AHIP 2025 Certification Exam Test Bank: Complete
Questions and Answers for All Modules
1. A Medicare Advantage plan is considering a new supplemental benefit that provides
non-medical transportation for enrollees with chronic conditions. Under CMS regulations for
2025, which of the following statements is correct regarding the permissible scope of this benefit?
A. The benefit must be primarily health-related and can be offered only if it has a reasonable expectation of
improving health outcomes.
B. The benefit can be offered without restriction as long as it is uniformly available to all enrollees with the
chronic condition.
C. The benefit must be approved by the state insurance commissioner before implementation.
D. The benefit is not allowed because non-medical transportation is excluded from Medicare Advantage
supplemental benefits.
Answer: A
Rationale: CMS requires supplemental benefits to be primarily health-related, meaning they must have a
reasonable expectation of improving or maintaining health or overall function. Uniformity is required,
but the benefit must still meet the health-related standard. State approval is not needed for Medicare
Advantage plans. Non-medical transportation is allowed if health-related.
2. In the context of Medicare Part D, a plan sponsor proposes a formulary that places all drugs for
a certain class on a non-preferred tier with a 50% coinsurance. The class includes multiple
therapeutically equivalent drugs. Which of the following actions by CMS would be most likely?
A. Approve the formulary because plans have broad discretion in tier placement.
B. Require the plan to place at least one drug in each class on a preferred tier to ensure adequate access.
C. Deny the formulary because it does not include any preferred tier drugs for that class.
D. Mandate that all drugs in the class be placed on the same tier to avoid steering.
Answer: B
Rationale: CMS requires Part D sponsors to include at least one drug per therapeutic category on a
preferred tier to ensure beneficiary access and cost-sharing reasonableness. While plans have
discretion, they must comply with CMS formulary guidelines. The other options are not consistent with
current CMS policies.
3. A Medicare Advantage plan receives a complaint that an agent used out-of-date marketing
materials that did not include the required CMS disclaimer about plan availability. The
compliance officer must evaluate the severity. Under CMS guidance, which factor is most critical
in determining whether this constitutes a significant non-compliance event?
A. Whether the agent was a top producer for the plan.
B. Whether the materials were used for more than 30 days.
C. Whether the omission has the potential to mislead beneficiaries.
Page 1
,D. Whether the plan has a corrective action plan in place.
Answer: C
Rationale: CMS focuses on the potential to mislead beneficiaries as the key indicator of significant
non-compliance. The duration of use, agent's status, or existence of a corrective plan are secondary. The
primary concern is beneficiary harm or risk of confusion.
4. A state Medicaid program is considering transitioning from fee-for-service to a managed care
model for long-term services and supports (LTSS). Which of the following outcomes is most likely
to occur based on evidence from similar transitions?
A. Increased utilization of institutional care due to capitation incentives.
B. Improved care coordination but potential for reduced access to home- and community-based services.
C. Higher administrative costs without change in quality outcomes.
D. Significant reduction in overall Medicaid spending within the first year.
Answer: B
Rationale: Managed care models for LTSS often improve care coordination, but capitation may create
incentives to limit expensive home- and community-based services, potentially reducing access.
Institutional care tends to decrease, not increase. Administrative costs may rise initially, but quality
often improves. Spending reductions typically take longer than one year.
5. Under the Affordable Care Act's medical loss ratio (MLR) requirements, an insurer in the
individual market reports an MLR of 72% for the 2024 reporting year. Which of the following is
the most accurate consequence?
A. The insurer must issue rebates to policyholders equal to the difference between the actual MLR and 80%.
B. The insurer must suspend marketing activities until MLR reaches 80%.
C. The insurer is subject to a penalty of 1% of premiums for each percentage point below 80%.
D. The insurer must increase premiums in the following year to cover administrative costs.
Answer: A
Rationale: The ACA requires individual market insurers to have an MLR of at least 80%. If below, they
must rebate the difference to enrollees. There is no marketing suspension or penalty per se; rebates are
the remedy. Premium increases are not mandated.
6. A health plan is designing a value-based insurance design (VBID) program for diabetes
management. Which of the following approaches is most consistent with the principles of VBID?
A. Waiving copayments for insulin and glucose test strips for all enrollees with diabetes.
B. Increasing copayments for high-cost diabetes medications to encourage generic use.
C. Requiring prior authorization for all diabetes-related services.
D. Offering a wellness program with gym membership discounts unrelated to diabetes.
Answer: A
Rationale: VBID aligns cost-sharing with clinical value, reducing barriers for high-value services like
insulin and monitoring supplies. Increasing copayments for any medication or adding prior
authorization would contradict VBID principles. Wellness programs unrelated to the condition are not
targeted VBID.
Page 2
,7. A Medicare Advantage plan receives a request for an expedited coverage determination for a
Part B drug that the enrollee has been taking for years. The plan denies the request, stating that
the drug is not on its formulary. Which of the following is the most appropriate next step for the
enrollee?
A. File a grievance with the plan within 60 days.
B. Request a reconsideration by an independent review entity (IRE).
C. Appeal the denial through the plan's internal appeals process.
D. Contact the state insurance department for external review.
Answer: C
Rationale: The first step in disputing a coverage determination is to use the plan's internal appeals
process. Grievances are for non-coverage issues. IRE review occurs after an adverse internal appeal
decision. State insurance departments do not handle Medicare Advantage appeals.
8. A large employer is considering offering a high-deductible health plan (HDHP) paired with a
health savings account (HSA) for the first time. The employer wants to maximize employee
participation. Which of the following design features is most likely to increase enrollment?
A. Setting the deductible at the maximum allowed by law to minimize premium costs.
B. Making a substantial employer contribution to employees' HSAs.
C. Offering the HDHP as the only plan option.
D. Requiring employees to complete a health risk assessment before enrollment.
Answer: B
Rationale: Employer HSA contributions reduce the out-of-pocket burden and incentivize enrollment. A
high deductible may deter enrollment. Offering only one plan may increase HDHP enrollment but could
lead to dissatisfaction. Requiring a health assessment could reduce enrollment.
9. Under the Medicare Access and CHIP Reauthorization Act (MACRA), a clinician participates in
an Advanced Alternative Payment Model (APM) and meets the threshold for being a Qualifying
APM Participant (QP). Which of the following is the most significant financial incentive for this
clinician?
A. A 5% lump-sum bonus payment each year through 2024.
B. Exclusion from the Merit-based Incentive Payment System (MIPS) reporting requirements.
C. A higher fee schedule update compared to non-QPs.
D. Automatic eligibility for participation in the Medicare Shared Savings Program.
Answer: B
Rationale: QP status exempts clinicians from MIPS reporting and its associated payment adjustments.
The 5% bonus ended after 2022. Fee schedule updates are not directly tied. QP status does not
automatically confer eligibility for other programs.
10. A Medicare Supplement (Medigap) insurer in a state with guaranteed issue rights receives an
application from an individual who is currently enrolled in a Medicare Advantage plan and wants
to switch to Original Medicare with a Medigap policy. The individual is within the trial period.
Which of the following is correct?
Page 3
, A. The insurer can deny the application if the individual has a pre-existing condition.
B. The insurer must issue the policy but may impose a waiting period for pre-existing conditions.
C. The insurer must issue the policy without any pre-existing condition exclusion or waiting period.
D. The insurer can charge a higher premium based on health status.
Answer: C
Rationale: During the trial period, individuals leaving Medicare Advantage have guaranteed issue rights
for Medigap. Insurers must issue any Medigap policy without medical underwriting, meaning no
pre-existing condition exclusions or waiting periods. Premiums must be offered at standard rates.
11. A health plan is evaluating a new Medicare Advantage plan that includes a supplemental
benefit for over-the-counter (OTC) items. Under CMS rules, which of the following best describes
how the plan must structure the OTC benefit to ensure actuarial equivalence and compliance with
the uniform benefit package requirements?
A. The OTC benefit must be offered as a standalone supplemental benefit with a separate premium and cannot
be integrated into the plan's basic benefit package.
B. The OTC benefit must be actuarially equivalent to a reduction in cost-sharing for covered Part D drugs, and
the plan must demonstrate that the OTC items are primarily used for a medical purpose.
C. The OTC benefit can be offered as a reduction in the Part B deductible, provided the plan submits an
actuarial certification that the benefit is at least actuarially equivalent to the value of the Part B deductible
reduction.
D. The OTC benefit must be structured as a supplemental benefit that is uniformly available to all enrollees, and
the plan must use a fixed dollar allowance that can be used for a defined list of OTC items approved by CMS.
Answer: D
Rationale: CMS requires that any supplemental benefit, including OTC allowances, be uniformly
available to all enrollees in the plan and be structured as a fixed dollar amount that can be used for
CMS-approved OTC items. Options A, B, and C are incorrect because they describe non-compliant
structures: A incorrectly suggests a separate premium, B misapplies actuarial equivalence to Part D,
and C incorrectly ties the benefit to Part B deductible reduction.
12. A Medicare Advantage plan is developing its network adequacy model for a new county. The
plan proposes to include telehealth services to meet access standards for certain specialty types.
Under the latest CMS guidelines for network adequacy in Medicare Advantage, which of the
following statements is accurate regarding the use of telehealth to satisfy time and distance
standards?
A. Telehealth providers can be used to meet time and distance standards for all specialty types, including
behavioral health, but only if the plan also offers in-person access within 30 minutes of enrollees' residences.
B. Telehealth can be counted toward meeting time and distance standards for behavioral health and
dermatology, but the plan must ensure that enrollees have the option to receive in-person care from a network
provider within the required time and distance if they request it.
C. Telehealth services can replace in-person requirements for any specialty, provided that the plan submits a
network adequacy waiver demonstrating that telehealth utilization rates exceed 50% in the county.
D. Telehealth is not permitted to be used for network adequacy purposes under any circumstances; plans must
rely solely on in-person providers to meet time and distance standards.
Answer: B
Page 4
Questions and Answers for All Modules
1. A Medicare Advantage plan is considering a new supplemental benefit that provides
non-medical transportation for enrollees with chronic conditions. Under CMS regulations for
2025, which of the following statements is correct regarding the permissible scope of this benefit?
A. The benefit must be primarily health-related and can be offered only if it has a reasonable expectation of
improving health outcomes.
B. The benefit can be offered without restriction as long as it is uniformly available to all enrollees with the
chronic condition.
C. The benefit must be approved by the state insurance commissioner before implementation.
D. The benefit is not allowed because non-medical transportation is excluded from Medicare Advantage
supplemental benefits.
Answer: A
Rationale: CMS requires supplemental benefits to be primarily health-related, meaning they must have a
reasonable expectation of improving or maintaining health or overall function. Uniformity is required,
but the benefit must still meet the health-related standard. State approval is not needed for Medicare
Advantage plans. Non-medical transportation is allowed if health-related.
2. In the context of Medicare Part D, a plan sponsor proposes a formulary that places all drugs for
a certain class on a non-preferred tier with a 50% coinsurance. The class includes multiple
therapeutically equivalent drugs. Which of the following actions by CMS would be most likely?
A. Approve the formulary because plans have broad discretion in tier placement.
B. Require the plan to place at least one drug in each class on a preferred tier to ensure adequate access.
C. Deny the formulary because it does not include any preferred tier drugs for that class.
D. Mandate that all drugs in the class be placed on the same tier to avoid steering.
Answer: B
Rationale: CMS requires Part D sponsors to include at least one drug per therapeutic category on a
preferred tier to ensure beneficiary access and cost-sharing reasonableness. While plans have
discretion, they must comply with CMS formulary guidelines. The other options are not consistent with
current CMS policies.
3. A Medicare Advantage plan receives a complaint that an agent used out-of-date marketing
materials that did not include the required CMS disclaimer about plan availability. The
compliance officer must evaluate the severity. Under CMS guidance, which factor is most critical
in determining whether this constitutes a significant non-compliance event?
A. Whether the agent was a top producer for the plan.
B. Whether the materials were used for more than 30 days.
C. Whether the omission has the potential to mislead beneficiaries.
Page 1
,D. Whether the plan has a corrective action plan in place.
Answer: C
Rationale: CMS focuses on the potential to mislead beneficiaries as the key indicator of significant
non-compliance. The duration of use, agent's status, or existence of a corrective plan are secondary. The
primary concern is beneficiary harm or risk of confusion.
4. A state Medicaid program is considering transitioning from fee-for-service to a managed care
model for long-term services and supports (LTSS). Which of the following outcomes is most likely
to occur based on evidence from similar transitions?
A. Increased utilization of institutional care due to capitation incentives.
B. Improved care coordination but potential for reduced access to home- and community-based services.
C. Higher administrative costs without change in quality outcomes.
D. Significant reduction in overall Medicaid spending within the first year.
Answer: B
Rationale: Managed care models for LTSS often improve care coordination, but capitation may create
incentives to limit expensive home- and community-based services, potentially reducing access.
Institutional care tends to decrease, not increase. Administrative costs may rise initially, but quality
often improves. Spending reductions typically take longer than one year.
5. Under the Affordable Care Act's medical loss ratio (MLR) requirements, an insurer in the
individual market reports an MLR of 72% for the 2024 reporting year. Which of the following is
the most accurate consequence?
A. The insurer must issue rebates to policyholders equal to the difference between the actual MLR and 80%.
B. The insurer must suspend marketing activities until MLR reaches 80%.
C. The insurer is subject to a penalty of 1% of premiums for each percentage point below 80%.
D. The insurer must increase premiums in the following year to cover administrative costs.
Answer: A
Rationale: The ACA requires individual market insurers to have an MLR of at least 80%. If below, they
must rebate the difference to enrollees. There is no marketing suspension or penalty per se; rebates are
the remedy. Premium increases are not mandated.
6. A health plan is designing a value-based insurance design (VBID) program for diabetes
management. Which of the following approaches is most consistent with the principles of VBID?
A. Waiving copayments for insulin and glucose test strips for all enrollees with diabetes.
B. Increasing copayments for high-cost diabetes medications to encourage generic use.
C. Requiring prior authorization for all diabetes-related services.
D. Offering a wellness program with gym membership discounts unrelated to diabetes.
Answer: A
Rationale: VBID aligns cost-sharing with clinical value, reducing barriers for high-value services like
insulin and monitoring supplies. Increasing copayments for any medication or adding prior
authorization would contradict VBID principles. Wellness programs unrelated to the condition are not
targeted VBID.
Page 2
,7. A Medicare Advantage plan receives a request for an expedited coverage determination for a
Part B drug that the enrollee has been taking for years. The plan denies the request, stating that
the drug is not on its formulary. Which of the following is the most appropriate next step for the
enrollee?
A. File a grievance with the plan within 60 days.
B. Request a reconsideration by an independent review entity (IRE).
C. Appeal the denial through the plan's internal appeals process.
D. Contact the state insurance department for external review.
Answer: C
Rationale: The first step in disputing a coverage determination is to use the plan's internal appeals
process. Grievances are for non-coverage issues. IRE review occurs after an adverse internal appeal
decision. State insurance departments do not handle Medicare Advantage appeals.
8. A large employer is considering offering a high-deductible health plan (HDHP) paired with a
health savings account (HSA) for the first time. The employer wants to maximize employee
participation. Which of the following design features is most likely to increase enrollment?
A. Setting the deductible at the maximum allowed by law to minimize premium costs.
B. Making a substantial employer contribution to employees' HSAs.
C. Offering the HDHP as the only plan option.
D. Requiring employees to complete a health risk assessment before enrollment.
Answer: B
Rationale: Employer HSA contributions reduce the out-of-pocket burden and incentivize enrollment. A
high deductible may deter enrollment. Offering only one plan may increase HDHP enrollment but could
lead to dissatisfaction. Requiring a health assessment could reduce enrollment.
9. Under the Medicare Access and CHIP Reauthorization Act (MACRA), a clinician participates in
an Advanced Alternative Payment Model (APM) and meets the threshold for being a Qualifying
APM Participant (QP). Which of the following is the most significant financial incentive for this
clinician?
A. A 5% lump-sum bonus payment each year through 2024.
B. Exclusion from the Merit-based Incentive Payment System (MIPS) reporting requirements.
C. A higher fee schedule update compared to non-QPs.
D. Automatic eligibility for participation in the Medicare Shared Savings Program.
Answer: B
Rationale: QP status exempts clinicians from MIPS reporting and its associated payment adjustments.
The 5% bonus ended after 2022. Fee schedule updates are not directly tied. QP status does not
automatically confer eligibility for other programs.
10. A Medicare Supplement (Medigap) insurer in a state with guaranteed issue rights receives an
application from an individual who is currently enrolled in a Medicare Advantage plan and wants
to switch to Original Medicare with a Medigap policy. The individual is within the trial period.
Which of the following is correct?
Page 3
, A. The insurer can deny the application if the individual has a pre-existing condition.
B. The insurer must issue the policy but may impose a waiting period for pre-existing conditions.
C. The insurer must issue the policy without any pre-existing condition exclusion or waiting period.
D. The insurer can charge a higher premium based on health status.
Answer: C
Rationale: During the trial period, individuals leaving Medicare Advantage have guaranteed issue rights
for Medigap. Insurers must issue any Medigap policy without medical underwriting, meaning no
pre-existing condition exclusions or waiting periods. Premiums must be offered at standard rates.
11. A health plan is evaluating a new Medicare Advantage plan that includes a supplemental
benefit for over-the-counter (OTC) items. Under CMS rules, which of the following best describes
how the plan must structure the OTC benefit to ensure actuarial equivalence and compliance with
the uniform benefit package requirements?
A. The OTC benefit must be offered as a standalone supplemental benefit with a separate premium and cannot
be integrated into the plan's basic benefit package.
B. The OTC benefit must be actuarially equivalent to a reduction in cost-sharing for covered Part D drugs, and
the plan must demonstrate that the OTC items are primarily used for a medical purpose.
C. The OTC benefit can be offered as a reduction in the Part B deductible, provided the plan submits an
actuarial certification that the benefit is at least actuarially equivalent to the value of the Part B deductible
reduction.
D. The OTC benefit must be structured as a supplemental benefit that is uniformly available to all enrollees, and
the plan must use a fixed dollar allowance that can be used for a defined list of OTC items approved by CMS.
Answer: D
Rationale: CMS requires that any supplemental benefit, including OTC allowances, be uniformly
available to all enrollees in the plan and be structured as a fixed dollar amount that can be used for
CMS-approved OTC items. Options A, B, and C are incorrect because they describe non-compliant
structures: A incorrectly suggests a separate premium, B misapplies actuarial equivalence to Part D,
and C incorrectly ties the benefit to Part B deductible reduction.
12. A Medicare Advantage plan is developing its network adequacy model for a new county. The
plan proposes to include telehealth services to meet access standards for certain specialty types.
Under the latest CMS guidelines for network adequacy in Medicare Advantage, which of the
following statements is accurate regarding the use of telehealth to satisfy time and distance
standards?
A. Telehealth providers can be used to meet time and distance standards for all specialty types, including
behavioral health, but only if the plan also offers in-person access within 30 minutes of enrollees' residences.
B. Telehealth can be counted toward meeting time and distance standards for behavioral health and
dermatology, but the plan must ensure that enrollees have the option to receive in-person care from a network
provider within the required time and distance if they request it.
C. Telehealth services can replace in-person requirements for any specialty, provided that the plan submits a
network adequacy waiver demonstrating that telehealth utilization rates exceed 50% in the county.
D. Telehealth is not permitted to be used for network adequacy purposes under any circumstances; plans must
rely solely on in-person providers to meet time and distance standards.
Answer: B
Page 4
