AHIP Certification Practice Exam 2027 | Health Insurance | Verified
Questions & Correct Answers
Medicare Advantage & Prescription Drug Coverage Edition |
Comprehensive Certification Assessment
SECTION 1: MEDICARE ADVANTAGE BASICS
1. What is Medicare Advantage (MA)?
A) A type of Medigap policy
B) A health plan option offered by private companies that contracts with Medicare
C) A supplemental insurance for low-income individuals
D) A prescription drug discount program
Correct Answer: B) A health plan option offered by private companies that contracts
with Medicare
Rationale: Medicare Advantage (Part C) is a health plan option offered by private insurance
companies approved by Medicare. These plans provide all Part A and Part B benefits, and
most include Part D prescription drug coverage. Medigap is a supplement, not Medicare
Advantage.
2. Which of the following is NOT a requirement for an individual to enroll in a
Medicare Advantage plan?
A) Be entitled to Medicare Part A
B) Be enrolled in Medicare Part B
C) Have a pre-existing condition
D) Live in the plan's service area
Correct Answer: C) Have a pre-existing condition
Rationale: Individuals cannot be denied enrollment in a Medicare Advantage plan due to a
pre-existing condition. They must be entitled to Medicare Part A, enrolled in Part B, and live
in the plan's service area.
,3. What is the annual election period (AEP) for Medicare Advantage and Part D plans?
A) January 1 – March 31
B) October 15 – December 7
C) November 1 – December 31
D) April 1 – June 30
Correct Answer: B) October 15 – December 7
Rationale: The Annual Election Period (AEP), also known as the Open Enrollment Period,
runs from October 15 to December 7 each year. During this time, beneficiaries can enroll in,
switch, or disenroll from Medicare Advantage and Part D plans. Coverage begins January 1.
4. What is the Medicare Advantage Open Enrollment Period (MA OEP)?
A) January 1 – March 31
B) October 15 – December 7
C) November 1 – December 31
D) April 1 – June 30
Correct Answer: A) January 1 – March 31
Rationale: The Medicare Advantage Open Enrollment Period (MA OEP) runs from January
1 to March 31 each year. During this time, beneficiaries enrolled in a Medicare Advantage
plan can switch to another MA plan or return to Original Medicare. This is not for initial
enrollment.
5. What is the Initial Enrollment Period (IEP) for Medicare?
A) A 3-month period
B) A 7-month period
C) A 6-month period
D) A 12-month period
Correct Answer: B) A 7-month period
Rationale: The Initial Enrollment Period (IEP) is a 7-month period that begins 3 months
before the month an individual turns 65, includes the birthday month, and ends 3 months
after. For example, if turning 65 in June, the IEP is March 1 – September 30.
,6. Which of the following is a characteristic of a Health Maintenance Organization
(HMO) Medicare Advantage plan?
A) Members can see any provider who accepts Medicare
B) Members generally must use network providers
C) Members do not need a primary care physician
D) Members can enroll at any time
Correct Answer: B) Members generally must use network providers
Rationale: HMO plans require members to use network providers and usually require a
primary care physician (PCP) who provides referrals for specialists. Non-network care is
generally not covered except in emergencies. HMOs typically have lower premiums and
out-of-pocket costs.
7. Which of the following is a characteristic of a Preferred Provider Organization
(PPO) Medicare Advantage plan?
A) Members must use network providers exclusively
B) Members can see any provider who accepts Medicare
C) Members must have a primary care physician
D) Members cannot enroll in Part D
Correct Answer: B) Members can see any provider who accepts Medicare
Rationale: PPO plans allow members to see any provider who accepts Medicare, but they
pay less when using network providers. PPOs do not require a primary care physician or
referrals. They typically have higher premiums than HMOs.
8. What is the maximum out-of-pocket (MOOP) limit for Medicare Advantage plans?
A) There is no limit
B) The limit is set annually by CMS
C) The limit is $5,000
D) The limit is $10,000
Correct Answer: B) The limit is set annually by CMS
, Rationale: CMS sets a maximum out-of-pocket (MOOP) limit for Medicare Advantage plans
annually. Once members reach this limit, the plan pays 100% of covered services for the
remainder of the year. The limit varies by plan type and year.
9. Which of the following services is NOT covered by Medicare Advantage plans?
A) Hospital stays
B) Doctor visits
C) Routine dental care
D) Emergency care
Correct Answer: C) Routine dental care
Rationale: Routine dental care is not covered by Original Medicare (Part A and Part B).
Some Medicare Advantage plans may offer dental coverage as a supplemental benefit, but
it is not required. Hospital stays, doctor visits, and emergency care are covered.
10. What is a Special Needs Plan (SNP)?
A) A plan for individuals with pre-existing conditions
B) A plan for individuals who are dual-eligible (Medicare and Medicaid)
C) A plan for individuals with chronic conditions
D) Both B and C
Correct Answer: D) Both B and C
Rationale: Special Needs Plans (SNPs) are a type of Medicare Advantage plan designed for
specific populations, including dual-eligible individuals (those with both Medicare and
Medicaid), institutionalized individuals, and those with chronic conditions. SNPs tailor
benefits to their specific populations.
11. What is a Dual-Eligible Special Needs Plan (D-SNP)?
A) A plan for individuals with Medicare only
B) A plan for individuals with both Medicare and Medicaid
C) A plan for individuals with private insurance
D) A plan for veterans
Questions & Correct Answers
Medicare Advantage & Prescription Drug Coverage Edition |
Comprehensive Certification Assessment
SECTION 1: MEDICARE ADVANTAGE BASICS
1. What is Medicare Advantage (MA)?
A) A type of Medigap policy
B) A health plan option offered by private companies that contracts with Medicare
C) A supplemental insurance for low-income individuals
D) A prescription drug discount program
Correct Answer: B) A health plan option offered by private companies that contracts
with Medicare
Rationale: Medicare Advantage (Part C) is a health plan option offered by private insurance
companies approved by Medicare. These plans provide all Part A and Part B benefits, and
most include Part D prescription drug coverage. Medigap is a supplement, not Medicare
Advantage.
2. Which of the following is NOT a requirement for an individual to enroll in a
Medicare Advantage plan?
A) Be entitled to Medicare Part A
B) Be enrolled in Medicare Part B
C) Have a pre-existing condition
D) Live in the plan's service area
Correct Answer: C) Have a pre-existing condition
Rationale: Individuals cannot be denied enrollment in a Medicare Advantage plan due to a
pre-existing condition. They must be entitled to Medicare Part A, enrolled in Part B, and live
in the plan's service area.
,3. What is the annual election period (AEP) for Medicare Advantage and Part D plans?
A) January 1 – March 31
B) October 15 – December 7
C) November 1 – December 31
D) April 1 – June 30
Correct Answer: B) October 15 – December 7
Rationale: The Annual Election Period (AEP), also known as the Open Enrollment Period,
runs from October 15 to December 7 each year. During this time, beneficiaries can enroll in,
switch, or disenroll from Medicare Advantage and Part D plans. Coverage begins January 1.
4. What is the Medicare Advantage Open Enrollment Period (MA OEP)?
A) January 1 – March 31
B) October 15 – December 7
C) November 1 – December 31
D) April 1 – June 30
Correct Answer: A) January 1 – March 31
Rationale: The Medicare Advantage Open Enrollment Period (MA OEP) runs from January
1 to March 31 each year. During this time, beneficiaries enrolled in a Medicare Advantage
plan can switch to another MA plan or return to Original Medicare. This is not for initial
enrollment.
5. What is the Initial Enrollment Period (IEP) for Medicare?
A) A 3-month period
B) A 7-month period
C) A 6-month period
D) A 12-month period
Correct Answer: B) A 7-month period
Rationale: The Initial Enrollment Period (IEP) is a 7-month period that begins 3 months
before the month an individual turns 65, includes the birthday month, and ends 3 months
after. For example, if turning 65 in June, the IEP is March 1 – September 30.
,6. Which of the following is a characteristic of a Health Maintenance Organization
(HMO) Medicare Advantage plan?
A) Members can see any provider who accepts Medicare
B) Members generally must use network providers
C) Members do not need a primary care physician
D) Members can enroll at any time
Correct Answer: B) Members generally must use network providers
Rationale: HMO plans require members to use network providers and usually require a
primary care physician (PCP) who provides referrals for specialists. Non-network care is
generally not covered except in emergencies. HMOs typically have lower premiums and
out-of-pocket costs.
7. Which of the following is a characteristic of a Preferred Provider Organization
(PPO) Medicare Advantage plan?
A) Members must use network providers exclusively
B) Members can see any provider who accepts Medicare
C) Members must have a primary care physician
D) Members cannot enroll in Part D
Correct Answer: B) Members can see any provider who accepts Medicare
Rationale: PPO plans allow members to see any provider who accepts Medicare, but they
pay less when using network providers. PPOs do not require a primary care physician or
referrals. They typically have higher premiums than HMOs.
8. What is the maximum out-of-pocket (MOOP) limit for Medicare Advantage plans?
A) There is no limit
B) The limit is set annually by CMS
C) The limit is $5,000
D) The limit is $10,000
Correct Answer: B) The limit is set annually by CMS
, Rationale: CMS sets a maximum out-of-pocket (MOOP) limit for Medicare Advantage plans
annually. Once members reach this limit, the plan pays 100% of covered services for the
remainder of the year. The limit varies by plan type and year.
9. Which of the following services is NOT covered by Medicare Advantage plans?
A) Hospital stays
B) Doctor visits
C) Routine dental care
D) Emergency care
Correct Answer: C) Routine dental care
Rationale: Routine dental care is not covered by Original Medicare (Part A and Part B).
Some Medicare Advantage plans may offer dental coverage as a supplemental benefit, but
it is not required. Hospital stays, doctor visits, and emergency care are covered.
10. What is a Special Needs Plan (SNP)?
A) A plan for individuals with pre-existing conditions
B) A plan for individuals who are dual-eligible (Medicare and Medicaid)
C) A plan for individuals with chronic conditions
D) Both B and C
Correct Answer: D) Both B and C
Rationale: Special Needs Plans (SNPs) are a type of Medicare Advantage plan designed for
specific populations, including dual-eligible individuals (those with both Medicare and
Medicaid), institutionalized individuals, and those with chronic conditions. SNPs tailor
benefits to their specific populations.
11. What is a Dual-Eligible Special Needs Plan (D-SNP)?
A) A plan for individuals with Medicare only
B) A plan for individuals with both Medicare and Medicaid
C) A plan for individuals with private insurance
D) A plan for veterans
