AHIP | Modules 1-5
OBJECTIVE ASSESSMENT - EXAM
AHIP Modules
1-5 Exam
Complete Q&As | Verified
100 100% 2026/2027
QUESTIONS VERIFIED EDITION
TOPICS COVERED
Medicare Advantage Plans (Part C) Enrollment Periods & Eligibility
Medicare Prescription Drug Coverage (Part D) Compliance & Marketing Guidelines
Medicare Supplement Insurance (Medigap)
COVER PAGE - 1
, SECTION 1 | Medicare Advantage Plans (Part C) | Q1-Q20 | AHIP Modules 1-5 Exam 2026/2027
Q1 Question 1 of 100
Q1. An 67-year-old beneficiary enlists in a Medicare Advantage Preferred Provider Organization (PPO)
plan during the Annual Election Period. He wants to know if he can see out-of-network providers for
routine cardiovascular checkups.
A. He is completely prohibited from seeking care outside the designated plan provider network.
B. He can see out-of-network providers but will typically face higher cost-sharing requirements.
C. He must obtain a formal primary care physician referral prior to seeing out-of-network specialists.
D. He will receive identical cost-sharing terms whether he uses in-network or out-of-network providers.
Correct Answer: B
Rationale:
PPO plans offer out-of-network coverage, though at higher cost-sharing rates than in-network care. HMOs usually require
in-network care except for emergencies.
Q2 Question 2 of 100
Q2. A 71-year-old woman with chronic heart failure considers an institutional-level Medicare Advantage
Special Needs Plan (I-SNP). She currently lives at home but receives extensive community-based
long-term care.
A. She can enroll without any specific clinical or residential restrictions as long as she has Part A and B.
B. She must be physically residing inside a skilled nursing facility for at least twelve consecutive months.
C. She must meet a state-defined level of care requirement equivalent to an institutional stay to qualify.
D. She is automatically barred from enrollment unless she is fully eligible for full state Medicaid benefits.
Correct Answer: C
Rationale:
I-SNPs serve individuals residing in or expecting to reside in an institution, or those living in the community who require an
institutional level of care.
AHIP Modules 1-5 Exam — 2026/2027 | Passing Score: 75% | Page 2 of 52
, SECTION 1 | Medicare Advantage Plans (Part C) | Q1-Q20 | AHIP Modules 1-5 Exam 2026/2027
Q3 Question 3 of 100
Q3. A beneficiary joins a Medicare Advantage Health Maintenance Organization (HMO) plan and seeks
specialized dermatological care. The specialist she wants to consult is within the plan's contracted
network.
A. She can schedule an appointment directly with the specialist without any gatekeeper involvement.
B. She is required to pay the full out-of-pocket cost and submit a claim manually to Medicare.
C. She must wait until the next Annual Election Period to receive specialized dermatological treatment.
D. She must obtain a prior referral from her assigned primary care physician to ensure coverage.
Correct Answer: D
Rationale:
HMO plans generally rely on a Primary Care Physician (PCP) gatekeeper model requiring referrals for specialist care,
unlike PPO models which allow direct access.
Q4 Question 4 of 100
Q4. A 66-year-old individual enrolled in a Medicare Advantage plan undergoes an urgent inpatient
surgical procedure. The individual wants to know how the Maximum Out-of-Pocket (MOOP) limit
protects his personal finances.
A. The MOOP limit establishes an absolute annual ceiling on beneficiary expenditures for Part A and Part B
services.
B. The MOOP limit covers all out-of-pocket expenses including plan premiums and out-of-network prescription drugs.
C. The MOOP limit forces the federal government to reimburse the plan for all costs exceeding ten thousand dollars.
D. The MOOP limit applies strictly to inpatient hospital deductions and excludes outpatient specialist copayments.
Correct Answer: A
Rationale:
The MOOP limit is a regulatory ceiling protecting beneficiaries from high costs for covered Part A and B services. It does
not include premiums or Part D drugs.
AHIP Modules 1-5 Exam — 2026/2027 | Passing Score: 75% | Page 3 of 52
, SECTION 1 | Medicare Advantage Plans (Part C) | Q1-Q20 | AHIP Modules 1-5 Exam 2026/2027
Q5 Question 5 of 100
Q5. A 69-year-old individual joins a Medicare Advantage Point-of-Service (MA-POS) plan to maintain
flexible access to his long-term physician. He wants to know how the POS mechanism alters traditional
HMO constraints.
A. The POS feature transforms the plan into an unrestricted commercial indemnity policy across the nation.
B. The POS feature permits coverage for specific out-of-network services, usually subject to higher
coinsurance.
C. The POS feature allows the member to opt out of federal Medicare rules entirely during medical crises.
D. The POS feature eliminates all deductibles and coinsurance obligations for in-network medical treatments.
Correct Answer: B
Rationale:
MA-POS plans add an out-of-network option to a standard HMO structure, allowing flexibility for certain services at a higher
cost-sharing rate.
Q6 Question 6 of 100
Q6. A 72-year-old male with End-Stage Renal Disease (ESRD) wants to transition from Original Medicare
to a Medicare Advantage plan. He is looking at local plan choices during the current Annual Election
Period.
A. He is completely prohibited from enrolling in Medicare Advantage unless he qualifies for a dual SNP.
B. He can only enroll if he undergoes a successful kidney transplant operation prior to his application date.
C. He is fully eligible to enroll in any available Medicare Advantage plan in his service area.
D. He must obtain a special medical waiver from the Department of Health and Human Services to apply.
Correct Answer: C
Rationale:
Starting in 2021, federal law allowed individuals with ESRD to enroll in Medicare Advantage plans without the previous
restrictive exclusions.
AHIP Modules 1-5 Exam — 2026/2027 | Passing Score: 75% | Page 4 of 52
OBJECTIVE ASSESSMENT - EXAM
AHIP Modules
1-5 Exam
Complete Q&As | Verified
100 100% 2026/2027
QUESTIONS VERIFIED EDITION
TOPICS COVERED
Medicare Advantage Plans (Part C) Enrollment Periods & Eligibility
Medicare Prescription Drug Coverage (Part D) Compliance & Marketing Guidelines
Medicare Supplement Insurance (Medigap)
COVER PAGE - 1
, SECTION 1 | Medicare Advantage Plans (Part C) | Q1-Q20 | AHIP Modules 1-5 Exam 2026/2027
Q1 Question 1 of 100
Q1. An 67-year-old beneficiary enlists in a Medicare Advantage Preferred Provider Organization (PPO)
plan during the Annual Election Period. He wants to know if he can see out-of-network providers for
routine cardiovascular checkups.
A. He is completely prohibited from seeking care outside the designated plan provider network.
B. He can see out-of-network providers but will typically face higher cost-sharing requirements.
C. He must obtain a formal primary care physician referral prior to seeing out-of-network specialists.
D. He will receive identical cost-sharing terms whether he uses in-network or out-of-network providers.
Correct Answer: B
Rationale:
PPO plans offer out-of-network coverage, though at higher cost-sharing rates than in-network care. HMOs usually require
in-network care except for emergencies.
Q2 Question 2 of 100
Q2. A 71-year-old woman with chronic heart failure considers an institutional-level Medicare Advantage
Special Needs Plan (I-SNP). She currently lives at home but receives extensive community-based
long-term care.
A. She can enroll without any specific clinical or residential restrictions as long as she has Part A and B.
B. She must be physically residing inside a skilled nursing facility for at least twelve consecutive months.
C. She must meet a state-defined level of care requirement equivalent to an institutional stay to qualify.
D. She is automatically barred from enrollment unless she is fully eligible for full state Medicaid benefits.
Correct Answer: C
Rationale:
I-SNPs serve individuals residing in or expecting to reside in an institution, or those living in the community who require an
institutional level of care.
AHIP Modules 1-5 Exam — 2026/2027 | Passing Score: 75% | Page 2 of 52
, SECTION 1 | Medicare Advantage Plans (Part C) | Q1-Q20 | AHIP Modules 1-5 Exam 2026/2027
Q3 Question 3 of 100
Q3. A beneficiary joins a Medicare Advantage Health Maintenance Organization (HMO) plan and seeks
specialized dermatological care. The specialist she wants to consult is within the plan's contracted
network.
A. She can schedule an appointment directly with the specialist without any gatekeeper involvement.
B. She is required to pay the full out-of-pocket cost and submit a claim manually to Medicare.
C. She must wait until the next Annual Election Period to receive specialized dermatological treatment.
D. She must obtain a prior referral from her assigned primary care physician to ensure coverage.
Correct Answer: D
Rationale:
HMO plans generally rely on a Primary Care Physician (PCP) gatekeeper model requiring referrals for specialist care,
unlike PPO models which allow direct access.
Q4 Question 4 of 100
Q4. A 66-year-old individual enrolled in a Medicare Advantage plan undergoes an urgent inpatient
surgical procedure. The individual wants to know how the Maximum Out-of-Pocket (MOOP) limit
protects his personal finances.
A. The MOOP limit establishes an absolute annual ceiling on beneficiary expenditures for Part A and Part B
services.
B. The MOOP limit covers all out-of-pocket expenses including plan premiums and out-of-network prescription drugs.
C. The MOOP limit forces the federal government to reimburse the plan for all costs exceeding ten thousand dollars.
D. The MOOP limit applies strictly to inpatient hospital deductions and excludes outpatient specialist copayments.
Correct Answer: A
Rationale:
The MOOP limit is a regulatory ceiling protecting beneficiaries from high costs for covered Part A and B services. It does
not include premiums or Part D drugs.
AHIP Modules 1-5 Exam — 2026/2027 | Passing Score: 75% | Page 3 of 52
, SECTION 1 | Medicare Advantage Plans (Part C) | Q1-Q20 | AHIP Modules 1-5 Exam 2026/2027
Q5 Question 5 of 100
Q5. A 69-year-old individual joins a Medicare Advantage Point-of-Service (MA-POS) plan to maintain
flexible access to his long-term physician. He wants to know how the POS mechanism alters traditional
HMO constraints.
A. The POS feature transforms the plan into an unrestricted commercial indemnity policy across the nation.
B. The POS feature permits coverage for specific out-of-network services, usually subject to higher
coinsurance.
C. The POS feature allows the member to opt out of federal Medicare rules entirely during medical crises.
D. The POS feature eliminates all deductibles and coinsurance obligations for in-network medical treatments.
Correct Answer: B
Rationale:
MA-POS plans add an out-of-network option to a standard HMO structure, allowing flexibility for certain services at a higher
cost-sharing rate.
Q6 Question 6 of 100
Q6. A 72-year-old male with End-Stage Renal Disease (ESRD) wants to transition from Original Medicare
to a Medicare Advantage plan. He is looking at local plan choices during the current Annual Election
Period.
A. He is completely prohibited from enrolling in Medicare Advantage unless he qualifies for a dual SNP.
B. He can only enroll if he undergoes a successful kidney transplant operation prior to his application date.
C. He is fully eligible to enroll in any available Medicare Advantage plan in his service area.
D. He must obtain a special medical waiver from the Department of Health and Human Services to apply.
Correct Answer: C
Rationale:
Starting in 2021, federal law allowed individuals with ESRD to enroll in Medicare Advantage plans without the previous
restrictive exclusions.
AHIP Modules 1-5 Exam — 2026/2027 | Passing Score: 75% | Page 4 of 52
