AHIP Medicare Certification Study Guide — 2026/2027 Edition
AHIP Medicare Certification Study
Guide
Latest 2026/2027 Edition
150 Original Practice Questions & Detailed Rationales
An original, independently developed study resource.
Content is based on publicly available CMS guidance and general Medicare program knowledge.
This guide is not affiliated with, endorsed by, or a reproduction of any official AHIP exam or commercial
question bank.
Page 1 of 67
, AHIP Medicare Certification Study Guide — 2026/2027 Edition
Contents
Section 1: Medicare Fundamentals (Questions 1–10)
Section 2: Medicare Part A (Questions 11–20)
Section 3: Medicare Part B (Questions 21–30)
Section 4: Medicare Part C (Medicare Advantage) (Questions 31–40)
Section 5: Medicare Part D (Questions 41–50)
Section 6: Medigap (Questions 51–60)
Section 7: Enrollment Periods (Questions 61–70)
Section 8: Financial Assistance (Questions 71–80)
Section 9: Compliance (Questions 81–90)
Section 10: Fraud, Waste & Abuse (Questions 91–100)
Section 11: Marketing & Communications (Questions 101–110)
Section 12: Ethics (Questions 111–120)
Section 13: Appeals & Grievances (Questions 121–130)
Section 14: Coordination of Benefits (Questions 131–140)
Section 15: Comprehensive Scenarios (Questions 141–150)
Page 2 of 67
, AHIP Medicare Certification Study Guide — 2026/2027 Edition
Section 1: Medicare Fundamentals
Question 1 [Foundational]
Medicare was established as a federal health insurance program under which piece of legislation?
A. The Social Security Amendments of 1965
B. The Employee Retirement Income Security Act of 1974
C. The Balanced Budget Act of 1997
D. The Affordable Care Act of 2010
Correct Answer: A
Detailed Rationale:
Medicare was created by the Social Security Amendments of 1965, which added Title XVIII to the Social
Security Act, establishing Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B). ERISA
(1974) governs private employer benefit plans, not Medicare itself. The Balanced Budget Act of 1997 created
the Medicare+Choice program (later Medicare Advantage), and the ACA (2010) modified but did not create
Medicare.
Question 2 [Foundational]
Which federal agency has primary administrative responsibility for the Medicare program?
A. The Social Security Administration (SSA)
B. The Centers for Medicare & Medicaid Services (CMS)
C. The Department of Labor (DOL)
D. The Health Resources and Services Administration (HRSA)
Correct Answer: B
Detailed Rationale:
CMS, an agency within the Department of Health and Human Services, administers Medicare, including
setting coverage rules, overseeing Medicare Advantage and Part D plan contracts, and enforcing compliance.
SSA processes many enrollment applications and determines eligibility for benefits, but CMS is the program
administrator. DOL oversees ERISA plans, and HRSA focuses on access to care for underserved populations.
Question 3 [Application]
A 63-year-old client asks when she will first become eligible for Medicare based on age alone, assuming
no disability. What should the agent tell her?
A. She becomes eligible the month she turns 62
B. She becomes eligible the first day of the month she turns 65, in most cases
C. She becomes eligible only after she begins collecting Social Security retirement benefits
D. She becomes eligible on January 1 of the year she turns 65
Correct Answer: B
Detailed Rationale:
Page 3 of 67
, AHIP Medicare Certification Study Guide — 2026/2027 Edition
Age-based Medicare eligibility generally begins the first day of the month a person turns 65 (if their birthday
is on the first of the month, eligibility begins the prior month). Eligibility is not tied to actually collecting
Social Security retirement benefits, since a person can delay claiming Social Security while still enrolling in
Medicare. Age 62 and January 1 are incorrect eligibility triggers.
Question 4 [Foundational]
Which of the following individuals under age 65 would generally qualify for Medicare based on
disability?
A. Someone who has received Social Security Disability Insurance (SSDI) for 24 months
B. Someone who has been unemployed for 24 months
C. Someone who has a temporary workplace injury
D. Someone who qualifies for unemployment benefits
Correct Answer: A
Detailed Rationale:
Individuals under 65 generally become eligible for Medicare after receiving SSDI benefits for 24 months.
Certain conditions, such as End-Stage Renal Disease and ALS, have different waiting period rules.
Unemployment status or a temporary injury alone does not confer Medicare eligibility.
Question 5 [Application]
A beneficiary asks an agent to explain the basic structure of Medicare. Which description is most
accurate?
A. Medicare consists only of Part A and Part B, collectively called Original Medicare
B. Medicare consists of Part A (hospital insurance), Part B (medical insurance), Part C (Medicare
Advantage, an alternative way to receive Parts A and B), and Part D (prescription drug coverage)
C. Medicare consists of Part A, Part B, and Medigap, which together form Original Medicare
D. Medicare consists of Part C and Part D only, since Parts A and B were phased out
Correct Answer: B
Detailed Rationale:
Medicare has four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage
plans that bundle Parts A and B and often Part D), and Part D (prescription drug coverage). Medigap is a
supplemental product sold by private insurers to work alongside Original Medicare; it is not a part of
Medicare itself. Original Medicare refers only to Parts A and B.
Question 6 [Advanced]
An agent is counseling a beneficiary who believes that enrolling in Medicare automatically terminates all
of her existing legal rights to appeal denied claims. Which statement correctly addresses this
misunderstanding?
A. Medicare beneficiaries have statutory rights to appeal coverage and payment decisions through a
structured, multi-level appeals process
Page 4 of 67
AHIP Medicare Certification Study
Guide
Latest 2026/2027 Edition
150 Original Practice Questions & Detailed Rationales
An original, independently developed study resource.
Content is based on publicly available CMS guidance and general Medicare program knowledge.
This guide is not affiliated with, endorsed by, or a reproduction of any official AHIP exam or commercial
question bank.
Page 1 of 67
, AHIP Medicare Certification Study Guide — 2026/2027 Edition
Contents
Section 1: Medicare Fundamentals (Questions 1–10)
Section 2: Medicare Part A (Questions 11–20)
Section 3: Medicare Part B (Questions 21–30)
Section 4: Medicare Part C (Medicare Advantage) (Questions 31–40)
Section 5: Medicare Part D (Questions 41–50)
Section 6: Medigap (Questions 51–60)
Section 7: Enrollment Periods (Questions 61–70)
Section 8: Financial Assistance (Questions 71–80)
Section 9: Compliance (Questions 81–90)
Section 10: Fraud, Waste & Abuse (Questions 91–100)
Section 11: Marketing & Communications (Questions 101–110)
Section 12: Ethics (Questions 111–120)
Section 13: Appeals & Grievances (Questions 121–130)
Section 14: Coordination of Benefits (Questions 131–140)
Section 15: Comprehensive Scenarios (Questions 141–150)
Page 2 of 67
, AHIP Medicare Certification Study Guide — 2026/2027 Edition
Section 1: Medicare Fundamentals
Question 1 [Foundational]
Medicare was established as a federal health insurance program under which piece of legislation?
A. The Social Security Amendments of 1965
B. The Employee Retirement Income Security Act of 1974
C. The Balanced Budget Act of 1997
D. The Affordable Care Act of 2010
Correct Answer: A
Detailed Rationale:
Medicare was created by the Social Security Amendments of 1965, which added Title XVIII to the Social
Security Act, establishing Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B). ERISA
(1974) governs private employer benefit plans, not Medicare itself. The Balanced Budget Act of 1997 created
the Medicare+Choice program (later Medicare Advantage), and the ACA (2010) modified but did not create
Medicare.
Question 2 [Foundational]
Which federal agency has primary administrative responsibility for the Medicare program?
A. The Social Security Administration (SSA)
B. The Centers for Medicare & Medicaid Services (CMS)
C. The Department of Labor (DOL)
D. The Health Resources and Services Administration (HRSA)
Correct Answer: B
Detailed Rationale:
CMS, an agency within the Department of Health and Human Services, administers Medicare, including
setting coverage rules, overseeing Medicare Advantage and Part D plan contracts, and enforcing compliance.
SSA processes many enrollment applications and determines eligibility for benefits, but CMS is the program
administrator. DOL oversees ERISA plans, and HRSA focuses on access to care for underserved populations.
Question 3 [Application]
A 63-year-old client asks when she will first become eligible for Medicare based on age alone, assuming
no disability. What should the agent tell her?
A. She becomes eligible the month she turns 62
B. She becomes eligible the first day of the month she turns 65, in most cases
C. She becomes eligible only after she begins collecting Social Security retirement benefits
D. She becomes eligible on January 1 of the year she turns 65
Correct Answer: B
Detailed Rationale:
Page 3 of 67
, AHIP Medicare Certification Study Guide — 2026/2027 Edition
Age-based Medicare eligibility generally begins the first day of the month a person turns 65 (if their birthday
is on the first of the month, eligibility begins the prior month). Eligibility is not tied to actually collecting
Social Security retirement benefits, since a person can delay claiming Social Security while still enrolling in
Medicare. Age 62 and January 1 are incorrect eligibility triggers.
Question 4 [Foundational]
Which of the following individuals under age 65 would generally qualify for Medicare based on
disability?
A. Someone who has received Social Security Disability Insurance (SSDI) for 24 months
B. Someone who has been unemployed for 24 months
C. Someone who has a temporary workplace injury
D. Someone who qualifies for unemployment benefits
Correct Answer: A
Detailed Rationale:
Individuals under 65 generally become eligible for Medicare after receiving SSDI benefits for 24 months.
Certain conditions, such as End-Stage Renal Disease and ALS, have different waiting period rules.
Unemployment status or a temporary injury alone does not confer Medicare eligibility.
Question 5 [Application]
A beneficiary asks an agent to explain the basic structure of Medicare. Which description is most
accurate?
A. Medicare consists only of Part A and Part B, collectively called Original Medicare
B. Medicare consists of Part A (hospital insurance), Part B (medical insurance), Part C (Medicare
Advantage, an alternative way to receive Parts A and B), and Part D (prescription drug coverage)
C. Medicare consists of Part A, Part B, and Medigap, which together form Original Medicare
D. Medicare consists of Part C and Part D only, since Parts A and B were phased out
Correct Answer: B
Detailed Rationale:
Medicare has four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage
plans that bundle Parts A and B and often Part D), and Part D (prescription drug coverage). Medigap is a
supplemental product sold by private insurers to work alongside Original Medicare; it is not a part of
Medicare itself. Original Medicare refers only to Parts A and B.
Question 6 [Advanced]
An agent is counseling a beneficiary who believes that enrolling in Medicare automatically terminates all
of her existing legal rights to appeal denied claims. Which statement correctly addresses this
misunderstanding?
A. Medicare beneficiaries have statutory rights to appeal coverage and payment decisions through a
structured, multi-level appeals process
Page 4 of 67
