AHIP FINAL EXAM 2025/2026 ACTUAL EXAM
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GRADED A+ LATEST
AHIP Final Exam 2025/2026
The exam covers Medicare Advantage, Part D, plan benefits, compliance,
fraud prevention, care coordination, member communications, and ethical
considerations. Each question includes the correct answer and detailed
rationale.
1.
Which of the following individuals is eligible to enroll in a Medicare
Advantage (MA) plan?
A. A 65-year-old with Medicare Part A only
B. A 72-year-old with Medicare Parts A and B who lives within the plan’s service
area
C. A 60-year-old with employer group coverage only
D. A 68-year-old who permanently resides outside the United States
✅Answer: B. A 72-year-old with Medicare Parts A and B who lives within
the plan’s service area
Rationale:
To enroll in an MA plan, a beneficiary must be entitled to Part A, enrolled in
Part B, and reside in the plan’s service area.
,2.
What is the primary goal of Medicare Advantage plans?
A. Replace Original Medicare with private coverage that adds more out-of-pocket
costs
B. Provide Medicare-covered benefits through private insurers that meet CMS
standards
C. Eliminate Part D coverage
D. Offer coverage only for hospital services
✅Answer: B. Provide Medicare-covered benefits through private insurers
that meet CMS standards
Rationale:
MA plans deliver Medicare benefits via CMS-approved private insurers, often
with additional benefits like vision or dental.
3.
Which of the following services are not covered under Medicare Part A?
A. Skilled nursing facility care
B. Hospice care
C. Home health services
D. Outpatient physical therapy
✅Answer: D. Outpatient physical therapy
Rationale:
Outpatient therapy is covered under Part B, not Part A, which primarily covers
inpatient and facility-based care.
4.
During the Annual Election Period (AEP), beneficiaries can:
A. Only drop their current plan
B. Only enroll in a new plan if they have a special circumstance
,C. Enroll, switch, or disenroll from Medicare Advantage or Part D plans
D. Only switch from MA to Original Medicare
✅Answer: C. Enroll, switch, or disenroll from Medicare Advantage or Part
D plans
Rationale:
AEP (October 15 – December 7) allows plan changes, enrollment, or
disenrollment for the upcoming year.
5.
Which of the following best defines a Special Enrollment Period (SEP)?
A. A set period when everyone can join Medicare
B. Time allowed for changes due to specific qualifying events
C. The first time a person becomes eligible for Medicare D.
Period between AEPs
✅Answer: B. Time allowed for changes due to specific qualifying events
Rationale:
SEPs occur after specific life events, such as moving out of a service area or
losing employer coverage.
6.
Which entity regulates and oversees Medicare Advantage and Part D plans?
A. The Department of Health and Human Services (HHS)
B. The Centers for Medicare & Medicaid Services (CMS)
C. The National Association of Insurance Commissioners (NAIC)
D. State insurance departments only
✅Answer: B. The Centers for Medicare & Medicaid Services (CMS)
Rationale:
CMS oversees all Medicare Advantage and Part D plans, ensuring compliance
with federal standards.
, 7.
A Marketing Misrepresentation occurs when:
A. An agent clearly explains all benefits
B. A plan is advertised with full disclosures
C. An agent provides false or misleading information to influence enrollment
D. CMS approves all materials before distribution
✅Answer: C. An agent provides false or misleading information to influence
enrollment
Rationale:
Misrepresentation violates CMS marketing rules and may lead to disciplinary
actions and revocation of certification.
8.
Which statement is true regarding Medicare Part D coverage stages?
A. The coverage gap (“donut hole”) no longer exists
B. Beneficiaries pay 100% of drug costs during the initial coverage phase
C. There are four stages: deductible, initial coverage, coverage gap, and
catastrophic coverage
D. Premiums vary only by income
✅Answer: C. There are four stages: deductible, initial coverage, coverage
gap, and catastrophic coverage
Rationale:
Part D follows four stages that determine member cost-sharing throughout the
plan year.
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GRADED A+ LATEST
AHIP Final Exam 2025/2026
The exam covers Medicare Advantage, Part D, plan benefits, compliance,
fraud prevention, care coordination, member communications, and ethical
considerations. Each question includes the correct answer and detailed
rationale.
1.
Which of the following individuals is eligible to enroll in a Medicare
Advantage (MA) plan?
A. A 65-year-old with Medicare Part A only
B. A 72-year-old with Medicare Parts A and B who lives within the plan’s service
area
C. A 60-year-old with employer group coverage only
D. A 68-year-old who permanently resides outside the United States
✅Answer: B. A 72-year-old with Medicare Parts A and B who lives within
the plan’s service area
Rationale:
To enroll in an MA plan, a beneficiary must be entitled to Part A, enrolled in
Part B, and reside in the plan’s service area.
,2.
What is the primary goal of Medicare Advantage plans?
A. Replace Original Medicare with private coverage that adds more out-of-pocket
costs
B. Provide Medicare-covered benefits through private insurers that meet CMS
standards
C. Eliminate Part D coverage
D. Offer coverage only for hospital services
✅Answer: B. Provide Medicare-covered benefits through private insurers
that meet CMS standards
Rationale:
MA plans deliver Medicare benefits via CMS-approved private insurers, often
with additional benefits like vision or dental.
3.
Which of the following services are not covered under Medicare Part A?
A. Skilled nursing facility care
B. Hospice care
C. Home health services
D. Outpatient physical therapy
✅Answer: D. Outpatient physical therapy
Rationale:
Outpatient therapy is covered under Part B, not Part A, which primarily covers
inpatient and facility-based care.
4.
During the Annual Election Period (AEP), beneficiaries can:
A. Only drop their current plan
B. Only enroll in a new plan if they have a special circumstance
,C. Enroll, switch, or disenroll from Medicare Advantage or Part D plans
D. Only switch from MA to Original Medicare
✅Answer: C. Enroll, switch, or disenroll from Medicare Advantage or Part
D plans
Rationale:
AEP (October 15 – December 7) allows plan changes, enrollment, or
disenrollment for the upcoming year.
5.
Which of the following best defines a Special Enrollment Period (SEP)?
A. A set period when everyone can join Medicare
B. Time allowed for changes due to specific qualifying events
C. The first time a person becomes eligible for Medicare D.
Period between AEPs
✅Answer: B. Time allowed for changes due to specific qualifying events
Rationale:
SEPs occur after specific life events, such as moving out of a service area or
losing employer coverage.
6.
Which entity regulates and oversees Medicare Advantage and Part D plans?
A. The Department of Health and Human Services (HHS)
B. The Centers for Medicare & Medicaid Services (CMS)
C. The National Association of Insurance Commissioners (NAIC)
D. State insurance departments only
✅Answer: B. The Centers for Medicare & Medicaid Services (CMS)
Rationale:
CMS oversees all Medicare Advantage and Part D plans, ensuring compliance
with federal standards.
, 7.
A Marketing Misrepresentation occurs when:
A. An agent clearly explains all benefits
B. A plan is advertised with full disclosures
C. An agent provides false or misleading information to influence enrollment
D. CMS approves all materials before distribution
✅Answer: C. An agent provides false or misleading information to influence
enrollment
Rationale:
Misrepresentation violates CMS marketing rules and may lead to disciplinary
actions and revocation of certification.
8.
Which statement is true regarding Medicare Part D coverage stages?
A. The coverage gap (“donut hole”) no longer exists
B. Beneficiaries pay 100% of drug costs during the initial coverage phase
C. There are four stages: deductible, initial coverage, coverage gap, and
catastrophic coverage
D. Premiums vary only by income
✅Answer: C. There are four stages: deductible, initial coverage, coverage
gap, and catastrophic coverage
Rationale:
Part D follows four stages that determine member cost-sharing throughout the
plan year.
