2027 AHIP FINAL EXAM – MEDICARE
CERTIFICATION – ACTUAL QUESTIONS &
ANSWERS (AHIP) GUARANTEE PASS (UPDATED
PDF)
2027 AHIP Medicare Certification Practice Exam
Topic: Medicare Basics, Marketing Compliance, and Fraud, Waste, and Abuse (FWA)
Table of Contents
1. Section 1: Medicare Basics (Parts A & B)
2. Section 2: Medicare Advantage (Part C)
3. Section 3: Medicare Prescription Drug Coverage (Part D)
4. Section 4: Marketing Guidelines & Compliance
5. Section 5: Enrollment Periods & Eligibility
6. Section 6: Fraud, Waste, and Abuse (FWA)
Section 1: Medicare Basics (Parts A & B)
1. Which of the following services is generally covered under Medicare Part A?
• A) Routine dental care
• B) Inpatient hospital care
• C) Outpatient physical therapy
• D) Monthly prescription drugs
Correct Answer: B
Rationale: Medicare Part A is hospital insurance. It covers inpatient hospital stays, care in a
skilled nursing facility, hospice care, and some home health care. Routine dental and outpatient
services are typically covered by Part B or not covered by original Medicare at all.
2. To be eligible for Medicare based on age, an individual must be at least:
• A) 62 years old
, • B) 65 years old
• C) 67 years old
• D) 70 years old
Correct Answer: B
Rationale: The standard age of eligibility for Medicare is 65. Individuals may qualify earlier if
they have certain disabilities or End-Stage Renal Disease (ESRD).
What is the "standard" monthly premium for Part B based on?
• A) The beneficiary's zip code
• B) The beneficiary's health status
• C) The beneficiary's modified adjusted gross income (MAGI)
• D) The number of doctors the beneficiary visits
Correct Answer: C
Rationale: While there is a standard premium set annually by CMS, beneficiaries with higher
incomes may pay an Income Related Monthly Adjustment Amount (IRMAA) based on their
MAGI.
Section 2: Medicare Advantage (Part C)
. Which statement is true regarding Medicare Advantage (MA) plans?
• A) They are supplemental insurance policies sold by private companies.
• B) They provide benefits exclusively through the federal government.
• C) They must provide all benefits covered by Original Medicare Parts A and B.
• D) They do not have annual out-of-pocket maximums.
Correct Answer: C
Rationale: MA plans are offered by private companies approved by Medicare. By law, they must
cover everything Original Medicare covers, though they may have different costs and additional
benefits like vision or dental.
17. A beneficiary enrolled in a Special Needs Plan (SNP) must:
• A) Have a high income
• B) Meet specific criteria, such as having a certain chronic condition or being dual-eligible
• C) Live in a rural area
, • D) Be under the age of 65
Correct Answer: B
Rationale: SNPs limit membership to people with specific diseases or characteristics (Chronic
Condition SNP, Dual Eligible SNP for those with Medicaid, or Institutional SNP).
18. Which of the following is a key operational difference between a Medicare Advantage
Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO)?
• A) HMOs allow out-of-network non-emergency care without extra costs.
• B) PPOs generally allow members to see out-of-network providers, usually at a higher
cost-sharing amount.
• C) HMOs never require members to select a Primary Care Physician (PCP).
• D) PPOs require referrals from a primary care physician to see any specialist.
Correct Answer: B
Rationale: PPO plans offer out-of-network coverage flexibility at higher cost-sharing rates,
whereas standard HMO plans generally require enrollees to receive care inside the plan network
(except in emergencies) and designate a PCP.
19. How does a Private Fee-For-Service (PFFS) Medicare Advantage plan operate
regarding provider participation?
• A) Providers automatically belong to a mandatory locked network that cannot change.
• B) Members must get a written referral from CMS prior to every specialist visit.
• C) Providers may decide on a visit-by-visit basis whether to accept the plan's payment
terms and conditions.
• D) Members are restricted to receiving care only within their home county.
Correct Answer: C
Rationale: In a non-network or combination PFFS plan, doctors and hospitals may choose
whether to accept the PFFS plan's terms and conditions of payment on a visit-by-visit basis.
20. What is true regarding the Maximum Out-of-Pocket (MOOP) limit in Medicare
Advantage plans?
• A) MOOP limits apply only to standalone Part D prescription drug expenses.
• B) CMS establishes mandatory annual MOOP limits for covered Part A and Part B
services to protect beneficiaries.
CERTIFICATION – ACTUAL QUESTIONS &
ANSWERS (AHIP) GUARANTEE PASS (UPDATED
PDF)
2027 AHIP Medicare Certification Practice Exam
Topic: Medicare Basics, Marketing Compliance, and Fraud, Waste, and Abuse (FWA)
Table of Contents
1. Section 1: Medicare Basics (Parts A & B)
2. Section 2: Medicare Advantage (Part C)
3. Section 3: Medicare Prescription Drug Coverage (Part D)
4. Section 4: Marketing Guidelines & Compliance
5. Section 5: Enrollment Periods & Eligibility
6. Section 6: Fraud, Waste, and Abuse (FWA)
Section 1: Medicare Basics (Parts A & B)
1. Which of the following services is generally covered under Medicare Part A?
• A) Routine dental care
• B) Inpatient hospital care
• C) Outpatient physical therapy
• D) Monthly prescription drugs
Correct Answer: B
Rationale: Medicare Part A is hospital insurance. It covers inpatient hospital stays, care in a
skilled nursing facility, hospice care, and some home health care. Routine dental and outpatient
services are typically covered by Part B or not covered by original Medicare at all.
2. To be eligible for Medicare based on age, an individual must be at least:
• A) 62 years old
, • B) 65 years old
• C) 67 years old
• D) 70 years old
Correct Answer: B
Rationale: The standard age of eligibility for Medicare is 65. Individuals may qualify earlier if
they have certain disabilities or End-Stage Renal Disease (ESRD).
What is the "standard" monthly premium for Part B based on?
• A) The beneficiary's zip code
• B) The beneficiary's health status
• C) The beneficiary's modified adjusted gross income (MAGI)
• D) The number of doctors the beneficiary visits
Correct Answer: C
Rationale: While there is a standard premium set annually by CMS, beneficiaries with higher
incomes may pay an Income Related Monthly Adjustment Amount (IRMAA) based on their
MAGI.
Section 2: Medicare Advantage (Part C)
. Which statement is true regarding Medicare Advantage (MA) plans?
• A) They are supplemental insurance policies sold by private companies.
• B) They provide benefits exclusively through the federal government.
• C) They must provide all benefits covered by Original Medicare Parts A and B.
• D) They do not have annual out-of-pocket maximums.
Correct Answer: C
Rationale: MA plans are offered by private companies approved by Medicare. By law, they must
cover everything Original Medicare covers, though they may have different costs and additional
benefits like vision or dental.
17. A beneficiary enrolled in a Special Needs Plan (SNP) must:
• A) Have a high income
• B) Meet specific criteria, such as having a certain chronic condition or being dual-eligible
• C) Live in a rural area
, • D) Be under the age of 65
Correct Answer: B
Rationale: SNPs limit membership to people with specific diseases or characteristics (Chronic
Condition SNP, Dual Eligible SNP for those with Medicaid, or Institutional SNP).
18. Which of the following is a key operational difference between a Medicare Advantage
Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO)?
• A) HMOs allow out-of-network non-emergency care without extra costs.
• B) PPOs generally allow members to see out-of-network providers, usually at a higher
cost-sharing amount.
• C) HMOs never require members to select a Primary Care Physician (PCP).
• D) PPOs require referrals from a primary care physician to see any specialist.
Correct Answer: B
Rationale: PPO plans offer out-of-network coverage flexibility at higher cost-sharing rates,
whereas standard HMO plans generally require enrollees to receive care inside the plan network
(except in emergencies) and designate a PCP.
19. How does a Private Fee-For-Service (PFFS) Medicare Advantage plan operate
regarding provider participation?
• A) Providers automatically belong to a mandatory locked network that cannot change.
• B) Members must get a written referral from CMS prior to every specialist visit.
• C) Providers may decide on a visit-by-visit basis whether to accept the plan's payment
terms and conditions.
• D) Members are restricted to receiving care only within their home county.
Correct Answer: C
Rationale: In a non-network or combination PFFS plan, doctors and hospitals may choose
whether to accept the PFFS plan's terms and conditions of payment on a visit-by-visit basis.
20. What is true regarding the Maximum Out-of-Pocket (MOOP) limit in Medicare
Advantage plans?
• A) MOOP limits apply only to standalone Part D prescription drug expenses.
• B) CMS establishes mandatory annual MOOP limits for covered Part A and Part B
services to protect beneficiaries.
