AHIP Final Exam 2026/2027
Complete Exam-Style Questions & ANSWERs
Medicare Advantage Plans (Part C)
Question 1
Robert is a 68-year-old retiree who recently moved to a rural area and is evaluating his Medicare
options. He wants to understand how a Medicare Advantage HMO differs from Original Medicare
regarding provider flexibility. What should Robert know about HMO network requirements under
Medicare Advantage?
A) HMO plans require members to use in-network providers except for emergency and urgent care
situations
B) HMO plans allow members to see any Medicare-approved provider nationwide at the same cost
C) HMO plans do not have any network restrictions but charge higher premiums for out-of-network use
D) HMO plans permit out-of-network visits with a small copayment as long as the provider accepts
Medicare
Correct ANSWER: A
Rationale: Medicare Advantage HMO plans require members to use in-network providers for routine
and specialist care. Out-of-network services are generally not covered except in emergencies or urgent
care situations. This is a fundamental distinction from Original Medicare, which allows beneficiaries to
see any provider who accepts Medicare assignment nationwide.
,Question 2
Margaret, age 72, has been enrolled in a Medicare Advantage PPO for three years and wants to
understand her out-of-network benefits. She occasionally visits a specialist who is not in her plan's
network. How does a PPO typically handle out-of-network services?
A) PPO plans cover out-of-network services at a higher cost-sharing level than in-network services
B) PPO plans never cover out-of-network services under any circumstances for Medicare beneficiaries
C) PPO plans cover out-of-network services at the same cost as in-network services for all members
D) PPO plans require prior authorization for all out-of-network services before any coverage applies
Correct ANSWER: A
Rationale: PPO plans allow members to receive care from out-of-network providers at a higher cost-
sharing level. This flexibility is the primary distinction between PPOs and HMOs within Medicare
Advantage. Members pay more for out-of-network services but retain the freedom to choose providers
outside the network.
Question 3
James is 65 and has end-stage renal disease (ESRD). He previously believed he could not join a Medicare
Advantage plan. Under current rules, what is his eligibility status for Medicare Advantage enrollment?
A) He may enroll in a Medicare Advantage plan because the ESRD exclusion was eliminated effective
2021
B) He remains permanently ineligible for Medicare Advantage due to his ESRD diagnosis under all
circumstances
,C) He can only enroll in a Special Needs Plan specifically designed for ESRD patients and no other MA
plan
D) He must wait until he has been on dialysis for at least 12 months before any MA enrollment is
possible
Correct ANSWER: A
Rationale: Since 2021, the ESRD exclusion for Medicare Advantage enrollment has been eliminated.
Individuals with ESRD may now enroll in any Medicare Advantage plan, not just Special Needs Plans. This
change expanded access to MA plans for beneficiaries with ESRD.
Question 4
Dorothy, age 70, is comparing Medicare Advantage plans and notices that some plans offer a Maximum
Out-of-Pocket (MOOP) limit while Original Medicare does not. She asks her agent what advantage the
MOOP provides. What is the correct explanation?
A) The MOOP limit caps annual spending on covered Part A and Part B services, providing financial
protection against catastrophic costs
B) The MOOP limit only applies to prescription drug costs under the Part D portion of a Medicare
Advantage plan
C) The MOOP limit is the same across all Medicare Advantage plans and is set uniformly by the federal
government
D) The MOOP limit applies only to inpatient hospital stays and excludes all outpatient services from the
cap
Correct ANSWER: A
, Rationale: The MOOP is a key advantage of Medicare Advantage plans, capping the amount a
beneficiary spends on covered Part A and Part B services in a calendar year. Original Medicare has no
such cap, leaving beneficiaries potentially exposed to unlimited out-of-pocket costs. Plans must set
MOOP limits at or below CMS-established thresholds.
Question 5
Frank is a 74-year-old veteran considering a Medicare Advantage HMO-POS plan. His neighbor told him
that POS plans offer more flexibility than standard HMOs. What feature distinguishes an HMO-POS from
a regular HMO?
A) HMO-POS plans allow members to self-refer to out-of-network providers for certain services at higher
cost-sharing
B) HMO-POS plans do not require a primary care physician or referrals for any specialist visits
C) HMO-POS plans cover all out-of-network services at the same rate as in-network services for
members
D) HMO-POS plans are only available to beneficiaries who qualify for both Medicare and Medicaid
simultaneously
Correct ANSWER: A
Rationale: HMO-POS plans combine the structure of an HMO with the flexibility to seek certain out-of-
network services at higher cost-sharing. This gives members more options than a standard HMO while
still maintaining the core HMO structure requiring primary care physician selection and referrals for
most in-network care.
Question 6
Complete Exam-Style Questions & ANSWERs
Medicare Advantage Plans (Part C)
Question 1
Robert is a 68-year-old retiree who recently moved to a rural area and is evaluating his Medicare
options. He wants to understand how a Medicare Advantage HMO differs from Original Medicare
regarding provider flexibility. What should Robert know about HMO network requirements under
Medicare Advantage?
A) HMO plans require members to use in-network providers except for emergency and urgent care
situations
B) HMO plans allow members to see any Medicare-approved provider nationwide at the same cost
C) HMO plans do not have any network restrictions but charge higher premiums for out-of-network use
D) HMO plans permit out-of-network visits with a small copayment as long as the provider accepts
Medicare
Correct ANSWER: A
Rationale: Medicare Advantage HMO plans require members to use in-network providers for routine
and specialist care. Out-of-network services are generally not covered except in emergencies or urgent
care situations. This is a fundamental distinction from Original Medicare, which allows beneficiaries to
see any provider who accepts Medicare assignment nationwide.
,Question 2
Margaret, age 72, has been enrolled in a Medicare Advantage PPO for three years and wants to
understand her out-of-network benefits. She occasionally visits a specialist who is not in her plan's
network. How does a PPO typically handle out-of-network services?
A) PPO plans cover out-of-network services at a higher cost-sharing level than in-network services
B) PPO plans never cover out-of-network services under any circumstances for Medicare beneficiaries
C) PPO plans cover out-of-network services at the same cost as in-network services for all members
D) PPO plans require prior authorization for all out-of-network services before any coverage applies
Correct ANSWER: A
Rationale: PPO plans allow members to receive care from out-of-network providers at a higher cost-
sharing level. This flexibility is the primary distinction between PPOs and HMOs within Medicare
Advantage. Members pay more for out-of-network services but retain the freedom to choose providers
outside the network.
Question 3
James is 65 and has end-stage renal disease (ESRD). He previously believed he could not join a Medicare
Advantage plan. Under current rules, what is his eligibility status for Medicare Advantage enrollment?
A) He may enroll in a Medicare Advantage plan because the ESRD exclusion was eliminated effective
2021
B) He remains permanently ineligible for Medicare Advantage due to his ESRD diagnosis under all
circumstances
,C) He can only enroll in a Special Needs Plan specifically designed for ESRD patients and no other MA
plan
D) He must wait until he has been on dialysis for at least 12 months before any MA enrollment is
possible
Correct ANSWER: A
Rationale: Since 2021, the ESRD exclusion for Medicare Advantage enrollment has been eliminated.
Individuals with ESRD may now enroll in any Medicare Advantage plan, not just Special Needs Plans. This
change expanded access to MA plans for beneficiaries with ESRD.
Question 4
Dorothy, age 70, is comparing Medicare Advantage plans and notices that some plans offer a Maximum
Out-of-Pocket (MOOP) limit while Original Medicare does not. She asks her agent what advantage the
MOOP provides. What is the correct explanation?
A) The MOOP limit caps annual spending on covered Part A and Part B services, providing financial
protection against catastrophic costs
B) The MOOP limit only applies to prescription drug costs under the Part D portion of a Medicare
Advantage plan
C) The MOOP limit is the same across all Medicare Advantage plans and is set uniformly by the federal
government
D) The MOOP limit applies only to inpatient hospital stays and excludes all outpatient services from the
cap
Correct ANSWER: A
, Rationale: The MOOP is a key advantage of Medicare Advantage plans, capping the amount a
beneficiary spends on covered Part A and Part B services in a calendar year. Original Medicare has no
such cap, leaving beneficiaries potentially exposed to unlimited out-of-pocket costs. Plans must set
MOOP limits at or below CMS-established thresholds.
Question 5
Frank is a 74-year-old veteran considering a Medicare Advantage HMO-POS plan. His neighbor told him
that POS plans offer more flexibility than standard HMOs. What feature distinguishes an HMO-POS from
a regular HMO?
A) HMO-POS plans allow members to self-refer to out-of-network providers for certain services at higher
cost-sharing
B) HMO-POS plans do not require a primary care physician or referrals for any specialist visits
C) HMO-POS plans cover all out-of-network services at the same rate as in-network services for
members
D) HMO-POS plans are only available to beneficiaries who qualify for both Medicare and Medicaid
simultaneously
Correct ANSWER: A
Rationale: HMO-POS plans combine the structure of an HMO with the flexibility to seek certain out-of-
network services at higher cost-sharing. This gives members more options than a standard HMO while
still maintaining the core HMO structure requiring primary care physician selection and referrals for
most in-network care.
Question 6
