Page 1 of 76
AHIP 2025/2026 Final Exam Updated 250+ Questions and Verified
Answers, 100% Guarantee Pass
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know
which of the following services Original Medicare will cover if the appropriate criteria are met. What
could you tell her? - Answer: Original Medicare covers ambulance services.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare
Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for
services. What advice would you give her? - Answer: Mrs. Duarte should file an appeal of this initial
determination within 120 days of the date she received the MSN in the mail.
Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare
enrollment period because the features of Part D might have changed. Mrs. Geisler can't remember
what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? -
Answer: Part D covers prescription drugs and she should look at her premiums, formulary, and cost-
sharing among other factors to see if they have changed.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that
might be of assistance? - Answer: She should contact her state Medicaid agency to see if she qualifies
for one of several programs that can help with Medicare costs for which she is responsible.
Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin receiving Social
Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she had been
automatically enrolled in Medicare Part B. She wants to understand what this means. What should you
tell Mrs. Quinn? - Answer: Part B primarily covers physician services. She will be paying a monthly
premium and, except for many preventive and screening tests, generally will have 20% co-payments for
these services, in addition to an annual deductible.
Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare Part A and Part
B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel
has told her about the Medigap Plan F in which he is enrolled. It not only provides foreign travel
emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What
should you tell her? - Answer: You are sorry to disappoint Anita, but a Medigap F plan is no longer
available to those who turn age 65 after January 1, 2020. Anita might instead consider other Medigap
plans that offer foreign travel benefits but do not cover the Part B deductible.
,Page 2 of 76
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan.
What should you tell him? - Answer: Mr. Singh can enroll in a stand-alone prescription drug plan and
continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare.
Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid
taxes during that entire period. She is concerned that she will not qualify for coverage under part A
because she was not born in the United States. What should you tell her? - Answer: Most individuals
who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes
while working, though some may be covered as a result of paying monthly premiums.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under
Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to
Medicare beneficiaries? - Answer: Beneficiaries under Original Medicare have no cost-sharing for most
preventive services.
Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he
would have certain services and items covered by the plan with minimal out-of-pocket costs because his
MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large
charges in excess of his maximum out-of-pocket limit that included some services and items he thought
would be fully covered. He called you to ask what he could do? What could you tell him? - Answer: You
can offer to review the plans appeal process to help him ask the plan to review the coverage decision.
Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three
plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include
drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug
coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug
plan. What should you tell him about this situation? - Answer: He could enroll either in one of the MA
plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone
Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone
prescription drug plan.
Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is not sure about
what type of plan designs are available through this program. What should you tell him about the types
of health plans that are available through the Medicare Advantage program? - Answer: There are
Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
,Page 3 of 76
Mr. Kelly wants to know whether he is eligible to sign up for a private fee-for-service (PFFS) plan. What
questions would you need to ask to determine his eligibility? - Answer: You would need to ask Mr. Kelly
if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area.
Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage.
What would be the correct description? - Answer: Medicare Advantage is a way of covering all the
Original Medicare benefits through private health insurance companies.
Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is
attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the
plan associated with the account will fit her needs. What specific piece of information about a Medicare
MSA plan would it be important for her to know, prior to enrolling in such a plan? - Answer: All MSAs
cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by
also enrolling in a separate prescription drug plan.
Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug
coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should
you tell her? - Answer: She could enroll in a PFFS plan and a stand-alone Medicare prescription drug
plan.
Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What
should you tell her? - Answer: Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in
Medicare Advantage.
Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan's terms and
conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan
charge? - Answer: Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the
PFFS plan's terms and condition of payment which may include balance billing up to 15%of the Medicare
rate.
Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage
previously available through her husband's employer. She is interested in enrolling in a Medicare Part D
prescription drug plan (PDP). What should you tell her? - Answer: If a Part D benefit is offered through
her plan she may choose to enroll in that plan or a standalone PDP.
Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help
paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know
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whether he might qualify. What should you tell him? - Answer: The extra help is available to
beneficiaries whose income and assets do not exceed annual limits specified by the government.
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a
prescription to help to regrow his hair. They are anxious to have their Medicare prescription drug plan
cover these drug needs. What should you tell them? - Answer: Medicare prescription drug plans are not
permitted to cover the prescription medications the Vaughns are interested in under Part D coverage,
however, plans may cover them as supplemental benefits and the Vaughns could look into that
possibility.
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic
reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What
could you tell him to do? - Answer: Mr. Zachow has a right to request a formulary exception to obtain
coverage for his Part D drug. He or his physician could obtain the standardized request form on the
plan's website, fill it out, and submit it to his plan.
Mr. Rice is 68, actively working, and has coverage for medical services and medications through his
employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B
and switching to an MA-PD because he is paying a very large part of his group coverage premium, and it
does not provide coverage for a number of his medications. Which of the following is NOT a
consideration when making the change? - Answer: Mr. Rice's retiree plan is required to take him back if,
within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his
Medicare Part D plan.
Who is most likely to benefit from the Medicare Prescription Payment Plan? - Answer: Kevin, who
suffered a heart attack at the beginning of the year requiring him to take an expensive brand name
blood thinner on a daily, as well as an equally expensive injectable cholesterol medication on a bi-
weekly basis for which he incurs high out-of-pocket costs.
Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an
automatic monthly withdrawal from his savings account until it is exhausted, and then have his
premiums withheld from his Social Security check. What should you tell him? - Answer: In general, he
must select a single Part D premium payment mechanism that will be used throughout the year.
Mr. Hildalgo complains to you that because he takes multiple expensive drugs, he has trouble paying his
cost sharing for his prescription drugs, particularly at the beginning of the year during the deductible
phase. He is happy with his plan and does not want to change. However, he said he had heard about a
new program called the Medicare Prescription Payment Plan and asked whether it might help. What do
AHIP 2025/2026 Final Exam Updated 250+ Questions and Verified
Answers, 100% Guarantee Pass
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like to know
which of the following services Original Medicare will cover if the appropriate criteria are met. What
could you tell her? - Answer: Original Medicare covers ambulance services.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare
Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for
services. What advice would you give her? - Answer: Mrs. Duarte should file an appeal of this initial
determination within 120 days of the date she received the MSN in the mail.
Mrs. Geisler's neighbor told her she should look at her Part D options during the annual Medicare
enrollment period because the features of Part D might have changed. Mrs. Geisler can't remember
what Part D is so she called you to ask what her neighbor was talking about. What could you tell her? -
Answer: Part D covers prescription drugs and she should look at her premiums, formulary, and cost-
sharing among other factors to see if they have changed.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park that
might be of assistance? - Answer: She should contact her state Medicaid agency to see if she qualifies
for one of several programs that can help with Medicare costs for which she is responsible.
Mrs. Quinn recently turned 66 and decided after many years of work to retire and begin receiving Social
Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she had been
automatically enrolled in Medicare Part B. She wants to understand what this means. What should you
tell Mrs. Quinn? - Answer: Part B primarily covers physician services. She will be paying a monthly
premium and, except for many preventive and screening tests, generally will have 20% co-payments for
these services, in addition to an annual deductible.
Anita Magri will turn age 65 in August 2023. Anita intends to enroll in Original Medicare Part A and Part
B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita's older neighbor Mel
has told her about the Medigap Plan F in which he is enrolled. It not only provides foreign travel
emergency benefits but also covers his Medicare Part B deductible. Anita comes to you for advice. What
should you tell her? - Answer: You are sorry to disappoint Anita, but a Medigap F plan is no longer
available to those who turn age 65 after January 1, 2020. Anita might instead consider other Medigap
plans that offer foreign travel benefits but do not cover the Part B deductible.
,Page 2 of 76
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage plan.
What should you tell him? - Answer: Mr. Singh can enroll in a stand-alone prescription drug plan and
continue to be covered for Part A and Part B services through Original Fee-for-Service Medicare.
Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and paid
taxes during that entire period. She is concerned that she will not qualify for coverage under part A
because she was not born in the United States. What should you tell her? - Answer: Most individuals
who are citizens and age 65 or over are covered under Part A by virtue of having paid Medicare taxes
while working, though some may be covered as a result of paying monthly premiums.
Mr. Xi will soon turn age 65 and has come to you for advice as to what services are provided under
Original Medicare. What should you tell Mr. Xi that best describes the health coverage provided to
Medicare beneficiaries? - Answer: Beneficiaries under Original Medicare have no cost-sharing for most
preventive services.
Mr. Barker enjoys a comfortable retirement income. He recently had surgery and expected that he
would have certain services and items covered by the plan with minimal out-of-pocket costs because his
MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large
charges in excess of his maximum out-of-pocket limit that included some services and items he thought
would be fully covered. He called you to ask what he could do? What could you tell him? - Answer: You
can offer to review the plans appeal process to help him ask the plan to review the coverage decision.
Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three
plans operated by the same organization in Mr. Lombardi's area. The MA PPO plan does not include
drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug
coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug
plan. What should you tell him about this situation? - Answer: He could enroll either in one of the MA
plans that include prescription drug coverage or Original Medicare with a Medigap plan and standalone
Part D prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone
prescription drug plan.
Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is not sure about
what type of plan designs are available through this program. What should you tell him about the types
of health plans that are available through the Medicare Advantage program? - Answer: There are
Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
,Page 3 of 76
Mr. Kelly wants to know whether he is eligible to sign up for a private fee-for-service (PFFS) plan. What
questions would you need to ask to determine his eligibility? - Answer: You would need to ask Mr. Kelly
if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area.
Mr. Wells is trying to understand the difference between Original Medicare and Medicare Advantage.
What would be the correct description? - Answer: Medicare Advantage is a way of covering all the
Original Medicare benefits through private health insurance companies.
Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is
attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the
plan associated with the account will fit her needs. What specific piece of information about a Medicare
MSA plan would it be important for her to know, prior to enrolling in such a plan? - Answer: All MSAs
cover Part A and Part B benefits, but not Part D prescription drug benefits, which could be obtained by
also enrolling in a separate prescription drug plan.
Mrs. Chou likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug
coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should
you tell her? - Answer: She could enroll in a PFFS plan and a stand-alone Medicare prescription drug
plan.
Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage. What
should you tell her? - Answer: Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in
Medicare Advantage.
Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan's terms and
conditions for payment. Mary Rodgers sees Dr. Brennan for treatment. How much may Dr. Brennan
charge? - Answer: Dr. Brennan can charge Mary Rogers no more than the cost sharing specified in the
PFFS plan's terms and condition of payment which may include balance billing up to 15%of the Medicare
rate.
Mrs. Lopez is enrolled in a cost plan for her Medicare benefits. She has recently lost creditable coverage
previously available through her husband's employer. She is interested in enrolling in a Medicare Part D
prescription drug plan (PDP). What should you tell her? - Answer: If a Part D benefit is offered through
her plan she may choose to enroll in that plan or a standalone PDP.
Mr. Shapiro gets by on a very small amount of fixed income. He has heard there may be extra help
paying for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know
, Page 4 of 76
whether he might qualify. What should you tell him? - Answer: The extra help is available to
beneficiaries whose income and assets do not exceed annual limits specified by the government.
Mr. and Mrs. Vaughn both take a specialized multivitamin prescription each day. Mr. Vaughn takes a
prescription to help to regrow his hair. They are anxious to have their Medicare prescription drug plan
cover these drug needs. What should you tell them? - Answer: Medicare prescription drug plans are not
permitted to cover the prescription medications the Vaughns are interested in under Part D coverage,
however, plans may cover them as supplemental benefits and the Vaughns could look into that
possibility.
Mr. Zachow has a condition for which three drugs are available. He has tried two but had an allergic
reaction to them. Only the third drug works for him and it is not on his Part D plan's formulary. What
could you tell him to do? - Answer: Mr. Zachow has a right to request a formulary exception to obtain
coverage for his Part D drug. He or his physician could obtain the standardized request form on the
plan's website, fill it out, and submit it to his plan.
Mr. Rice is 68, actively working, and has coverage for medical services and medications through his
employer's group health plan. He is entitled to premium free Part A and thinking of enrolling in Part B
and switching to an MA-PD because he is paying a very large part of his group coverage premium, and it
does not provide coverage for a number of his medications. Which of the following is NOT a
consideration when making the change? - Answer: Mr. Rice's retiree plan is required to take him back if,
within 63 days of having voluntarily quit the employer's plan, he decides that he prefers it to his
Medicare Part D plan.
Who is most likely to benefit from the Medicare Prescription Payment Plan? - Answer: Kevin, who
suffered a heart attack at the beginning of the year requiring him to take an expensive brand name
blood thinner on a daily, as well as an equally expensive injectable cholesterol medication on a bi-
weekly basis for which he incurs high out-of-pocket costs.
Mr. Torres has a small savings account. He would like to pay for his monthly Part D premiums with an
automatic monthly withdrawal from his savings account until it is exhausted, and then have his
premiums withheld from his Social Security check. What should you tell him? - Answer: In general, he
must select a single Part D premium payment mechanism that will be used throughout the year.
Mr. Hildalgo complains to you that because he takes multiple expensive drugs, he has trouble paying his
cost sharing for his prescription drugs, particularly at the beginning of the year during the deductible
phase. He is happy with his plan and does not want to change. However, he said he had heard about a
new program called the Medicare Prescription Payment Plan and asked whether it might help. What do
