2025 AHIP FINAL EXAM
PROFESSIONAL STUDY AND
REVIEW WORKBOOK: STEP-BY-
STEP GUIDE TO CERTIFICATION
SUCCESS
Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage
(MA) health plans. This year she has decided to focus on non-MA products. What advice would
you give Melanie if she wishes to continue to receive renewal fees?
a. All that she needs to do is avoid being terminated for cause.
b. All that she needs to do is meet state licensure requirements moving forward.
c. Melanie will need to do nothing to continue receiving renewal fees since the initial sale was
made when she met all requirements.
d. Melanie must remain trained, tested, licensed, and appointed, regardless of whether she
is actively selling MA products.
Rationale: Renewal fees for Medicare Advantage sales require the agent to maintain their
certification and appointment status. Option d is correct because CMS mandates ongoing
compliance. The other options are incorrect since avoiding termination or maintaining only
licensure (a, b) is insufficient, and doing nothing (c) would cause noncompliance.
Agent Chan is conducting a sales presentation on senior issues where he hopes to enroll some
attendees in the Medicare Advantage (MA) plans he represents. What action(s) may Agent Chan
take during the event?
a. Sell personal information obtained as part of a raffle to a third-party marketeer.
b. Discuss plan specific information such as premiums and benefits.
c. Indicate that in order to participate attendees must provide their contact information.
d. Conduct free health screenings as part of the event.
Rationale: Option b is correct because discussing plan-specific details is allowed at a formal
sales event. The other actions violate CMS marketing rules — selling data (a) breaches privacy,
,forcing information (c) is coercive, and offering health screenings (d) is prohibited at sales
events.
Mr. Decaro has looked at Medicare prescription drug plans in his area and noted a wide range in
premiums. He thought that all the drug plans were required to offer the same standard benefits.
What should you tell him?
a. Medicare permits plans that have the highest quality services to reduce their premiums below
the standard amount.
b. Some prescription drug plans may have higher operating costs and/or may offer
enhanced coverage in return for an additional premium amount.
c. The premiums differ because some plans intend to market to sicker beneficiaries.
d. All drug plans must offer exactly the same coverage model, so the difference is in financial
estimates.
Rationale: Option b is correct because plans can offer enhanced benefits or charge more based
on costs. The others are incorrect since (a) misrepresents CMS rules, (c) implies discrimination,
and (d) ignores that benefit variations are permitted.
Mrs. Duarte is enrolled in Original Medicare Parts A and B and disagrees with a determination
that partially denied one of her claims. What advice would you give her?
a. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date
she received the MSN in the mail.
b. She should file an appeal within 90 days and then request reconsideration within 10 days.
c. She has no right to appeal since her claim was partially paid.
d. She should request a reconsideration within 60 days of receiving the MSN.
Rationale: Option a is correct because Medicare allows 120 days to file an appeal after
receiving a Medicare Summary Notice. The other timeframes (b, d) are incorrect, and (c) is false
since all beneficiaries have appeal rights.
Ms. Hernandez has typically sought approval of her insurance materials from her State
Department of Insurance. What should you advise her about marketing Medicare Advantage
plans?
,a. She should continue to seek state approval.
b. Materials for marketing Medicare health plans to individuals are subject to Medicare’s
national requirements and must be approved by CMS, not the state.
c. Only her company needs to review and approve materials.
d. She should check with the Department of Insurance to see if it can review for CMS.
Rationale: Option b is correct because CMS (the Centers for Medicare & Medicaid Services)
regulates all MA marketing materials. The others incorrectly imply state-level approval or
insufficient oversight.
Mr. Shapiro has heard there may be extra help paying for Part D prescription drugs for low-
income beneficiaries. What should you tell him?
a. He must apply at the same time he enrolls in a Part D plan.
b. The extra help is available only to beneficiaries enrolled in Medicaid.
c. The government pays extra per beneficiary to offset costs under plan criteria.
d. The extra help is available to beneficiaries whose income and assets do not exceed annual
limits specified by the government.
Rationale: Option d is correct because the “Extra Help” (Low-Income Subsidy) is based on
financial eligibility limits. The other options (a–c) incorrectly describe the timing or scope of
eligibility.
Mr. Fitzgerald is moving to another state and learns his stand-alone prescription drug plan is
unavailable there. What can you tell him?
a. Because he is moving outside of the service area, the plan must automatically disenroll
him. He will have a special election period to select a new plan.
b. He must continue using mail order until the next enrollment period.
c. He can keep his plan indefinitely.
d. He should request an exception to keep the plan until the AEP.
Rationale: Option a is correct because moving outside a plan’s service area qualifies for a
Special Enrollment Period (SEP). The other options are false — plans do not operate nationally
and no exceptions apply.
Agent Willis had clients who switched plans during the AEP but now regrets their choices. What
can he do during the MA-OEP?
, a. Call them to tell them they can switch back.
b. Email them in January to ask if they are happy.
c. Send them information about MA-OEP and flyers on his plans.
d. Wait until October and send them information about the plans he represents.
Rationale: Option d is correct because agents cannot initiate contact or market during the MA-
OEP. Only the beneficiary may reach out. Options a–c involve prohibited outreach during this
period.
Mr. McTaggert wants to know how a Private Fee-for-Service (PFFS) plan differs from an HMO
or PPO.
a. PFFS plans cannot include Part D coverage.
b. Enrollees in a PFFS plan can obtain care from any provider who accepts Original
Medicare and agrees to the plan’s terms and conditions.
c. PFFS plans are the same as Medicare supplement plans.
d. All providers who take Medicare must accept the PFFS plan.
Rationale: Option b is correct because providers must agree to the plan’s terms before providing
care. The other options incorrectly describe plan flexibility or provider obligations.
You decide to focus your efforts on marketing to employer and union groups. Which statement
best describes compliance requirements?
a. You do not need to complete a scope of appointment, but CMS can ask for one if complaints
occur.
b. You can make unsolicited contacts but not cross-sell.
c. You do not need to take an annual test, but you cannot provide more than light snacks.
d. You are not required to submit communication and marketing materials specific to
employer plans to CMS at the time of use, but CMS may request and review them if
complaints occur.
Rationale: Option d is correct because employer and union group marketing materials are
subject to different CMS review rules. The other statements contain incorrect compliance or
marketing rules.
PROFESSIONAL STUDY AND
REVIEW WORKBOOK: STEP-BY-
STEP GUIDE TO CERTIFICATION
SUCCESS
Last year Agent Melanie Meyers marketed and enrolled several clients in Medicare Advantage
(MA) health plans. This year she has decided to focus on non-MA products. What advice would
you give Melanie if she wishes to continue to receive renewal fees?
a. All that she needs to do is avoid being terminated for cause.
b. All that she needs to do is meet state licensure requirements moving forward.
c. Melanie will need to do nothing to continue receiving renewal fees since the initial sale was
made when she met all requirements.
d. Melanie must remain trained, tested, licensed, and appointed, regardless of whether she
is actively selling MA products.
Rationale: Renewal fees for Medicare Advantage sales require the agent to maintain their
certification and appointment status. Option d is correct because CMS mandates ongoing
compliance. The other options are incorrect since avoiding termination or maintaining only
licensure (a, b) is insufficient, and doing nothing (c) would cause noncompliance.
Agent Chan is conducting a sales presentation on senior issues where he hopes to enroll some
attendees in the Medicare Advantage (MA) plans he represents. What action(s) may Agent Chan
take during the event?
a. Sell personal information obtained as part of a raffle to a third-party marketeer.
b. Discuss plan specific information such as premiums and benefits.
c. Indicate that in order to participate attendees must provide their contact information.
d. Conduct free health screenings as part of the event.
Rationale: Option b is correct because discussing plan-specific details is allowed at a formal
sales event. The other actions violate CMS marketing rules — selling data (a) breaches privacy,
,forcing information (c) is coercive, and offering health screenings (d) is prohibited at sales
events.
Mr. Decaro has looked at Medicare prescription drug plans in his area and noted a wide range in
premiums. He thought that all the drug plans were required to offer the same standard benefits.
What should you tell him?
a. Medicare permits plans that have the highest quality services to reduce their premiums below
the standard amount.
b. Some prescription drug plans may have higher operating costs and/or may offer
enhanced coverage in return for an additional premium amount.
c. The premiums differ because some plans intend to market to sicker beneficiaries.
d. All drug plans must offer exactly the same coverage model, so the difference is in financial
estimates.
Rationale: Option b is correct because plans can offer enhanced benefits or charge more based
on costs. The others are incorrect since (a) misrepresents CMS rules, (c) implies discrimination,
and (d) ignores that benefit variations are permitted.
Mrs. Duarte is enrolled in Original Medicare Parts A and B and disagrees with a determination
that partially denied one of her claims. What advice would you give her?
a. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date
she received the MSN in the mail.
b. She should file an appeal within 90 days and then request reconsideration within 10 days.
c. She has no right to appeal since her claim was partially paid.
d. She should request a reconsideration within 60 days of receiving the MSN.
Rationale: Option a is correct because Medicare allows 120 days to file an appeal after
receiving a Medicare Summary Notice. The other timeframes (b, d) are incorrect, and (c) is false
since all beneficiaries have appeal rights.
Ms. Hernandez has typically sought approval of her insurance materials from her State
Department of Insurance. What should you advise her about marketing Medicare Advantage
plans?
,a. She should continue to seek state approval.
b. Materials for marketing Medicare health plans to individuals are subject to Medicare’s
national requirements and must be approved by CMS, not the state.
c. Only her company needs to review and approve materials.
d. She should check with the Department of Insurance to see if it can review for CMS.
Rationale: Option b is correct because CMS (the Centers for Medicare & Medicaid Services)
regulates all MA marketing materials. The others incorrectly imply state-level approval or
insufficient oversight.
Mr. Shapiro has heard there may be extra help paying for Part D prescription drugs for low-
income beneficiaries. What should you tell him?
a. He must apply at the same time he enrolls in a Part D plan.
b. The extra help is available only to beneficiaries enrolled in Medicaid.
c. The government pays extra per beneficiary to offset costs under plan criteria.
d. The extra help is available to beneficiaries whose income and assets do not exceed annual
limits specified by the government.
Rationale: Option d is correct because the “Extra Help” (Low-Income Subsidy) is based on
financial eligibility limits. The other options (a–c) incorrectly describe the timing or scope of
eligibility.
Mr. Fitzgerald is moving to another state and learns his stand-alone prescription drug plan is
unavailable there. What can you tell him?
a. Because he is moving outside of the service area, the plan must automatically disenroll
him. He will have a special election period to select a new plan.
b. He must continue using mail order until the next enrollment period.
c. He can keep his plan indefinitely.
d. He should request an exception to keep the plan until the AEP.
Rationale: Option a is correct because moving outside a plan’s service area qualifies for a
Special Enrollment Period (SEP). The other options are false — plans do not operate nationally
and no exceptions apply.
Agent Willis had clients who switched plans during the AEP but now regrets their choices. What
can he do during the MA-OEP?
, a. Call them to tell them they can switch back.
b. Email them in January to ask if they are happy.
c. Send them information about MA-OEP and flyers on his plans.
d. Wait until October and send them information about the plans he represents.
Rationale: Option d is correct because agents cannot initiate contact or market during the MA-
OEP. Only the beneficiary may reach out. Options a–c involve prohibited outreach during this
period.
Mr. McTaggert wants to know how a Private Fee-for-Service (PFFS) plan differs from an HMO
or PPO.
a. PFFS plans cannot include Part D coverage.
b. Enrollees in a PFFS plan can obtain care from any provider who accepts Original
Medicare and agrees to the plan’s terms and conditions.
c. PFFS plans are the same as Medicare supplement plans.
d. All providers who take Medicare must accept the PFFS plan.
Rationale: Option b is correct because providers must agree to the plan’s terms before providing
care. The other options incorrectly describe plan flexibility or provider obligations.
You decide to focus your efforts on marketing to employer and union groups. Which statement
best describes compliance requirements?
a. You do not need to complete a scope of appointment, but CMS can ask for one if complaints
occur.
b. You can make unsolicited contacts but not cross-sell.
c. You do not need to take an annual test, but you cannot provide more than light snacks.
d. You are not required to submit communication and marketing materials specific to
employer plans to CMS at the time of use, but CMS may request and review them if
complaints occur.
Rationale: Option d is correct because employer and union group marketing materials are
subject to different CMS review rules. The other statements contain incorrect compliance or
marketing rules.
