AHIP CERTIFICATION FINAL EXAM 2025:
COMPLETE Q&A TEST BANK WITH 100%
VERIFIED ANSWERS ALREADY A SCORE
1. A Medicare Advantage plan is considering whether to include a new specialty pharmacy in its
network. The pharmacy offers a unique medication therapy management program that has been
shown to reduce hospital readmissions for chronic heart failure patients. Under CMS regulations,
which of the following considerations is most critical for the plan to evaluate when determining
network adequacy for this specialty?
A. The pharmacy's proximity to the plan's enrollees within the required time and distance standards
B. The pharmacy's accreditation from the Utilization Review Accreditation Commission (URAC)
C. The pharmacy's ability to provide 90-day supplies of all covered Part D drugs
D. The pharmacy's contract pricing being at or below the plan's maximum allowable cost list
Answer: A
Rationale: CMS network adequacy standards for Medicare Advantage plans require that specialty
pharmacies meet specific time and distance criteria to ensure enrollee access. While accreditation and
pricing are important, the primary regulatory focus is on geographic access. Option A directly
addresses this core requirement.
2. A beneficiary enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan is considering
disenrolling to switch to Original Medicare with a stand-alone Part D plan. The beneficiary is
currently in the third month of a 12-month contract. Which of the following statements accurately
describes the disenrollment options available to this beneficiary?
A. The beneficiary may disenroll from the MA-PD plan during the Annual Election Period (AEP) from October
15 to December 7, with coverage change effective January 1.
B. The beneficiary may disenroll at any time using a Special Election Period (SEP) because they are within the
first 12 months of enrollment.
C. The beneficiary may disenroll only if they move out of the plan's service area or if the plan terminates its
contract with CMS.
D. The beneficiary may disenroll during the Medicare Advantage Disenrollment Period (MADP) from January
1 to February 14, but only to return to Original Medicare.
Answer: D
Rationale: The Medicare Advantage Disenrollment Period (MADP) allows MA-PD enrollees to disenroll
and return to Original Medicare (with or without a stand-alone Part D plan) from January 1 to
February 14. The beneficiary is past the first 3 months of enrollment, so the 12-month trial period SEP
(option B) is not applicable. AEP (option A) is for plan changes, not disenrollment to Original
Medicare. Option C is too restrictive.
Page 1
,3. A Medicare Advantage plan receives a request from an enrollee for a retrospective prior
authorization for a service that was provided urgently while the enrollee was traveling outside the
plan's network. The plan's medical necessity criteria would have denied the service if requested
prospectively. Under CMS regulations, how should the plan process this request?
A. Deny the request because the service did not meet medical necessity criteria at the time it was provided.
B. Approve the request because retrospective prior authorization is not permitted for out-of-network urgent
services.
C. Approve the request if the enrollee had a reasonable expectation that the service was covered, even if medical
necessity criteria were not met.
D. Apply the same medical necessity criteria as for a prospective request and issue a denial if criteria are not
satisfied.
Answer: C
Rationale: CMS rules for urgent out-of-network care require plans to consider the enrollee's reasonable
expectation of coverage. If the enrollee reasonably believed the service was covered, the plan cannot
retrospectively deny based on medical necessity criteria that would have been applied prospectively.
Options A and D ignore this protection. Option B is incorrect because retrospective prior authorization
is sometimes used but must follow these rules.
4. An employer sponsors a group Medicare Advantage plan for its retirees. The plan has a 5-star
quality rating from CMS. The employer wants to offer a supplemental benefit that provides a $50
monthly reduction in the Part B premium for enrollees who complete a wellness program. Under
CMS rules, which of the following is a key consideration for this supplemental benefit?
A. The benefit must be offered uniformly to all enrollees in the plan without any conditions.
B. The benefit must be primarily health-related, and the wellness program must meet CMS-defined standards.
C. The benefit is prohibited because it reduces the Part B premium, which is a federal entitlement.
D. The benefit can be offered only if the employer pays the entire Part B premium for all enrollees.
Answer: B
Rationale: CMS allows Medicare Advantage plans to offer supplemental benefits that are primarily
health-related. A Part B premium reduction tied to a wellness program can qualify if the program meets
CMS standards (e.g., evidence-based, not discriminatory). Option A is incorrect because the benefit can
be conditional on program completion. Option C is false; such reductions are permitted. Option D is not
a requirement.
5. A Medicare Advantage plan is designing its network for the upcoming year. It plans to include a
large hospital system that requires an exclusive contract, meaning the plan cannot contract with
any other hospital in the same geographic area. Which of the following statements best describes
CMS's stance on exclusive contracts in Medicare Advantage networks?
A. Exclusive contracts are prohibited because they limit beneficiary choice and access to care.
B. Exclusive contracts are permitted as long as the plan demonstrates that the arrangement does not adversely
affect access to care.
C. Exclusive contracts are permitted only for specialty hospitals, not for general acute care hospitals.
D. Exclusive contracts are allowed only if the plan has a 5-star rating and offers out-of-network coverage at
in-network cost sharing.
Page 2
,Answer: B
Rationale: CMS does not explicitly prohibit exclusive contracts, but they must not result in inadequate
access. The plan must demonstrate that beneficiaries still have reasonable access to covered services,
including through out-of-network options if necessary. Option A is too absolute. Options C and D
impose restrictions not found in CMS guidance.
6. A Medicare beneficiary is enrolled in a standalone Prescription Drug Plan (PDP) and also has
coverage from a former employer's retiree health plan that includes drug coverage. The employer
plan is not creditable coverage. The beneficiary reaches the Part D coverage gap (donut hole) in
October. Which of the following correctly describes how the beneficiary's costs are affected?
A. The beneficiary pays 25% of the cost of brand-name drugs and 25% of the cost of generic drugs while in the
gap.
B. The beneficiary pays 25% of the cost of brand-name drugs and 37% of the cost of generic drugs while in the
gap.
C. The beneficiary pays 25% of the cost of brand-name drugs and 75% of the cost of generic drugs while in the
gap.
D. The beneficiary pays 25% of the cost of brand-name drugs and 37% of the cost of generic drugs, but only if
the employer plan pays its share.
Answer: B
Rationale: In 2025, the Part D coverage gap requires beneficiaries to pay 25% for brand-name drugs
(manufacturer discount covers 70%, plan pays 5%) and 37% for generic drugs (plan pays 63%). Option
A incorrectly states 25% for generics. Option C has 75% for generics, which was the rate before the
Affordable Care Act changes. Option D incorrectly ties the cost to employer plan payment.
7. A Medicare Advantage plan receives a complaint from an enrollee about a denial of coverage for
a skilled nursing facility (SNF) stay. The plan's initial determination was based on the enrollee not
having a prior qualifying inpatient hospital stay of at least 3 days. However, the enrollee had a
2-day hospital stay followed by observation status for 2 days. Under Medicare rules, which of the
following is correct?
A. The SNF stay is covered because observation status counts toward the 3-day qualifying stay.
B. The SNF stay is not covered because observation status does not count toward the 3-day qualifying stay.
C. The SNF stay is covered because the enrollee had a total of 4 days of hospital-related care.
D. The SNF stay is not covered because the enrollee did not have a 3-day inpatient stay, but the plan may cover
it as a supplemental benefit.
Answer: B
Rationale: Medicare requires a prior inpatient hospital stay of at least 3 consecutive days (not counting
the discharge day) for SNF coverage. Observation status does not count as inpatient. Option A is
incorrect. Option C is incorrect because observation days do not count. Option D is plausible but not
standard; plans may offer supplemental SNF coverage without the 3-day rule, but that is not the default
Medicare rule.
Page 3
, 8. A Medicare Advantage plan is evaluating a new technology that uses artificial intelligence to
predict which enrollees are at high risk for falls. The plan wants to use this tool to target enrollees
for a fall prevention program. Under CMS regulations regarding electronic health records and
risk adjustment, which of the following is a key compliance consideration?
A. The plan must ensure that the AI tool is certified by the Office of the National Coordinator for Health
Information Technology (ONC).
B. The plan must validate that the AI tool does not discriminate on the basis of race, ethnicity, or socioeconomic
status.
C. The plan must obtain prior approval from CMS before using any predictive modeling for care management.
D. The plan must use the AI tool's predictions to adjust risk scores for payment purposes.
Answer: B
Rationale: CMS requires that algorithms used for care management do not perpetuate disparities. Plans
must ensure their tools are validated for fairness across demographic groups. Option A is not a specific
requirement for AI tools used in care management. Option C is incorrect; prior approval is not needed.
Option D is incorrect because risk adjustment is based on diagnoses, not predictive scores.
9. A beneficiary is enrolled in a Medicare Advantage plan that includes Part D coverage. The
beneficiary is prescribed a brand-name drug that is not on the plan's formulary but is medically
necessary. The beneficiary's physician submits a prior authorization request with supporting
documentation. The plan denies the request because the drug is excluded from coverage under Part
D (e.g., for weight loss). Which of the following actions can the beneficiary take?
A. Request an exception to the formulary, and if denied, appeal the decision through the plan's internal appeals
process and then to an independent review entity (IRE).
B. Request a coverage determination, and if denied, file a grievance with the plan and then with CMS.
C. Request a redetermination, and if denied, request a reconsideration by a Medicare Administrative Contractor
(MAC).
D. Request an expedited appeal directly to the Office of Medicare Hearings and Appeals (OMHA) without first
going through the plan's internal process.
Answer: A
Rationale: For a formulary exclusion, the beneficiary can request a formulary exception. If denied, the
standard appeals process applies: plan redetermination, then independent review entity (IRE)
reconsideration. Option B confuses grievances with appeals. Option C incorrectly involves MACs, which
handle Part A/B, not Part D. Option D bypasses required internal steps.
10. A Medicare Advantage plan is conducting its annual quality improvement project. The plan
selects a measure from the CMS Star Ratings program: 'Controlling High Blood Pressure.' The
plan's current rate is 55%, and the national average is 60%. The plan implements a multi-faceted
intervention including provider education, patient reminders, and home blood pressure
monitoring. After one year, the rate increases to 62%. Which of the following best describes how
this improvement will affect the plan's Star Rating?
A. The plan will receive a 4-star rating on this measure because it exceeded the national average.
B. The plan's improvement will be evaluated against the cut points established by CMS for the current year,
which may change annually.
C. The plan will automatically receive a higher rating because it improved by more than 5 percentage points.
Page 4
COMPLETE Q&A TEST BANK WITH 100%
VERIFIED ANSWERS ALREADY A SCORE
1. A Medicare Advantage plan is considering whether to include a new specialty pharmacy in its
network. The pharmacy offers a unique medication therapy management program that has been
shown to reduce hospital readmissions for chronic heart failure patients. Under CMS regulations,
which of the following considerations is most critical for the plan to evaluate when determining
network adequacy for this specialty?
A. The pharmacy's proximity to the plan's enrollees within the required time and distance standards
B. The pharmacy's accreditation from the Utilization Review Accreditation Commission (URAC)
C. The pharmacy's ability to provide 90-day supplies of all covered Part D drugs
D. The pharmacy's contract pricing being at or below the plan's maximum allowable cost list
Answer: A
Rationale: CMS network adequacy standards for Medicare Advantage plans require that specialty
pharmacies meet specific time and distance criteria to ensure enrollee access. While accreditation and
pricing are important, the primary regulatory focus is on geographic access. Option A directly
addresses this core requirement.
2. A beneficiary enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan is considering
disenrolling to switch to Original Medicare with a stand-alone Part D plan. The beneficiary is
currently in the third month of a 12-month contract. Which of the following statements accurately
describes the disenrollment options available to this beneficiary?
A. The beneficiary may disenroll from the MA-PD plan during the Annual Election Period (AEP) from October
15 to December 7, with coverage change effective January 1.
B. The beneficiary may disenroll at any time using a Special Election Period (SEP) because they are within the
first 12 months of enrollment.
C. The beneficiary may disenroll only if they move out of the plan's service area or if the plan terminates its
contract with CMS.
D. The beneficiary may disenroll during the Medicare Advantage Disenrollment Period (MADP) from January
1 to February 14, but only to return to Original Medicare.
Answer: D
Rationale: The Medicare Advantage Disenrollment Period (MADP) allows MA-PD enrollees to disenroll
and return to Original Medicare (with or without a stand-alone Part D plan) from January 1 to
February 14. The beneficiary is past the first 3 months of enrollment, so the 12-month trial period SEP
(option B) is not applicable. AEP (option A) is for plan changes, not disenrollment to Original
Medicare. Option C is too restrictive.
Page 1
,3. A Medicare Advantage plan receives a request from an enrollee for a retrospective prior
authorization for a service that was provided urgently while the enrollee was traveling outside the
plan's network. The plan's medical necessity criteria would have denied the service if requested
prospectively. Under CMS regulations, how should the plan process this request?
A. Deny the request because the service did not meet medical necessity criteria at the time it was provided.
B. Approve the request because retrospective prior authorization is not permitted for out-of-network urgent
services.
C. Approve the request if the enrollee had a reasonable expectation that the service was covered, even if medical
necessity criteria were not met.
D. Apply the same medical necessity criteria as for a prospective request and issue a denial if criteria are not
satisfied.
Answer: C
Rationale: CMS rules for urgent out-of-network care require plans to consider the enrollee's reasonable
expectation of coverage. If the enrollee reasonably believed the service was covered, the plan cannot
retrospectively deny based on medical necessity criteria that would have been applied prospectively.
Options A and D ignore this protection. Option B is incorrect because retrospective prior authorization
is sometimes used but must follow these rules.
4. An employer sponsors a group Medicare Advantage plan for its retirees. The plan has a 5-star
quality rating from CMS. The employer wants to offer a supplemental benefit that provides a $50
monthly reduction in the Part B premium for enrollees who complete a wellness program. Under
CMS rules, which of the following is a key consideration for this supplemental benefit?
A. The benefit must be offered uniformly to all enrollees in the plan without any conditions.
B. The benefit must be primarily health-related, and the wellness program must meet CMS-defined standards.
C. The benefit is prohibited because it reduces the Part B premium, which is a federal entitlement.
D. The benefit can be offered only if the employer pays the entire Part B premium for all enrollees.
Answer: B
Rationale: CMS allows Medicare Advantage plans to offer supplemental benefits that are primarily
health-related. A Part B premium reduction tied to a wellness program can qualify if the program meets
CMS standards (e.g., evidence-based, not discriminatory). Option A is incorrect because the benefit can
be conditional on program completion. Option C is false; such reductions are permitted. Option D is not
a requirement.
5. A Medicare Advantage plan is designing its network for the upcoming year. It plans to include a
large hospital system that requires an exclusive contract, meaning the plan cannot contract with
any other hospital in the same geographic area. Which of the following statements best describes
CMS's stance on exclusive contracts in Medicare Advantage networks?
A. Exclusive contracts are prohibited because they limit beneficiary choice and access to care.
B. Exclusive contracts are permitted as long as the plan demonstrates that the arrangement does not adversely
affect access to care.
C. Exclusive contracts are permitted only for specialty hospitals, not for general acute care hospitals.
D. Exclusive contracts are allowed only if the plan has a 5-star rating and offers out-of-network coverage at
in-network cost sharing.
Page 2
,Answer: B
Rationale: CMS does not explicitly prohibit exclusive contracts, but they must not result in inadequate
access. The plan must demonstrate that beneficiaries still have reasonable access to covered services,
including through out-of-network options if necessary. Option A is too absolute. Options C and D
impose restrictions not found in CMS guidance.
6. A Medicare beneficiary is enrolled in a standalone Prescription Drug Plan (PDP) and also has
coverage from a former employer's retiree health plan that includes drug coverage. The employer
plan is not creditable coverage. The beneficiary reaches the Part D coverage gap (donut hole) in
October. Which of the following correctly describes how the beneficiary's costs are affected?
A. The beneficiary pays 25% of the cost of brand-name drugs and 25% of the cost of generic drugs while in the
gap.
B. The beneficiary pays 25% of the cost of brand-name drugs and 37% of the cost of generic drugs while in the
gap.
C. The beneficiary pays 25% of the cost of brand-name drugs and 75% of the cost of generic drugs while in the
gap.
D. The beneficiary pays 25% of the cost of brand-name drugs and 37% of the cost of generic drugs, but only if
the employer plan pays its share.
Answer: B
Rationale: In 2025, the Part D coverage gap requires beneficiaries to pay 25% for brand-name drugs
(manufacturer discount covers 70%, plan pays 5%) and 37% for generic drugs (plan pays 63%). Option
A incorrectly states 25% for generics. Option C has 75% for generics, which was the rate before the
Affordable Care Act changes. Option D incorrectly ties the cost to employer plan payment.
7. A Medicare Advantage plan receives a complaint from an enrollee about a denial of coverage for
a skilled nursing facility (SNF) stay. The plan's initial determination was based on the enrollee not
having a prior qualifying inpatient hospital stay of at least 3 days. However, the enrollee had a
2-day hospital stay followed by observation status for 2 days. Under Medicare rules, which of the
following is correct?
A. The SNF stay is covered because observation status counts toward the 3-day qualifying stay.
B. The SNF stay is not covered because observation status does not count toward the 3-day qualifying stay.
C. The SNF stay is covered because the enrollee had a total of 4 days of hospital-related care.
D. The SNF stay is not covered because the enrollee did not have a 3-day inpatient stay, but the plan may cover
it as a supplemental benefit.
Answer: B
Rationale: Medicare requires a prior inpatient hospital stay of at least 3 consecutive days (not counting
the discharge day) for SNF coverage. Observation status does not count as inpatient. Option A is
incorrect. Option C is incorrect because observation days do not count. Option D is plausible but not
standard; plans may offer supplemental SNF coverage without the 3-day rule, but that is not the default
Medicare rule.
Page 3
, 8. A Medicare Advantage plan is evaluating a new technology that uses artificial intelligence to
predict which enrollees are at high risk for falls. The plan wants to use this tool to target enrollees
for a fall prevention program. Under CMS regulations regarding electronic health records and
risk adjustment, which of the following is a key compliance consideration?
A. The plan must ensure that the AI tool is certified by the Office of the National Coordinator for Health
Information Technology (ONC).
B. The plan must validate that the AI tool does not discriminate on the basis of race, ethnicity, or socioeconomic
status.
C. The plan must obtain prior approval from CMS before using any predictive modeling for care management.
D. The plan must use the AI tool's predictions to adjust risk scores for payment purposes.
Answer: B
Rationale: CMS requires that algorithms used for care management do not perpetuate disparities. Plans
must ensure their tools are validated for fairness across demographic groups. Option A is not a specific
requirement for AI tools used in care management. Option C is incorrect; prior approval is not needed.
Option D is incorrect because risk adjustment is based on diagnoses, not predictive scores.
9. A beneficiary is enrolled in a Medicare Advantage plan that includes Part D coverage. The
beneficiary is prescribed a brand-name drug that is not on the plan's formulary but is medically
necessary. The beneficiary's physician submits a prior authorization request with supporting
documentation. The plan denies the request because the drug is excluded from coverage under Part
D (e.g., for weight loss). Which of the following actions can the beneficiary take?
A. Request an exception to the formulary, and if denied, appeal the decision through the plan's internal appeals
process and then to an independent review entity (IRE).
B. Request a coverage determination, and if denied, file a grievance with the plan and then with CMS.
C. Request a redetermination, and if denied, request a reconsideration by a Medicare Administrative Contractor
(MAC).
D. Request an expedited appeal directly to the Office of Medicare Hearings and Appeals (OMHA) without first
going through the plan's internal process.
Answer: A
Rationale: For a formulary exclusion, the beneficiary can request a formulary exception. If denied, the
standard appeals process applies: plan redetermination, then independent review entity (IRE)
reconsideration. Option B confuses grievances with appeals. Option C incorrectly involves MACs, which
handle Part A/B, not Part D. Option D bypasses required internal steps.
10. A Medicare Advantage plan is conducting its annual quality improvement project. The plan
selects a measure from the CMS Star Ratings program: 'Controlling High Blood Pressure.' The
plan's current rate is 55%, and the national average is 60%. The plan implements a multi-faceted
intervention including provider education, patient reminders, and home blood pressure
monitoring. After one year, the rate increases to 62%. Which of the following best describes how
this improvement will affect the plan's Star Rating?
A. The plan will receive a 4-star rating on this measure because it exceeded the national average.
B. The plan's improvement will be evaluated against the cut points established by CMS for the current year,
which may change annually.
C. The plan will automatically receive a higher rating because it improved by more than 5 percentage points.
Page 4
