2027 AHIP Final Exam – Medicare
Certification – Actual Questions & Answers
(AHIP) Guarantee Pass (Updated Pdf)
QUESTION 1
Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to
pick up costs not covered by that plan. What should you tell him?
A) You can sell him a Medigap plan to help with costs not covered under Medicare Advantage.
B) It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and
besides, Medigap only works with Original Medicare.
C) Medigap plans are designed to work alongside Medicare Advantage plans.
D) He must disenroll from his MA plan before buying a Medigap plan.
Correct Answer: B
Rationale: Federal law prohibits the sale of a Medigap policy to any individual enrolled in a
Medicare Advantage plan. Medigap policies are designed exclusively to supplement Original
Medicare (Parts A and B) cost-sharing and cannot be used to cover MA plan deductibles, copays,
or coinsurance.
QUESTION 2
Edward suffered from serious kidney disease. As a result, Edward became eligible for Medicare
coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and
Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and
asks you if his Medicare coverage will continue. What should you say?
A) His Medicare coverage will end 12 months after transplant surgery, regardless of his age.
B) His Medicare coverage will continue as long as he receives follow-up care for the transplant.
C) His Medicare coverage will end 36 months after the transplant unless he otherwise qualifies.
D) His Medicare coverage ends immediately after transplant surgery.
Correct Answer: C
Rationale: For beneficiaries who qualify for Medicare solely due to ESRD, Medicare coverage
terminates 36 months after a successful kidney transplant. Coverage continues for those 36
,post-transplant months unless the individual becomes eligible for Medicare due to age (65+) or
another qualifying disability before that period ends.
QUESTION 3
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the
Part D low-income subsidy (Extra Help). Where might he turn for help with his prescription drug
costs?
A) Apply for Medicaid to cover prescription costs.
B) Seek assistance from pharmaceutical company discount programs.
C) Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical
Assistance Program (SPAP).
D) Try to enroll in a Medigap plan with drug coverage.
Correct Answer: C
Rationale: Many states operate State Pharmaceutical Assistance Programs (SPAPs) that provide
additional financial help with Part D premiums and cost-sharing to residents who do not qualify
for the federal Low-Income Subsidy. SPAP eligibility, benefits, and income limits vary by state.
Medigap policies with drug coverage are no longer sold to new Medicare beneficiaries.
QUESTION 4
Mrs. Ramos is considering a Medicare Advantage Prescription Drug (MA-PD) plan. She is
currently taking a brand-name medication that is not on the plan's formulary. Under CMS
guidelines, what option does she have?
A) She may request a formulary exception to cover the medication.
B) She must switch to a different medication that is on the formulary.
C) She may pay full price for the drug out-of-pocket and have it count toward her True Out-of-
Pocket (TrOOP) costs.
D) She cannot enroll in that plan if her drug is not on the formulary.
Correct Answer: A
Rationale: Medicare Part D plans are required to have an exceptions process that allows
enrollees to request coverage for a non-formulary drug or a lower cost-sharing tier. The plan
,must grant the exception if the prescribing physician provides supporting documentation that
the requested drug is medically necessary over the formulary alternatives.
QUESTION 5
During a sales presentation, a beneficiary asks you about the "Star Ratings" for Medicare
Advantage plans. Which of the following is an accurate statement you can make?
A) Star Ratings are based on member satisfaction and quality of care, measured on a 1-to-5
scale, with 5 being the highest.
B) Star Ratings are determined by the number of beneficiaries enrolled in the plan.
C) Plans with a 5-Star rating are only available during the Annual Election Period.
D) Star Ratings are published by the National Association of Insurance Commissioners (NAIC).
Correct Answer: A
Rationale: CMS assigns Star Ratings to Medicare Advantage and Part D plans each year based
on more than 40 quality and performance measures, including member satisfaction, preventive
care, and chronic condition management. Ratings range from 1 to 5 stars, with 5 being
excellent. The 5-Star Special Enrollment Period allows beneficiaries to enroll in a 5-Star plan
outside of normal election periods.
QUESTION 6
Mr. Jenkins is turning 65 next month and currently has employer group health coverage through
his own job. He asks if he must enroll in Medicare Part B immediately. What is your best
response?
A) Yes, he must enroll in Part B during his Initial Enrollment Period or face a lifetime penalty.
B) No, he can delay Part B enrollment without penalty as long as he has creditable coverage
through his or a spouse's current employment.
C) No, but he must enroll in Part A immediately to avoid penalties.
D) Yes, but only if his employer has fewer than 20 employees.
Correct Answer: B
Rationale: Individuals who have creditable group health coverage based on current
employment (their own or a spouse's) may delay enrolling in Medicare Part B without incurring
, a late enrollment penalty. The Special Enrollment Period (SEP) allows them to enroll in Part B
within 8 months after the employment or coverage ends, whichever comes first.
QUESTION 7
Which of the following marketing practices is strictly prohibited under CMS Medicare
Communications and Marketing Guidelines?
A) Sending a postcard to beneficiaries advertising a free educational dinner event.
B) Conducting a sales presentation immediately following an educational event in the same
hotel ballroom.
C) Offering a $5 Starbucks gift card to beneficiaries who attend a sales presentation.
D) Distributing plan-specific brochures at a community health fair.
Correct Answer: B
Rationale: CMS strictly prohibits "pitching" or conducting sales presentations immediately after
educational events. A 12-hour separation is required between an educational event and a sales
event held in the same location, unless they are held on different days. While nominal gifts
(under $15) are permitted, conducting sales at educational events is not.
QUESTION 8
Mrs. O'Malley is enrolled in Original Medicare and has a standalone Part D plan. She is admitted
to a skilled nursing facility (SNF) after a 3-day qualifying hospital stay. Under Medicare Part A,
how many days of SNF care are covered at 100% with no coinsurance?
A) 20 days
B) 30 days
C) 60 days
D) 100 days
Correct Answer: A
Rationale: Medicare Part A covers skilled nursing facility care for up to 100 days per benefit
period following a qualifying 3-day inpatient hospital stay. Days 1–20 are covered at 100% with
no coinsurance. Days 21–100 require a daily coinsurance ($204 per day in 2026). Days beyond
100 are not covered by Medicare.
Certification – Actual Questions & Answers
(AHIP) Guarantee Pass (Updated Pdf)
QUESTION 1
Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to
pick up costs not covered by that plan. What should you tell him?
A) You can sell him a Medigap plan to help with costs not covered under Medicare Advantage.
B) It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and
besides, Medigap only works with Original Medicare.
C) Medigap plans are designed to work alongside Medicare Advantage plans.
D) He must disenroll from his MA plan before buying a Medigap plan.
Correct Answer: B
Rationale: Federal law prohibits the sale of a Medigap policy to any individual enrolled in a
Medicare Advantage plan. Medigap policies are designed exclusively to supplement Original
Medicare (Parts A and B) cost-sharing and cannot be used to cover MA plan deductibles, copays,
or coinsurance.
QUESTION 2
Edward suffered from serious kidney disease. As a result, Edward became eligible for Medicare
coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and
Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and
asks you if his Medicare coverage will continue. What should you say?
A) His Medicare coverage will end 12 months after transplant surgery, regardless of his age.
B) His Medicare coverage will continue as long as he receives follow-up care for the transplant.
C) His Medicare coverage will end 36 months after the transplant unless he otherwise qualifies.
D) His Medicare coverage ends immediately after transplant surgery.
Correct Answer: C
Rationale: For beneficiaries who qualify for Medicare solely due to ESRD, Medicare coverage
terminates 36 months after a successful kidney transplant. Coverage continues for those 36
,post-transplant months unless the individual becomes eligible for Medicare due to age (65+) or
another qualifying disability before that period ends.
QUESTION 3
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the
Part D low-income subsidy (Extra Help). Where might he turn for help with his prescription drug
costs?
A) Apply for Medicaid to cover prescription costs.
B) Seek assistance from pharmaceutical company discount programs.
C) Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical
Assistance Program (SPAP).
D) Try to enroll in a Medigap plan with drug coverage.
Correct Answer: C
Rationale: Many states operate State Pharmaceutical Assistance Programs (SPAPs) that provide
additional financial help with Part D premiums and cost-sharing to residents who do not qualify
for the federal Low-Income Subsidy. SPAP eligibility, benefits, and income limits vary by state.
Medigap policies with drug coverage are no longer sold to new Medicare beneficiaries.
QUESTION 4
Mrs. Ramos is considering a Medicare Advantage Prescription Drug (MA-PD) plan. She is
currently taking a brand-name medication that is not on the plan's formulary. Under CMS
guidelines, what option does she have?
A) She may request a formulary exception to cover the medication.
B) She must switch to a different medication that is on the formulary.
C) She may pay full price for the drug out-of-pocket and have it count toward her True Out-of-
Pocket (TrOOP) costs.
D) She cannot enroll in that plan if her drug is not on the formulary.
Correct Answer: A
Rationale: Medicare Part D plans are required to have an exceptions process that allows
enrollees to request coverage for a non-formulary drug or a lower cost-sharing tier. The plan
,must grant the exception if the prescribing physician provides supporting documentation that
the requested drug is medically necessary over the formulary alternatives.
QUESTION 5
During a sales presentation, a beneficiary asks you about the "Star Ratings" for Medicare
Advantage plans. Which of the following is an accurate statement you can make?
A) Star Ratings are based on member satisfaction and quality of care, measured on a 1-to-5
scale, with 5 being the highest.
B) Star Ratings are determined by the number of beneficiaries enrolled in the plan.
C) Plans with a 5-Star rating are only available during the Annual Election Period.
D) Star Ratings are published by the National Association of Insurance Commissioners (NAIC).
Correct Answer: A
Rationale: CMS assigns Star Ratings to Medicare Advantage and Part D plans each year based
on more than 40 quality and performance measures, including member satisfaction, preventive
care, and chronic condition management. Ratings range from 1 to 5 stars, with 5 being
excellent. The 5-Star Special Enrollment Period allows beneficiaries to enroll in a 5-Star plan
outside of normal election periods.
QUESTION 6
Mr. Jenkins is turning 65 next month and currently has employer group health coverage through
his own job. He asks if he must enroll in Medicare Part B immediately. What is your best
response?
A) Yes, he must enroll in Part B during his Initial Enrollment Period or face a lifetime penalty.
B) No, he can delay Part B enrollment without penalty as long as he has creditable coverage
through his or a spouse's current employment.
C) No, but he must enroll in Part A immediately to avoid penalties.
D) Yes, but only if his employer has fewer than 20 employees.
Correct Answer: B
Rationale: Individuals who have creditable group health coverage based on current
employment (their own or a spouse's) may delay enrolling in Medicare Part B without incurring
, a late enrollment penalty. The Special Enrollment Period (SEP) allows them to enroll in Part B
within 8 months after the employment or coverage ends, whichever comes first.
QUESTION 7
Which of the following marketing practices is strictly prohibited under CMS Medicare
Communications and Marketing Guidelines?
A) Sending a postcard to beneficiaries advertising a free educational dinner event.
B) Conducting a sales presentation immediately following an educational event in the same
hotel ballroom.
C) Offering a $5 Starbucks gift card to beneficiaries who attend a sales presentation.
D) Distributing plan-specific brochures at a community health fair.
Correct Answer: B
Rationale: CMS strictly prohibits "pitching" or conducting sales presentations immediately after
educational events. A 12-hour separation is required between an educational event and a sales
event held in the same location, unless they are held on different days. While nominal gifts
(under $15) are permitted, conducting sales at educational events is not.
QUESTION 8
Mrs. O'Malley is enrolled in Original Medicare and has a standalone Part D plan. She is admitted
to a skilled nursing facility (SNF) after a 3-day qualifying hospital stay. Under Medicare Part A,
how many days of SNF care are covered at 100% with no coinsurance?
A) 20 days
B) 30 days
C) 60 days
D) 100 days
Correct Answer: A
Rationale: Medicare Part A covers skilled nursing facility care for up to 100 days per benefit
period following a qualifying 3-day inpatient hospital stay. Days 1–20 are covered at 100% with
no coinsurance. Days 21–100 require a daily coinsurance ($204 per day in 2026). Days beyond
100 are not covered by Medicare.
