AHIP Final Exam 2027 | and Correct Answers with Rationales |
A+ Graded | Latest - 190 Questions and Answers Already Graded
A+ Premium Exam Tested And Verified
Subject Area Health Insurance and Managed Care (AHIP Certification)
Description This comprehensive final exam covers advanced topics in health insurance,
including Medicare Advantage, Part D, Medigap, Medicaid integration, risk
adjustment, network adequacy, compliance, and ethical marketing. It is designed
for senior-level undergraduates and graduate students pursuing AHIP certification,
with emphasis on current regulatory standards and real-world application.
Expected Grade A+
Total Questions 190
Duration 3 hours
Learning Outcomes 1. Analyze complex Medicare Advantage and Part D plan designs and their
regulatory implications.
2. Evaluate risk adjustment methodologies and their impact on plan
reimbursement.
3. Apply compliance and ethical standards to marketing and enrollment scenarios.
4. Synthesize knowledge of Medicaid-Medicare integration and dual-eligible
special needs plans.
Accreditation This exam adheres to the latest AHIP certification standards and U.S. university
accreditation requirements for graduate-level health policy and insurance
coursework.
Page 1
,1. A Medicare Advantage plan is evaluating its network adequacy for a new PPO
product in a rural county. The plan must ensure that at least one of each provider
type is available within certain time and distance standards. Which of the following
provider types is subject to the strictest time and distance standard under CMS
regulations?
A. Primary care physicians
B. Cardiologists
C. Hospitals (acute care)
D. Skilled nursing facilities
Answer: A. Primary care physicians
CMS applies the strictest time and distance standards to primary care providers to
ensure access to basic medical services. Specialists and facilities have more lenient
thresholds because patients can travel further for non-urgent care.
2. A Part D sponsor is designing a formulary for a new enhanced alternative plan.
Under CMS formulary guidelines, which of the following classes is required to
include all drugs in the protected class categories, and what is the minimum number
of drugs per category?
A. Antidepressants; at least two drugs per category
B. Antipsychotics; at least one drug per category
C. Anticonvulsants; at least two drugs per category
D. Immunosuppressants; at least one drug per category
Answer: C. Anticonvulsants; at least two drugs per category
CMS requires Part D sponsors to include all drugs in six protected classes (including
anticonvulsants) and at least two drugs per category. This ensures adequate access for
patients with complex conditions.
Page 2
,3. A Medicare Advantage plan uses a hierarchical condition category (HCC) risk
adjustment model. Which of the following conditions, if documented properly, would
result in the highest risk score adjustment for the upcoming payment year?
A. Diabetes with chronic complications
B. Congestive heart failure
C. Chronic obstructive pulmonary disease
D. End-stage renal disease (ESRD)
Answer: D. End-stage renal disease (ESRD)
ESRD carries the highest HCC risk adjustment factor because it involves intensive
resource utilization (dialysis, transplant). The CMS-HCC model assigns ESRD a much
higher weight than other chronic conditions.
4. A beneficiary enrolled in a Medicare Advantage plan moves to a county outside
the plan's service area. Which of the following describes the correct enrollment and
disenrollment rules?
A. The beneficiary must disenroll immediately and enroll in Original Medicare during a
Special Enrollment Period (SEP).
B. The beneficiary may remain enrolled until the next Annual Enrollment Period (AEP) and
then switch.
C. The beneficiary can disenroll at any time and join a new plan in the new county using a
SEP.
D. The beneficiary is automatically disenrolled after 30 days if no new plan is chosen.
Answer: C. The beneficiary can disenroll at any time and join a new plan in the
new county using a SEP.
A permanent move outside the service area triggers a Special Enrollment Period (SEP)
allowing the beneficiary to disenroll from the current MA plan and enroll in a new plan
in the new area, without waiting for AEP.
Page 3
, 5. A Medicare Advantage plan is considering offering a supplemental benefit of a
gym membership. Under CMS regulations, which of the following is true regarding
the uniformity requirement for such benefits?
A. The benefit must be offered uniformly to all enrollees in the same plan type.
B. The plan may target the benefit only to enrollees with specific chronic conditions.
C. The plan may offer the benefit only in certain geographic areas within the service area.
D. The benefit must be provided as a reduction in the Part B premium.
Answer: B. The plan may target the benefit only to enrollees with specific chronic
conditions.
CMS allows MA plans to offer supplemental benefits that are targeted to subgroups
with specific chronic conditions, as long as the benefit is medically related. Uniformity
is not required for such benefits under the CHRONIC Care Act.
6. A dual-eligible beneficiary is enrolled in a D-SNP that integrates Medicare and
Medicaid benefits. Which of the following best describes the coordination of
cost-sharing for a Medicare-covered service?
A. Medicare pays first, and Medicaid pays any remaining cost-sharing up to the state's limit.
B. Medicaid pays first, and Medicare pays the remainder.
C. The D-SNP is responsible for all cost-sharing, and no state Medicaid payment is made.
D. The beneficiary is responsible for all cost-sharing, which is then reimbursed by Medicaid.
Answer: A. Medicare pays first, and Medicaid pays any remaining cost-sharing up
to the state's limit.
For dual-eligible beneficiaries, Medicare is the primary payer for Medicare-covered
services. Medicaid then covers the beneficiary's cost-sharing obligations (deductibles,
coinsurance) up to the state's Medicaid payment limits.
7. An agent is conducting a marketing event for a Medicare Advantage plan. Which
of the following actions by the agent violates CMS marketing guidelines?
A. Providing a meal that costs $15 per attendee.
B. Distributing a brochure that includes the plan's Star Ratings.
C. Collecting scope of appointment forms at the event.
D. Offering a door prize worth $25 to all attendees.
Answer: C. Collecting scope of appointment forms at the event.
CMS prohibits collecting scope of appointment forms at marketing events; they must be
collected prior to the event or during a one-on-one appointment. Providing nominal
meals and gifts under $15 is allowed.
Page 4
A+ Graded | Latest - 190 Questions and Answers Already Graded
A+ Premium Exam Tested And Verified
Subject Area Health Insurance and Managed Care (AHIP Certification)
Description This comprehensive final exam covers advanced topics in health insurance,
including Medicare Advantage, Part D, Medigap, Medicaid integration, risk
adjustment, network adequacy, compliance, and ethical marketing. It is designed
for senior-level undergraduates and graduate students pursuing AHIP certification,
with emphasis on current regulatory standards and real-world application.
Expected Grade A+
Total Questions 190
Duration 3 hours
Learning Outcomes 1. Analyze complex Medicare Advantage and Part D plan designs and their
regulatory implications.
2. Evaluate risk adjustment methodologies and their impact on plan
reimbursement.
3. Apply compliance and ethical standards to marketing and enrollment scenarios.
4. Synthesize knowledge of Medicaid-Medicare integration and dual-eligible
special needs plans.
Accreditation This exam adheres to the latest AHIP certification standards and U.S. university
accreditation requirements for graduate-level health policy and insurance
coursework.
Page 1
,1. A Medicare Advantage plan is evaluating its network adequacy for a new PPO
product in a rural county. The plan must ensure that at least one of each provider
type is available within certain time and distance standards. Which of the following
provider types is subject to the strictest time and distance standard under CMS
regulations?
A. Primary care physicians
B. Cardiologists
C. Hospitals (acute care)
D. Skilled nursing facilities
Answer: A. Primary care physicians
CMS applies the strictest time and distance standards to primary care providers to
ensure access to basic medical services. Specialists and facilities have more lenient
thresholds because patients can travel further for non-urgent care.
2. A Part D sponsor is designing a formulary for a new enhanced alternative plan.
Under CMS formulary guidelines, which of the following classes is required to
include all drugs in the protected class categories, and what is the minimum number
of drugs per category?
A. Antidepressants; at least two drugs per category
B. Antipsychotics; at least one drug per category
C. Anticonvulsants; at least two drugs per category
D. Immunosuppressants; at least one drug per category
Answer: C. Anticonvulsants; at least two drugs per category
CMS requires Part D sponsors to include all drugs in six protected classes (including
anticonvulsants) and at least two drugs per category. This ensures adequate access for
patients with complex conditions.
Page 2
,3. A Medicare Advantage plan uses a hierarchical condition category (HCC) risk
adjustment model. Which of the following conditions, if documented properly, would
result in the highest risk score adjustment for the upcoming payment year?
A. Diabetes with chronic complications
B. Congestive heart failure
C. Chronic obstructive pulmonary disease
D. End-stage renal disease (ESRD)
Answer: D. End-stage renal disease (ESRD)
ESRD carries the highest HCC risk adjustment factor because it involves intensive
resource utilization (dialysis, transplant). The CMS-HCC model assigns ESRD a much
higher weight than other chronic conditions.
4. A beneficiary enrolled in a Medicare Advantage plan moves to a county outside
the plan's service area. Which of the following describes the correct enrollment and
disenrollment rules?
A. The beneficiary must disenroll immediately and enroll in Original Medicare during a
Special Enrollment Period (SEP).
B. The beneficiary may remain enrolled until the next Annual Enrollment Period (AEP) and
then switch.
C. The beneficiary can disenroll at any time and join a new plan in the new county using a
SEP.
D. The beneficiary is automatically disenrolled after 30 days if no new plan is chosen.
Answer: C. The beneficiary can disenroll at any time and join a new plan in the
new county using a SEP.
A permanent move outside the service area triggers a Special Enrollment Period (SEP)
allowing the beneficiary to disenroll from the current MA plan and enroll in a new plan
in the new area, without waiting for AEP.
Page 3
, 5. A Medicare Advantage plan is considering offering a supplemental benefit of a
gym membership. Under CMS regulations, which of the following is true regarding
the uniformity requirement for such benefits?
A. The benefit must be offered uniformly to all enrollees in the same plan type.
B. The plan may target the benefit only to enrollees with specific chronic conditions.
C. The plan may offer the benefit only in certain geographic areas within the service area.
D. The benefit must be provided as a reduction in the Part B premium.
Answer: B. The plan may target the benefit only to enrollees with specific chronic
conditions.
CMS allows MA plans to offer supplemental benefits that are targeted to subgroups
with specific chronic conditions, as long as the benefit is medically related. Uniformity
is not required for such benefits under the CHRONIC Care Act.
6. A dual-eligible beneficiary is enrolled in a D-SNP that integrates Medicare and
Medicaid benefits. Which of the following best describes the coordination of
cost-sharing for a Medicare-covered service?
A. Medicare pays first, and Medicaid pays any remaining cost-sharing up to the state's limit.
B. Medicaid pays first, and Medicare pays the remainder.
C. The D-SNP is responsible for all cost-sharing, and no state Medicaid payment is made.
D. The beneficiary is responsible for all cost-sharing, which is then reimbursed by Medicaid.
Answer: A. Medicare pays first, and Medicaid pays any remaining cost-sharing up
to the state's limit.
For dual-eligible beneficiaries, Medicare is the primary payer for Medicare-covered
services. Medicaid then covers the beneficiary's cost-sharing obligations (deductibles,
coinsurance) up to the state's Medicaid payment limits.
7. An agent is conducting a marketing event for a Medicare Advantage plan. Which
of the following actions by the agent violates CMS marketing guidelines?
A. Providing a meal that costs $15 per attendee.
B. Distributing a brochure that includes the plan's Star Ratings.
C. Collecting scope of appointment forms at the event.
D. Offering a door prize worth $25 to all attendees.
Answer: C. Collecting scope of appointment forms at the event.
CMS prohibits collecting scope of appointment forms at marketing events; they must be
collected prior to the event or during a one-on-one appointment. Providing nominal
meals and gifts under $15 is allowed.
Page 4
