AHIP-style Practice AHIP Final Exam Test
Questions & Answers | Verified and 100%
Correct | A+ Graded | Latest 2025/2026
Edition
(Question → Answer → Brief rationale/explanation)
1. Q: Which program primarily provides hospital insurance for people age 65+ and certain
disabled individuals?
A: Medicare Part A.
Rationale: Part A covers inpatient hospital, skilled nursing (limited), hospice, and some
home health.
2. Q: Which part of Medicare covers physician services and outpatient care?
A: Medicare Part B.
Rationale: Part B funds physician visits, outpatient services, preventive services, and
medical supplies.
3. Q: Medicare Part D covers which of the following? (A) Hospital stays (B) Prescription
drugs (C) Long-term custodial care
A: (B) Prescription drugs.
Rationale: Part D is the outpatient prescription drug benefit.
4. Q: What is the “Initial Enrollment Period” for Medicare?
A: 7-month period: 3 months before the month of turning 65, month turning 65,
and 3 months after.
Rationale: Standard IEP timing for initial Medicare eligibility.
5. Q: If a beneficiary delays Part B beyond the IEP but has qualifying employer coverage,
which enrollment period applies when that coverage ends?
A: Special Enrollment Period (SEP).
Rationale: SEP allows Part B enrollment without penalty when employer coverage ends.
6. Q: Which Medicare plan type combines Part A, Part B, and usually Part D into one plan
offered by private companies?
A: Medicare Advantage (Part C).
Rationale: MA plans are alternative coverage delivered by private insurers.
,7. Q: A Medicare Advantage plan may require prior authorization for a service. This is an
example of which managed care tool?
A: Utilization management (prior authorization).
Rationale: Prior auth is a utilization review method to control services.
8. Q: Which form is used to enroll in a Medicare Prescription Drug Plan (Part D)?
A: CMS-accepted enrollment forms or online enrollment (Form varies by carrier),
commonly via plan enrollment application.
Rationale: Enrollment uses the plan’s application or Medicare.gov enrollment channels.
9. Q: What is the Medicare “donut hole” (coverage gap) primarily associated with?
A: Part D prescription drug benefit coverage gap where beneficiaries face higher
cost-sharing after reaching a spending threshold (structure updated by law).
Rationale: The gap refers to the drug spending phase between initial coverage and
catastrophic coverage.
10.Q: True or False — A licensed agent may contact a Medicare beneficiary at any time to
discuss plans.
A: False.
Rationale: Contact must follow marketing rules, consent, and no unsolicited
door-to-door or cold calls in restricted circumstances.
11.Q: Which of these is an example of prohibited marketing activity for Medicare
Advantage? (A) Calling members without prior relationship after opt-in (B) Unsolicited
in-home visits to enroll beneficiaries
A: (B) Unsolicited in-home visits to enroll beneficiaries.
Rationale: In-home solicitation without appointment is prohibited; (A) could be allowed if
consented.
12.Q: Which entity administers Medicare nationwide?
A: Centers for Medicare & Medicaid Services (CMS).
Rationale: CMS manages Medicare program rules and payments.
13.Q: What is the purpose of a Medicare Summary Notice (MSN) or Explanation of Benefits
(EOB)?
A: To inform beneficiaries about services billed, paid, denied, and any cost
sharing.
Rationale: It explains claims processing and patient financial responsibility.
14.Q: A Medicare beneficiary has both Medicare and Medicaid. Which program pays first for
Medicare-covered services?
A: Medicare pays first; Medicaid may pay remaining costs.
Rationale: Medicare is primary for dual-eligibles for Medicare-covered services.
, 15.Q: What is an Advance Beneficiary Notice (ABN) used for?
A: To notify a Medicare beneficiary when a service may be denied by Medicare
and the beneficiary may be financially responsible.
Rationale: ABN documents potential noncoverage and beneficiary choice.
16.Q: Which term refers to fraudulent claims or actions that result in unnecessary Medicare
payments?
A: Fraud (and Abuse).
Rationale: Fraud = intentional deception causing unauthorized benefit; abuse =
improper but not necessarily intentional.
17.Q: Under Medicare, which type of care is generally not covered: (A) Custodial long-term
care (B) Skilled nursing for rehabilitative needs
A: (A) Custodial long-term care.
Rationale: Custodial personal care is generally excluded; skilled needs may be covered
short term.
18.Q: What is the maximum enrollment period for Annual Election Period (AEP) for
Medicare Advantage and Part D?
A: October 15 – December 7 (annual).
Rationale: Standard AEP window each year.
19.Q: Which document should plans provide to new members to explain benefits, coverage
rules, and rights?
A: Evidence of Coverage (EOC) / Member Handbook.
Rationale: EOC contains benefits, rules, and member rights.
20.Q: Which act strengthened penalties for health care fraud and created compliance
program expectations (HIPAA, False Claims Act are part of framework)?
A: False Claims Act (FCA) and other statutes; HIPAA addresses privacy/security.
Rationale: FCA, HIPAA, and related laws help combat healthcare fraud; compliance
programs help detect/prevent.
21.Q: What does “dual eligible” mean?
A: An individual eligible for both Medicare and Medicaid.
Rationale: Dual-eligibles receive benefits under both programs.
22.Q: A beneficiary chooses a Medicare Advantage plan during AEP and the plan receives
the enrollment by Dec 7. Coverage begins on:
A: January 1 of the next year.
Rationale: AEP enrollments effective Jan 1.
23.Q: In Part D, what is the Low-Income Subsidy (LIS) intended to do?
A: Reduce premiums, deductibles, and cost sharing for low-income beneficiaries.
Questions & Answers | Verified and 100%
Correct | A+ Graded | Latest 2025/2026
Edition
(Question → Answer → Brief rationale/explanation)
1. Q: Which program primarily provides hospital insurance for people age 65+ and certain
disabled individuals?
A: Medicare Part A.
Rationale: Part A covers inpatient hospital, skilled nursing (limited), hospice, and some
home health.
2. Q: Which part of Medicare covers physician services and outpatient care?
A: Medicare Part B.
Rationale: Part B funds physician visits, outpatient services, preventive services, and
medical supplies.
3. Q: Medicare Part D covers which of the following? (A) Hospital stays (B) Prescription
drugs (C) Long-term custodial care
A: (B) Prescription drugs.
Rationale: Part D is the outpatient prescription drug benefit.
4. Q: What is the “Initial Enrollment Period” for Medicare?
A: 7-month period: 3 months before the month of turning 65, month turning 65,
and 3 months after.
Rationale: Standard IEP timing for initial Medicare eligibility.
5. Q: If a beneficiary delays Part B beyond the IEP but has qualifying employer coverage,
which enrollment period applies when that coverage ends?
A: Special Enrollment Period (SEP).
Rationale: SEP allows Part B enrollment without penalty when employer coverage ends.
6. Q: Which Medicare plan type combines Part A, Part B, and usually Part D into one plan
offered by private companies?
A: Medicare Advantage (Part C).
Rationale: MA plans are alternative coverage delivered by private insurers.
,7. Q: A Medicare Advantage plan may require prior authorization for a service. This is an
example of which managed care tool?
A: Utilization management (prior authorization).
Rationale: Prior auth is a utilization review method to control services.
8. Q: Which form is used to enroll in a Medicare Prescription Drug Plan (Part D)?
A: CMS-accepted enrollment forms or online enrollment (Form varies by carrier),
commonly via plan enrollment application.
Rationale: Enrollment uses the plan’s application or Medicare.gov enrollment channels.
9. Q: What is the Medicare “donut hole” (coverage gap) primarily associated with?
A: Part D prescription drug benefit coverage gap where beneficiaries face higher
cost-sharing after reaching a spending threshold (structure updated by law).
Rationale: The gap refers to the drug spending phase between initial coverage and
catastrophic coverage.
10.Q: True or False — A licensed agent may contact a Medicare beneficiary at any time to
discuss plans.
A: False.
Rationale: Contact must follow marketing rules, consent, and no unsolicited
door-to-door or cold calls in restricted circumstances.
11.Q: Which of these is an example of prohibited marketing activity for Medicare
Advantage? (A) Calling members without prior relationship after opt-in (B) Unsolicited
in-home visits to enroll beneficiaries
A: (B) Unsolicited in-home visits to enroll beneficiaries.
Rationale: In-home solicitation without appointment is prohibited; (A) could be allowed if
consented.
12.Q: Which entity administers Medicare nationwide?
A: Centers for Medicare & Medicaid Services (CMS).
Rationale: CMS manages Medicare program rules and payments.
13.Q: What is the purpose of a Medicare Summary Notice (MSN) or Explanation of Benefits
(EOB)?
A: To inform beneficiaries about services billed, paid, denied, and any cost
sharing.
Rationale: It explains claims processing and patient financial responsibility.
14.Q: A Medicare beneficiary has both Medicare and Medicaid. Which program pays first for
Medicare-covered services?
A: Medicare pays first; Medicaid may pay remaining costs.
Rationale: Medicare is primary for dual-eligibles for Medicare-covered services.
, 15.Q: What is an Advance Beneficiary Notice (ABN) used for?
A: To notify a Medicare beneficiary when a service may be denied by Medicare
and the beneficiary may be financially responsible.
Rationale: ABN documents potential noncoverage and beneficiary choice.
16.Q: Which term refers to fraudulent claims or actions that result in unnecessary Medicare
payments?
A: Fraud (and Abuse).
Rationale: Fraud = intentional deception causing unauthorized benefit; abuse =
improper but not necessarily intentional.
17.Q: Under Medicare, which type of care is generally not covered: (A) Custodial long-term
care (B) Skilled nursing for rehabilitative needs
A: (A) Custodial long-term care.
Rationale: Custodial personal care is generally excluded; skilled needs may be covered
short term.
18.Q: What is the maximum enrollment period for Annual Election Period (AEP) for
Medicare Advantage and Part D?
A: October 15 – December 7 (annual).
Rationale: Standard AEP window each year.
19.Q: Which document should plans provide to new members to explain benefits, coverage
rules, and rights?
A: Evidence of Coverage (EOC) / Member Handbook.
Rationale: EOC contains benefits, rules, and member rights.
20.Q: Which act strengthened penalties for health care fraud and created compliance
program expectations (HIPAA, False Claims Act are part of framework)?
A: False Claims Act (FCA) and other statutes; HIPAA addresses privacy/security.
Rationale: FCA, HIPAA, and related laws help combat healthcare fraud; compliance
programs help detect/prevent.
21.Q: What does “dual eligible” mean?
A: An individual eligible for both Medicare and Medicaid.
Rationale: Dual-eligibles receive benefits under both programs.
22.Q: A beneficiary chooses a Medicare Advantage plan during AEP and the plan receives
the enrollment by Dec 7. Coverage begins on:
A: January 1 of the next year.
Rationale: AEP enrollments effective Jan 1.
23.Q: In Part D, what is the Low-Income Subsidy (LIS) intended to do?
A: Reduce premiums, deductibles, and cost sharing for low-income beneficiaries.
