AHIP Final Exam 2025/2026 – Updated
Questions and Revised Answers | 100%
Guarantee Pass
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?
You can offer to review the plans appeal process to help him ask the plan to review the coverage
decision.
Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree
group health plan that includes drug coverage with nominal copays. He heard about a
neighbor's MA-PD plan that you represent and because he takes numerous prescription
drugs, he is considering signing up for it. What should you tell him?
He should compare the benefits in his employer-sponsored retiree group health plan with the
benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage
for his prescription needs.
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at
severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is
likely to be most appropriate for him?
C-SNP
Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes
to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have
prescription drug coverage since her doctor recently prescribed several expensive
medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan.
How would you advise Mrs. Chi?
,Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription
drug plan.
Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his
investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His
friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco
would like to join that plan. What should you tell him?
SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he
is unlikely to qualify and would not be able to enroll in the SNP.
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has
received under Original Medicare, but he would like to know more about Medicare
Advantage Special Needs Plans (SNPs). What could you tell him?
SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they
provide prescription drug coverage that could be very helpful as well.
Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was
disappointed with the service she received from her primary care physician because she was
told she would have to wait five weeks to get an appointment when she was feeling ill. She
called you to ask what she could do so she would not have to put up with such poor access to
care. What could you tell her?
She could file a grievance with her plan to complain about the lack of timeliness in getting an
appointment.
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently
stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to
enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell
him?
He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.
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?
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.
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?
,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.
Ms. Gibson recently lost her employer group health and drug coverage and now she wants to
enroll in a PPO that does not include drug coverage. What should you tell her about obtaining
drug coverage?
She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D
prescription drug plan.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an
attractive premium. He wants to know if he must use doctors in a network as his current HMO
plan requires him to do. What should you tell him?
He may receive health care services from any doctor allowed to bill Medicare, as long as he
shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's
payment terms and conditions, which could include balance billing.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which
providers she can go to for her health care. What should you tell her?
Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but
generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of
the PPO network.
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?
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.
Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA)
Plans?
MSAs may have either a partial network, full network, or no network of providers. MSA plans
cover Part A and Part B benefits but not Part D prescription drug benefits. Non-network
providers must accept the same amount that Original Medicare would pay them as payment in
full.
, Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her?
Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.
Mrs. Wang wants to know generally how the benefits under Original Medicare might compare
to the benefits package of a Medicare Advantage Plan before she starts looking at specific
plans. What could you tell her?
Medicare Advantage Plans do not necessarily have to cover all of the Original Medicare Part A
and Part B services but must include a maximum out-of-pocket limit.
Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty
years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap
Incorporated and contributed to the Medicare system. Juan suffers from diabetes. He will
soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent.
How would you respond?
Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled
in Part B. Juan should go to the Social Security website to enroll in Medicare Part A and B if he
has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan.
Mr. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be the correct description?
Medicare Advantage is a way of covering all the Original Medicare benefits through private
health insurance companies.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him?
In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from
providers within the plan's network (except in an emergency or where care is unavailable within
the network).
Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses
no medications and sees no reason to spend money on a Medicare prescription drug plan if
she does not need the coverage. She currently does not have creditable coverage. What could
you tell her about the implications of such a decision?
If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so,
and if she does sign up at a later date, her premium will be permanently increased by 1% of the
national average premium for every month that she was not covered.
Questions and Revised Answers | 100%
Guarantee Pass
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?
You can offer to review the plans appeal process to help him ask the plan to review the coverage
decision.
Mr. Romero is 64, retiring soon, and considering enrollment in his employer-sponsored retiree
group health plan that includes drug coverage with nominal copays. He heard about a
neighbor's MA-PD plan that you represent and because he takes numerous prescription
drugs, he is considering signing up for it. What should you tell him?
He should compare the benefits in his employer-sponsored retiree group health plan with the
benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage
for his prescription needs.
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at
severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is
likely to be most appropriate for him?
C-SNP
Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level. She wishes
to enroll in a MA MSA plan that she heard about from her neighbor. She also wants to have
prescription drug coverage since her doctor recently prescribed several expensive
medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan.
How would you advise Mrs. Chi?
,Mrs. Chi may enroll in a MA MSA plan and remain in her current standalone Part D prescription
drug plan.
Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his
investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His
friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco
would like to join that plan. What should you tell him?
SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he
is unlikely to qualify and would not be able to enroll in the SNP.
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has
received under Original Medicare, but he would like to know more about Medicare
Advantage Special Needs Plans (SNPs). What could you tell him?
SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they
provide prescription drug coverage that could be very helpful as well.
Mrs. Burton is a retiree with substantial income. She is enrolled in an MA-PD plan and was
disappointed with the service she received from her primary care physician because she was
told she would have to wait five weeks to get an appointment when she was feeling ill. She
called you to ask what she could do so she would not have to put up with such poor access to
care. What could you tell her?
She could file a grievance with her plan to complain about the lack of timeliness in getting an
appointment.
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently
stopped paying his Part B premium. Mr. Castillo is still covered by Part A. He would like to
enroll in a Medicare Advantage (MA) plan and is still covered by Part A. What should you tell
him?
He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare Part B.
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?
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.
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?
,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.
Ms. Gibson recently lost her employer group health and drug coverage and now she wants to
enroll in a PPO that does not include drug coverage. What should you tell her about obtaining
drug coverage?
She can enroll in the PPO, but she will not be able to purchase a stand-alone Medicare Part D
prescription drug plan.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an
attractive premium. He wants to know if he must use doctors in a network as his current HMO
plan requires him to do. What should you tell him?
He may receive health care services from any doctor allowed to bill Medicare, as long as he
shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's
payment terms and conditions, which could include balance billing.
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which
providers she can go to for her health care. What should you tell her?
Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but
generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of
the PPO network.
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?
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.
Which of the following statement(s) is/are correct about a Medicare Savings Account (MSA)
Plans?
MSAs may have either a partial network, full network, or no network of providers. MSA plans
cover Part A and Part B benefits but not Part D prescription drug benefits. Non-network
providers must accept the same amount that Original Medicare would pay them as payment in
full.
, Mrs. Radford asks whether there are any special eligibility requirements for Medicare
Advantage. What should you tell her?
Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare Advantage.
Mrs. Wang wants to know generally how the benefits under Original Medicare might compare
to the benefits package of a Medicare Advantage Plan before she starts looking at specific
plans. What could you tell her?
Medicare Advantage Plans do not necessarily have to cover all of the Original Medicare Part A
and Part B services but must include a maximum out-of-pocket limit.
Juan Hernandez is turning 65 next month, Juan legally entered the United States over twenty
years ago but is not a citizen. Since his entry into the country, Juan has worked at Smallcap
Incorporated and contributed to the Medicare system. Juan suffers from diabetes. He will
soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent.
How would you respond?
Juan is eligible to enroll in a Medicare Advantage as long as he is entitled to Part A and enrolled
in Part B. Juan should go to the Social Security website to enroll in Medicare Part A and B if he
has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan.
Mr. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be the correct description?
Medicare Advantage is a way of covering all the Original Medicare benefits through private
health insurance companies.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to
access providers. What should you tell him?
In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from
providers within the plan's network (except in an emergency or where care is unavailable within
the network).
Mrs. Quinn has just turned 65, is in excellent health and has a relatively high income. She uses
no medications and sees no reason to spend money on a Medicare prescription drug plan if
she does not need the coverage. She currently does not have creditable coverage. What could
you tell her about the implications of such a decision?
If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so,
and if she does sign up at a later date, her premium will be permanently increased by 1% of the
national average premium for every month that she was not covered.
