AHIP FINAL EXAM –
QUESTIONS AND ANSWERS
2026/2027
Q1: A beneficiary turns 65 and is still working with employer -sponsored health
insurance. When is the Initial Enrollment Period (IEP) for Medicare Part B?
A. The 3 months before the month of the 65th birthday, the month of the birthday, and
3 months after
B. The month of the 65th birthday only
C. January 1 through March 31 of the year they turn 65
D. 6 months before through 6 months after the 65th birthday
Correct Answer: A
Rationale: Correct because the Initial Enrollment Period (IEP) for Medicare Part B is
a 7-month window: 3 months before the month of the 65th birthday, the month of the
birthday, and 3 months after. Per AHIP guidelines, beneficiaries who are still working
may delay Part B without penalty if they have credible employer coverage, but the IEP
window itself remains unchanged. Missing the IEP can result in late enrollment
penalties and coverage gaps.
Q2: A client asks about Medicare Part A coverage for a skilled nursing facility (SNF)
stay. Which statement is accurate?
A. Part A covers 100% of SNF costs for up to 90 days
B. Part A covers up to 100 days per benefit period with coinsurance after
day 20
C. Part A does not cover SNF stays at all
D. Part A covers SNF only if the beneficiary is enrolled in Medicare Advantage
Correct Answer: B
,Rationale: Correct because Medicare Part A covers up to 100 days of SNF care per
benefit period, with days 1–20 fully covered, days 21–100 requiring daily coinsurance,
and no coverage after day 100. Per AHIP Medicare Part A guidelines, a 3-day
qualifying hospital stay is required before SNF admission. Medicare Advantage (D)
does not change Part A SNF benefit rules, as MA plans must provide at least equivalent
coverage.
Q3: Which Medicare Advantage plan type allows beneficiaries to see any provider who
accepts Medicare, without requiring a referral?
A. HMO
B. PPO
C. PFFS
D. SNP
Correct Answer: B
Rationale: Correct because PPO (Preferred Provider Organization) plans allow
beneficiaries to see any Medicare-accepting provider without referrals, though out-of-
network costs are higher. Per AHIP Medicare Advantage guidelines, HMOs (A) require
PCP referrals and network restrictions, PFFS plans (C) have no network but providers
must agree to plan terms, and SNPs (D) are specialized plans for specific conditions.
Understanding plan types is essential for proper beneficiary counseling.
Q4: A beneficiary wants to switch from Original Medicare to a Medicare Advantage
plan during the Annual Enrollment Period (AEP). When does the AEP occur?
A. January 1 – March 31
B. April 1 – June 30
C. October 15 – December 7
D. July 1 – September 30
Correct Answer: C
Rationale: Correct because the Annual Enrollment Period (AEP) runs from October
15 through December 7 each year, during which beneficiaries can switch between
Original Medicare and Medicare Advantage, enroll in a Part D plan, or switch Part D
, plans. Per AHIP enrollment period guidelines, the AEP is the primary opportunity for
beneficiaries to make comprehensive coverage changes. Changes made during AEP
take effect on January 1 of the following year.
Q5: What is the "donut hole" in Medicare Part D coverage officially called?
A. Coverage gap
B. Deductible phase
C. Catastrophic phase
D. Initial coverage phase
Correct Answer: A
Rationale: Correct because the "donut hole" is the Coverage Gap phase in Medicare
Part D, where beneficiaries pay a larger share of drug costs until they reach
catastrophic coverage. Per AHIP Part D guidelines, in 2026 the coverage gap begins
after the beneficiary and plan have spent
5,100oncovereddrugs,andcatastrophiccoveragebeginsat
8,000 in total out-of-pocket spending (TrOOP). Manufacturer discounts apply in the
gap, reducing beneficiary costs to 25% for brand-name drugs.
Q6: A beneficiary with End-Stage Renal Disease (ESRD) is eligible for Medicare
regardless of age. How long must the beneficiary have been on dialysis or have had a
kidney transplant before Medicare coverage begins?
A. Immediately upon diagnosis
B. After 3 months of dialysis
C. After 12 months of dialysis or immediately post-transplant
D. After 6 months of dialysis
Correct Answer: B
Rationale: Correct because ESRD beneficiaries are generally eligible for Medicare
after 3 months of regular dialysis or immediately after a kidney transplant. Per AHIP
Medicare eligibility guidelines, there is no waiting period for post -transplant
QUESTIONS AND ANSWERS
2026/2027
Q1: A beneficiary turns 65 and is still working with employer -sponsored health
insurance. When is the Initial Enrollment Period (IEP) for Medicare Part B?
A. The 3 months before the month of the 65th birthday, the month of the birthday, and
3 months after
B. The month of the 65th birthday only
C. January 1 through March 31 of the year they turn 65
D. 6 months before through 6 months after the 65th birthday
Correct Answer: A
Rationale: Correct because the Initial Enrollment Period (IEP) for Medicare Part B is
a 7-month window: 3 months before the month of the 65th birthday, the month of the
birthday, and 3 months after. Per AHIP guidelines, beneficiaries who are still working
may delay Part B without penalty if they have credible employer coverage, but the IEP
window itself remains unchanged. Missing the IEP can result in late enrollment
penalties and coverage gaps.
Q2: A client asks about Medicare Part A coverage for a skilled nursing facility (SNF)
stay. Which statement is accurate?
A. Part A covers 100% of SNF costs for up to 90 days
B. Part A covers up to 100 days per benefit period with coinsurance after
day 20
C. Part A does not cover SNF stays at all
D. Part A covers SNF only if the beneficiary is enrolled in Medicare Advantage
Correct Answer: B
,Rationale: Correct because Medicare Part A covers up to 100 days of SNF care per
benefit period, with days 1–20 fully covered, days 21–100 requiring daily coinsurance,
and no coverage after day 100. Per AHIP Medicare Part A guidelines, a 3-day
qualifying hospital stay is required before SNF admission. Medicare Advantage (D)
does not change Part A SNF benefit rules, as MA plans must provide at least equivalent
coverage.
Q3: Which Medicare Advantage plan type allows beneficiaries to see any provider who
accepts Medicare, without requiring a referral?
A. HMO
B. PPO
C. PFFS
D. SNP
Correct Answer: B
Rationale: Correct because PPO (Preferred Provider Organization) plans allow
beneficiaries to see any Medicare-accepting provider without referrals, though out-of-
network costs are higher. Per AHIP Medicare Advantage guidelines, HMOs (A) require
PCP referrals and network restrictions, PFFS plans (C) have no network but providers
must agree to plan terms, and SNPs (D) are specialized plans for specific conditions.
Understanding plan types is essential for proper beneficiary counseling.
Q4: A beneficiary wants to switch from Original Medicare to a Medicare Advantage
plan during the Annual Enrollment Period (AEP). When does the AEP occur?
A. January 1 – March 31
B. April 1 – June 30
C. October 15 – December 7
D. July 1 – September 30
Correct Answer: C
Rationale: Correct because the Annual Enrollment Period (AEP) runs from October
15 through December 7 each year, during which beneficiaries can switch between
Original Medicare and Medicare Advantage, enroll in a Part D plan, or switch Part D
, plans. Per AHIP enrollment period guidelines, the AEP is the primary opportunity for
beneficiaries to make comprehensive coverage changes. Changes made during AEP
take effect on January 1 of the following year.
Q5: What is the "donut hole" in Medicare Part D coverage officially called?
A. Coverage gap
B. Deductible phase
C. Catastrophic phase
D. Initial coverage phase
Correct Answer: A
Rationale: Correct because the "donut hole" is the Coverage Gap phase in Medicare
Part D, where beneficiaries pay a larger share of drug costs until they reach
catastrophic coverage. Per AHIP Part D guidelines, in 2026 the coverage gap begins
after the beneficiary and plan have spent
5,100oncovereddrugs,andcatastrophiccoveragebeginsat
8,000 in total out-of-pocket spending (TrOOP). Manufacturer discounts apply in the
gap, reducing beneficiary costs to 25% for brand-name drugs.
Q6: A beneficiary with End-Stage Renal Disease (ESRD) is eligible for Medicare
regardless of age. How long must the beneficiary have been on dialysis or have had a
kidney transplant before Medicare coverage begins?
A. Immediately upon diagnosis
B. After 3 months of dialysis
C. After 12 months of dialysis or immediately post-transplant
D. After 6 months of dialysis
Correct Answer: B
Rationale: Correct because ESRD beneficiaries are generally eligible for Medicare
after 3 months of regular dialysis or immediately after a kidney transplant. Per AHIP
Medicare eligibility guidelines, there is no waiting period for post -transplant
