The AHIP Medicare & You final exam is a 150-question, multiple-choice, open-book test required for
agents selling Medicare Advantage and Part D plans. The exam covers Medicare Parts A, B, C, and D,
enrollment periods (AEP, IEP, SEP, GEP), CMS compliance and marketing rules (Scope of Appointment,
SOA, 48-hour rule), plan benefits, cost-sharing, appeals, grievances, Special Needs Plans (SNPs), and Part
D drug coverage
SECTION 1: MEDICARE ADVANTAGE PLANS AND PLAN TYPES
1. Mrs. Robles is considering a Medicare Advantage PPO and has questions about which providers she
can go to for her health care. What should you tell her?
A) She may only see providers within the PPO network under any circumstances
B) She can obtain care from any provider who participates in Original Medicare, but will generally have
higher cost-sharing if the provider is out-of-network
C) She must obtain a referral from her PCP before seeing any specialist, in or out of network
D) PPO plans do not allow any out-of-network care except in emergencies
Correct Answer: B) She can obtain care from any provider who participates in Original Medicare, but will
generally have higher cost-sharing if the provider is out-of-network
Rationale: PPO plans, unlike HMOs, allow members to see out-of-network providers who participate in
Original Medicare. However, cost-sharing (copays/coinsurance) is typically higher for out-of-network
care, which is the key distinguishing feature of PPO flexibility compared to HMO network restrictions.
This flexibility comes at the cost of higher out-of-pocket expenses when using non-network providers.
2. Mrs. Lester is age 75, has a comfortable income, and wishes to enroll in an MA MSA plan she heard
about from her neighbor. She also wants prescription drug coverage and is currently enrolled in Original
Medicare and a standalone Part D plan. How would you advise her?
A) She cannot enroll in an MA MSA plan because she already has Part D coverage
B) She must drop her standalone Part D plan before enrolling in an MA MSA plan
C) She may enroll in an MA MSA plan and remain in her current standalone Part D prescription drug plan
D) MA MSA plans automatically include Part D coverage, so a separate PDP is unnecessary
,Correct Answer: C) She may enroll in an MA MSA plan and remain in her current standalone Part D
prescription drug plan
Rationale: MA MSA plans do not include Part D prescription drug coverage. Because of this, MSA
enrollees are permitted to keep or enroll in a standalone Part D plan (PDP) to maintain drug coverage,
unlike most other MA plan types which would cause automatic disenrollment from a standalone PDP.
This is a unique feature of MSA plans.
3. Mr. Dalton is in excellent health, lives in his own home, and has a sizeable income from his
investments. His friend is enrolled in a Medicare Advantage Special Needs Plan (SNP) with low cost-
sharing, and Mr. Dalton wants to join. What should you tell him?
A) He can enroll in any SNP regardless of his health status or income
B) SNPs limit enrollment to certain subpopulations of beneficiaries, and given his situation, he is unlikely
to qualify
C) SNPs are open enrollment plans available to all Medicare beneficiaries each year
D) He must first enroll in Original Medicare for one year before becoming SNP-eligible
Correct Answer: B) SNPs limit enrollment to certain subpopulations of beneficiaries, and given his
situation, he is unlikely to qualify
Rationale: Special Needs Plans (SNPs) are restricted to specific subpopulations: chronic condition SNPs
(C-SNPs), dual-eligible SNPs (D-SNPs), or institutional SNPs (I-SNPs). Since Mr. Dalton is in excellent
health, not dual-eligible, and living in his own home, he would not qualify for any SNP category. SNPs are
designed to provide targeted care coordination for vulnerable populations with specific needs.
4. What types of Medicare Advantage plans are available to beneficiaries?
A) PPO, HMO, MSA, Cost Plan, PFFS
B) HMO only
C) PPO and MSA only
D) Cost Plan and PFFS only
Correct Answer: A) PPO, HMO, MSA, Cost Plan, PFFS
Rationale: Medicare Advantage (MA) plans, also known as Part C, are offered by private insurance
companies. The primary types include Health Maintenance Organizations (HMOs), Preferred Provider
Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Medical Savings Account (MSA) plans, and
Cost Plans (in limited areas). This variety allows beneficiaries to choose a plan that best fits their
healthcare needs and budget, with each type having different rules for cost-sharing, network usage, and
referrals.
5. Which individuals are eligible for Medicare-Medicaid Plans (MMPs)?
A) Those enrolled in Medicare Part A only
,B) Medicare and Medicaid dual eligibles, including Part D coverage
C) Individuals under age 65 without disabilities
D) Those with employer-sponsored plans only
Correct Answer: B) Medicare and Medicaid dual eligibles, including Part D coverage
Rationale: MMPs, often known as Dual Eligible Special Needs Plans (D-SNPs), are specifically designed
for individuals who are entitled to both Medicare and Medicaid. These plans are required to cover
Medicare Part D prescription drugs and coordinate benefits between Medicare and Medicaid to provide
comprehensive coverage and reduce out-of-pocket costs for this vulnerable population.
6. What is a key feature of a Medicare Cost Plan?
A) Requires only Part A enrollment
B) Allows non-network provider visits with higher coinsurance and deductibles
C) Limits enrollment to HMO periods
D) Excludes Part D prescription drug coverage
Correct Answer: B) Allows non-network provider visits with higher coinsurance and deductibles
Rationale: Medicare Cost Plans are a type of Medicare Advantage plan that allows beneficiaries to use
out-of-network providers, but at a higher cost. They provide a "point of service" option, meaning you
can see any Medicare-participating provider, but your cost-sharing (coinsurance and deductibles) will be
higher than if you used an in-network provider.
7. When can individuals with End-Stage Renal Disease (ESRD) enroll in Medicare?
A) Only during the Annual Enrollment Period (AEP)
B) Anytime, with coverage beginning the fourth month after dialysis starts
C) During a Special Enrollment Period (SEP) for employment changes
D) Only at age 65
Correct Answer: B) Anytime, with coverage beginning the fourth month after dialysis starts
Rationale: Individuals with ESRD are eligible for Medicare regardless of age. Enrollment can occur at any
time, and coverage typically begins on the first day of the fourth month of a regular course of dialysis, or
the month of a kidney transplant, whichever is applicable. This special eligibility rule ensures that
individuals with this serious condition can access Medicare coverage when needed.
8. Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and
will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell
him?
A) He must wait until age 65 to enroll in Medicare
, B) He may sign-up for Medicare at any time, however coverage usually begins on the fourth month after
dialysis treatments start
C) He can only enroll during the Annual Enrollment Period
D) He is not eligible for Medicare because of his age
Correct Answer: B) He may sign-up for Medicare at any time, however coverage usually begins on the
fourth month after dialysis treatments start
Rationale: Individuals with ESRD are eligible for Medicare regardless of age. Coverage typically begins on
the first day of the fourth month of dialysis treatments. This special provision ensures that individuals
with kidney failure can access necessary medical coverage without waiting until age 65.
9. What is a key feature of a Medicare Preferred Provider Organization (PPO) plan?
A) Requires all care to be received in-network
B) Requires a referral to see a specialist
C) Has lower out-of-pocket costs for using network providers but allows out-of-network coverage at a
higher cost
D) Does not cover preventive services
Correct Answer: C) Has lower out-of-pocket costs for using network providers but allows out-of-network
coverage at a higher cost
Rationale: PPO plans offer flexibility by allowing beneficiaries to see any provider, whether in-network
or out-of-network. However, to get the plan's lowest cost-sharing (copayments, coinsurance, and
deductibles), beneficiaries should use the plan's network of contracted providers. Out-of-network care is
typically covered but with significantly higher cost-sharing.
10. What is a key feature of a Medicare Health Maintenance Organization (HMO) plan?
A) Allows the use of out-of-network providers without a referral
B) Has lower out-of-pocket costs for using network providers and typically requires a referral for
specialists
C) Does not cover emergency or urgent care
D) Is only available in rural areas
Correct Answer: B) Has lower out-of-pocket costs for using network providers and typically requires a
referral for specialists
Rationale: HMO plans generally have lower premiums and predictable costs. They require beneficiaries
to use a network of providers and typically choose a Primary Care Physician (PCP) who coordinates care
and provides referrals to see specialists. Out-of-network care is usually not covered except for
emergency or urgent care.
agents selling Medicare Advantage and Part D plans. The exam covers Medicare Parts A, B, C, and D,
enrollment periods (AEP, IEP, SEP, GEP), CMS compliance and marketing rules (Scope of Appointment,
SOA, 48-hour rule), plan benefits, cost-sharing, appeals, grievances, Special Needs Plans (SNPs), and Part
D drug coverage
SECTION 1: MEDICARE ADVANTAGE PLANS AND PLAN TYPES
1. Mrs. Robles is considering a Medicare Advantage PPO and has questions about which providers she
can go to for her health care. What should you tell her?
A) She may only see providers within the PPO network under any circumstances
B) She can obtain care from any provider who participates in Original Medicare, but will generally have
higher cost-sharing if the provider is out-of-network
C) She must obtain a referral from her PCP before seeing any specialist, in or out of network
D) PPO plans do not allow any out-of-network care except in emergencies
Correct Answer: B) She can obtain care from any provider who participates in Original Medicare, but will
generally have higher cost-sharing if the provider is out-of-network
Rationale: PPO plans, unlike HMOs, allow members to see out-of-network providers who participate in
Original Medicare. However, cost-sharing (copays/coinsurance) is typically higher for out-of-network
care, which is the key distinguishing feature of PPO flexibility compared to HMO network restrictions.
This flexibility comes at the cost of higher out-of-pocket expenses when using non-network providers.
2. Mrs. Lester is age 75, has a comfortable income, and wishes to enroll in an MA MSA plan she heard
about from her neighbor. She also wants prescription drug coverage and is currently enrolled in Original
Medicare and a standalone Part D plan. How would you advise her?
A) She cannot enroll in an MA MSA plan because she already has Part D coverage
B) She must drop her standalone Part D plan before enrolling in an MA MSA plan
C) She may enroll in an MA MSA plan and remain in her current standalone Part D prescription drug plan
D) MA MSA plans automatically include Part D coverage, so a separate PDP is unnecessary
,Correct Answer: C) She may enroll in an MA MSA plan and remain in her current standalone Part D
prescription drug plan
Rationale: MA MSA plans do not include Part D prescription drug coverage. Because of this, MSA
enrollees are permitted to keep or enroll in a standalone Part D plan (PDP) to maintain drug coverage,
unlike most other MA plan types which would cause automatic disenrollment from a standalone PDP.
This is a unique feature of MSA plans.
3. Mr. Dalton is in excellent health, lives in his own home, and has a sizeable income from his
investments. His friend is enrolled in a Medicare Advantage Special Needs Plan (SNP) with low cost-
sharing, and Mr. Dalton wants to join. What should you tell him?
A) He can enroll in any SNP regardless of his health status or income
B) SNPs limit enrollment to certain subpopulations of beneficiaries, and given his situation, he is unlikely
to qualify
C) SNPs are open enrollment plans available to all Medicare beneficiaries each year
D) He must first enroll in Original Medicare for one year before becoming SNP-eligible
Correct Answer: B) SNPs limit enrollment to certain subpopulations of beneficiaries, and given his
situation, he is unlikely to qualify
Rationale: Special Needs Plans (SNPs) are restricted to specific subpopulations: chronic condition SNPs
(C-SNPs), dual-eligible SNPs (D-SNPs), or institutional SNPs (I-SNPs). Since Mr. Dalton is in excellent
health, not dual-eligible, and living in his own home, he would not qualify for any SNP category. SNPs are
designed to provide targeted care coordination for vulnerable populations with specific needs.
4. What types of Medicare Advantage plans are available to beneficiaries?
A) PPO, HMO, MSA, Cost Plan, PFFS
B) HMO only
C) PPO and MSA only
D) Cost Plan and PFFS only
Correct Answer: A) PPO, HMO, MSA, Cost Plan, PFFS
Rationale: Medicare Advantage (MA) plans, also known as Part C, are offered by private insurance
companies. The primary types include Health Maintenance Organizations (HMOs), Preferred Provider
Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Medical Savings Account (MSA) plans, and
Cost Plans (in limited areas). This variety allows beneficiaries to choose a plan that best fits their
healthcare needs and budget, with each type having different rules for cost-sharing, network usage, and
referrals.
5. Which individuals are eligible for Medicare-Medicaid Plans (MMPs)?
A) Those enrolled in Medicare Part A only
,B) Medicare and Medicaid dual eligibles, including Part D coverage
C) Individuals under age 65 without disabilities
D) Those with employer-sponsored plans only
Correct Answer: B) Medicare and Medicaid dual eligibles, including Part D coverage
Rationale: MMPs, often known as Dual Eligible Special Needs Plans (D-SNPs), are specifically designed
for individuals who are entitled to both Medicare and Medicaid. These plans are required to cover
Medicare Part D prescription drugs and coordinate benefits between Medicare and Medicaid to provide
comprehensive coverage and reduce out-of-pocket costs for this vulnerable population.
6. What is a key feature of a Medicare Cost Plan?
A) Requires only Part A enrollment
B) Allows non-network provider visits with higher coinsurance and deductibles
C) Limits enrollment to HMO periods
D) Excludes Part D prescription drug coverage
Correct Answer: B) Allows non-network provider visits with higher coinsurance and deductibles
Rationale: Medicare Cost Plans are a type of Medicare Advantage plan that allows beneficiaries to use
out-of-network providers, but at a higher cost. They provide a "point of service" option, meaning you
can see any Medicare-participating provider, but your cost-sharing (coinsurance and deductibles) will be
higher than if you used an in-network provider.
7. When can individuals with End-Stage Renal Disease (ESRD) enroll in Medicare?
A) Only during the Annual Enrollment Period (AEP)
B) Anytime, with coverage beginning the fourth month after dialysis starts
C) During a Special Enrollment Period (SEP) for employment changes
D) Only at age 65
Correct Answer: B) Anytime, with coverage beginning the fourth month after dialysis starts
Rationale: Individuals with ESRD are eligible for Medicare regardless of age. Enrollment can occur at any
time, and coverage typically begins on the first day of the fourth month of a regular course of dialysis, or
the month of a kidney transplant, whichever is applicable. This special eligibility rule ensures that
individuals with this serious condition can access Medicare coverage when needed.
8. Mr. Davis is 52 years old and has recently been diagnosed with end-stage renal disease (ESRD) and
will soon begin dialysis. He is wondering if he can obtain coverage under Medicare. What should you tell
him?
A) He must wait until age 65 to enroll in Medicare
, B) He may sign-up for Medicare at any time, however coverage usually begins on the fourth month after
dialysis treatments start
C) He can only enroll during the Annual Enrollment Period
D) He is not eligible for Medicare because of his age
Correct Answer: B) He may sign-up for Medicare at any time, however coverage usually begins on the
fourth month after dialysis treatments start
Rationale: Individuals with ESRD are eligible for Medicare regardless of age. Coverage typically begins on
the first day of the fourth month of dialysis treatments. This special provision ensures that individuals
with kidney failure can access necessary medical coverage without waiting until age 65.
9. What is a key feature of a Medicare Preferred Provider Organization (PPO) plan?
A) Requires all care to be received in-network
B) Requires a referral to see a specialist
C) Has lower out-of-pocket costs for using network providers but allows out-of-network coverage at a
higher cost
D) Does not cover preventive services
Correct Answer: C) Has lower out-of-pocket costs for using network providers but allows out-of-network
coverage at a higher cost
Rationale: PPO plans offer flexibility by allowing beneficiaries to see any provider, whether in-network
or out-of-network. However, to get the plan's lowest cost-sharing (copayments, coinsurance, and
deductibles), beneficiaries should use the plan's network of contracted providers. Out-of-network care is
typically covered but with significantly higher cost-sharing.
10. What is a key feature of a Medicare Health Maintenance Organization (HMO) plan?
A) Allows the use of out-of-network providers without a referral
B) Has lower out-of-pocket costs for using network providers and typically requires a referral for
specialists
C) Does not cover emergency or urgent care
D) Is only available in rural areas
Correct Answer: B) Has lower out-of-pocket costs for using network providers and typically requires a
referral for specialists
Rationale: HMO plans generally have lower premiums and predictable costs. They require beneficiaries
to use a network of providers and typically choose a Primary Care Physician (PCP) who coordinates care
and provides referrals to see specialists. Out-of-network care is usually not covered except for
emergency or urgent care.
