AHIP TEST
2026–2027 Updated Exam Test Bank
Subject: Medicare Advantage, Part D, and CMS Regulations
Medicare Brokers, Independent Agents, Compliance Officers & AHIP
Audience:
Candidates
Format: Comprehensive Exam-Ready Test Bank with In-Depth Rationales
Update Cycle: Fully Aligned with latest CMS Regulations and MACRA Guidelines
CMS GUIDELINES & MEDICARE REGULATION COMPLIANCE BLUEPRINT
,AHIP TEST — 2026–2027 UPDATED EXAM TEST BANK MEDICARE COMPLIANCE & EXAM STUDY GUIDE
AHIP Certification Exam Study Guide Blueprint
This exam prep study material is systematically compiled directly from official Medicare compliance,
training, and certification guidelines. It covers the core aspects of Medicare Advantage (MA) plans,
Medicare Part D Prescription Drug Plans (PDP), Medicare Supplement (Medigap) plans, and the rigid
marketing and enrollment regulations established by the Centers for Medicare & Medicaid Services
(CMS). Each topic area is mapped directly to corresponding practice questions to ensure
student-friendly, high-yield preparation.
Core Course Mapping & Chapter Breakdown
Chapter Focus Area & Major Topics Learning Objectives & Core
Competency
Chapter 1: Medicare Original Medicare (Part A/B), Medigap Explain Part A & B structures, outline
Basics, Benefits & options, deductible/coinsurance gaps, Medigap Open Enrollment rights,
Medigap MACRA legislation, Skilled Nursing identify SNF daily benefit tiers, and
Facility (SNF) guidelines, and End-Stage explain how MACRA altered first-dollar
Renal Disease (ESRD) eligibility. coverage (Part B deductibles).
Chapter 2: Medicare HMO, PPO, Private Fee-for-Service Distinguish managed care structures
Advantage Plan (PFFS), Medical Savings Account (MSA) (HMO/PPO) from PFFS and MSAs.
Designs plan structures, networks, out-of-pocket Master network rules, out-of-pocket
limits, and Special Enrollment Periods maximum rules, and residency-based
(SEP). SEPs.
Chapter 3: Medicare Part D enrollment rules, formularies, Compare standalone PDP vs. MA-PD.
Part D Prescription therapeutic categories, SPAPs, Apply formulary requirements,
Drug Plans manufacturer help, and Part D premium transition refills, state-specific
variations and Social Security premium pharmaceutical support, and premium
withholding. billing regulations.
Chapter 4: CMS agent compensation rules, Delineate compliant referral methods,
Marketing cold-contact boundaries, referral calculate pro-rated initial commissions
Compliance & CMS collection restrictions, advertising rules, vs. lifetime renewals, apply event
Regulations educational vs. sales events, and state restrictions, and comply with state
investigations. regulatory reviews.
Chapter 5: Enrollment applications assistance limits, Analyze application processing and
Enrollment safeguarding PII/PHI (Goldstein rules), data protection timelines, identify illegal
Procedures & Qualified Medicare Beneficiary (QMB) out-of-network balance billing in QMB
Compliance protection, and spousal enrollment plans, and enforce spousal signature
signatures. restrictions.
Crucial Distinctions & Commonly Confused Concepts
AHIP Certification Exam Prep Blueprint Page 2 CMS Regulatory Update 2026–2027
,AHIP TEST — 2026–2027 UPDATED EXAM TEST BANK MEDICARE COMPLIANCE & EXAM STUDY GUIDE
1. Medicare Supplement (Medigap) vs. Medicare Advantage (Part C): Medigap plans are private
secondary insurance that wrap around Original Medicare (Part A & B) to pay cost-sharing amounts, but
do not replace them. In contrast, Medicare Advantage replaces Original Medicare and acts as a single
integrated network plan.
2. Educational Events vs. Sales/Marketing Events: Under CMS guidelines, educational events are
strictly designed to inform enrollees on general topics (no marketing material distribution, personal
appointments, or plan-specific enrollments are permitted). Sales events are marketing meetings where
specific plans can be discussed, and enrollment forms can be handed out.
3. Standing Standalone PDP in MA-PDs vs. PFFS/MSA: In standard HMO/PPO plans, a member
cannot enroll in a standalone Part D plan without being automatically disenrolled from their medical
plan. However, enrollees in Medical Savings Account (MSA) plans or certain PFFS/Cost plans are
explicitly allowed (and sometimes required) to purchase standalone PDPs to obtain drug benefits.
AHIP Certification Exam Prep Blueprint Page 3 CMS Regulatory Update 2026–2027
, AHIP TEST — 2026–2027 UPDATED EXAM TEST BANK MEDICARE COMPLIANCE & EXAM STUDY GUIDE
Chapter 1: Medicare Basics, Benefits & Medigap Coverage
Question 1: What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) have upon Medigap plans?
A. The Part A deductible will no longer be covered for individuals newly eligible for Medicare starting
January 1, 2020.
B. The Part B deductible is no longer covered under Medigap plans for all enrollees starting January
1, 2020.
C. The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting
January 1, 2020.
D. MACRA provides funding to help individuals age 59 and above enroll in Medigap plans.
ANSWER ■: C — The Part B deductible will no longer be covered for individuals newly eligible
for Medicare starting January 1, 2020.
Explanation: Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), newly
eligible Medicare beneficiaries (those who turn 65 or become eligible due to disability on or after
January 1, 2020) cannot purchase Medigap plans that cover the Part B deductible (such as Plan C or
Plan F). Beneficiaries who were eligible for Medicare prior to January 1, 2020, are grandfathered and
may keep or purchase these plans. Option A and B are incorrect because the Part A deductible is not
affected by this MACRA provision.
AHIP Certification Exam Prep Blueprint Page 4 CMS Regulatory Update 2026–2027
2026–2027 Updated Exam Test Bank
Subject: Medicare Advantage, Part D, and CMS Regulations
Medicare Brokers, Independent Agents, Compliance Officers & AHIP
Audience:
Candidates
Format: Comprehensive Exam-Ready Test Bank with In-Depth Rationales
Update Cycle: Fully Aligned with latest CMS Regulations and MACRA Guidelines
CMS GUIDELINES & MEDICARE REGULATION COMPLIANCE BLUEPRINT
,AHIP TEST — 2026–2027 UPDATED EXAM TEST BANK MEDICARE COMPLIANCE & EXAM STUDY GUIDE
AHIP Certification Exam Study Guide Blueprint
This exam prep study material is systematically compiled directly from official Medicare compliance,
training, and certification guidelines. It covers the core aspects of Medicare Advantage (MA) plans,
Medicare Part D Prescription Drug Plans (PDP), Medicare Supplement (Medigap) plans, and the rigid
marketing and enrollment regulations established by the Centers for Medicare & Medicaid Services
(CMS). Each topic area is mapped directly to corresponding practice questions to ensure
student-friendly, high-yield preparation.
Core Course Mapping & Chapter Breakdown
Chapter Focus Area & Major Topics Learning Objectives & Core
Competency
Chapter 1: Medicare Original Medicare (Part A/B), Medigap Explain Part A & B structures, outline
Basics, Benefits & options, deductible/coinsurance gaps, Medigap Open Enrollment rights,
Medigap MACRA legislation, Skilled Nursing identify SNF daily benefit tiers, and
Facility (SNF) guidelines, and End-Stage explain how MACRA altered first-dollar
Renal Disease (ESRD) eligibility. coverage (Part B deductibles).
Chapter 2: Medicare HMO, PPO, Private Fee-for-Service Distinguish managed care structures
Advantage Plan (PFFS), Medical Savings Account (MSA) (HMO/PPO) from PFFS and MSAs.
Designs plan structures, networks, out-of-pocket Master network rules, out-of-pocket
limits, and Special Enrollment Periods maximum rules, and residency-based
(SEP). SEPs.
Chapter 3: Medicare Part D enrollment rules, formularies, Compare standalone PDP vs. MA-PD.
Part D Prescription therapeutic categories, SPAPs, Apply formulary requirements,
Drug Plans manufacturer help, and Part D premium transition refills, state-specific
variations and Social Security premium pharmaceutical support, and premium
withholding. billing regulations.
Chapter 4: CMS agent compensation rules, Delineate compliant referral methods,
Marketing cold-contact boundaries, referral calculate pro-rated initial commissions
Compliance & CMS collection restrictions, advertising rules, vs. lifetime renewals, apply event
Regulations educational vs. sales events, and state restrictions, and comply with state
investigations. regulatory reviews.
Chapter 5: Enrollment applications assistance limits, Analyze application processing and
Enrollment safeguarding PII/PHI (Goldstein rules), data protection timelines, identify illegal
Procedures & Qualified Medicare Beneficiary (QMB) out-of-network balance billing in QMB
Compliance protection, and spousal enrollment plans, and enforce spousal signature
signatures. restrictions.
Crucial Distinctions & Commonly Confused Concepts
AHIP Certification Exam Prep Blueprint Page 2 CMS Regulatory Update 2026–2027
,AHIP TEST — 2026–2027 UPDATED EXAM TEST BANK MEDICARE COMPLIANCE & EXAM STUDY GUIDE
1. Medicare Supplement (Medigap) vs. Medicare Advantage (Part C): Medigap plans are private
secondary insurance that wrap around Original Medicare (Part A & B) to pay cost-sharing amounts, but
do not replace them. In contrast, Medicare Advantage replaces Original Medicare and acts as a single
integrated network plan.
2. Educational Events vs. Sales/Marketing Events: Under CMS guidelines, educational events are
strictly designed to inform enrollees on general topics (no marketing material distribution, personal
appointments, or plan-specific enrollments are permitted). Sales events are marketing meetings where
specific plans can be discussed, and enrollment forms can be handed out.
3. Standing Standalone PDP in MA-PDs vs. PFFS/MSA: In standard HMO/PPO plans, a member
cannot enroll in a standalone Part D plan without being automatically disenrolled from their medical
plan. However, enrollees in Medical Savings Account (MSA) plans or certain PFFS/Cost plans are
explicitly allowed (and sometimes required) to purchase standalone PDPs to obtain drug benefits.
AHIP Certification Exam Prep Blueprint Page 3 CMS Regulatory Update 2026–2027
, AHIP TEST — 2026–2027 UPDATED EXAM TEST BANK MEDICARE COMPLIANCE & EXAM STUDY GUIDE
Chapter 1: Medicare Basics, Benefits & Medigap Coverage
Question 1: What impact, if any, will the Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) have upon Medigap plans?
A. The Part A deductible will no longer be covered for individuals newly eligible for Medicare starting
January 1, 2020.
B. The Part B deductible is no longer covered under Medigap plans for all enrollees starting January
1, 2020.
C. The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting
January 1, 2020.
D. MACRA provides funding to help individuals age 59 and above enroll in Medigap plans.
ANSWER ■: C — The Part B deductible will no longer be covered for individuals newly eligible
for Medicare starting January 1, 2020.
Explanation: Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), newly
eligible Medicare beneficiaries (those who turn 65 or become eligible due to disability on or after
January 1, 2020) cannot purchase Medigap plans that cover the Part B deductible (such as Plan C or
Plan F). Beneficiaries who were eligible for Medicare prior to January 1, 2020, are grandfathered and
may keep or purchase these plans. Option A and B are incorrect because the Part A deductible is not
affected by this MACRA provision.
AHIP Certification Exam Prep Blueprint Page 4 CMS Regulatory Update 2026–2027
