AHIP 2027 FINAL EXAM Medicare Certification
(AHIP) | 2026–2027 | Tested Questions With
Verified Answers & Expert Rationales
1. 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 must wait until age 65 to enroll in Medicare.
• B) He may sign up for Medicare at any time; however, coverage usually begins on the fourth
month after dialysis treatments start.
• C) He is not eligible for Medicare because ESRD is not a qualifying condition.
• D) He can only enroll during the Annual Election Period.
✅ CORRECT ANSWER: B) He may sign up for Medicare at any time; however, coverage
usually begins on the fourth month after dialysis treatments start.
📘 EXPERT RATIONALE: Individuals under age 65 with ESRD are eligible for Medicare. Coverage
typically begins on the first day of the fourth month of dialysis treatments. If the individual
participates in a self-dialysis training program or receives a kidney transplant, different timing
rules may apply.
________________________________________________________________________________
2. Juan Perez, turning age 65 next month, intends to work for several more years at
Smallcap, Inc. (fewer than 20 employees). He asks if he will be entitled to Medicare
and how enrolling would impact his employer-sponsored coverage. What should you
tell him?
• A) He is not eligible for Medicare until he retires.
• B) Juan is likely eligible for Medicare once he turns age 65. If he enrolls, Medicare would
become the primary payor of his healthcare claims and Smallcap does not have to continue
to offer him coverage comparable to those under age 65 under its employer-sponsored
group health plan.
• C) He should delay Medicare because his employer coverage is always primary.
• D) Medicare is secondary regardless of employer size.
✅ CORRECT ANSWER: B) Juan is likely eligible for Medicare once he turns age 65. If he
enrolls, Medicare would become the primary payor of his healthcare claims and Smallcap
does not have to continue to offer him coverage comparable to those under age 65 under
its employer-sponsored group health plan.
📘 EXPERT RATIONALE: For employers with fewer than 20 employees, Medicare is the primary
payer. The employer plan becomes secondary. Juan must enroll in Part B to avoid gaps in primary
coverage. The employer is not required to offer the same coverage to Medicare-eligible employees
at small companies.
,________________________________________________________________________________
3. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what
coverage Medicare Supplemental Insurance (Medigap) provides. What could you tell
Mr. Moy?
• A) Medigap covers prescription drugs.
• B) Medigap helps cover cost-sharing under Original Medicare (Parts A and B) such as
deductibles, coinsurance, and copayments.
• C) Medigap can be purchased to supplement a Medicare Advantage plan.
• D) Medigap is free for all Medicare beneficiaries.
✅ CORRECT ANSWER: B) Medigap helps cover cost-sharing under Original Medicare
(Parts A and B) such as deductibles, coinsurance, and copayments.
📘 EXPERT RATIONALE: Medigap (Medicare Supplement Insurance) policies are designed to fill
gaps in Original Medicare coverage by paying for out-of-pocket costs like deductibles, coinsurance,
and copayments. Medigap cannot be used with Medicare Advantage plans, and it does not cover
prescription drugs (Part D).
________________________________________________________________________________
4. Ms. Henderson believes she will qualify for Medicare Coverage at 65 without
paying premiums because she has worked 40 years and paid Medicare taxes. What
should you tell her?
• A) She will qualify for premium-free Part A and Part B.
• B) She will qualify for premium-free Part A, but Part B requires a monthly premium.
• C) She must pay premiums for both Part A and Part B regardless of work history.
• D) She does not qualify because she must have 50 quarters of coverage.
✅ CORRECT ANSWER: B) She will qualify for premium-free Part A, but Part B requires a
monthly premium.
📘 EXPERT RATIONALE: Individuals who have worked and paid Medicare taxes for at least 40
quarters (10 years) receive premium-free Medicare Part A. However, Medicare Part B always
requires a monthly premium, which is based on income. Most beneficiaries pay the standard
premium amount.
________________________________________________________________________________
5. Mr. Patel wants to understand health care costs under Original Medicare for
inpatient hospital services. What could you tell him?
• A) There is no cost-sharing for hospital stays under Original Medicare.
• B) Under Original Medicare, there is a single deductible amount due for the first 60 days of
any inpatient hospital stay, after which it converts into a per-day coinsurance amount
through day 90. After day 90, he would pay a daily amount up to 60 lifetime reserve days,
after which he would be responsible for all costs.
• C) He pays a flat copay for each day in the hospital.
,• D) Hospital costs are covered 100% after the deductible is met.
✅ CORRECT ANSWER: B) Under Original Medicare, there is a single deductible amount
due for the first 60 days of any inpatient hospital stay, after which it converts into a per-
day coinsurance amount through day 90. After day 90, he would pay a daily amount up to
60 lifetime reserve days, after which he would be responsible for all costs.
📘 EXPERT RATIONALE: Original Medicare Part A has a benefit period structure. The beneficiary
pays the inpatient hospital deductible for days 1-60. Days 61-90 require a daily coinsurance. After
90 days, the beneficiary can use up to 60 lifetime reserve days at a higher daily coinsurance.
Beyond that, the beneficiary pays all costs.
________________________________________________________________________________
6. To obtain Part B coverage, what must a beneficiary pay?
• A) Nothing; Part B is premium-free for everyone.
• B) A standard monthly premium, though it is higher for individuals with higher incomes.
• C) Only a deductible, with no monthly premium.
• D) A percentage of their Social Security benefits.
✅ CORRECT ANSWER: B) A standard monthly premium, though it is higher for
individuals with higher incomes.
📘 EXPERT RATIONALE: Medicare Part B requires a monthly premium. Most beneficiaries pay the
standard premium. However, individuals with higher incomes (above certain thresholds) pay an
Income-Related Monthly Adjustment Amount (IRMAA), which increases their Part B premium.
________________________________________________________________________________
7. Mr. Alonso wants to know what costs he would generally expect when enrolling in a
standard Medicare Part D prescription drug plan. What should you tell him?
• A) He would pay only a monthly premium with no other costs.
• B) He generally would pay a monthly premium, annual deductible, and per-prescription
cost-sharing.
• C) Part D has no premiums or deductibles.
• D) He pays a percentage of his income for Part D coverage.
✅ CORRECT ANSWER: B) He generally would pay a monthly premium, annual deductible,
and per-prescription cost-sharing.
📘 EXPERT RATIONALE: Standard Medicare Part D plans typically require beneficiaries to pay a
monthly premium, meet an annual deductible (up to the maximum allowed by CMS), and pay cost-
sharing (copays or coinsurance) for each prescription. The exact amounts vary by plan.
________________________________________________________________________________
8. Ms. Moore plans to retire at 65 and is concerned her considerable income will
make it impossible for her to qualify for Medicare. What could you tell her?
• A) Medicare eligibility is based on income, so she may not qualify.
, • B) Medicare is a program for people age 65 or older and those under age 65 with certain
disabilities, end-stage renal disease, and Lou Gehrig's disease, so she will be eligible for
Medicare regardless of income.
• C) She must have a low income to qualify for Medicare.
• D) She can only qualify if she has no other insurance.
✅ CORRECT ANSWER: B) Medicare is a program for people age 65 or older and those
under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease,
so she will be eligible for Medicare regardless of income.
📘 EXPERT RATIONALE: Medicare eligibility is not income-based. It is based on age (65+),
disability status (after 24 months of SSDI), ESRD, or ALS (Lou Gehrig's disease). While higher-
income beneficiaries pay more for Parts B and D through IRMAA, income does not affect eligibility.
________________________________________________________________________________
9. What best describes health coverage for Medicare beneficiaries under Original
Medicare?
• A) Original Medicare covers all health care costs with no out-of-pocket expenses.
• B) Medicare does not cover massage therapy, or, in general, glasses or dentures.
• C) Original Medicare covers long-term custodial care in nursing homes.
• D) Original Medicare includes prescription drug coverage.
✅ CORRECT ANSWER: B) Medicare does not cover massage therapy, or, in general,
glasses or dentures.
📘 EXPERT RATIONALE: Original Medicare (Parts A and B) does not cover most routine vision
care (eyeglasses), dental care (dentures), hearing aids, or massage therapy. It also does not cover
long-term custodial care. Prescription drug coverage requires enrollment in a separate Part D
plan.
________________________________________________________________________________
10. Mrs. Duarte reviewed her Medicare Summary Notice (MSN) and disagrees with a
determination that partially denied one of her claims. What advice would you give
her?
• A) She should file an appeal of this initial determination within 120 days of the date she
received the MSN in the mail.
• B) She cannot appeal Medicare decisions.
• C) She must file the appeal within 30 days.
• D) She should contact her Medigap insurer to resolve the issue.
✅ CORRECT ANSWER: A) She should file an appeal of this initial determination within
120 days of the date she received the MSN in the mail.
📘 EXPERT RATIONALE: Medicare beneficiaries have the right to appeal coverage decisions. The
first level of appeal (redetermination) must be filed within 120 days of receiving the Medicare
(AHIP) | 2026–2027 | Tested Questions With
Verified Answers & Expert Rationales
1. 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 must wait until age 65 to enroll in Medicare.
• B) He may sign up for Medicare at any time; however, coverage usually begins on the fourth
month after dialysis treatments start.
• C) He is not eligible for Medicare because ESRD is not a qualifying condition.
• D) He can only enroll during the Annual Election Period.
✅ CORRECT ANSWER: B) He may sign up for Medicare at any time; however, coverage
usually begins on the fourth month after dialysis treatments start.
📘 EXPERT RATIONALE: Individuals under age 65 with ESRD are eligible for Medicare. Coverage
typically begins on the first day of the fourth month of dialysis treatments. If the individual
participates in a self-dialysis training program or receives a kidney transplant, different timing
rules may apply.
________________________________________________________________________________
2. Juan Perez, turning age 65 next month, intends to work for several more years at
Smallcap, Inc. (fewer than 20 employees). He asks if he will be entitled to Medicare
and how enrolling would impact his employer-sponsored coverage. What should you
tell him?
• A) He is not eligible for Medicare until he retires.
• B) Juan is likely eligible for Medicare once he turns age 65. If he enrolls, Medicare would
become the primary payor of his healthcare claims and Smallcap does not have to continue
to offer him coverage comparable to those under age 65 under its employer-sponsored
group health plan.
• C) He should delay Medicare because his employer coverage is always primary.
• D) Medicare is secondary regardless of employer size.
✅ CORRECT ANSWER: B) Juan is likely eligible for Medicare once he turns age 65. If he
enrolls, Medicare would become the primary payor of his healthcare claims and Smallcap
does not have to continue to offer him coverage comparable to those under age 65 under
its employer-sponsored group health plan.
📘 EXPERT RATIONALE: For employers with fewer than 20 employees, Medicare is the primary
payer. The employer plan becomes secondary. Juan must enroll in Part B to avoid gaps in primary
coverage. The employer is not required to offer the same coverage to Medicare-eligible employees
at small companies.
,________________________________________________________________________________
3. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what
coverage Medicare Supplemental Insurance (Medigap) provides. What could you tell
Mr. Moy?
• A) Medigap covers prescription drugs.
• B) Medigap helps cover cost-sharing under Original Medicare (Parts A and B) such as
deductibles, coinsurance, and copayments.
• C) Medigap can be purchased to supplement a Medicare Advantage plan.
• D) Medigap is free for all Medicare beneficiaries.
✅ CORRECT ANSWER: B) Medigap helps cover cost-sharing under Original Medicare
(Parts A and B) such as deductibles, coinsurance, and copayments.
📘 EXPERT RATIONALE: Medigap (Medicare Supplement Insurance) policies are designed to fill
gaps in Original Medicare coverage by paying for out-of-pocket costs like deductibles, coinsurance,
and copayments. Medigap cannot be used with Medicare Advantage plans, and it does not cover
prescription drugs (Part D).
________________________________________________________________________________
4. Ms. Henderson believes she will qualify for Medicare Coverage at 65 without
paying premiums because she has worked 40 years and paid Medicare taxes. What
should you tell her?
• A) She will qualify for premium-free Part A and Part B.
• B) She will qualify for premium-free Part A, but Part B requires a monthly premium.
• C) She must pay premiums for both Part A and Part B regardless of work history.
• D) She does not qualify because she must have 50 quarters of coverage.
✅ CORRECT ANSWER: B) She will qualify for premium-free Part A, but Part B requires a
monthly premium.
📘 EXPERT RATIONALE: Individuals who have worked and paid Medicare taxes for at least 40
quarters (10 years) receive premium-free Medicare Part A. However, Medicare Part B always
requires a monthly premium, which is based on income. Most beneficiaries pay the standard
premium amount.
________________________________________________________________________________
5. Mr. Patel wants to understand health care costs under Original Medicare for
inpatient hospital services. What could you tell him?
• A) There is no cost-sharing for hospital stays under Original Medicare.
• B) Under Original Medicare, there is a single deductible amount due for the first 60 days of
any inpatient hospital stay, after which it converts into a per-day coinsurance amount
through day 90. After day 90, he would pay a daily amount up to 60 lifetime reserve days,
after which he would be responsible for all costs.
• C) He pays a flat copay for each day in the hospital.
,• D) Hospital costs are covered 100% after the deductible is met.
✅ CORRECT ANSWER: B) Under Original Medicare, there is a single deductible amount
due for the first 60 days of any inpatient hospital stay, after which it converts into a per-
day coinsurance amount through day 90. After day 90, he would pay a daily amount up to
60 lifetime reserve days, after which he would be responsible for all costs.
📘 EXPERT RATIONALE: Original Medicare Part A has a benefit period structure. The beneficiary
pays the inpatient hospital deductible for days 1-60. Days 61-90 require a daily coinsurance. After
90 days, the beneficiary can use up to 60 lifetime reserve days at a higher daily coinsurance.
Beyond that, the beneficiary pays all costs.
________________________________________________________________________________
6. To obtain Part B coverage, what must a beneficiary pay?
• A) Nothing; Part B is premium-free for everyone.
• B) A standard monthly premium, though it is higher for individuals with higher incomes.
• C) Only a deductible, with no monthly premium.
• D) A percentage of their Social Security benefits.
✅ CORRECT ANSWER: B) A standard monthly premium, though it is higher for
individuals with higher incomes.
📘 EXPERT RATIONALE: Medicare Part B requires a monthly premium. Most beneficiaries pay the
standard premium. However, individuals with higher incomes (above certain thresholds) pay an
Income-Related Monthly Adjustment Amount (IRMAA), which increases their Part B premium.
________________________________________________________________________________
7. Mr. Alonso wants to know what costs he would generally expect when enrolling in a
standard Medicare Part D prescription drug plan. What should you tell him?
• A) He would pay only a monthly premium with no other costs.
• B) He generally would pay a monthly premium, annual deductible, and per-prescription
cost-sharing.
• C) Part D has no premiums or deductibles.
• D) He pays a percentage of his income for Part D coverage.
✅ CORRECT ANSWER: B) He generally would pay a monthly premium, annual deductible,
and per-prescription cost-sharing.
📘 EXPERT RATIONALE: Standard Medicare Part D plans typically require beneficiaries to pay a
monthly premium, meet an annual deductible (up to the maximum allowed by CMS), and pay cost-
sharing (copays or coinsurance) for each prescription. The exact amounts vary by plan.
________________________________________________________________________________
8. Ms. Moore plans to retire at 65 and is concerned her considerable income will
make it impossible for her to qualify for Medicare. What could you tell her?
• A) Medicare eligibility is based on income, so she may not qualify.
, • B) Medicare is a program for people age 65 or older and those under age 65 with certain
disabilities, end-stage renal disease, and Lou Gehrig's disease, so she will be eligible for
Medicare regardless of income.
• C) She must have a low income to qualify for Medicare.
• D) She can only qualify if she has no other insurance.
✅ CORRECT ANSWER: B) Medicare is a program for people age 65 or older and those
under age 65 with certain disabilities, end-stage renal disease, and Lou Gehrig's disease,
so she will be eligible for Medicare regardless of income.
📘 EXPERT RATIONALE: Medicare eligibility is not income-based. It is based on age (65+),
disability status (after 24 months of SSDI), ESRD, or ALS (Lou Gehrig's disease). While higher-
income beneficiaries pay more for Parts B and D through IRMAA, income does not affect eligibility.
________________________________________________________________________________
9. What best describes health coverage for Medicare beneficiaries under Original
Medicare?
• A) Original Medicare covers all health care costs with no out-of-pocket expenses.
• B) Medicare does not cover massage therapy, or, in general, glasses or dentures.
• C) Original Medicare covers long-term custodial care in nursing homes.
• D) Original Medicare includes prescription drug coverage.
✅ CORRECT ANSWER: B) Medicare does not cover massage therapy, or, in general,
glasses or dentures.
📘 EXPERT RATIONALE: Original Medicare (Parts A and B) does not cover most routine vision
care (eyeglasses), dental care (dentures), hearing aids, or massage therapy. It also does not cover
long-term custodial care. Prescription drug coverage requires enrollment in a separate Part D
plan.
________________________________________________________________________________
10. Mrs. Duarte reviewed her Medicare Summary Notice (MSN) and disagrees with a
determination that partially denied one of her claims. What advice would you give
her?
• A) She should file an appeal of this initial determination within 120 days of the date she
received the MSN in the mail.
• B) She cannot appeal Medicare decisions.
• C) She must file the appeal within 30 days.
• D) She should contact her Medigap insurer to resolve the issue.
✅ CORRECT ANSWER: A) She should file an appeal of this initial determination within
120 days of the date she received the MSN in the mail.
📘 EXPERT RATIONALE: Medicare beneficiaries have the right to appeal coverage decisions. The
first level of appeal (redetermination) must be filed within 120 days of receiving the Medicare
