2025 AHIP FINAL EXAM
COMPREHENSIVE REVIEW AND
STUDY GUIDE: MEDICARE
TRAINING, ETHICS, AND
COMPLIANCE MASTERY
Mr. Langley just turned 65 and has worked for 35 years paying Medicare taxes. He wants to
know if he qualifies for premium-free Part A coverage.
A) No, he must pay full premiums because only federal employees qualify.
B) No, he must pay premiums unless he is currently receiving Social Security.
C) Yes, he qualifies for premium-free Part A because he paid Medicare taxes for at least 10
years.
D) Yes, but only if he enrolls in a Medicare Advantage plan.
Rationale: Individuals with 40 quarters (10 years) of Medicare-covered employment qualify for
premium-free Part A. Options A and D are incorrect—federal employment or Advantage
enrollment are not requirements. Option B is wrong because receiving Social Security is not
mandatory to qualify.
Ms. Carter is 67 and recently retired. She delayed enrolling in Part B because she had employer
coverage. She now wants to enroll. What should you tell her?
A) She must wait for the next General Enrollment Period and pay a penalty.
B) She can enroll anytime within eight months after her employer coverage ends.
C) She can enroll during a Special Enrollment Period lasting eight months after losing
employer coverage.
D) She can only enroll during the Open Enrollment Period in October.
Rationale: A Special Enrollment Period allows penalty-free Part B enrollment within 8 months
after employer coverage ends. The General Enrollment Period (A) applies only if this window is
missed.
Mr. Jenkins is 70 and has both Medicare and Medicaid. Which of the following statements is
true?
A) He must choose between Medicare and Medicaid for coverage.
B) Medicare pays first, and Medicaid covers remaining eligible costs.
C) Medicaid always pays first for hospital stays.
,D) Medicaid replaces Medicare coverage entirely.
Rationale: For dual-eligible beneficiaries, Medicare pays primary and Medicaid pays secondary.
Medicaid never replaces Medicare.
Mrs. Howard wants to know what services Medicare Part B covers.
A) Inpatient hospital care and skilled nursing
B) Hospice care and home health services
C) Outpatient medical services, doctor visits, and preventive care
D) Long-term custodial care
Rationale: Part B covers outpatient and preventive services. Inpatient and hospice are Part A.
Long-term care is not covered by Medicare.
Mr. O’Neill enrolled in a Medicare Advantage plan but wants to return to Original Medicare
during the year. When can he do this?
A) Anytime he chooses
B) Only during the first month after joining
C) During the Annual Election Period (Oct 15–Dec 7)
D) Only if he moves out of his plan’s service area
Rationale: Beneficiaries can switch between Medicare Advantage and Original Medicare during
the Annual Election Period or if they qualify for a Special Enrollment Period (e.g., moving out of
area).
Mrs. Vega is enrolled in Medicare Part D. She wants to know what the “donut hole” means.
A) The period when she cannot get any medications
B) The time when only generics are covered
C) A temporary coverage gap where she pays a higher share of drug costs
D) The deductible period before coverage begins
Rationale: The “donut hole” refers to the coverage gap phase in Part D when beneficiaries pay a
higher percentage of drug costs until catastrophic coverage starts.
Mr. Flores has chronic heart failure and diabetes. Which Medicare Advantage plan would best
meet his needs?
A) PFFS Plan
B) MSA Plan
C) Chronic Condition Special Needs Plan (C-SNP)
D) PPO Plan
Rationale: C-SNPs are tailored for beneficiaries with specific chronic conditions such as
diabetes or heart failure. The other plans are general options without specialized management.
,Mrs. Turner missed her Medicare Part D Initial Enrollment Period and has no creditable drug
coverage. What happens when she enrolls late?
A) She must wait two years to join
B) She can enroll but pay a higher Part D deductible
C) She will pay a lifetime late enrollment penalty added to her Part D premium
D) She loses Part D eligibility permanently
Rationale: The late enrollment penalty applies to those without creditable coverage for 63+ days
after eligibility. It is an ongoing premium surcharge.
Mr. Patel is covered under a Medicare Advantage plan that includes prescription drugs (MA-
PD). He also wants to buy a separate Part D plan. What should you tell him?
A) It is encouraged to enhance coverage
B) He cannot enroll in a stand-alone Part D plan if he already has an MA-PD plan
C) He can only do so if both plans are from the same company
D) He can enroll in both only during the Open Enrollment Period
Rationale: Enrolling in both an MA-PD and a separate Part D plan is not allowed because the
MA-PD already includes drug coverage.
Ms. Novak has a Medicare Advantage PPO plan and wants to see a specialist who is not in her
network. What should you tell her?
A) She cannot see out-of-network doctors under any condition
B) She must switch to Original Medicare to see that doctor
C) She can see the doctor but may pay higher cost-sharing for out-of-network care
D) She can see any doctor at no additional cost
Rationale: PPO plans allow out-of-network care but with higher cost-sharing. Only HMOs
typically restrict care to network providers.
Mr. Han is 66 and still working. His employer provides health insurance for all employees
regardless of age. He is wondering whether to sign up for Medicare Part B. What should you tell
him?
A) He must enroll immediately or pay a late penalty later.
B) He can delay enrolling in Part B without penalty as long as he has active employer
coverage.
C) He should decline both Part A and Part B until he retires.
D) He can only sign up during the General Enrollment Period in January.
Rationale: Individuals with active employer coverage may delay Part B without penalty. Option
A is incorrect since penalties apply only when employer coverage ends.
, Mrs. Clark recently turned 65 and was automatically enrolled in Medicare Part A and Part B
because she was already receiving Social Security benefits. She doesn’t want Part B. What can
she do?
A) She can decline Part B coverage by following the instructions that come with her
Medicare card.
B) She must keep Part B until next year’s Open Enrollment.
C) She can only cancel Part B coverage through her employer.
D) She must pay the Part B premium for at least six months before canceling.
Rationale: Beneficiaries automatically enrolled in Part B can opt out by contacting Social
Security before coverage begins. There’s no mandatory payment period.
Mr. Lopez just retired at age 65 and is deciding between Original Medicare and a Medicare
Advantage plan. What is a key difference?
A) Medicare Advantage plans are administered directly by the government.
B) Medicare Advantage plans are offered by private companies and may include extra
benefits like dental or vision.
C) Original Medicare covers prescription drugs automatically.
D) Medicare Advantage plans never require provider networks.
Rationale: Medicare Advantage (Part C) is offered by private insurers and may include
additional benefits. Original Medicare is government-administered and doesn’t include drug
coverage.
Mrs. Patel enrolled in a Medicare Part D plan but later realized her medications were not
covered. What should she do?
A) She must wait until next year to switch plans.
B) She can request a formulary exception or change plans during the next Open
Enrollment Period.
C) She can add another Part D plan to cover those drugs.
D) She should cancel her current plan immediately.
Rationale: Beneficiaries can request a formulary exception or switch plans during the Annual
Election Period. Holding two Part D plans simultaneously is not allowed.
Mr. and Mrs. Roberts are both on Medicare and travel frequently throughout the U.S. Which
type of plan would offer them the greatest flexibility in choosing providers?
A) HMO
B) PPO
C) SNP
D) MSA
Rationale: PPO plans allow members to use any provider nationwide that accepts Medicare,
though out-of-network care costs more. HMOs restrict care to network providers.
COMPREHENSIVE REVIEW AND
STUDY GUIDE: MEDICARE
TRAINING, ETHICS, AND
COMPLIANCE MASTERY
Mr. Langley just turned 65 and has worked for 35 years paying Medicare taxes. He wants to
know if he qualifies for premium-free Part A coverage.
A) No, he must pay full premiums because only federal employees qualify.
B) No, he must pay premiums unless he is currently receiving Social Security.
C) Yes, he qualifies for premium-free Part A because he paid Medicare taxes for at least 10
years.
D) Yes, but only if he enrolls in a Medicare Advantage plan.
Rationale: Individuals with 40 quarters (10 years) of Medicare-covered employment qualify for
premium-free Part A. Options A and D are incorrect—federal employment or Advantage
enrollment are not requirements. Option B is wrong because receiving Social Security is not
mandatory to qualify.
Ms. Carter is 67 and recently retired. She delayed enrolling in Part B because she had employer
coverage. She now wants to enroll. What should you tell her?
A) She must wait for the next General Enrollment Period and pay a penalty.
B) She can enroll anytime within eight months after her employer coverage ends.
C) She can enroll during a Special Enrollment Period lasting eight months after losing
employer coverage.
D) She can only enroll during the Open Enrollment Period in October.
Rationale: A Special Enrollment Period allows penalty-free Part B enrollment within 8 months
after employer coverage ends. The General Enrollment Period (A) applies only if this window is
missed.
Mr. Jenkins is 70 and has both Medicare and Medicaid. Which of the following statements is
true?
A) He must choose between Medicare and Medicaid for coverage.
B) Medicare pays first, and Medicaid covers remaining eligible costs.
C) Medicaid always pays first for hospital stays.
,D) Medicaid replaces Medicare coverage entirely.
Rationale: For dual-eligible beneficiaries, Medicare pays primary and Medicaid pays secondary.
Medicaid never replaces Medicare.
Mrs. Howard wants to know what services Medicare Part B covers.
A) Inpatient hospital care and skilled nursing
B) Hospice care and home health services
C) Outpatient medical services, doctor visits, and preventive care
D) Long-term custodial care
Rationale: Part B covers outpatient and preventive services. Inpatient and hospice are Part A.
Long-term care is not covered by Medicare.
Mr. O’Neill enrolled in a Medicare Advantage plan but wants to return to Original Medicare
during the year. When can he do this?
A) Anytime he chooses
B) Only during the first month after joining
C) During the Annual Election Period (Oct 15–Dec 7)
D) Only if he moves out of his plan’s service area
Rationale: Beneficiaries can switch between Medicare Advantage and Original Medicare during
the Annual Election Period or if they qualify for a Special Enrollment Period (e.g., moving out of
area).
Mrs. Vega is enrolled in Medicare Part D. She wants to know what the “donut hole” means.
A) The period when she cannot get any medications
B) The time when only generics are covered
C) A temporary coverage gap where she pays a higher share of drug costs
D) The deductible period before coverage begins
Rationale: The “donut hole” refers to the coverage gap phase in Part D when beneficiaries pay a
higher percentage of drug costs until catastrophic coverage starts.
Mr. Flores has chronic heart failure and diabetes. Which Medicare Advantage plan would best
meet his needs?
A) PFFS Plan
B) MSA Plan
C) Chronic Condition Special Needs Plan (C-SNP)
D) PPO Plan
Rationale: C-SNPs are tailored for beneficiaries with specific chronic conditions such as
diabetes or heart failure. The other plans are general options without specialized management.
,Mrs. Turner missed her Medicare Part D Initial Enrollment Period and has no creditable drug
coverage. What happens when she enrolls late?
A) She must wait two years to join
B) She can enroll but pay a higher Part D deductible
C) She will pay a lifetime late enrollment penalty added to her Part D premium
D) She loses Part D eligibility permanently
Rationale: The late enrollment penalty applies to those without creditable coverage for 63+ days
after eligibility. It is an ongoing premium surcharge.
Mr. Patel is covered under a Medicare Advantage plan that includes prescription drugs (MA-
PD). He also wants to buy a separate Part D plan. What should you tell him?
A) It is encouraged to enhance coverage
B) He cannot enroll in a stand-alone Part D plan if he already has an MA-PD plan
C) He can only do so if both plans are from the same company
D) He can enroll in both only during the Open Enrollment Period
Rationale: Enrolling in both an MA-PD and a separate Part D plan is not allowed because the
MA-PD already includes drug coverage.
Ms. Novak has a Medicare Advantage PPO plan and wants to see a specialist who is not in her
network. What should you tell her?
A) She cannot see out-of-network doctors under any condition
B) She must switch to Original Medicare to see that doctor
C) She can see the doctor but may pay higher cost-sharing for out-of-network care
D) She can see any doctor at no additional cost
Rationale: PPO plans allow out-of-network care but with higher cost-sharing. Only HMOs
typically restrict care to network providers.
Mr. Han is 66 and still working. His employer provides health insurance for all employees
regardless of age. He is wondering whether to sign up for Medicare Part B. What should you tell
him?
A) He must enroll immediately or pay a late penalty later.
B) He can delay enrolling in Part B without penalty as long as he has active employer
coverage.
C) He should decline both Part A and Part B until he retires.
D) He can only sign up during the General Enrollment Period in January.
Rationale: Individuals with active employer coverage may delay Part B without penalty. Option
A is incorrect since penalties apply only when employer coverage ends.
, Mrs. Clark recently turned 65 and was automatically enrolled in Medicare Part A and Part B
because she was already receiving Social Security benefits. She doesn’t want Part B. What can
she do?
A) She can decline Part B coverage by following the instructions that come with her
Medicare card.
B) She must keep Part B until next year’s Open Enrollment.
C) She can only cancel Part B coverage through her employer.
D) She must pay the Part B premium for at least six months before canceling.
Rationale: Beneficiaries automatically enrolled in Part B can opt out by contacting Social
Security before coverage begins. There’s no mandatory payment period.
Mr. Lopez just retired at age 65 and is deciding between Original Medicare and a Medicare
Advantage plan. What is a key difference?
A) Medicare Advantage plans are administered directly by the government.
B) Medicare Advantage plans are offered by private companies and may include extra
benefits like dental or vision.
C) Original Medicare covers prescription drugs automatically.
D) Medicare Advantage plans never require provider networks.
Rationale: Medicare Advantage (Part C) is offered by private insurers and may include
additional benefits. Original Medicare is government-administered and doesn’t include drug
coverage.
Mrs. Patel enrolled in a Medicare Part D plan but later realized her medications were not
covered. What should she do?
A) She must wait until next year to switch plans.
B) She can request a formulary exception or change plans during the next Open
Enrollment Period.
C) She can add another Part D plan to cover those drugs.
D) She should cancel her current plan immediately.
Rationale: Beneficiaries can request a formulary exception or switch plans during the Annual
Election Period. Holding two Part D plans simultaneously is not allowed.
Mr. and Mrs. Roberts are both on Medicare and travel frequently throughout the U.S. Which
type of plan would offer them the greatest flexibility in choosing providers?
A) HMO
B) PPO
C) SNP
D) MSA
Rationale: PPO plans allow members to use any provider nationwide that accepts Medicare,
though out-of-network care costs more. HMOs restrict care to network providers.
