NEWEST AHIP MEDICARE FINAL EXAM ACTUAL AND
COMPLETE EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS A NEW UPDATED VERSION
EDITION 2026-2027 (100% CORRECT VERIFIED ANSWERS)
FREQUENTLY TESTED QUESTIONS AND SOLUTIONS
ALREADY GRADED A+ |INSTANT DOWNLOAD PDF
1. Mrs. Chen is a new Medicare beneficiary who is concerned about her
limited income. She asks about programs that can help pay for her Medicare
costs. What should you tell her?
A) The Medicare Savings Program is only available to beneficiaries under age
65.
B) The Qualified Medicare Beneficiary (QMB) program helps pay for Part A
and Part B premiums, deductibles, and coinsurance, but only for those in
Original Medicare.
C) The Medicare Savings Programs are administered by states and have
income and resource limits that vary by state.
D) Extra Help is a federal program that helps with Medicare Part D costs, but
it does not consider state residency.
Rationale: Medicare Savings Programs (MSPs) are state-administered with varying
income/resource thresholds. QMB is one type of MSP and covers costs in both
Original Medicare and Medicare Advantage, not just Original Medicare. Extra
Help is federal and does consider state Medicaid status. MSPs are available to those
65+ or disabled, not only under 65.
,2. Mr. Rodriguez has Original Medicare and a standalone Part D plan. He is
considering switching to a Medicare Advantage (MA) plan during the Annual
Enrollment Period (AEP). Which statement is accurate regarding his rights?
A) He can only switch from Original Medicare to an MA plan during the AEP
if he also drops his Part D plan.
B) He may make one election to change from Original Medicare to an MA
plan during the AEP, effective January 1.
C) He cannot switch to an MA plan if he has a Medigap policy.
D) He must wait until the Medicare Open Enrollment Period (OEP) from
January 1 to March 31 to make this change.
Rationale: During AEP (Oct 15-Dec 7), beneficiaries can switch from Original
Medicare to an MA plan, effective Jan 1. They do not need to separately drop Part
D, as the MA plan replaces it. Medigap can be dropped but is not a barrier. The
OEP is for MA-to-MA or MA-to-Original changes, not Original-to-MA.
3. Mrs. Gupta is enrolled in a Medicare Advantage HMO plan. She wants to
see a specialist who is out-of-network. Under CMS rules, when must the plan
cover out-of-network emergency or urgent care services?
A) Only if the specialist obtains prior authorization from the plan.
B) The plan must cover emergency and urgent care services out-of-network
without prior authorization, and cost-sharing cannot be higher than in-network
for emergency care.
C) The plan is never required to cover out-of-network services, even in
emergencies.
D) The plan may charge balance billing for out-of-network emergency services.
Rationale: MA plans must cover emergency and urgent care out-of-network with no
prior authorization and apply in-network cost-sharing for emergencies. Balance billing is
,prohibited for covered emergency services. Routine specialist visits do require network use
or prior authorization.
4. Mr. Thompson is turning 65 in three months and is still working. He has
employer group health coverage. What is the general rule regarding enrollment
in Medicare Part B without penalty?
A) He must enroll in Part B during his Initial Enrollment Period (IEP) to avoid
a late enrollment penalty, regardless of employment.
B) He can delay Part B enrollment without penalty if he has creditable
coverage based on current employment, and he will have a Special Enrollment
Period (SEP) when that coverage ends.
C) He cannot delay Part B if his employer has fewer than 20 employees.
D) The late enrollment penalty is waived for all working individuals over 65.
Rationale: The SEP allows delay of Part B without penalty if covered by employer
group health plan based on current employment. If employer has <20 employees,
Medicare is primary, but delay may still be allowed with SEP. The penalty is not
waived for all; it depends on creditable coverage.
5. Which of the following is true regarding Medicare Part D's "coverage gap"
or "donut hole" for 2026?
A) Beneficiaries pay 25% of the cost for brand-name drugs throughout the gap.
B) The coverage gap has been effectively closed; beneficiaries pay no more
than 25% of the cost for covered brand-name and generic drugs while in the
gap.
C) There is no coverage gap in 2026; Part D has a flat copay for all tiers.
D) The coverage gap only applies to beneficiaries who do not receive Extra
Help.
, Rationale: The Affordable Care Act closed the donut hole; in 2026, beneficiaries
pay 25% for both brand and generic in the coverage gap. Extra Help recipients have
different cost-sharing but the gap still applies to them in terms of TrOOP.
6. Mrs. O'Brien is enrolled in a Medicare Advantage plan and has a chronic
condition. She wants to know if she can be disenrolled for non-payment of
premiums during the first year of enrollment. What is correct?
A) She cannot be disenrolled for non-payment of premiums in the first year.
B) The plan may disenroll her for non-payment of plan premiums after a grace
period, but not for non-payment of Part B premiums (if the plan doesn't collect
them).
C) Non-payment of any premium, including Part B, results in immediate
disenrollment.
D) CMS prohibits disenrollment for non-payment of premiums for any reason.
Rationale: MA plans may disenroll for non-payment of plan premiums after notice
and grace period. Part B premiums are paid to Medicare, not the plan, so non-
payment results in loss of Medicare, not plan disenrollment per se.
7. Mr. Klein has a Medicare Supplement (Medigap) policy and Original
Medicare. He is moving to a new state. What are his rights regarding his
Medigap policy?
A) He must purchase a new Medigap policy in the new state, as his current
policy is invalid.
B) He has guaranteed issue rights to buy a Medigap policy in the new state if
he moves out of his current plan's service area.
C) He can keep his Medigap policy only if the new state accepts the same
premium.
D) He loses all Medigap protections upon moving.
COMPLETE EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS A NEW UPDATED VERSION
EDITION 2026-2027 (100% CORRECT VERIFIED ANSWERS)
FREQUENTLY TESTED QUESTIONS AND SOLUTIONS
ALREADY GRADED A+ |INSTANT DOWNLOAD PDF
1. Mrs. Chen is a new Medicare beneficiary who is concerned about her
limited income. She asks about programs that can help pay for her Medicare
costs. What should you tell her?
A) The Medicare Savings Program is only available to beneficiaries under age
65.
B) The Qualified Medicare Beneficiary (QMB) program helps pay for Part A
and Part B premiums, deductibles, and coinsurance, but only for those in
Original Medicare.
C) The Medicare Savings Programs are administered by states and have
income and resource limits that vary by state.
D) Extra Help is a federal program that helps with Medicare Part D costs, but
it does not consider state residency.
Rationale: Medicare Savings Programs (MSPs) are state-administered with varying
income/resource thresholds. QMB is one type of MSP and covers costs in both
Original Medicare and Medicare Advantage, not just Original Medicare. Extra
Help is federal and does consider state Medicaid status. MSPs are available to those
65+ or disabled, not only under 65.
,2. Mr. Rodriguez has Original Medicare and a standalone Part D plan. He is
considering switching to a Medicare Advantage (MA) plan during the Annual
Enrollment Period (AEP). Which statement is accurate regarding his rights?
A) He can only switch from Original Medicare to an MA plan during the AEP
if he also drops his Part D plan.
B) He may make one election to change from Original Medicare to an MA
plan during the AEP, effective January 1.
C) He cannot switch to an MA plan if he has a Medigap policy.
D) He must wait until the Medicare Open Enrollment Period (OEP) from
January 1 to March 31 to make this change.
Rationale: During AEP (Oct 15-Dec 7), beneficiaries can switch from Original
Medicare to an MA plan, effective Jan 1. They do not need to separately drop Part
D, as the MA plan replaces it. Medigap can be dropped but is not a barrier. The
OEP is for MA-to-MA or MA-to-Original changes, not Original-to-MA.
3. Mrs. Gupta is enrolled in a Medicare Advantage HMO plan. She wants to
see a specialist who is out-of-network. Under CMS rules, when must the plan
cover out-of-network emergency or urgent care services?
A) Only if the specialist obtains prior authorization from the plan.
B) The plan must cover emergency and urgent care services out-of-network
without prior authorization, and cost-sharing cannot be higher than in-network
for emergency care.
C) The plan is never required to cover out-of-network services, even in
emergencies.
D) The plan may charge balance billing for out-of-network emergency services.
Rationale: MA plans must cover emergency and urgent care out-of-network with no
prior authorization and apply in-network cost-sharing for emergencies. Balance billing is
,prohibited for covered emergency services. Routine specialist visits do require network use
or prior authorization.
4. Mr. Thompson is turning 65 in three months and is still working. He has
employer group health coverage. What is the general rule regarding enrollment
in Medicare Part B without penalty?
A) He must enroll in Part B during his Initial Enrollment Period (IEP) to avoid
a late enrollment penalty, regardless of employment.
B) He can delay Part B enrollment without penalty if he has creditable
coverage based on current employment, and he will have a Special Enrollment
Period (SEP) when that coverage ends.
C) He cannot delay Part B if his employer has fewer than 20 employees.
D) The late enrollment penalty is waived for all working individuals over 65.
Rationale: The SEP allows delay of Part B without penalty if covered by employer
group health plan based on current employment. If employer has <20 employees,
Medicare is primary, but delay may still be allowed with SEP. The penalty is not
waived for all; it depends on creditable coverage.
5. Which of the following is true regarding Medicare Part D's "coverage gap"
or "donut hole" for 2026?
A) Beneficiaries pay 25% of the cost for brand-name drugs throughout the gap.
B) The coverage gap has been effectively closed; beneficiaries pay no more
than 25% of the cost for covered brand-name and generic drugs while in the
gap.
C) There is no coverage gap in 2026; Part D has a flat copay for all tiers.
D) The coverage gap only applies to beneficiaries who do not receive Extra
Help.
, Rationale: The Affordable Care Act closed the donut hole; in 2026, beneficiaries
pay 25% for both brand and generic in the coverage gap. Extra Help recipients have
different cost-sharing but the gap still applies to them in terms of TrOOP.
6. Mrs. O'Brien is enrolled in a Medicare Advantage plan and has a chronic
condition. She wants to know if she can be disenrolled for non-payment of
premiums during the first year of enrollment. What is correct?
A) She cannot be disenrolled for non-payment of premiums in the first year.
B) The plan may disenroll her for non-payment of plan premiums after a grace
period, but not for non-payment of Part B premiums (if the plan doesn't collect
them).
C) Non-payment of any premium, including Part B, results in immediate
disenrollment.
D) CMS prohibits disenrollment for non-payment of premiums for any reason.
Rationale: MA plans may disenroll for non-payment of plan premiums after notice
and grace period. Part B premiums are paid to Medicare, not the plan, so non-
payment results in loss of Medicare, not plan disenrollment per se.
7. Mr. Klein has a Medicare Supplement (Medigap) policy and Original
Medicare. He is moving to a new state. What are his rights regarding his
Medigap policy?
A) He must purchase a new Medigap policy in the new state, as his current
policy is invalid.
B) He has guaranteed issue rights to buy a Medigap policy in the new state if
he moves out of his current plan's service area.
C) He can keep his Medigap policy only if the new state accepts the same
premium.
D) He loses all Medigap protections upon moving.
