AHIP 2027 MEDICARE TRAINING AND
CERTIFICATION EXAM QUESTIONS
AND ANSWERS
1. A consumer is looking to enroll in a Medicare Advantage plan but is concerned about the
cost of services. Which of the following is a mandatory feature of all Medicare Advantage
plans that protects members from high out-of-pocket costs?
A. A lifetime maximum benefit limit.
B. A guarantee that premiums will never increase.
C. Zero-dollar deductibles for all specialist visits.
D. An annual maximum out-of-pocket (MOOP) limit for Part A and B services.
Answer: D
Conceptual Explanation: CMS requires all Medicare Advantage (Part C) plans to have an
annual maximum out-of-pocket (MOOP) limit on member cost-sharing for inclusive Part A
and Part B services. Once this limit is reached, the plan pays 100% of covered services for
the remainder of the year.
2. Mrs. Green will turn 65 in August. She has been receiving Social Security benefits for two
years. How will she be enrolled in Medicare?
A. She must visit the Social Security office to apply manually.
,B. She will be automatically enrolled in Part A only; Part B requires an application.
C. She will be automatically enrolled in Part A and Part B.
D. She must wait until the General Enrollment Period in January.
Answer: C
Conceptual Explanation: Individuals who are already receiving Social Security or Railroad
Retirement Board benefits are automatically enrolled in both Medicare Part A and Part B
starting the first day of the month they turn 65.
3. Which of the following describes the ‘Donut Hole’ (Coverage Gap) phase in Part D
prescription drug coverage for the 2025-2027 cycle following the Inflation Reduction Act
implementation?
A. The beneficiary pays 50% of the cost of generic drugs.
B. Manufacturers are no longer required to provide discounts.
C. The beneficiary pays a flat $500 deductible before coverage starts.
D. The coverage gap has been effectively eliminated, replaced by a $2,000 annual out-of-
pocket cap.
Answer: D
Conceptual Explanation: Under the Inflation Reduction Act, for plan years starting 2025
and beyond, the structure of Part D has changed to eliminate the coverage gap, setting a
hard $2,000 annual out-of-pocket cap for beneficiaries.
, 4. An agent is conducting a marketing appointment. Which of the following actions is
prohibited by CMS regulations?
A. Providing a Summary of Benefits to the client.
B. Asking for referrals from the client.
C. Requiring a client to provide phone numbers of friends as a condition of enrollment.
D. Explaining the difference between an HMO and a PPO.
Answer: C
Conceptual Explanation: Agents are strictly prohibited from requiring referrals or making
them a condition of enrollment. While they may ask for referrals, they cannot offer
incentives or mandate them.
5. What is the primary difference between a Medicare Advantage HMO and a Medicare
Advantage PPO?
A. PPOs do not cover emergency care outside the service area.
B. PPOs are always more expensive than HMOs.
C. HMOs allow members to see any doctor who accepts Medicare.
D. HMOs generally require a Primary Care Physician (PCP) and referrals for specialists,
whereas PPOs generally do not.
Answer: D
CERTIFICATION EXAM QUESTIONS
AND ANSWERS
1. A consumer is looking to enroll in a Medicare Advantage plan but is concerned about the
cost of services. Which of the following is a mandatory feature of all Medicare Advantage
plans that protects members from high out-of-pocket costs?
A. A lifetime maximum benefit limit.
B. A guarantee that premiums will never increase.
C. Zero-dollar deductibles for all specialist visits.
D. An annual maximum out-of-pocket (MOOP) limit for Part A and B services.
Answer: D
Conceptual Explanation: CMS requires all Medicare Advantage (Part C) plans to have an
annual maximum out-of-pocket (MOOP) limit on member cost-sharing for inclusive Part A
and Part B services. Once this limit is reached, the plan pays 100% of covered services for
the remainder of the year.
2. Mrs. Green will turn 65 in August. She has been receiving Social Security benefits for two
years. How will she be enrolled in Medicare?
A. She must visit the Social Security office to apply manually.
,B. She will be automatically enrolled in Part A only; Part B requires an application.
C. She will be automatically enrolled in Part A and Part B.
D. She must wait until the General Enrollment Period in January.
Answer: C
Conceptual Explanation: Individuals who are already receiving Social Security or Railroad
Retirement Board benefits are automatically enrolled in both Medicare Part A and Part B
starting the first day of the month they turn 65.
3. Which of the following describes the ‘Donut Hole’ (Coverage Gap) phase in Part D
prescription drug coverage for the 2025-2027 cycle following the Inflation Reduction Act
implementation?
A. The beneficiary pays 50% of the cost of generic drugs.
B. Manufacturers are no longer required to provide discounts.
C. The beneficiary pays a flat $500 deductible before coverage starts.
D. The coverage gap has been effectively eliminated, replaced by a $2,000 annual out-of-
pocket cap.
Answer: D
Conceptual Explanation: Under the Inflation Reduction Act, for plan years starting 2025
and beyond, the structure of Part D has changed to eliminate the coverage gap, setting a
hard $2,000 annual out-of-pocket cap for beneficiaries.
, 4. An agent is conducting a marketing appointment. Which of the following actions is
prohibited by CMS regulations?
A. Providing a Summary of Benefits to the client.
B. Asking for referrals from the client.
C. Requiring a client to provide phone numbers of friends as a condition of enrollment.
D. Explaining the difference between an HMO and a PPO.
Answer: C
Conceptual Explanation: Agents are strictly prohibited from requiring referrals or making
them a condition of enrollment. While they may ask for referrals, they cannot offer
incentives or mandate them.
5. What is the primary difference between a Medicare Advantage HMO and a Medicare
Advantage PPO?
A. PPOs do not cover emergency care outside the service area.
B. PPOs are always more expensive than HMOs.
C. HMOs allow members to see any doctor who accepts Medicare.
D. HMOs generally require a Primary Care Physician (PCP) and referrals for specialists,
whereas PPOs generally do not.
Answer: D
