CIGNA MEDICARE CERTIFICATION STUDY
GUIDE 2024 - LATEST 2025/2026 EDITION BY
CIGNA HEALTHCARE PROFESSIONALS -
ULTIMATE PREP TO PASS
1. A beneficiary is currently enrolled in Original Medicare Parts A and B and wishes to switch to a
CIGNA Medicare Advantage (MA) plan during the Annual Enrollment Period (AEP). Which of
the following best describes the effective date of coverage if the enrollment application is submitted
on December 1, 2024?
A. Coverage begins January 1, 2025, provided the application is received by December 7, 2024.
B. Coverage begins February 1, 2025, because the AEP ends December 7, 2024, and processing takes 30 days.
C. Coverage begins the first of the month after the plan receives the enrollment request, as long as the request is
made during AEP.
D. Coverage begins January 1, 2025, regardless of the submission date within AEP, as long as the request is
received by December 31, 2024.
Answer: A
Rationale: CMS rules state that for AEP (October 15–December 7), coverage effective date is January 1
of the following year if the enrollment request is received by December 7. Option A is correct. Option B
incorrectly extends the AEP deadline. Option C describes a different rule (e.g., for special enrollment
periods). Option D incorrectly extends AEP to December 31.
2. A CIGNA Medicare Advantage plan imposes a $5,000 out-of-pocket maximum for in-network
services. A beneficiary with a chronic condition has already incurred $4,800 in covered in-network
costs for the year. In November, the beneficiary requires an inpatient hospitalization that costs
$10,000. Which of the following accurately describes the beneficiary's financial responsibility for
this hospitalization?
A. The beneficiary pays the full $10,000 because the out-of-pocket maximum applies only to Part D drugs, not
inpatient services.
B. The beneficiary pays $200, the remaining amount to reach the out-of-pocket maximum, and the plan covers
the rest.
C. The beneficiary pays a $1,600 deductible plus 20% coinsurance, totaling $3,600.
D. The beneficiary pays a copayment of $500 per day for the first 5 days, totaling $2,500.
Answer: B
Rationale: Medicare Advantage plans have an annual out-of-pocket maximum for in-network services.
Once the beneficiary has incurred $4,800, only $200 remains before reaching the $5,000 limit.
Therefore, the beneficiary pays only $200 for the hospitalization; the plan covers the remaining $9,800.
Option A is incorrect because the out-of-pocket limit applies to Part A and B services. Options C and D
describe cost-sharing that would apply before the limit is reached.
Page 1
,3. A CIGNA Medicare Advantage plan uses a preferred provider organization (PPO) network. A
beneficiary receives emergency care at an out-of-network hospital while traveling. Under CMS
regulations, which of the following statements is correct regarding the beneficiary's cost-sharing
for this emergency service?
A. The plan may charge a higher coinsurance for out-of-network emergency care, but cannot exceed 50% of the
Medicare-approved amount.
B. The beneficiary must pay the full cost of emergency care if the hospital is out-of-network, with no plan
coverage.
C. The plan must cover emergency services at the same cost-sharing as in-network emergency services,
regardless of network status.
D. The plan may charge a copayment for out-of-network emergency care, but only if the beneficiary did not
notify the plan within 24 hours.
Answer: C
Rationale: CMS requires Medicare Advantage plans to cover emergency services at in-network
cost-sharing levels, regardless of where the service is provided, to ensure beneficiaries are not deterred
from seeking emergency care. Option C is correct. Options A and B are incorrect because they impose
higher costs or deny coverage. Option D is incorrect because prior notification is not required for
emergency care.
4. A beneficiary enrolled in a CIGNA Medicare Advantage Prescription Drug (MA-PD) plan
enters the coverage gap (donut hole) in 2024. The beneficiary has total drug costs of $5,000, with
$3,000 in the initial coverage phase and $2,000 in the coverage gap. Which of the following best
describes the beneficiary's cost-sharing for brand-name drugs during the coverage gap?
A. The beneficiary pays 25% of the drug cost, and the plan pays 75%, with the manufacturer discount covering
70% of the total cost.
B. The beneficiary pays 25% of the drug cost, and the manufacturer provides a 70% discount on brand-name
drugs, with the plan paying 5%.
C. The beneficiary pays 25% of the drug cost, and the plan pays 75% of the cost, with no manufacturer discount.
D. The beneficiary pays the full cost of brand-name drugs until catastrophic coverage begins.
Answer: B
Rationale: In 2024, the Inflation Reduction Act modified the coverage gap: beneficiaries pay 25% of
brand-name drug costs, manufacturers provide a 70% discount, and plans cover 5%. Option B correctly
describes this. Option A misstates the discount and plan share. Option C omits the manufacturer
discount. Option D is outdated.
5. A CIGNA Medicare Advantage plan denies coverage for a hip replacement surgery, citing that
the procedure is not medically necessary. The beneficiary wishes to appeal. Which of the following
accurately describes the first level of appeal and the timeframe for the plan's decision?
A. The beneficiary must request a reconsideration by an Independent Review Entity (IRE) within 60 days; the
IRE must decide within 30 days.
B. The beneficiary must file a written appeal with the plan within 60 days of the denial notice; the plan must
issue a decision within 30 days (or 72 hours if expedited).
C. The beneficiary must request a hearing before an Administrative Law Judge (ALJ) within 120 days; the ALJ
must decide within 90 days.
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,D. The beneficiary must file a grievance with the plan within 30 days; the plan must respond within 15 days.
Answer: B
Rationale: The first level of appeal for a Medicare Advantage plan denial is a plan-level reconsideration.
The beneficiary must file within 60 days of the denial notice, and the plan must decide within 30 days
(standard) or 72 hours (expedited). Option B is correct. Option A describes the second level (IRE).
Option C describes a later level (ALJ). Option D describes a grievance, which is for quality issues, not
coverage denials.
6. A beneficiary is eligible for both Medicare and Medicaid (dual eligible). The beneficiary enrolls
in a CIGNA Medicare Advantage Dual Eligible Special Needs Plan (D-SNP). Which of the
following best describes the coordination of benefits for a covered Part B service?
A. Medicare pays first, then Medicaid pays any remaining cost-sharing up to state Medicaid limits, and the
D-SNP may wrap around additional benefits.
B. Medicaid pays first because the beneficiary is dual eligible, then Medicare pays secondary, and the D-SNP
pays last.
C. The D-SNP pays all costs, and neither Medicare nor Medicaid pays anything.
D. Medicare pays first, and the D-SNP pays all remaining cost-sharing, with Medicaid only covering services
not covered by Medicare.
Answer: A
Rationale: For dual eligibles, Medicare is the primary payer. Medicaid pays secondary, covering
Medicare premiums and cost-sharing (deductibles, coinsurance, copays) up to state limits. D-SNPs often
provide additional benefits (wrap-around). Option A correctly describes this. Option B incorrectly
makes Medicaid primary. Option C is false because Medicare and Medicaid still pay. Option D
misstates Medicaid's role.
7. A CIGNA Medicare Advantage plan offers a Special Supplemental Benefits for the Chronically
Ill (SSBCI) program. Which of the following benefits is most likely to be offered under SSBCI for a
beneficiary with diabetes?
A. A gym membership for general fitness.
B. Meal delivery services tailored to diabetic dietary needs.
C. Over-the-counter vitamins and supplements.
D. Transportation to a non-medical social event.
Answer: B
Rationale: SSBCI benefits are designed to address the specific needs of chronically ill beneficiaries. For
diabetes, meal delivery with diabetic-appropriate meals directly supports disease management. Option B
is correct. Options A, C, and D are more general supplemental benefits not necessarily tied to a chronic
condition's specific needs, though they could be offered under other authorities.
8. A beneficiary is enrolled in a CIGNA Medicare Advantage plan that uses a tiered pharmacy
network. The beneficiary takes a brand-name drug on Tier 3. The plan's formulary includes a
generic alternative on Tier 1. Which of the following is the plan permitted to do regarding
coverage of the brand-name drug?
A. Require the beneficiary to try the generic first (step therapy) before covering the brand-name drug.
Page 3
, B. Deny coverage entirely for the brand-name drug because a generic alternative is available.
C. Cover the brand-name drug at the same cost-sharing as the generic if the beneficiary requests it.
D. Cover the brand-name drug only if the beneficiary obtains prior authorization and pays a higher coinsurance.
Answer: A
Rationale: Medicare Advantage plans may use step therapy to require trial of a lower-cost generic before
covering a brand-name drug. Option A is correct. Option B is incorrect because plans must have an
exception process. Option C is incorrect because cost-sharing tiers differ. Option D describes prior
authorization, which may be used but is not the only option; step therapy is also permissible.
9. A beneficiary enrolled in a CIGNA Medicare Advantage plan receives a notice that their plan
will be non-renewed for the following year. The beneficiary wants to enroll in a different CIGNA
Medicare Advantage plan. Which enrollment period applies?
A. The beneficiary may enroll in a new plan during the Medicare Advantage Open Enrollment Period (MA
OEP) from January 1 to March 31.
B. The beneficiary may enroll in a new plan during the Annual Enrollment Period (AEP) from October 15 to
December 7.
C. The beneficiary has a Special Enrollment Period (SEP) from December 8 to the end of February of the
following year to enroll in another plan.
D. The beneficiary must wait until the next AEP to enroll, but may request a coverage gap exception.
Answer: C
Rationale: When a plan is non-renewed, CMS provides a Special Enrollment Period (SEP) from
December 8 through the last day of February of the following year to allow beneficiaries to enroll in
another plan. Option C is correct. Option A (MA OEP) is for those already in MA to change plans once.
Option B (AEP) has already passed. Option D is incorrect because an SEP is available.
10. A CIGNA Medicare Advantage plan includes a $0 premium and a $0 deductible for medical
services. The plan has a maximum out-of-pocket limit of $3,000. A beneficiary incurs $2,500 in
covered medical expenses in January. In February, the beneficiary requires a surgical procedure
with a Medicare-approved amount of $15,000. The plan's cost-sharing for surgery is 20%
coinsurance after deductible. Which of the following best describes the beneficiary's total
out-of-pocket cost for the year?
A. $2,500 (January expenses) plus $3,000 (20% of $15,000) = $5,500, but capped at $3,000, so $3,000.
B. $2,500 (January expenses) plus $500 (remaining to reach $3,000 cap) = $3,000.
C. $2,500 (January expenses) plus $3,000 (20% of $15,000) = $5,500, but the plan pays all, so $0.
D. $2,500 (January expenses) plus $2,500 (20% of $15,000 minus $500 already paid) = $5,000, capped at
$3,000, so $3,000.
Answer: B
Rationale: Since the plan has a $0 deductible, the $2,500 in January counts toward the out-of-pocket
maximum. The surgery's 20% coinsurance ($3,000) would bring total costs to $5,500, but the maximum
is $3,000. The beneficiary has already incurred $2,500, so only $500 more is needed to reach the cap.
Thus, total out-of-pocket is $3,000. Option B correctly calculates this. Options A and D misapply the
cap. Option C is incorrect because the beneficiary must pay up to the cap.
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GUIDE 2024 - LATEST 2025/2026 EDITION BY
CIGNA HEALTHCARE PROFESSIONALS -
ULTIMATE PREP TO PASS
1. A beneficiary is currently enrolled in Original Medicare Parts A and B and wishes to switch to a
CIGNA Medicare Advantage (MA) plan during the Annual Enrollment Period (AEP). Which of
the following best describes the effective date of coverage if the enrollment application is submitted
on December 1, 2024?
A. Coverage begins January 1, 2025, provided the application is received by December 7, 2024.
B. Coverage begins February 1, 2025, because the AEP ends December 7, 2024, and processing takes 30 days.
C. Coverage begins the first of the month after the plan receives the enrollment request, as long as the request is
made during AEP.
D. Coverage begins January 1, 2025, regardless of the submission date within AEP, as long as the request is
received by December 31, 2024.
Answer: A
Rationale: CMS rules state that for AEP (October 15–December 7), coverage effective date is January 1
of the following year if the enrollment request is received by December 7. Option A is correct. Option B
incorrectly extends the AEP deadline. Option C describes a different rule (e.g., for special enrollment
periods). Option D incorrectly extends AEP to December 31.
2. A CIGNA Medicare Advantage plan imposes a $5,000 out-of-pocket maximum for in-network
services. A beneficiary with a chronic condition has already incurred $4,800 in covered in-network
costs for the year. In November, the beneficiary requires an inpatient hospitalization that costs
$10,000. Which of the following accurately describes the beneficiary's financial responsibility for
this hospitalization?
A. The beneficiary pays the full $10,000 because the out-of-pocket maximum applies only to Part D drugs, not
inpatient services.
B. The beneficiary pays $200, the remaining amount to reach the out-of-pocket maximum, and the plan covers
the rest.
C. The beneficiary pays a $1,600 deductible plus 20% coinsurance, totaling $3,600.
D. The beneficiary pays a copayment of $500 per day for the first 5 days, totaling $2,500.
Answer: B
Rationale: Medicare Advantage plans have an annual out-of-pocket maximum for in-network services.
Once the beneficiary has incurred $4,800, only $200 remains before reaching the $5,000 limit.
Therefore, the beneficiary pays only $200 for the hospitalization; the plan covers the remaining $9,800.
Option A is incorrect because the out-of-pocket limit applies to Part A and B services. Options C and D
describe cost-sharing that would apply before the limit is reached.
Page 1
,3. A CIGNA Medicare Advantage plan uses a preferred provider organization (PPO) network. A
beneficiary receives emergency care at an out-of-network hospital while traveling. Under CMS
regulations, which of the following statements is correct regarding the beneficiary's cost-sharing
for this emergency service?
A. The plan may charge a higher coinsurance for out-of-network emergency care, but cannot exceed 50% of the
Medicare-approved amount.
B. The beneficiary must pay the full cost of emergency care if the hospital is out-of-network, with no plan
coverage.
C. The plan must cover emergency services at the same cost-sharing as in-network emergency services,
regardless of network status.
D. The plan may charge a copayment for out-of-network emergency care, but only if the beneficiary did not
notify the plan within 24 hours.
Answer: C
Rationale: CMS requires Medicare Advantage plans to cover emergency services at in-network
cost-sharing levels, regardless of where the service is provided, to ensure beneficiaries are not deterred
from seeking emergency care. Option C is correct. Options A and B are incorrect because they impose
higher costs or deny coverage. Option D is incorrect because prior notification is not required for
emergency care.
4. A beneficiary enrolled in a CIGNA Medicare Advantage Prescription Drug (MA-PD) plan
enters the coverage gap (donut hole) in 2024. The beneficiary has total drug costs of $5,000, with
$3,000 in the initial coverage phase and $2,000 in the coverage gap. Which of the following best
describes the beneficiary's cost-sharing for brand-name drugs during the coverage gap?
A. The beneficiary pays 25% of the drug cost, and the plan pays 75%, with the manufacturer discount covering
70% of the total cost.
B. The beneficiary pays 25% of the drug cost, and the manufacturer provides a 70% discount on brand-name
drugs, with the plan paying 5%.
C. The beneficiary pays 25% of the drug cost, and the plan pays 75% of the cost, with no manufacturer discount.
D. The beneficiary pays the full cost of brand-name drugs until catastrophic coverage begins.
Answer: B
Rationale: In 2024, the Inflation Reduction Act modified the coverage gap: beneficiaries pay 25% of
brand-name drug costs, manufacturers provide a 70% discount, and plans cover 5%. Option B correctly
describes this. Option A misstates the discount and plan share. Option C omits the manufacturer
discount. Option D is outdated.
5. A CIGNA Medicare Advantage plan denies coverage for a hip replacement surgery, citing that
the procedure is not medically necessary. The beneficiary wishes to appeal. Which of the following
accurately describes the first level of appeal and the timeframe for the plan's decision?
A. The beneficiary must request a reconsideration by an Independent Review Entity (IRE) within 60 days; the
IRE must decide within 30 days.
B. The beneficiary must file a written appeal with the plan within 60 days of the denial notice; the plan must
issue a decision within 30 days (or 72 hours if expedited).
C. The beneficiary must request a hearing before an Administrative Law Judge (ALJ) within 120 days; the ALJ
must decide within 90 days.
Page 2
,D. The beneficiary must file a grievance with the plan within 30 days; the plan must respond within 15 days.
Answer: B
Rationale: The first level of appeal for a Medicare Advantage plan denial is a plan-level reconsideration.
The beneficiary must file within 60 days of the denial notice, and the plan must decide within 30 days
(standard) or 72 hours (expedited). Option B is correct. Option A describes the second level (IRE).
Option C describes a later level (ALJ). Option D describes a grievance, which is for quality issues, not
coverage denials.
6. A beneficiary is eligible for both Medicare and Medicaid (dual eligible). The beneficiary enrolls
in a CIGNA Medicare Advantage Dual Eligible Special Needs Plan (D-SNP). Which of the
following best describes the coordination of benefits for a covered Part B service?
A. Medicare pays first, then Medicaid pays any remaining cost-sharing up to state Medicaid limits, and the
D-SNP may wrap around additional benefits.
B. Medicaid pays first because the beneficiary is dual eligible, then Medicare pays secondary, and the D-SNP
pays last.
C. The D-SNP pays all costs, and neither Medicare nor Medicaid pays anything.
D. Medicare pays first, and the D-SNP pays all remaining cost-sharing, with Medicaid only covering services
not covered by Medicare.
Answer: A
Rationale: For dual eligibles, Medicare is the primary payer. Medicaid pays secondary, covering
Medicare premiums and cost-sharing (deductibles, coinsurance, copays) up to state limits. D-SNPs often
provide additional benefits (wrap-around). Option A correctly describes this. Option B incorrectly
makes Medicaid primary. Option C is false because Medicare and Medicaid still pay. Option D
misstates Medicaid's role.
7. A CIGNA Medicare Advantage plan offers a Special Supplemental Benefits for the Chronically
Ill (SSBCI) program. Which of the following benefits is most likely to be offered under SSBCI for a
beneficiary with diabetes?
A. A gym membership for general fitness.
B. Meal delivery services tailored to diabetic dietary needs.
C. Over-the-counter vitamins and supplements.
D. Transportation to a non-medical social event.
Answer: B
Rationale: SSBCI benefits are designed to address the specific needs of chronically ill beneficiaries. For
diabetes, meal delivery with diabetic-appropriate meals directly supports disease management. Option B
is correct. Options A, C, and D are more general supplemental benefits not necessarily tied to a chronic
condition's specific needs, though they could be offered under other authorities.
8. A beneficiary is enrolled in a CIGNA Medicare Advantage plan that uses a tiered pharmacy
network. The beneficiary takes a brand-name drug on Tier 3. The plan's formulary includes a
generic alternative on Tier 1. Which of the following is the plan permitted to do regarding
coverage of the brand-name drug?
A. Require the beneficiary to try the generic first (step therapy) before covering the brand-name drug.
Page 3
, B. Deny coverage entirely for the brand-name drug because a generic alternative is available.
C. Cover the brand-name drug at the same cost-sharing as the generic if the beneficiary requests it.
D. Cover the brand-name drug only if the beneficiary obtains prior authorization and pays a higher coinsurance.
Answer: A
Rationale: Medicare Advantage plans may use step therapy to require trial of a lower-cost generic before
covering a brand-name drug. Option A is correct. Option B is incorrect because plans must have an
exception process. Option C is incorrect because cost-sharing tiers differ. Option D describes prior
authorization, which may be used but is not the only option; step therapy is also permissible.
9. A beneficiary enrolled in a CIGNA Medicare Advantage plan receives a notice that their plan
will be non-renewed for the following year. The beneficiary wants to enroll in a different CIGNA
Medicare Advantage plan. Which enrollment period applies?
A. The beneficiary may enroll in a new plan during the Medicare Advantage Open Enrollment Period (MA
OEP) from January 1 to March 31.
B. The beneficiary may enroll in a new plan during the Annual Enrollment Period (AEP) from October 15 to
December 7.
C. The beneficiary has a Special Enrollment Period (SEP) from December 8 to the end of February of the
following year to enroll in another plan.
D. The beneficiary must wait until the next AEP to enroll, but may request a coverage gap exception.
Answer: C
Rationale: When a plan is non-renewed, CMS provides a Special Enrollment Period (SEP) from
December 8 through the last day of February of the following year to allow beneficiaries to enroll in
another plan. Option C is correct. Option A (MA OEP) is for those already in MA to change plans once.
Option B (AEP) has already passed. Option D is incorrect because an SEP is available.
10. A CIGNA Medicare Advantage plan includes a $0 premium and a $0 deductible for medical
services. The plan has a maximum out-of-pocket limit of $3,000. A beneficiary incurs $2,500 in
covered medical expenses in January. In February, the beneficiary requires a surgical procedure
with a Medicare-approved amount of $15,000. The plan's cost-sharing for surgery is 20%
coinsurance after deductible. Which of the following best describes the beneficiary's total
out-of-pocket cost for the year?
A. $2,500 (January expenses) plus $3,000 (20% of $15,000) = $5,500, but capped at $3,000, so $3,000.
B. $2,500 (January expenses) plus $500 (remaining to reach $3,000 cap) = $3,000.
C. $2,500 (January expenses) plus $3,000 (20% of $15,000) = $5,500, but the plan pays all, so $0.
D. $2,500 (January expenses) plus $2,500 (20% of $15,000 minus $500 already paid) = $5,000, capped at
$3,000, so $3,000.
Answer: B
Rationale: Since the plan has a $0 deductible, the $2,500 in January counts toward the out-of-pocket
maximum. The surgery's 20% coinsurance ($3,000) would bring total costs to $5,500, but the maximum
is $3,000. The beneficiary has already incurred $2,500, so only $500 more is needed to reach the cap.
Thus, total out-of-pocket is $3,000. Option B correctly calculates this. Options A and D misapply the
cap. Option C is incorrect because the beneficiary must pay up to the cap.
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