AHIP Final latest Exam Prep 2026 - 2027 Study
Guide Questions Answers Verified Master Key
Updated
1. A beneficiary enrolled in Original Medicare (Part A and Part B) wants to switch to a Medicare
Advantage (MA) plan during the Annual Election Period (AEP). Which statement about the
transition is correct?
A. They must disenroll from Part B before enrolling in an MA plan.
B. They can enroll in an MA plan and will be automatically disenrolled from Original Medicare.
C. They must first enroll in a Part D plan separately.
D. They can only switch to an MA plan during the Medicare Advantage Open Enrollment Period (MA OEP).
Answer: B
Rationale: When a beneficiary enrolls in an MA plan during AEP, they are automatically disenrolled from
Original Medicare. Part B remains active as it is included in the MA plan. Option A is incorrect because
Part B is required for MA enrollment. Option C is incorrect because MA plans often include Part D.
Option D is incorrect because AEP is the correct period.
2. Which of the following best describes the 'donut hole' (coverage gap) in Medicare Part D for
2026?
A. Beneficiaries pay 25% of drug costs until they reach the catastrophic threshold.
B. There is no coverage gap; the donut hole has been eliminated.
C. Beneficiaries pay 5% of drug costs after initial coverage limit.
D. Manufacturer discounts apply only to brand-name drugs during the gap.
Answer: A
Rationale: Under the Inflation Reduction Act, the coverage gap was restructured but not eliminated. In
2026, beneficiaries pay 25% of costs for both brand and generic drugs in the gap until reaching the
catastrophic threshold. Option B is false; the gap still exists. Option C describes catastrophic coverage.
Option D is incomplete; discounts apply to both brand and generic.
3. A Medicare Advantage plan must cover all Medicare Part A and Part B services. However,
which of the following is true regarding cost-sharing for these services?
A. Cost-sharing for Part B services cannot exceed Original Medicare amounts.
B. Plans may charge different copayments for the same service based on provider type.
C. Out-of-pocket maximums are optional for MA plans.
D. Plans must use the same deductible as Original Medicare.
Answer: B
Rationale: MA plans can vary cost-sharing by provider type (e.g., higher copay for specialists vs. PCP).
Option A is false; MA plans can have lower or higher cost-sharing. Option C is false; MA plans must
have a maximum out-of-pocket limit. Option D is false; plans can set their own deductibles.
Page 1
,4. A dual-eligible beneficiary (Medicare and Medicaid) is enrolled in a Medicare Advantage Dual
Eligible Special Needs Plan (D-SNP). Which statement about cost-sharing is correct?
A. The D-SNP must cover all Medicare cost-sharing amounts that Medicaid would otherwise cover.
B. The beneficiary can be charged copayments up to the Original Medicare amount.
C. Medicaid is the secondary payer and covers only Part D premiums.
D. The D-SNP cannot coordinate benefits with Medicaid.
Answer: A
Rationale: D-SNPs must cover all Medicare cost-sharing that would be covered by Medicaid, ensuring no
additional liability for the beneficiary. Option B is incorrect because cost-sharing cannot exceed
Medicaid limits. Option C is incorrect; Medicaid covers many costs beyond Part D. Option D is
incorrect; coordination is required.
5. Which of the following is a requirement for a Medicare Supplement (Medigap) plan to be sold to
a beneficiary newly eligible for Medicare due to ESRD?
A. The plan must be offered during the open enrollment period for ESRD beneficiaries.
B. The beneficiary must have had prior creditable coverage.
C. Medigap plans are not available to ESRD beneficiaries under any circumstances.
D. The plan must be guaranteed issue if the beneficiary is under 65.
Answer: A
Rationale: Under federal law, ESRD beneficiaries have a one-time open enrollment period of 6 months to
purchase any Medigap plan when they first enroll in Medicare Part B. Option B is not required. Option
C is false; they are available. Option D is false; guaranteed issue applies to those under 65 only in some
states.
6. A beneficiary enrolled in a Medicare Advantage plan with a $0 premium and a $3,000
out-of-pocket maximum wants to switch to Original Medicare with a Medigap plan G and a Part D
plan. When can they enroll in Medigap plan G without medical underwriting?
A. During the 12-month trial right period after first enrolling in MA.
B. During the Annual Election Period each year.
C. Only during the Medigap Open Enrollment Period that starts when they turn 65 and enroll in Part B.
D. At any time, as long as they have guaranteed issue rights.
Answer: C
Rationale: The Medigap Open Enrollment Period is a one-time 6-month period starting when the
beneficiary is both 65 and enrolled in Part B. During this period, insurers cannot deny coverage or
charge higher premiums due to health. Option A refers to a different trial right for MA plans. Option B
is incorrect; AEP is for MA/Part D changes. Option D is incorrect; guaranteed issue is limited.
7. Under the Health Insurance Marketplace, which of the following is true about premium tax
credits for 2026?
A. They are only available to individuals with income below 138% of FPL.
B. They are available to individuals with income up to 400% of FPL, with no upper limit for certain states.
C. They must be reconciled at tax filing and any excess paid back dollar-for-dollar.
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,D. They can only be used for silver-level plans.
Answer: B
Rationale: The Inflation Reduction Act extended enhanced premium tax credits through 2025, but for
2026, the law reverts to the original structure: credits available up to 400% FPL, though some states
have implemented their own subsidies. Option A is incorrect; that threshold applies to Medicaid
expansion. Option C is incorrect; there is a cap on repayment. Option D is incorrect; credits apply to
any metal level.
8. A Medicare Advantage plan receives a Star Rating of 3.5 for 2026. Which of the following is true
about the plan's ability to receive bonus payments?
A. The plan receives a 1.5% bonus payment for being above average.
B. The plan receives no bonus because it did not achieve 4 stars.
C. The plan receives a 0.5% bonus payment.
D. The plan receives a 5% bonus payment for meeting quality thresholds.
Answer: C
Rationale: For 2026, plans with a Star Rating of 3.5 or above receive a bonus payment of 0.5% of their
benchmark. Option A is incorrect; 1.5% bonus requires 4 stars or higher. Option B is incorrect; 3.5
qualifies. Option D is incorrect; 5% is not a standard bonus.
9. Which of the following is a requirement for a Medicare Advantage plan to offer a supplemental
benefit that is not covered by Original Medicare?
A. The benefit must be primarily health-related and available to all enrollees.
B. The benefit must be offered as a stand-alone product separate from the MA plan.
C. The benefit can be limited to enrollees with specific chronic conditions only.
D. The benefit must have a copayment that does not exceed the Part B deductible.
Answer: A
Rationale: Supplemental benefits must be primarily health-related and must be uniformly available to all
enrollees in the plan. Option B is incorrect; they are integrated into the MA plan. Option C is incorrect;
while some benefits can target chronic conditions, they must be offered to all if they are supplemental.
Option D is incorrect; there is no such copayment limit.
10. A beneficiary is enrolled in a Medicare Advantage plan that includes Part D coverage. They
move to a new state outside the plan's service area. Which of the following is true?
A. They must wait until the next Annual Election Period to enroll in a new plan.
B. They have a Special Enrollment Period to enroll in a new MA plan or Original Medicare with Part D.
C. They can only enroll in a stand-alone Part D plan and must remain in Original Medicare.
D. They can keep their current MA plan and use out-of-network providers.
Answer: B
Rationale: Moving out of the service area qualifies for a Special Enrollment Period (SEP) that allows
enrollment in a new MA plan or Original Medicare with or without Part D. Option A is incorrect; SEP is
available. Option C is incorrect; they can also choose another MA plan. Option D is incorrect; MA
plans generally require in-network providers except for emergencies.
Page 3
, 11. A Medicare Advantage plan must ensure that its network includes an adequate number of each
type of provider. What is the primary regulatory mechanism used to enforce this requirement?
A. Annual network adequacy review by the state insurance commissioner
B. CMS's network adequacy criteria and annual attestation by the plan
C. Beneficiary satisfaction surveys that trigger penalties for low ratings
D. Quarterly reporting of provider-to-enrollee ratios to the public
Answer: B
Rationale: CMS establishes network adequacy standards for Medicare Advantage plans, requiring plans
to attest annually that their networks meet these criteria. State insurance commissioners do not have
primary authority, and while satisfaction surveys influence star ratings, they are not the direct
enforcement mechanism.
12. A Medicare beneficiary with End-Stage Renal Disease (ESRD) who is currently enrolled in
Original Medicare wants to switch to a Medicare Advantage plan. Which of the following is
correct?
A. ESRD beneficiaries are permanently barred from enrolling in any Medicare Advantage plan
B. ESRD beneficiaries may enroll only in a Special Needs Plan designed for ESRD
C. ESRD beneficiaries may enroll in any Medicare Advantage plan if they have an existing ESRD-related
coverage exception
D. ESRD beneficiaries may enroll in any Medicare Advantage plan during the annual election period, but only
if the plan offers ESRD coverage
Answer: B
Rationale: Under current law, beneficiaries with ESRD generally cannot enroll in a Medicare Advantage
plan unless it is a Special Needs Plan (SNP) specifically for ESRD. However, there are limited
exceptions such as those who already had ESRD and were in a plan before diagnosis. Option B is the
most accurate general rule.
13. During the Medicare Advantage Open Enrollment Period (MA OEP), which of the following
actions is a beneficiary permitted to take?
A. Switch from one Medicare Advantage plan to another Medicare Advantage plan
B. Disenroll from Medicare Advantage to return to Original Medicare and enroll in a Part D plan
C. Enroll in a Medicare Advantage plan for the first time after previously being in Original Medicare
D. Change from a Medicare Advantage plan to a Medicare Supplement plan
Answer: A
Rationale: The MA OEP (January 1 – March 31) allows a beneficiary enrolled in a Medicare Advantage
plan to switch to another MA plan or disenroll to Original Medicare. However, disenrolling to Original
Medicare does not automatically allow enrollment in a Part D plan-that would require a separate
enrollment period. Option A is correct; option C describes the Annual Election Period.
14. A Medicare Part D sponsor must establish a coverage gap discount program. Which of the
following accurately describes the manufacturer discount in the coverage gap for brand-name
drugs in 2026?
Page 4
Guide Questions Answers Verified Master Key
Updated
1. A beneficiary enrolled in Original Medicare (Part A and Part B) wants to switch to a Medicare
Advantage (MA) plan during the Annual Election Period (AEP). Which statement about the
transition is correct?
A. They must disenroll from Part B before enrolling in an MA plan.
B. They can enroll in an MA plan and will be automatically disenrolled from Original Medicare.
C. They must first enroll in a Part D plan separately.
D. They can only switch to an MA plan during the Medicare Advantage Open Enrollment Period (MA OEP).
Answer: B
Rationale: When a beneficiary enrolls in an MA plan during AEP, they are automatically disenrolled from
Original Medicare. Part B remains active as it is included in the MA plan. Option A is incorrect because
Part B is required for MA enrollment. Option C is incorrect because MA plans often include Part D.
Option D is incorrect because AEP is the correct period.
2. Which of the following best describes the 'donut hole' (coverage gap) in Medicare Part D for
2026?
A. Beneficiaries pay 25% of drug costs until they reach the catastrophic threshold.
B. There is no coverage gap; the donut hole has been eliminated.
C. Beneficiaries pay 5% of drug costs after initial coverage limit.
D. Manufacturer discounts apply only to brand-name drugs during the gap.
Answer: A
Rationale: Under the Inflation Reduction Act, the coverage gap was restructured but not eliminated. In
2026, beneficiaries pay 25% of costs for both brand and generic drugs in the gap until reaching the
catastrophic threshold. Option B is false; the gap still exists. Option C describes catastrophic coverage.
Option D is incomplete; discounts apply to both brand and generic.
3. A Medicare Advantage plan must cover all Medicare Part A and Part B services. However,
which of the following is true regarding cost-sharing for these services?
A. Cost-sharing for Part B services cannot exceed Original Medicare amounts.
B. Plans may charge different copayments for the same service based on provider type.
C. Out-of-pocket maximums are optional for MA plans.
D. Plans must use the same deductible as Original Medicare.
Answer: B
Rationale: MA plans can vary cost-sharing by provider type (e.g., higher copay for specialists vs. PCP).
Option A is false; MA plans can have lower or higher cost-sharing. Option C is false; MA plans must
have a maximum out-of-pocket limit. Option D is false; plans can set their own deductibles.
Page 1
,4. A dual-eligible beneficiary (Medicare and Medicaid) is enrolled in a Medicare Advantage Dual
Eligible Special Needs Plan (D-SNP). Which statement about cost-sharing is correct?
A. The D-SNP must cover all Medicare cost-sharing amounts that Medicaid would otherwise cover.
B. The beneficiary can be charged copayments up to the Original Medicare amount.
C. Medicaid is the secondary payer and covers only Part D premiums.
D. The D-SNP cannot coordinate benefits with Medicaid.
Answer: A
Rationale: D-SNPs must cover all Medicare cost-sharing that would be covered by Medicaid, ensuring no
additional liability for the beneficiary. Option B is incorrect because cost-sharing cannot exceed
Medicaid limits. Option C is incorrect; Medicaid covers many costs beyond Part D. Option D is
incorrect; coordination is required.
5. Which of the following is a requirement for a Medicare Supplement (Medigap) plan to be sold to
a beneficiary newly eligible for Medicare due to ESRD?
A. The plan must be offered during the open enrollment period for ESRD beneficiaries.
B. The beneficiary must have had prior creditable coverage.
C. Medigap plans are not available to ESRD beneficiaries under any circumstances.
D. The plan must be guaranteed issue if the beneficiary is under 65.
Answer: A
Rationale: Under federal law, ESRD beneficiaries have a one-time open enrollment period of 6 months to
purchase any Medigap plan when they first enroll in Medicare Part B. Option B is not required. Option
C is false; they are available. Option D is false; guaranteed issue applies to those under 65 only in some
states.
6. A beneficiary enrolled in a Medicare Advantage plan with a $0 premium and a $3,000
out-of-pocket maximum wants to switch to Original Medicare with a Medigap plan G and a Part D
plan. When can they enroll in Medigap plan G without medical underwriting?
A. During the 12-month trial right period after first enrolling in MA.
B. During the Annual Election Period each year.
C. Only during the Medigap Open Enrollment Period that starts when they turn 65 and enroll in Part B.
D. At any time, as long as they have guaranteed issue rights.
Answer: C
Rationale: The Medigap Open Enrollment Period is a one-time 6-month period starting when the
beneficiary is both 65 and enrolled in Part B. During this period, insurers cannot deny coverage or
charge higher premiums due to health. Option A refers to a different trial right for MA plans. Option B
is incorrect; AEP is for MA/Part D changes. Option D is incorrect; guaranteed issue is limited.
7. Under the Health Insurance Marketplace, which of the following is true about premium tax
credits for 2026?
A. They are only available to individuals with income below 138% of FPL.
B. They are available to individuals with income up to 400% of FPL, with no upper limit for certain states.
C. They must be reconciled at tax filing and any excess paid back dollar-for-dollar.
Page 2
,D. They can only be used for silver-level plans.
Answer: B
Rationale: The Inflation Reduction Act extended enhanced premium tax credits through 2025, but for
2026, the law reverts to the original structure: credits available up to 400% FPL, though some states
have implemented their own subsidies. Option A is incorrect; that threshold applies to Medicaid
expansion. Option C is incorrect; there is a cap on repayment. Option D is incorrect; credits apply to
any metal level.
8. A Medicare Advantage plan receives a Star Rating of 3.5 for 2026. Which of the following is true
about the plan's ability to receive bonus payments?
A. The plan receives a 1.5% bonus payment for being above average.
B. The plan receives no bonus because it did not achieve 4 stars.
C. The plan receives a 0.5% bonus payment.
D. The plan receives a 5% bonus payment for meeting quality thresholds.
Answer: C
Rationale: For 2026, plans with a Star Rating of 3.5 or above receive a bonus payment of 0.5% of their
benchmark. Option A is incorrect; 1.5% bonus requires 4 stars or higher. Option B is incorrect; 3.5
qualifies. Option D is incorrect; 5% is not a standard bonus.
9. Which of the following is a requirement for a Medicare Advantage plan to offer a supplemental
benefit that is not covered by Original Medicare?
A. The benefit must be primarily health-related and available to all enrollees.
B. The benefit must be offered as a stand-alone product separate from the MA plan.
C. The benefit can be limited to enrollees with specific chronic conditions only.
D. The benefit must have a copayment that does not exceed the Part B deductible.
Answer: A
Rationale: Supplemental benefits must be primarily health-related and must be uniformly available to all
enrollees in the plan. Option B is incorrect; they are integrated into the MA plan. Option C is incorrect;
while some benefits can target chronic conditions, they must be offered to all if they are supplemental.
Option D is incorrect; there is no such copayment limit.
10. A beneficiary is enrolled in a Medicare Advantage plan that includes Part D coverage. They
move to a new state outside the plan's service area. Which of the following is true?
A. They must wait until the next Annual Election Period to enroll in a new plan.
B. They have a Special Enrollment Period to enroll in a new MA plan or Original Medicare with Part D.
C. They can only enroll in a stand-alone Part D plan and must remain in Original Medicare.
D. They can keep their current MA plan and use out-of-network providers.
Answer: B
Rationale: Moving out of the service area qualifies for a Special Enrollment Period (SEP) that allows
enrollment in a new MA plan or Original Medicare with or without Part D. Option A is incorrect; SEP is
available. Option C is incorrect; they can also choose another MA plan. Option D is incorrect; MA
plans generally require in-network providers except for emergencies.
Page 3
, 11. A Medicare Advantage plan must ensure that its network includes an adequate number of each
type of provider. What is the primary regulatory mechanism used to enforce this requirement?
A. Annual network adequacy review by the state insurance commissioner
B. CMS's network adequacy criteria and annual attestation by the plan
C. Beneficiary satisfaction surveys that trigger penalties for low ratings
D. Quarterly reporting of provider-to-enrollee ratios to the public
Answer: B
Rationale: CMS establishes network adequacy standards for Medicare Advantage plans, requiring plans
to attest annually that their networks meet these criteria. State insurance commissioners do not have
primary authority, and while satisfaction surveys influence star ratings, they are not the direct
enforcement mechanism.
12. A Medicare beneficiary with End-Stage Renal Disease (ESRD) who is currently enrolled in
Original Medicare wants to switch to a Medicare Advantage plan. Which of the following is
correct?
A. ESRD beneficiaries are permanently barred from enrolling in any Medicare Advantage plan
B. ESRD beneficiaries may enroll only in a Special Needs Plan designed for ESRD
C. ESRD beneficiaries may enroll in any Medicare Advantage plan if they have an existing ESRD-related
coverage exception
D. ESRD beneficiaries may enroll in any Medicare Advantage plan during the annual election period, but only
if the plan offers ESRD coverage
Answer: B
Rationale: Under current law, beneficiaries with ESRD generally cannot enroll in a Medicare Advantage
plan unless it is a Special Needs Plan (SNP) specifically for ESRD. However, there are limited
exceptions such as those who already had ESRD and were in a plan before diagnosis. Option B is the
most accurate general rule.
13. During the Medicare Advantage Open Enrollment Period (MA OEP), which of the following
actions is a beneficiary permitted to take?
A. Switch from one Medicare Advantage plan to another Medicare Advantage plan
B. Disenroll from Medicare Advantage to return to Original Medicare and enroll in a Part D plan
C. Enroll in a Medicare Advantage plan for the first time after previously being in Original Medicare
D. Change from a Medicare Advantage plan to a Medicare Supplement plan
Answer: A
Rationale: The MA OEP (January 1 – March 31) allows a beneficiary enrolled in a Medicare Advantage
plan to switch to another MA plan or disenroll to Original Medicare. However, disenrolling to Original
Medicare does not automatically allow enrollment in a Part D plan-that would require a separate
enrollment period. Option A is correct; option C describes the Annual Election Period.
14. A Medicare Part D sponsor must establish a coverage gap discount program. Which of the
following accurately describes the manufacturer discount in the coverage gap for brand-name
drugs in 2026?
Page 4
