AHIP - 2026 - MODULES 1-5
QUESTIONS AND ANSWERS
Mr.9Capadona9would9like9to9purchase9a9Medicare9Advantage9(MA)9plan9and9a9Mediga
p9plan9to9pick9up9costs9not9covered9by9that9plan.9What9should9you9tell9him?9-
9ans✔It9is9illegal9for9you9to9sell9Mr.9Capadona9a9Medigap9plan9if9he9is9enrolled9in9an9
MA9plan,9and9besides,9Medigap9only9works9with9Original9Medicare.
Agent9John9Miller9is9meeting9with9Jerry9Smith,9a9new9prospect.9Jerry9is9currently9enrol
led9in9Medicare9Parts9A9and9B.9Jerry9has9also9purchased9a9Medicare9Supplement9(M
edigap)9plan9which9he9has9had9for9several9years.9However,9the9plan9does9not9provide
9drug9benefits.9How9would9you9advise9Agent9John9Miller9to9proceed?9-
9ans✔Tell9prospect9Jerry9Smith9that9he9should9consider9adding9a9standalone9Part9D9p
rescription9drug9coverage9policy9to9his9present9coverage.
Mr.9Wu9is9eligible9for9Medicare.9He9has9limited9financial9resources9but9failed9to9qualify
9for9the9Part9D9low-
income9subsidy.9Where9might9he9turn9for9help9with9his9prescription9drug9costs?9-
9ans✔Mr.9Wu9may9still9qualify9for9help9in9paying9Part9D9costs9through9his9State9Phar
maceutical9Assistance9Program9(SPAP).
Mr.9Vasquez9is9in9good9health9and9is9preparing9a9budget9in9anticipation9of9his9retirem
ent9when9he9turns966.9He9wants9to9understand9the9health9care9costs9he9might9be9exp
osed9to9under9Medicare9if9he9were9to9require9hospitalization9because9of9an9illness.9In9
general9terms,9what9could9you9tell9him9about9his9costs9for9inpatient9hospital9services9
under9Original9Medicare?9-
9ans✔Under9Original9Medicare,9there9is9a9single9deductible9amount9due9for9the9first96
09days9of9any9inpatient9hospital9stay,9after9which9it9converts9into9a9per-
day9coinsurance9amount9through9day990.9After9day990,9he9would9pay9a9daily9amount9
up9to9609days9over9his9lifetime,9after9which9he9would9be9responsible9for9all9costs.
Mr.9Moy9will9soon9turn9age965.9He9is9slightly9younger9than9his9wife.9Mr.9Moy's9wife9ha
s9a9Medicare9Advantage9plan,9but9he9wants9to9understand9what9coverage9Medicare9S
upplemental9Insurance9provides9since9his9health9care9needs9are9different9from9his9wif
e's9needs.9What9could9you9tell9Mr.9Moy?9-
9ans✔Medicare9Supplemental9Insurance9would9help9cover9his9Part9A9deductible9and9
Part9B9coinsurance9or9copayments9in9Original9Fee-for-
,Service9(FFS)9Medicare9as9well9as9possibly9some9services9that9Medicare9does9not9co
ver.
Juan9Perez,9who9is9turning9age9659next9month,9intends9to9work9for9several9more9year
s9at9Smallcap,9Incorporated.9Smallcap9has9a9workforce9of9159employees9and9offers9e
mployer-
sponsored9healthcare9coverage.9Juan9is9a9naturalized9citizen9and9has9contributed9to9t
he9Medicare9system9for9over9209years.9Juan9asks9you9if9he9will9be9entitled9to9Medicar
e9and9if9he9enrolls9how9that9will9impact9his9employer-
9sponsored9healthcare9coverage.9How9would9you9respond?9-
9ans✔Juan9is9likely9to9be9eligible9for9Medicare9once9he9turns9age9659and9if9he9enrolls
,9Medicare9would9become9the9primary9payor9of9his9healthcare9claims9and9Smallcap9d
oes9not9have9to9continue9to9offer9him9coverage9comparable9to9those9under9age9659un
der9its9employer-
sponsored9group9health9plan.9Juan9is9likely9to9be9eligible9for9Medicare9once9he9turns9
age9659and9if9he9enrolls,9Medicare9would9become9the9primary9payor9of9his9healthcare
9claims9but9Smallcap9must9continue9to9offer9him9coverage9under9its9employer-
sponsored9group9health9plan9and9would9become9a9secondary9payor.
Ms.9Kumar9plans9to9retire9when9she9turns9659in9a9few9months.9She9is9in9excellent9he
alth9and9will9have9considerable9income9when9she9retires.9She9is9concerned9that9her9i
ncome9will9make9it9impossible9for9her9to9qualify9for9Medicare.9What9could9you9tell9her9
to9address9her9concern?9-
9ans✔Medicare9is9a9program9for9people9age9659or9older9and9those9under9age9659with
9certain9disabilities,9end-
stage9renal9disease,9and9Lou9Gehrig's9disease9so9she9will9be9eligible9for9Medicare.
Mrs.9Ellis9recently9turned9669and9decided9after9many9years9of9work9to9retire9and9begi
n9receiving9Social9Security9benefits.9Shortly9thereafter9Mrs.9Ellis9received9a9letter9infor
ming9her9that9she9had9been9automatically9enrolled9in9Medicare9Part9B.9She9wants9to9
understand9what9this9means.9What9should9you9tell9Mrs.9Ellis?9-
9ans✔Part9B9primarily9covers9physician9services.9She9will9be9paying9a9monthly9premiu
m9and,9except9for9many9preventive9and9screening9tests,9generally9will9have920%9co-
payments9for9these9services,9in9addition9to9an9annual9deductible.
Mr.9Singh9would9like9drug9coverage9but9does9not9want9to9be9enrolled9in9a9Medicare9A
dvantage9plan.9What9should9you9tell9him?9-9ans✔Mr.9Singh9can9enroll9in9a9stand-
alone9prescription9drug9plan9and9continue9to9be9covered9for9Part9A9and9Part9B9servic
es9through9Original9Fee-for-Service9Medicare.
Mrs.9Cook9is9an9elderly9retiree.9Mrs.9Cook9has9a9low9fixed9income.9What9could9you9te
ll9Mrs.9Cook9that9might9be9of9assistance?9-
9ans✔She9should9contact9her9state9Medicaid9agency9to9see9if9she9qualifies9for9one9of
9several9programs9that9can9help9with9Medicare9costs9for9which9she9is9responsible.
, Ms.9Henderson9believes9that9she9will9qualify9for9Medicare9Coverage9when9she9turns96
5,9without9paying9any9premiums,9because9she9has9been9working9for9409years9and9pa
ying9Medicare9taxes.9What9should9you9tell9her?9-
9ans✔To9obtain9Part9B9coverage,9she9must9pay9a9standard9monthly9premium,9though9
it9is9higher9for9individuals9with9higher9incomes.
Mr.9Bauer9is9499years9old,9but9eighteen9months9ago9he9was9declared9disabled9by9the
9Social9Security9Administration9and9has9been9receiving9disability9payments.9He9is9won
dering9whether9he9can9obtain9coverage9under9Medicare.9What9should9you9tell9him?9-
9ans✔After9receiving9such9disability9payments9for9249months,9he9will9be9automatically9
enrolled9in9Medicare,9regardless9of9age.
Mr.9Schmidt9would9like9to9plan9for9retirement9and9has9asked9you9what9is9covered9und
er9Original9Fee-for-Service9(FFS)9Medicare.9What9could9you9tell9him?9-
9ans✔Part9A,9which9covers9hospital,9skilled9nursing9facility,9hospice,9and9home9health
9services9and9Part9B,9which9covers9professional9services9such9as9those9provided9by9a
9doctor9are9covered9under9Original9Medicare.
Anthony9Boniface9turned9659in92024.9He9was9not9receiving9Social9Security9or9Railroa
d9Retirement9Benefits9on9his965th9birthday.9He9was9interested9in9obtaining9Medicare9c
overage9and9is9eligible9for9premium-
free9Part9A.9Before9he9could9enroll9in9Medicare,9his9entire9area9was9impacted9by9a9hu
rricane9causing9massive9flooding9and9severe9wind9damage.9The9Federal9government9
declared9this9to9be9a9natural9disaster9which9has9recently9ended.9During9this9period9An
thony's9initial9enrollment9period9expired.9Anthony9asks9you9how9he9can9now9obtain9M
edicare9coverage.9What9should9you9say?9-
9ans✔Anthony9is9eligible9for9a9special9enrollment9period9(SEP)9because9he9missed9an
9enrollment9period9due9to9the9impact9of9the9Federally9declared9disaster.9This9SEP9will
9allow9Anthony9to9enroll9in9Part9B9up9to9six9months9after9the9end9of9the9emergency9de
claration.9Anthony9may9enroll9in9premium-
free9Part9A9at9any9time9and9his9Part9A9coverage9will9be9retroactive9for9up9to969months
.
Ms.9Lewis9has9aggressive9cancer9and9would9like9to9know9if9Medicare9will9cover9hospi
ce9services9in9case9she9needs9them.9What9should9you9tell9her?9-
9ans✔Medicare9covers9hospice9services,9and9they9will9be9available9for9her.
Edward9suffered9from9serious9kidney9disease.9As9a9result,9Edward9became9eligible9for
9Medicare9coverage9due9to9end-
stage9renal9disease9(ESRD).9A9close9relative9donated9their9kidney9and9Edward9succe
ssfully9underwent9transplant9surgery9129months9ago.9Edward9is9now9age9509and9asks
9you9if9his9Medicare9coverage9will9continue,9what9should9you9say?9-
9ans✔Individuals9eligible9for9Medicare9based9on9ESRD9generally9lose9eligibility9369mo
nths9after9the9month9in9which9the9individual9receives9a9kidney9transplant9unless9they9
are9eligible9for9Medicare9on9another9basis9such9as9age9or9disability.9Edward9may,9ho
QUESTIONS AND ANSWERS
Mr.9Capadona9would9like9to9purchase9a9Medicare9Advantage9(MA)9plan9and9a9Mediga
p9plan9to9pick9up9costs9not9covered9by9that9plan.9What9should9you9tell9him?9-
9ans✔It9is9illegal9for9you9to9sell9Mr.9Capadona9a9Medigap9plan9if9he9is9enrolled9in9an9
MA9plan,9and9besides,9Medigap9only9works9with9Original9Medicare.
Agent9John9Miller9is9meeting9with9Jerry9Smith,9a9new9prospect.9Jerry9is9currently9enrol
led9in9Medicare9Parts9A9and9B.9Jerry9has9also9purchased9a9Medicare9Supplement9(M
edigap)9plan9which9he9has9had9for9several9years.9However,9the9plan9does9not9provide
9drug9benefits.9How9would9you9advise9Agent9John9Miller9to9proceed?9-
9ans✔Tell9prospect9Jerry9Smith9that9he9should9consider9adding9a9standalone9Part9D9p
rescription9drug9coverage9policy9to9his9present9coverage.
Mr.9Wu9is9eligible9for9Medicare.9He9has9limited9financial9resources9but9failed9to9qualify
9for9the9Part9D9low-
income9subsidy.9Where9might9he9turn9for9help9with9his9prescription9drug9costs?9-
9ans✔Mr.9Wu9may9still9qualify9for9help9in9paying9Part9D9costs9through9his9State9Phar
maceutical9Assistance9Program9(SPAP).
Mr.9Vasquez9is9in9good9health9and9is9preparing9a9budget9in9anticipation9of9his9retirem
ent9when9he9turns966.9He9wants9to9understand9the9health9care9costs9he9might9be9exp
osed9to9under9Medicare9if9he9were9to9require9hospitalization9because9of9an9illness.9In9
general9terms,9what9could9you9tell9him9about9his9costs9for9inpatient9hospital9services9
under9Original9Medicare?9-
9ans✔Under9Original9Medicare,9there9is9a9single9deductible9amount9due9for9the9first96
09days9of9any9inpatient9hospital9stay,9after9which9it9converts9into9a9per-
day9coinsurance9amount9through9day990.9After9day990,9he9would9pay9a9daily9amount9
up9to9609days9over9his9lifetime,9after9which9he9would9be9responsible9for9all9costs.
Mr.9Moy9will9soon9turn9age965.9He9is9slightly9younger9than9his9wife.9Mr.9Moy's9wife9ha
s9a9Medicare9Advantage9plan,9but9he9wants9to9understand9what9coverage9Medicare9S
upplemental9Insurance9provides9since9his9health9care9needs9are9different9from9his9wif
e's9needs.9What9could9you9tell9Mr.9Moy?9-
9ans✔Medicare9Supplemental9Insurance9would9help9cover9his9Part9A9deductible9and9
Part9B9coinsurance9or9copayments9in9Original9Fee-for-
,Service9(FFS)9Medicare9as9well9as9possibly9some9services9that9Medicare9does9not9co
ver.
Juan9Perez,9who9is9turning9age9659next9month,9intends9to9work9for9several9more9year
s9at9Smallcap,9Incorporated.9Smallcap9has9a9workforce9of9159employees9and9offers9e
mployer-
sponsored9healthcare9coverage.9Juan9is9a9naturalized9citizen9and9has9contributed9to9t
he9Medicare9system9for9over9209years.9Juan9asks9you9if9he9will9be9entitled9to9Medicar
e9and9if9he9enrolls9how9that9will9impact9his9employer-
9sponsored9healthcare9coverage.9How9would9you9respond?9-
9ans✔Juan9is9likely9to9be9eligible9for9Medicare9once9he9turns9age9659and9if9he9enrolls
,9Medicare9would9become9the9primary9payor9of9his9healthcare9claims9and9Smallcap9d
oes9not9have9to9continue9to9offer9him9coverage9comparable9to9those9under9age9659un
der9its9employer-
sponsored9group9health9plan.9Juan9is9likely9to9be9eligible9for9Medicare9once9he9turns9
age9659and9if9he9enrolls,9Medicare9would9become9the9primary9payor9of9his9healthcare
9claims9but9Smallcap9must9continue9to9offer9him9coverage9under9its9employer-
sponsored9group9health9plan9and9would9become9a9secondary9payor.
Ms.9Kumar9plans9to9retire9when9she9turns9659in9a9few9months.9She9is9in9excellent9he
alth9and9will9have9considerable9income9when9she9retires.9She9is9concerned9that9her9i
ncome9will9make9it9impossible9for9her9to9qualify9for9Medicare.9What9could9you9tell9her9
to9address9her9concern?9-
9ans✔Medicare9is9a9program9for9people9age9659or9older9and9those9under9age9659with
9certain9disabilities,9end-
stage9renal9disease,9and9Lou9Gehrig's9disease9so9she9will9be9eligible9for9Medicare.
Mrs.9Ellis9recently9turned9669and9decided9after9many9years9of9work9to9retire9and9begi
n9receiving9Social9Security9benefits.9Shortly9thereafter9Mrs.9Ellis9received9a9letter9infor
ming9her9that9she9had9been9automatically9enrolled9in9Medicare9Part9B.9She9wants9to9
understand9what9this9means.9What9should9you9tell9Mrs.9Ellis?9-
9ans✔Part9B9primarily9covers9physician9services.9She9will9be9paying9a9monthly9premiu
m9and,9except9for9many9preventive9and9screening9tests,9generally9will9have920%9co-
payments9for9these9services,9in9addition9to9an9annual9deductible.
Mr.9Singh9would9like9drug9coverage9but9does9not9want9to9be9enrolled9in9a9Medicare9A
dvantage9plan.9What9should9you9tell9him?9-9ans✔Mr.9Singh9can9enroll9in9a9stand-
alone9prescription9drug9plan9and9continue9to9be9covered9for9Part9A9and9Part9B9servic
es9through9Original9Fee-for-Service9Medicare.
Mrs.9Cook9is9an9elderly9retiree.9Mrs.9Cook9has9a9low9fixed9income.9What9could9you9te
ll9Mrs.9Cook9that9might9be9of9assistance?9-
9ans✔She9should9contact9her9state9Medicaid9agency9to9see9if9she9qualifies9for9one9of
9several9programs9that9can9help9with9Medicare9costs9for9which9she9is9responsible.
, Ms.9Henderson9believes9that9she9will9qualify9for9Medicare9Coverage9when9she9turns96
5,9without9paying9any9premiums,9because9she9has9been9working9for9409years9and9pa
ying9Medicare9taxes.9What9should9you9tell9her?9-
9ans✔To9obtain9Part9B9coverage,9she9must9pay9a9standard9monthly9premium,9though9
it9is9higher9for9individuals9with9higher9incomes.
Mr.9Bauer9is9499years9old,9but9eighteen9months9ago9he9was9declared9disabled9by9the
9Social9Security9Administration9and9has9been9receiving9disability9payments.9He9is9won
dering9whether9he9can9obtain9coverage9under9Medicare.9What9should9you9tell9him?9-
9ans✔After9receiving9such9disability9payments9for9249months,9he9will9be9automatically9
enrolled9in9Medicare,9regardless9of9age.
Mr.9Schmidt9would9like9to9plan9for9retirement9and9has9asked9you9what9is9covered9und
er9Original9Fee-for-Service9(FFS)9Medicare.9What9could9you9tell9him?9-
9ans✔Part9A,9which9covers9hospital,9skilled9nursing9facility,9hospice,9and9home9health
9services9and9Part9B,9which9covers9professional9services9such9as9those9provided9by9a
9doctor9are9covered9under9Original9Medicare.
Anthony9Boniface9turned9659in92024.9He9was9not9receiving9Social9Security9or9Railroa
d9Retirement9Benefits9on9his965th9birthday.9He9was9interested9in9obtaining9Medicare9c
overage9and9is9eligible9for9premium-
free9Part9A.9Before9he9could9enroll9in9Medicare,9his9entire9area9was9impacted9by9a9hu
rricane9causing9massive9flooding9and9severe9wind9damage.9The9Federal9government9
declared9this9to9be9a9natural9disaster9which9has9recently9ended.9During9this9period9An
thony's9initial9enrollment9period9expired.9Anthony9asks9you9how9he9can9now9obtain9M
edicare9coverage.9What9should9you9say?9-
9ans✔Anthony9is9eligible9for9a9special9enrollment9period9(SEP)9because9he9missed9an
9enrollment9period9due9to9the9impact9of9the9Federally9declared9disaster.9This9SEP9will
9allow9Anthony9to9enroll9in9Part9B9up9to9six9months9after9the9end9of9the9emergency9de
claration.9Anthony9may9enroll9in9premium-
free9Part9A9at9any9time9and9his9Part9A9coverage9will9be9retroactive9for9up9to969months
.
Ms.9Lewis9has9aggressive9cancer9and9would9like9to9know9if9Medicare9will9cover9hospi
ce9services9in9case9she9needs9them.9What9should9you9tell9her?9-
9ans✔Medicare9covers9hospice9services,9and9they9will9be9available9for9her.
Edward9suffered9from9serious9kidney9disease.9As9a9result,9Edward9became9eligible9for
9Medicare9coverage9due9to9end-
stage9renal9disease9(ESRD).9A9close9relative9donated9their9kidney9and9Edward9succe
ssfully9underwent9transplant9surgery9129months9ago.9Edward9is9now9age9509and9asks
9you9if9his9Medicare9coverage9will9continue,9what9should9you9say?9-
9ans✔Individuals9eligible9for9Medicare9based9on9ESRD9generally9lose9eligibility9369mo
nths9after9the9month9in9which9the9individual9receives9a9kidney9transplant9unless9they9
are9eligible9for9Medicare9on9another9basis9such9as9age9or9disability.9Edward9may,9ho
