Page 1 of 41
AHIP FINAL EXAM –MEDICARE
CERTIFICATION
QUESTIONS AND CORRECT
ANSWERS WITH DETAILED
RATIONALES CURRENT
TESTING
D
SECTION 1: MEDICARE BASICS & ELIGIBILITY
O
1. Mr. Carlini has heard that Medicare prescription drug plans are only offered through
private companies under a program known as Medicare Advantage (MA), not by the
N
government. He likes Original Medicare and does not want to sign up for an MA product,
O
but he also wants prescription drug coverage. What should you tell him?
T
A. He must enroll in a Medicare Advantage plan to get prescription drug coverage.
B. He can stay with Original Medicare and also enroll in a Medicare prescription drug plan
C
through a private company that has contracted with the government to provide only such drug
O
coverage. C. He cannot get prescription drug coverage unless he enrolls in a Medicare
PY
Advantage plan.
D. He should wait until he turns 65 to enroll in a prescription drug plan.
Correct answer: B. He can stay with Original Medicare and also enroll in a Medicare
prescription drug plan through a private company that has contracted with the
government to provide only such drug coverage.
Rationale: Beneficiaries can remain in Original Medicare (Parts A and B) and enroll in a
standalone Medicare Prescription Drug Plan (PDP) offered by a private company. PDPs are
available to all Medicare beneficiaries, regardless of whether they are in Original Medicare or
a Medicare Advantage plan.
2. Ms. Daley is considering a Medicare Advantage plan that has a 5-star rating in customer
service and care coordination, and received an overall plan performance of 4-stars. Which
of the following would be the correct statement to say to her?
A. The Medicare Advantage plan received a 5-star rating in customer service and care
coordination with an overall performance rating of 4-stars.
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B. The Medicare Advantage plan received a 5-star overall rating.
C. The Medicare Advantage plan received a 4-star rating in customer service.
D. The Medicare Advantage plan is not rated.
Correct answer: A. The Medicare Advantage plan received a 5star rating in customer service
and care coordination with an overall performance rating of 4-stars.
Rationale: When discussing plan star ratings, agents must accurately represent the specific
ratings. If the plan received a 5star rating in customer service and care coordination but an
overall performance rating of 4-stars, both must be stated correctly.
3. Mrs. Pena is 66 years old, has coverage under an employer plan and will retire next year.
She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage.
What can you tell her?
A. She must enroll in Part B during the General Enrollment Period (January 1 – March 31) to
D
avoid a gap in coverage.
B.
O
She may enroll at any time while she is covered under her employer plan, but she will have a
special eight-month enrollment period that differs from the standard general enrollment period,
N
during which she may enroll in Medicare Part B.
O
C. She must enroll in Part B immediately to avoid a late enrollment penalty.
T
D. She cannot enroll in Part B until she retires.
Correct answer: B. She may enroll at any time while she is covered under her employer
C
plan, but she will have a special eight-month enrollment period that differs from the
O
standard general enrollment period, during which she may enroll in Medicare Part B.
Rationale: Individuals covered under an employer group health plan based on current employment
PY
(their own or a spouse's) have a Special Enrollment Period (SEP) to enroll in Part B. This SEP
lasts for eight months after the employment or coverage ends, allowing them to enroll without
penalty.
4. Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a
Medigap plan to pick up costs not covered by that plan. What should you tell him?
A. You can sell him a Medigap plan to help with costs not covered under Medicare Advantage.
B. It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and
besides, Medigap only works with Original Medicare.
C. Medigap plans are designed to work alongside Medicare Advantage plans.
D. He must disenroll from his MA plan before buying a Medigap plan.
Correct answer: B. It is illegal for you to sell Mr. Capadona a Medigap plan if he is
enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
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Rationale: Federal law prohibits the sale of a Medigap policy to an individual enrolled in a
Medicare Advantage plan. Medigap plans are designed to supplement Original Medicare (Parts A
and B) and cannot pay deductibles, copayments, or coinsurance associated with Medicare
Advantage plans. This prevents duplicate coverage and ensures proper coordination of benefits.
5. Mr. Moy will soon turn age 65. He wants to understand what coverage Medicare
Supplemental Insurance provides. What could you tell Mr. Moy?
A. It covers everything Original Medicare does not.
B. It provides prescription drug coverage.
C. Medicare Supplemental Insurance would help cover his Part A deductible and Part B
coinsurance or copayments in Original Feefor-Service (FFS) Medicare as well as possibly
some services that Medicare does not cover.
D. It is only available for Medicare Advantage enrollees.
D
Correct answer: C. Medicare Supplemental Insurance would help cover his Part A
deductible and Part B coinsurance or copayments in Original Fee-for-Service (FFS)
O
Medicare as well as possibly some services that Medicare does not cover.
Rationale: Medigap policies help pay many out-of-pocket costs not covered by Original
N
Medicare, such as deductibles, coinsurance, and copayments. Some plans also cover foreign
O
travel emergency care. Medigap does not cover services like long-term care, vision, dental,
T
hearing aids, or private nursing.
C
6. Mrs. Ramos is enrolled in a Medicare Advantage plan that includes prescription drug
plan (PDP) coverage. She is traveling and wishes to fill a prescription at a retail pharmacy.
O
What should you tell her?
PY
A. She can only fill prescriptions at network pharmacies.
B. She may be able to fill prescriptions at out-of-network pharmacies, but may pay higher cost-
sharing.
C. She must pay full price and submit a claim for reimbursement.
D. She cannot fill prescriptions while traveling.
Correct answer: B. She may be able to fill prescriptions at out-ofnetwork pharmacies, but
may pay higher cost-sharing. Rationale: Medicare Advantage Prescription Drug (MA-PD) plans
typically have network pharmacies, but many plans provide coverage for out-of-network
pharmacies in certain situations, such as when a beneficiary is traveling. However, the beneficiary
may pay higher cost-sharing at out-of-network pharmacies.
7. Mr. Bickford did not quite qualify for the extra help low-income subsidy under the
Medicare Part D Prescription Drug program and he is wondering if there is any other option
he has for obtaining help with his considerable drug costs. What should you tell him?
A. There are no other options for help with drug costs.
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B. He could check with the manufacturers of his medications to see if they offer an assistance
program to help people with limited means obtain the medications they need. Alternatively, he
could check to see whether his state has a pharmacy assistance program to help him with his
expenses.
C. He should enroll in a Medicare Advantage plan to get better drug coverage.
D. He should appeal the decision regarding the low-income subsidy. Correct answer: B. He
could check with the manufacturers of his medications to see if they offer an assistance
program to help people with limited means obtain the medications they need.
Alternatively, he could check to see whether his state has a pharmacy assistance program
to help him with his expenses.
Rationale: Beneficiaries who do not qualify for the Low-Income Subsidy (LIS/Extra Help) may
still find assistance through pharmaceutical manufacturer patient assistance programs or state
pharmacy assistance programs (SPAPs). These programs can help reduce out-of-pocket costs for
D
medications.
O
8. Which of the following is true about Medicare Part A? A. It covers outpatient
services and physician visits.
N
B. It is premium-free for most beneficiaries who have worked at least 40 quarters.
O
C. It covers prescription drugs.
T
D. It is only available to individuals over age 70.
C
Correct answer: B. It is premium-free for most beneficiaries who have worked at least 40
quarters.
O
Rationale: Medicare Part A (Hospital Insurance) covers inpatient hospital stays, skilled nursing
PY
facility care, hospice, and some home health care. Most beneficiaries receive Part A premium-free
if they or their spouse paid Medicare taxes for at least 40 quarters (10 years).
9. Which of the following is true about Medicare Part B? A. It covers inpatient
hospital stays.
B. It covers outpatient services, physician visits, and preventive services.
C. It is always premium-free.
D. It covers prescription drugs.
Correct answer: B. It covers outpatient services, physician visits, and preventive services.
Rationale: Medicare Part B (Medical Insurance) covers outpatient care, doctor visits, preventive
services, durable medical equipment (DME), and some home health care.
10. What is the Initial Enrollment Period (IEP) for Medicare? A. A 3-month period before
the month of the 65th birthday.
AHIP FINAL EXAM –MEDICARE
CERTIFICATION
QUESTIONS AND CORRECT
ANSWERS WITH DETAILED
RATIONALES CURRENT
TESTING
D
SECTION 1: MEDICARE BASICS & ELIGIBILITY
O
1. Mr. Carlini has heard that Medicare prescription drug plans are only offered through
private companies under a program known as Medicare Advantage (MA), not by the
N
government. He likes Original Medicare and does not want to sign up for an MA product,
O
but he also wants prescription drug coverage. What should you tell him?
T
A. He must enroll in a Medicare Advantage plan to get prescription drug coverage.
B. He can stay with Original Medicare and also enroll in a Medicare prescription drug plan
C
through a private company that has contracted with the government to provide only such drug
O
coverage. C. He cannot get prescription drug coverage unless he enrolls in a Medicare
PY
Advantage plan.
D. He should wait until he turns 65 to enroll in a prescription drug plan.
Correct answer: B. He can stay with Original Medicare and also enroll in a Medicare
prescription drug plan through a private company that has contracted with the
government to provide only such drug coverage.
Rationale: Beneficiaries can remain in Original Medicare (Parts A and B) and enroll in a
standalone Medicare Prescription Drug Plan (PDP) offered by a private company. PDPs are
available to all Medicare beneficiaries, regardless of whether they are in Original Medicare or
a Medicare Advantage plan.
2. Ms. Daley is considering a Medicare Advantage plan that has a 5-star rating in customer
service and care coordination, and received an overall plan performance of 4-stars. Which
of the following would be the correct statement to say to her?
A. The Medicare Advantage plan received a 5-star rating in customer service and care
coordination with an overall performance rating of 4-stars.
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B. The Medicare Advantage plan received a 5-star overall rating.
C. The Medicare Advantage plan received a 4-star rating in customer service.
D. The Medicare Advantage plan is not rated.
Correct answer: A. The Medicare Advantage plan received a 5star rating in customer service
and care coordination with an overall performance rating of 4-stars.
Rationale: When discussing plan star ratings, agents must accurately represent the specific
ratings. If the plan received a 5star rating in customer service and care coordination but an
overall performance rating of 4-stars, both must be stated correctly.
3. Mrs. Pena is 66 years old, has coverage under an employer plan and will retire next year.
She heard she must enroll in Part B at the beginning of the year to ensure no gap in coverage.
What can you tell her?
A. She must enroll in Part B during the General Enrollment Period (January 1 – March 31) to
D
avoid a gap in coverage.
B.
O
She may enroll at any time while she is covered under her employer plan, but she will have a
special eight-month enrollment period that differs from the standard general enrollment period,
N
during which she may enroll in Medicare Part B.
O
C. She must enroll in Part B immediately to avoid a late enrollment penalty.
T
D. She cannot enroll in Part B until she retires.
Correct answer: B. She may enroll at any time while she is covered under her employer
C
plan, but she will have a special eight-month enrollment period that differs from the
O
standard general enrollment period, during which she may enroll in Medicare Part B.
Rationale: Individuals covered under an employer group health plan based on current employment
PY
(their own or a spouse's) have a Special Enrollment Period (SEP) to enroll in Part B. This SEP
lasts for eight months after the employment or coverage ends, allowing them to enroll without
penalty.
4. Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a
Medigap plan to pick up costs not covered by that plan. What should you tell him?
A. You can sell him a Medigap plan to help with costs not covered under Medicare Advantage.
B. It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and
besides, Medigap only works with Original Medicare.
C. Medigap plans are designed to work alongside Medicare Advantage plans.
D. He must disenroll from his MA plan before buying a Medigap plan.
Correct answer: B. It is illegal for you to sell Mr. Capadona a Medigap plan if he is
enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
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Rationale: Federal law prohibits the sale of a Medigap policy to an individual enrolled in a
Medicare Advantage plan. Medigap plans are designed to supplement Original Medicare (Parts A
and B) and cannot pay deductibles, copayments, or coinsurance associated with Medicare
Advantage plans. This prevents duplicate coverage and ensures proper coordination of benefits.
5. Mr. Moy will soon turn age 65. He wants to understand what coverage Medicare
Supplemental Insurance provides. What could you tell Mr. Moy?
A. It covers everything Original Medicare does not.
B. It provides prescription drug coverage.
C. Medicare Supplemental Insurance would help cover his Part A deductible and Part B
coinsurance or copayments in Original Feefor-Service (FFS) Medicare as well as possibly
some services that Medicare does not cover.
D. It is only available for Medicare Advantage enrollees.
D
Correct answer: C. Medicare Supplemental Insurance would help cover his Part A
deductible and Part B coinsurance or copayments in Original Fee-for-Service (FFS)
O
Medicare as well as possibly some services that Medicare does not cover.
Rationale: Medigap policies help pay many out-of-pocket costs not covered by Original
N
Medicare, such as deductibles, coinsurance, and copayments. Some plans also cover foreign
O
travel emergency care. Medigap does not cover services like long-term care, vision, dental,
T
hearing aids, or private nursing.
C
6. Mrs. Ramos is enrolled in a Medicare Advantage plan that includes prescription drug
plan (PDP) coverage. She is traveling and wishes to fill a prescription at a retail pharmacy.
O
What should you tell her?
PY
A. She can only fill prescriptions at network pharmacies.
B. She may be able to fill prescriptions at out-of-network pharmacies, but may pay higher cost-
sharing.
C. She must pay full price and submit a claim for reimbursement.
D. She cannot fill prescriptions while traveling.
Correct answer: B. She may be able to fill prescriptions at out-ofnetwork pharmacies, but
may pay higher cost-sharing. Rationale: Medicare Advantage Prescription Drug (MA-PD) plans
typically have network pharmacies, but many plans provide coverage for out-of-network
pharmacies in certain situations, such as when a beneficiary is traveling. However, the beneficiary
may pay higher cost-sharing at out-of-network pharmacies.
7. Mr. Bickford did not quite qualify for the extra help low-income subsidy under the
Medicare Part D Prescription Drug program and he is wondering if there is any other option
he has for obtaining help with his considerable drug costs. What should you tell him?
A. There are no other options for help with drug costs.
, Page 4 of 41
B. He could check with the manufacturers of his medications to see if they offer an assistance
program to help people with limited means obtain the medications they need. Alternatively, he
could check to see whether his state has a pharmacy assistance program to help him with his
expenses.
C. He should enroll in a Medicare Advantage plan to get better drug coverage.
D. He should appeal the decision regarding the low-income subsidy. Correct answer: B. He
could check with the manufacturers of his medications to see if they offer an assistance
program to help people with limited means obtain the medications they need.
Alternatively, he could check to see whether his state has a pharmacy assistance program
to help him with his expenses.
Rationale: Beneficiaries who do not qualify for the Low-Income Subsidy (LIS/Extra Help) may
still find assistance through pharmaceutical manufacturer patient assistance programs or state
pharmacy assistance programs (SPAPs). These programs can help reduce out-of-pocket costs for
D
medications.
O
8. Which of the following is true about Medicare Part A? A. It covers outpatient
services and physician visits.
N
B. It is premium-free for most beneficiaries who have worked at least 40 quarters.
O
C. It covers prescription drugs.
T
D. It is only available to individuals over age 70.
C
Correct answer: B. It is premium-free for most beneficiaries who have worked at least 40
quarters.
O
Rationale: Medicare Part A (Hospital Insurance) covers inpatient hospital stays, skilled nursing
PY
facility care, hospice, and some home health care. Most beneficiaries receive Part A premium-free
if they or their spouse paid Medicare taxes for at least 40 quarters (10 years).
9. Which of the following is true about Medicare Part B? A. It covers inpatient
hospital stays.
B. It covers outpatient services, physician visits, and preventive services.
C. It is always premium-free.
D. It covers prescription drugs.
Correct answer: B. It covers outpatient services, physician visits, and preventive services.
Rationale: Medicare Part B (Medical Insurance) covers outpatient care, doctor visits, preventive
services, durable medical equipment (DME), and some home health care.
10. What is the Initial Enrollment Period (IEP) for Medicare? A. A 3-month period before
the month of the 65th birthday.
