2026 AHIP MODULE 2 PRACTICE EXAM
1. Regarding MA eligibility, What should the beneficiary be told?
A. Medigap enrollment is required
B. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in the plan service area,
and meet applicable lawful-presence requirements
C. Part D is required before MA enrollment
D. Part A alone is always sufficient
Correct Answer: B. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in
the plan service area, and meet applicable lawful-presence requirements
Rationale: Basic MA eligibility generally includes entitlement to Part A, enrollment in Part B, residence in the
plan service area, and applicable status requirements.
2. A beneficiary is comparing several Medicare statements involving MA benefit requirement. Which
statement should be selected as the accurate one?
A. MA plans may omit Part A hospital services
B. MA plans replace Medicare hospice with no coverage
C. MA plans need cover only preventive care
D. MA plans must cover all medically necessary services covered by Original Medicare except hospice is
generally paid through Original Medicare while the person remains in the MA plan
Correct Answer: D. MA plans must cover all medically necessary services covered by Original Medicare except
hospice is generally paid through Original Medicare while the person remains in the MA plan
Rationale: Medicare Advantage plans must furnish Part A and Part B benefits, while Medicare-covered hospice
is generally paid through Original Medicare during the hospice election.
3. Robert is reviewing Medicare coverage at a community information session and asks about SNP
purpose. Which statement best resolves the question?
A. Special Needs Plans are designed for defined groups such as certain dual-eligible, institutionalized, or
chronic-condition populations
B. SNPs cannot include care coordination
C. SNPs are open only to people with Medigap
D. SNPs are employer plans only
Correct Answer: A. Special Needs Plans are designed for defined groups such as certain dual-eligible,
institutionalized, or chronic-condition populations
Rationale: SNPs tailor benefits, provider choices, and care management to specific eligible populations.
4. During a compliance review, an agent must give an accurate explanation of Star Ratings without
overstating or omitting a key rule. Which explanation should the agent use?
A. Star Ratings are state insurance license grades
B. They apply only to Medigap
C. CMS Star Ratings help beneficiaries compare plan quality using a 1-to-5-star scale
D. A 5-star rating guarantees the lowest premium
Correct Answer: C. CMS Star Ratings help beneficiaries compare plan quality using a 1-to-5-star scale
Rationale: Medicare Star Ratings summarize quality and performance information for health and drug plans and
can support comparison shopping.
5. Regarding D-SNP, Which statement is most accurate?
A. A D-SNP is a Medigap plan
B. A D-SNP is for any person with diabetes only
C. A D-SNP serves people who are eligible for both Medicare and Medicaid under plan-specific eligibility rules
D. A D-SNP is limited to people with employer coverage
Correct Answer: C. A D-SNP serves people who are eligible for both Medicare and Medicaid under
plan-specific eligibility rules
Rationale: Dual-Eligible SNPs serve beneficiaries who have both Medicare and Medicaid eligibility, with details
depending on the plan and state arrangements.
6. A beneficiary is comparing several Medicare statements involving MA eligibility. Which statement
should be selected as the accurate one?
,A. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in the plan service area,
and meet applicable lawful-presence requirements
B. Part A alone is always sufficient
C. Medigap enrollment is required
D. Part D is required before MA enrollment
Correct Answer: A. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in
the plan service area, and meet applicable lawful-presence requirements
Rationale: Basic MA eligibility generally includes entitlement to Part A, enrollment in Part B, residence in the
plan service area, and applicable status requirements.
7. Priya is reviewing Medicare coverage after receiving a plan notice and asks about Standalone PDP with
MA. How should this situation be interpreted?
A. A stand-alone PDP is always required with MA-PD
B. Enrolling in a PDP never affects MA status
C. Two Part D plans can be held simultaneously
D. A beneficiary in most MA plans that include drug coverage should not separately enroll in a stand-alone PDP
because doing so can trigger disenrollment from the MA plan
Correct Answer: D. A beneficiary in most MA plans that include drug coverage should not separately enroll in a
stand-alone PDP because doing so can trigger disenrollment from the MA plan
Rationale: Medicare generally does not allow duplicative Part D enrollment; joining a stand-alone PDP can cause
disenrollment from certain MA plans.
8. During a compliance review, an agent must give an accurate explanation of Medicare Cost plan without
overstating or omitting a key rule. Which explanation should the agent use?
A. A Cost plan always requires referrals for all care
B. A Medicare Cost plan may allow members to receive Original Medicare coverage for services obtained outside
the plan network under applicable rules
C. A Cost plan is Part D only
D. A Cost plan is identical to Medigap
Correct Answer: B. A Medicare Cost plan may allow members to receive Original Medicare coverage for
services obtained outside the plan network under applicable rules
Rationale: Section 1876 Cost plans differ from MA because Original Medicare may pay for certain services
received outside the cost plan network.
9. Regarding MA out-of-pocket maximum, Which action or explanation is most appropriate?
A. MA plans have an annual maximum out-of-pocket limit for Part A and Part B services covered by the plan
B. Only PDPs have an MOOP
C. MA plans may never limit member cost sharing
D. Original Medicare and MA both have no annual limit
Correct Answer: A. MA plans have an annual maximum out-of-pocket limit for Part A and
Part B services covered by the plan
Rationale: MA plans must limit annual beneficiary cost sharing for covered Part A and Part B services, providing
protection not built into Original Medicare alone.
10. A beneficiary is comparing several Medicare statements involving Supplemental benefits. Which
statement should be selected as the accurate one?
A. Supplemental benefits are guaranteed by Original Medicare
B. MA plans may offer additional benefits beyond Original Medicare, subject to CMS and plan rules
C. Every MA plan must offer identical extras
D. MA plans are prohibited from any supplemental benefits
Correct Answer: B. MA plans may offer additional benefits beyond Original Medicare, subject to CMS and plan
rules
Rationale: Many MA plans offer additional benefits such as certain dental, vision, hearing, transportation, or
other supplemental services, but details vary.
11. Janet is reviewing Medicare coverage during an annual coverage review and asks about PPO flexibility.
Which response best applies?
A. A PPO requires Medigap
B. A PPO prohibits all out-of-network care
, C. A PPO cannot have a network
D. A PPO generally permits use of out-of-network providers for covered services at higher cost when the provider
accepts the plan terms
Correct Answer: D. A PPO generally permits use of out-of-network providers for covered services at higher cost
when the provider accepts the plan terms
Rationale: PPOs typically offer a preferred network but allow covered out-of-network services at different cost
sharing, subject to plan rules.
12. During a compliance review, an agent must give an accurate explanation of HMO network without
overstating or omitting a key rule. Which explanation should the agent use?
A. An HMO has no service area
B. An HMO cannot include Part D
C. An HMO generally uses a provider network and usually requires non-emergency care to be obtained
in-network subject to plan rules
D. An HMO must pay all out-of-network routine care at in-network rates
Correct Answer: C. An HMO generally uses a provider network and usually requires non-emergency care to be
obtained in-network subject to plan rules
Rationale: HMO plans generally organize care through a network and may restrict routine coverage outside that
network, while emergency and urgently needed care have protections.
13. Regarding Referral rules, Which option best reflects Medicare rules?
A. Referral rules are set by Medigap
B. No MA plan may require referrals
C. All MA plans require referrals for every specialist
D. Referral requirements depend on the MA plan type and plan rules; HMOs commonly use referrals more than
PPOs
Correct Answer: D. Referral requirements depend on the MA plan type and plan rules; HMOs commonly use
referrals more than PPOs
Rationale: Plan design matters: referral and prior-authorization processes vary across MA products.
14. A beneficiary is comparing several Medicare statements involving Part B premium in MA. Which
statement should be selected as the accurate one?
A. Part B automatically terminates after MA enrollment
B. The MA plan permanently replaces the Part B premium
C. An MA enrollee generally must continue paying the Part B premium
D. Only PDP enrollees pay Part B premiums
Correct Answer: C. An MA enrollee generally must continue paying the Part B premium
Rationale: Medicare Advantage provides Part A and Part B benefits through a private plan, but the beneficiary
generally remains enrolled in Part B and keeps paying its premium.
15. Walter is reviewing Medicare coverage at a community information session and asks about MA
out-of-pocket maximum. Which statement best resolves the question?
A. Original Medicare and MA both have no annual limit
B. MA plans have an annual maximum out-of-pocket limit for Part A and Part B services covered by the plan
C. MA plans may never limit member cost sharing
D. Only PDPs have an MOOP
Correct Answer: B. MA plans have an annual maximum out-of-pocket limit for Part A and
Part B services covered by the plan
Rationale: MA plans must limit annual beneficiary cost sharing for covered Part A and Part B services, providing
protection not built into Original Medicare alone.
16. During a compliance review, an agent must give an accurate explanation of Organization determination
without overstating or omitting a key rule. Which explanation should the agent use?
A. An MA organization determination is the plan decision about coverage or payment for a Part C service
B. It is the same as an annual notice of change
C. It is only a Part D formulary tier
D. It is a state licensure decision
Correct Answer: A. An MA organization determination is the plan decision about coverage or payment for a
Part C service
1. Regarding MA eligibility, What should the beneficiary be told?
A. Medigap enrollment is required
B. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in the plan service area,
and meet applicable lawful-presence requirements
C. Part D is required before MA enrollment
D. Part A alone is always sufficient
Correct Answer: B. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in
the plan service area, and meet applicable lawful-presence requirements
Rationale: Basic MA eligibility generally includes entitlement to Part A, enrollment in Part B, residence in the
plan service area, and applicable status requirements.
2. A beneficiary is comparing several Medicare statements involving MA benefit requirement. Which
statement should be selected as the accurate one?
A. MA plans may omit Part A hospital services
B. MA plans replace Medicare hospice with no coverage
C. MA plans need cover only preventive care
D. MA plans must cover all medically necessary services covered by Original Medicare except hospice is
generally paid through Original Medicare while the person remains in the MA plan
Correct Answer: D. MA plans must cover all medically necessary services covered by Original Medicare except
hospice is generally paid through Original Medicare while the person remains in the MA plan
Rationale: Medicare Advantage plans must furnish Part A and Part B benefits, while Medicare-covered hospice
is generally paid through Original Medicare during the hospice election.
3. Robert is reviewing Medicare coverage at a community information session and asks about SNP
purpose. Which statement best resolves the question?
A. Special Needs Plans are designed for defined groups such as certain dual-eligible, institutionalized, or
chronic-condition populations
B. SNPs cannot include care coordination
C. SNPs are open only to people with Medigap
D. SNPs are employer plans only
Correct Answer: A. Special Needs Plans are designed for defined groups such as certain dual-eligible,
institutionalized, or chronic-condition populations
Rationale: SNPs tailor benefits, provider choices, and care management to specific eligible populations.
4. During a compliance review, an agent must give an accurate explanation of Star Ratings without
overstating or omitting a key rule. Which explanation should the agent use?
A. Star Ratings are state insurance license grades
B. They apply only to Medigap
C. CMS Star Ratings help beneficiaries compare plan quality using a 1-to-5-star scale
D. A 5-star rating guarantees the lowest premium
Correct Answer: C. CMS Star Ratings help beneficiaries compare plan quality using a 1-to-5-star scale
Rationale: Medicare Star Ratings summarize quality and performance information for health and drug plans and
can support comparison shopping.
5. Regarding D-SNP, Which statement is most accurate?
A. A D-SNP is a Medigap plan
B. A D-SNP is for any person with diabetes only
C. A D-SNP serves people who are eligible for both Medicare and Medicaid under plan-specific eligibility rules
D. A D-SNP is limited to people with employer coverage
Correct Answer: C. A D-SNP serves people who are eligible for both Medicare and Medicaid under
plan-specific eligibility rules
Rationale: Dual-Eligible SNPs serve beneficiaries who have both Medicare and Medicaid eligibility, with details
depending on the plan and state arrangements.
6. A beneficiary is comparing several Medicare statements involving MA eligibility. Which statement
should be selected as the accurate one?
,A. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in the plan service area,
and meet applicable lawful-presence requirements
B. Part A alone is always sufficient
C. Medigap enrollment is required
D. Part D is required before MA enrollment
Correct Answer: A. To enroll in Medicare Advantage, a person generally must have Part A and Part B, live in
the plan service area, and meet applicable lawful-presence requirements
Rationale: Basic MA eligibility generally includes entitlement to Part A, enrollment in Part B, residence in the
plan service area, and applicable status requirements.
7. Priya is reviewing Medicare coverage after receiving a plan notice and asks about Standalone PDP with
MA. How should this situation be interpreted?
A. A stand-alone PDP is always required with MA-PD
B. Enrolling in a PDP never affects MA status
C. Two Part D plans can be held simultaneously
D. A beneficiary in most MA plans that include drug coverage should not separately enroll in a stand-alone PDP
because doing so can trigger disenrollment from the MA plan
Correct Answer: D. A beneficiary in most MA plans that include drug coverage should not separately enroll in a
stand-alone PDP because doing so can trigger disenrollment from the MA plan
Rationale: Medicare generally does not allow duplicative Part D enrollment; joining a stand-alone PDP can cause
disenrollment from certain MA plans.
8. During a compliance review, an agent must give an accurate explanation of Medicare Cost plan without
overstating or omitting a key rule. Which explanation should the agent use?
A. A Cost plan always requires referrals for all care
B. A Medicare Cost plan may allow members to receive Original Medicare coverage for services obtained outside
the plan network under applicable rules
C. A Cost plan is Part D only
D. A Cost plan is identical to Medigap
Correct Answer: B. A Medicare Cost plan may allow members to receive Original Medicare coverage for
services obtained outside the plan network under applicable rules
Rationale: Section 1876 Cost plans differ from MA because Original Medicare may pay for certain services
received outside the cost plan network.
9. Regarding MA out-of-pocket maximum, Which action or explanation is most appropriate?
A. MA plans have an annual maximum out-of-pocket limit for Part A and Part B services covered by the plan
B. Only PDPs have an MOOP
C. MA plans may never limit member cost sharing
D. Original Medicare and MA both have no annual limit
Correct Answer: A. MA plans have an annual maximum out-of-pocket limit for Part A and
Part B services covered by the plan
Rationale: MA plans must limit annual beneficiary cost sharing for covered Part A and Part B services, providing
protection not built into Original Medicare alone.
10. A beneficiary is comparing several Medicare statements involving Supplemental benefits. Which
statement should be selected as the accurate one?
A. Supplemental benefits are guaranteed by Original Medicare
B. MA plans may offer additional benefits beyond Original Medicare, subject to CMS and plan rules
C. Every MA plan must offer identical extras
D. MA plans are prohibited from any supplemental benefits
Correct Answer: B. MA plans may offer additional benefits beyond Original Medicare, subject to CMS and plan
rules
Rationale: Many MA plans offer additional benefits such as certain dental, vision, hearing, transportation, or
other supplemental services, but details vary.
11. Janet is reviewing Medicare coverage during an annual coverage review and asks about PPO flexibility.
Which response best applies?
A. A PPO requires Medigap
B. A PPO prohibits all out-of-network care
, C. A PPO cannot have a network
D. A PPO generally permits use of out-of-network providers for covered services at higher cost when the provider
accepts the plan terms
Correct Answer: D. A PPO generally permits use of out-of-network providers for covered services at higher cost
when the provider accepts the plan terms
Rationale: PPOs typically offer a preferred network but allow covered out-of-network services at different cost
sharing, subject to plan rules.
12. During a compliance review, an agent must give an accurate explanation of HMO network without
overstating or omitting a key rule. Which explanation should the agent use?
A. An HMO has no service area
B. An HMO cannot include Part D
C. An HMO generally uses a provider network and usually requires non-emergency care to be obtained
in-network subject to plan rules
D. An HMO must pay all out-of-network routine care at in-network rates
Correct Answer: C. An HMO generally uses a provider network and usually requires non-emergency care to be
obtained in-network subject to plan rules
Rationale: HMO plans generally organize care through a network and may restrict routine coverage outside that
network, while emergency and urgently needed care have protections.
13. Regarding Referral rules, Which option best reflects Medicare rules?
A. Referral rules are set by Medigap
B. No MA plan may require referrals
C. All MA plans require referrals for every specialist
D. Referral requirements depend on the MA plan type and plan rules; HMOs commonly use referrals more than
PPOs
Correct Answer: D. Referral requirements depend on the MA plan type and plan rules; HMOs commonly use
referrals more than PPOs
Rationale: Plan design matters: referral and prior-authorization processes vary across MA products.
14. A beneficiary is comparing several Medicare statements involving Part B premium in MA. Which
statement should be selected as the accurate one?
A. Part B automatically terminates after MA enrollment
B. The MA plan permanently replaces the Part B premium
C. An MA enrollee generally must continue paying the Part B premium
D. Only PDP enrollees pay Part B premiums
Correct Answer: C. An MA enrollee generally must continue paying the Part B premium
Rationale: Medicare Advantage provides Part A and Part B benefits through a private plan, but the beneficiary
generally remains enrolled in Part B and keeps paying its premium.
15. Walter is reviewing Medicare coverage at a community information session and asks about MA
out-of-pocket maximum. Which statement best resolves the question?
A. Original Medicare and MA both have no annual limit
B. MA plans have an annual maximum out-of-pocket limit for Part A and Part B services covered by the plan
C. MA plans may never limit member cost sharing
D. Only PDPs have an MOOP
Correct Answer: B. MA plans have an annual maximum out-of-pocket limit for Part A and
Part B services covered by the plan
Rationale: MA plans must limit annual beneficiary cost sharing for covered Part A and Part B services, providing
protection not built into Original Medicare alone.
16. During a compliance review, an agent must give an accurate explanation of Organization determination
without overstating or omitting a key rule. Which explanation should the agent use?
A. An MA organization determination is the plan decision about coverage or payment for a Part C service
B. It is the same as an annual notice of change
C. It is only a Part D formulary tier
D. It is a state licensure decision
Correct Answer: A. An MA organization determination is the plan decision about coverage or payment for a
Part C service
