paying his cost sharing for his prescription drugs, particularly at the beginning of the
year during the deductible phase. He is happy with his plan and does not want to change.
However, he said he had heard about a new program called the Medicare Prescription
Payment Plan and asked whether it might help. What do you tell him?
A) The Medicare Prescription Payment Plan eliminates all out-of-pocket costs for prescription
drugs.
B) The Medicare Prescription Payment Plan helps spread out beneficiary cost-sharing payments
but does not decrease the total amount owed.
C) The Medicare Prescription Payment Plan is only available to beneficiaries who are also
enrolled in Medicaid.
D) The Medicare Prescription Payment Plan replaces his current Part D plan with a new one that
has no deductible.
Correct Answer: B – The Medicare Prescription Payment Plan allows beneficiaries to spread
their out-of-pocket prescription drug costs over the calendar year, but it does not reduce the
total amount they owe. It is a payment option, not a discount program.
2. 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?
A) He can switch payment methods at any time during the year without restriction.
B) He must select a single Part D premium payment mechanism that will be used throughout
the year.
C) He can split his premium payments between multiple methods as long as he notifies the plan
in writing.
D) He can only pay Part D premiums through Social Security withholding.
Correct Answer: B – Beneficiaries must select a single payment method for their Part D
premiums and generally cannot change it mid-year unless they experience a qualifying event.
3. 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?
A) TrOOP is the total amount of out-of-pocket costs that a beneficiary pays before Medicare
begins covering services.
B) TrOOP stands for true out-of-pocket costs that count toward the Medicare Part D catastrophic
limit and include not only expenses paid by a beneficiary but also in some instances amounts
paid by or through qualified State Pharmaceutical Assistance Programs.
C) TrOOP is a program that provides free prescription drugs to low-income beneficiaries.
,D) TrOOP is the annual deductible that must be met before Part D coverage begins.
Correct Answer: B – TrOOP (true out-of-pocket costs) includes expenses paid by the beneficiary
and, in some cases, amounts paid by qualified State Pharmaceutical Assistance Programs
(SPAPs) that count toward the catastrophic coverage threshold.
4. 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?
A) Medicare will cover all skilled nursing facility care for up to 100 days with no cost-sharing.
B) Medicare will cover Mrs. Shields's skilled nursing services provided during the first 20 days of
her stay, after which she would have a copay until she has been in the facility for 100 days.
C) Medicare does not cover skilled nursing facility care under any circumstances.
D) Medicare will cover skilled nursing facility care only if she has a Medigap policy.
Correct Answer: B – Original Medicare covers the first 20 days of skilled nursing facility care in
full, with a copayment required for days 21 through 100.
5. 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?
A) Medicare covers glasses, dentures, and massage therapy if ordered by a physician.
B) Medicare covers glasses and dentures but not massage therapy.
C) Medicare does not cover massage therapy, or, in general, glasses or dentures.
D) Medicare covers massage therapy but not glasses or dentures.
Correct Answer: C – Original Medicare generally does not cover glasses, dentures, or massage
therapy. These are considered non-covered services and items.
6. Mrs. Park is an elderly retiree with a low fixed income. What could you tell Mrs. Park that
might be of assistance?
A) She should apply for a Medicare Advantage plan which will eliminate all her out-of-pocket
costs.
B) She should contact her state Medicaid agency to see if she qualifies for one of several
programs that can help with Medicare costs for which she is responsible.
C) She should purchase a Medigap policy to cover all her Medicare cost-sharing.
D) She should switch to a private insurance plan outside of Medicare.
Correct Answer: B – Low-income beneficiaries may qualify for Medicare Savings Programs
(MSPs) through their state Medicaid agency, which can help pay Medicare premiums,
deductibles, and coinsurance.
7. 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
,Medicare Part D prescription drug plan. What should you tell him?
A) He would generally pay only a monthly premium with no other costs.
B) He would generally pay a monthly premium, annual deductible, and per-prescription cost-
sharing.
C) He would generally pay only the cost of the drugs themselves at the pharmacy.
D) He would generally pay an enrollment fee and a monthly premium.
Correct Answer: B – Standard Part D plans typically include a monthly premium, an annual
deductible, and cost-sharing (copayments or coinsurance) for each prescription.
8. 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?
A) She can purchase a new Medigap plan that covers prescription drugs and drop her current
policy.
B) Mrs. Gonzalez cannot purchase a Medigap plan that covers drugs, but she could keep her
Medigap policy and enroll in a Part D prescription drug plan.
C) She must drop her Medigap policy and enroll in a Medicare Advantage plan to get drug
coverage.
D) She can add a drug rider to her existing Medigap policy at any time.
Correct Answer: B – Medigap plans sold after January 1, 2006, are not permitted to cover
prescription drugs. Beneficiaries who need drug coverage should enroll in a standalone Part D
plan while keeping their Medigap policy.
9. 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?
A) He is not eligible for Medicare because he is under age 65.
B) He may sign up for Medicare at any time; however, coverage usually begins on the fourth
month after dialysis treatments start.
C) He must wait until he turns 65 to enroll in Medicare.
D) He is eligible for Medicare only if he also has a disability that has lasted at least 24 months.
Correct Answer: B – Individuals with ESRD are eligible for Medicare regardless of age. Coverage
typically begins the fourth month after dialysis treatments start, though there is a three-month
waiting period.
10. 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?
A) Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she
received the MSN in the mail.
B) Mrs. Duarte should pay the denied amount and not challenge the determination.
C) Mrs. Duarte should contact her Medicare Advantage plan directly.
, D) Mrs. Duarte should file a complaint with the state insurance department.
Correct Answer: A – Beneficiaries have the right to appeal Medicare claim denials. For Original
Medicare, the appeal must be filed within 120 days of receiving the Medicare Summary Notice.
11. Mrs. Geisler's neighbor told her she should look at her Part D options during the annual
Medicare enrollment period because the 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?
A) Part D covers hospital insurance and she should look at her premiums and deductibles.
B) Part D covers prescription drugs and she should look at her premiums, formulary, and cost-
sharing among other factors to see if they have changed.
C) Part D covers dental and vision services.
D) Part D is the same as Medicare Advantage.
Correct Answer: B – Medicare Part D provides prescription drug coverage. Beneficiaries should
review their plan's premiums, formulary (list of covered drugs), and cost-sharing each year
during the Annual Enrollment Period to see if changes have been made.
12. Which of the following is an example of waste in the Medicare program?
A) Knowingly submitting a claim for services not rendered.
B) Overuse of services or other practices that directly or indirectly result in unnecessary costs to
the Medicare Program.
C) Offering kickbacks to physicians for referrals.
D) Failing to maintain patient privacy.
Correct Answer: B – Waste includes the overuse of services and other practices that result in
unnecessary costs to the Medicare program. Unlike fraud, waste is not typically intentional.
13. Once a corrective action plan is started, the corrective action plan must be monitored
annually to ensure it is effective. Is this statement true or false?
A) True
B) False
Correct Answer: B – Corrective action plans must be monitored more frequently than annually
to ensure they are effective. Annual monitoring alone is insufficient.
14. Which of the following should be reported to a Compliance Department?
A) Suspected fraud, waste, and abuse (FWA)
B) Potential health privacy violations
C) Unethical behavior and employee misconduct
D) All of the above
Correct Answer: D – All of these issues—suspected FWA, potential health privacy violations,
unethical behavior, and employee misconduct—should be reported to a Compliance
Department.
