AHIP 2027 Actual Exam Questions & Verified
Answers
Medicare, Health Insurance, and Compliance
Examination
QUESTION 1
An individual is turning 65 next month and is currently covered under an employer-sponsored group health
plan through their own employment. The employer has 50 employees. What action should the individual
take regarding Medicare enrollment?
Answer: Enroll in Medicare Part A and Part B during the Initial Enrollment Period, as Medicare is primary
and the group plan is secondary
Rationale: For individuals aged 65 or older who are covered under a group health plan based on their own
current employment (or a spouse's employment), the group plan is primary if the employer has 20 or more
employees. However, with 50 employees, the group plan is primary and Medicare is secondary. The
individual should still enroll in Medicare Part A and Part B during the Initial Enrollment Period (IEP) to avoid
potential late enrollment penalties for Part B. The IEP begins 3 months before the month the individual
turns 65, includes the month of the 65th birthday, and extends 3 months after. Failure to enroll in Part B
during this window may result in a 10% premium penalty for each 12-month period the individual was
eligible but not enrolled, unless they qualify for a Special Enrollment Period (SEP) based on continued
coverage through employment.
QUESTION 2
A Medicare beneficiary has both Medicare Part A and Part B. They are considering enrolling in a Medicare
Advantage (Part C) plan. Which of the following is TRUE regarding Medicare Advantage plans?
Answer: Medicare Advantage plans must cover all Medicare-covered services and may offer additional
benefits such as dental, vision, and hearing
Rationale: Medicare Advantage (Part C) plans are offered by private insurance companies approved by
Medicare. These plans must provide at least the same coverage as Original Medicare (Parts A and B) but
can offer additional benefits such as dental, vision, hearing, and prescription drug coverage (Part D). Some
plans may also offer wellness programs, gym memberships, and transportation to medical appointments.
Beneficiaries enrolled in Medicare Advantage plans receive their Medicare benefits through the plan rather
than through Original Medicare. These plans may have different cost-sharing structures (copayments,
coinsurance) and out-of-pocket maximums. Enrollees must continue to pay their Medicare Part B premium
,in addition to any plan premium. Medicare Advantage plans are often structured as HMO, PPO, or Private
Fee-for-Service (PFFS) plans.
QUESTION 3
A Medicare beneficiary who has a Medigap (Medicare Supplement) policy is considering switching to a
Medicare Advantage plan. What is the most important consideration?
Answer: Once enrolled in Medicare Advantage, the beneficiary cannot use their Medigap policy to pay the
Medicare Advantage plan's cost-sharing requirements
Rationale: Federal law prohibits the sale of Medigap policies to Medicare Advantage enrollees. If a
beneficiary is enrolled in a Medicare Advantage plan, they cannot also maintain a Medigap policy. The
Medigap policy would not cover the cost-sharing requirements (copayments, coinsurance, deductibles) of
the Medicare Advantage plan. If the beneficiary wants to return to Original Medicare later, they may have
limited rights to purchase a Medigap policy, depending on the situation (trial rights, guaranteed issue
rights). The beneficiary should carefully evaluate the benefits and costs of both options before making a
switch. Medicare Advantage plans often have networks and may restrict which providers the beneficiary
can use, which is different from Original Medicare with a Medigap policy.
QUESTION 4
A Medicare beneficiary is enrolled in a Medicare Part D prescription drug plan. The plan's formulary is
being updated, and a medication the beneficiary has been taking is being removed from the formulary.
What is the plan's obligation to the beneficiary?
Answer: The plan must provide a 60-day notice of the formulary change and offer a one-time, 30-day
supply of the affected medication at the same cost-sharing level
Rationale: Part D plans are required to provide written notice to beneficiaries at least 60 days before a
formulary change that removes a medication or makes it more restrictive. The plan must also allow the
beneficiary to request a formulary exception or request a one-time, 30-day supply of the affected
medication at the same cost-sharing level as if the medication were still on the formulary. This notice gives
the beneficiary time to work with their prescriber to switch to a covered alternative medication or request an
exception. The plan is not required to cover the medication after the 60-day notice period unless an
exception is approved. The beneficiary should contact the plan for information about the formulary change
and their options.
QUESTION 5
A Medicare beneficiary has an employer-sponsored retiree health plan that provides prescription drug
coverage. The beneficiary is considering enrolling in a Part D plan. Which statement is TRUE regarding
creditable coverage?
,Answer: The retiree plan must provide a notice each year indicating whether the coverage is creditable or
non-creditable
Rationale: Creditable coverage means that the coverage's expected value is at least equal to that of
standard Medicare Part D coverage. If the beneficiary's coverage is determined to be creditable, they can
delay enrolling in Part D without incurring a late enrollment penalty. If the coverage is non-creditable, the
beneficiary should enroll in Part D during their Initial Enrollment Period or during a Special Enrollment
Period (SEP) to avoid the penalty. The retiree plan is required to provide an annual notice to all Medicare-
eligible beneficiaries about the creditable status of their coverage. This notice is typically sent in September
each year. The beneficiary should carefully review the notice to determine their options. If the coverage is
non-creditable and they delay enrollment, they may face a penalty when they eventually enroll in Part D.
QUESTION 6
A Medicare beneficiary with Original Medicare is considering purchasing a Medigap policy. During the
Medigap Open Enrollment Period, what protections apply?
Answer: The beneficiary has guaranteed issue rights, meaning they cannot be denied a Medigap policy
based on health conditions or charged a higher premium due to health status
Rationale: The Medigap Open Enrollment Period is a 6-month period that begins the first day of the month
the beneficiary is 65 or older and enrolled in Medicare Part B. During this period, insurers are required to
offer any Medigap policy they sell at the same premium as they would to a healthy person, regardless of
the beneficiary's health status or pre-existing conditions. This is a guaranteed issue right. The insurer
cannot deny coverage or charge a higher premium based on health conditions. After the open enrollment
period, the beneficiary may be subject to medical underwriting and may be denied coverage or charged a
higher premium. There are limited exceptions to medical underwriting, including certain guaranteed issue
rights (such as when losing employer coverage or when a plan is discontinued).
QUESTION 7
A Medicare beneficiary is enrolled in a Medicare Advantage plan. The beneficiary has a chronic condition
and requires frequent specialist visits. Which statement is correct regarding referrals and prior
authorization?
Answer: The Medicare Advantage plan may require referrals from a primary care provider and prior
authorization for certain services
Rationale: Medicare Advantage plans may require beneficiaries to obtain referrals from a primary care
provider (PCP) and prior authorization for certain services, depending on the type of plan (HMO vs. PPO).
In HMO plans, the PCP typically coordinates all care and must provide referrals for specialist visits. In PPO
plans, beneficiaries can see any provider in the network without a referral, though they may pay higher
costs for out-of-network care. Prior authorization is a process where the plan reviews a requested service
or procedure to determine if it is medically necessary and covered. The plan must respond to prior
, authorization requests within a reasonable timeframe. The beneficiary should be aware of the plan's rules
and requirements. Failure to obtain necessary referrals or prior authorization may result in denial of
coverage.
QUESTION 8
A Medicare beneficiary is receiving a notice from their Part D plan regarding a coverage determination. The
plan has denied coverage for a prescribed medication. What is the beneficiary's first step in appealing this
decision?
Answer: File a redetermination request (first-level appeal) with the plan within 60 days of receiving the
denial notice
Rationale: Medicare beneficiaries have the right to appeal coverage decisions made by their Part D plan.
The first level of appeal is a redetermination request, which is filed directly with the plan. The request must
be filed within 60 calendar days of the date of the denial notice. The plan must respond within a specific
timeframe (7 days for standard requests, 72 hours for expedited requests if the beneficiary's life or health is
at risk). If the redetermination is denied, the beneficiary can appeal to the next level (reconsideration by an
independent review entity). The appeals process has five levels. Beneficiaries should keep copies of all
documents and communications related to the appeal. The beneficiary has the right to representation
during the appeals process.
QUESTION 9
A Medicare beneficiary is interested in enrolling in a Medicare Advantage plan for the first time. What is the
annual enrollment period for Medicare Advantage and Part D plans?
Answer: The Annual Enrollment Period (AEP) runs from October 15 to December 7 each year
Rationale: The Annual Enrollment Period (AEP), also known as the Fall Open Enrollment Period, runs from
October 15 to December 7 each year. During this period, Medicare beneficiaries can enroll in, switch, or
drop Medicare Advantage (Part C) and Part D prescription drug plans. Changes made during AEP take
effect on January 1 of the following year. The AEP is the primary opportunity for beneficiaries to review and
change their coverage for the upcoming year. Beneficiaries should compare plans annually because plan
benefits, formularies, premiums, and networks can change from year to year. There is also a Medicare
Advantage Open Enrollment Period (OEP) from January 1 to March 31, which allows beneficiaries enrolled
in a Medicare Advantage plan to switch to another Medicare Advantage plan or return to Original Medicare
(with or without a Part D plan).
QUESTION 10
A Medicare beneficiary is considering a Medicare Savings Program (MSP) to help with Medicare costs.
Which statement is correct about Medicare Savings Programs?
Answers
Medicare, Health Insurance, and Compliance
Examination
QUESTION 1
An individual is turning 65 next month and is currently covered under an employer-sponsored group health
plan through their own employment. The employer has 50 employees. What action should the individual
take regarding Medicare enrollment?
Answer: Enroll in Medicare Part A and Part B during the Initial Enrollment Period, as Medicare is primary
and the group plan is secondary
Rationale: For individuals aged 65 or older who are covered under a group health plan based on their own
current employment (or a spouse's employment), the group plan is primary if the employer has 20 or more
employees. However, with 50 employees, the group plan is primary and Medicare is secondary. The
individual should still enroll in Medicare Part A and Part B during the Initial Enrollment Period (IEP) to avoid
potential late enrollment penalties for Part B. The IEP begins 3 months before the month the individual
turns 65, includes the month of the 65th birthday, and extends 3 months after. Failure to enroll in Part B
during this window may result in a 10% premium penalty for each 12-month period the individual was
eligible but not enrolled, unless they qualify for a Special Enrollment Period (SEP) based on continued
coverage through employment.
QUESTION 2
A Medicare beneficiary has both Medicare Part A and Part B. They are considering enrolling in a Medicare
Advantage (Part C) plan. Which of the following is TRUE regarding Medicare Advantage plans?
Answer: Medicare Advantage plans must cover all Medicare-covered services and may offer additional
benefits such as dental, vision, and hearing
Rationale: Medicare Advantage (Part C) plans are offered by private insurance companies approved by
Medicare. These plans must provide at least the same coverage as Original Medicare (Parts A and B) but
can offer additional benefits such as dental, vision, hearing, and prescription drug coverage (Part D). Some
plans may also offer wellness programs, gym memberships, and transportation to medical appointments.
Beneficiaries enrolled in Medicare Advantage plans receive their Medicare benefits through the plan rather
than through Original Medicare. These plans may have different cost-sharing structures (copayments,
coinsurance) and out-of-pocket maximums. Enrollees must continue to pay their Medicare Part B premium
,in addition to any plan premium. Medicare Advantage plans are often structured as HMO, PPO, or Private
Fee-for-Service (PFFS) plans.
QUESTION 3
A Medicare beneficiary who has a Medigap (Medicare Supplement) policy is considering switching to a
Medicare Advantage plan. What is the most important consideration?
Answer: Once enrolled in Medicare Advantage, the beneficiary cannot use their Medigap policy to pay the
Medicare Advantage plan's cost-sharing requirements
Rationale: Federal law prohibits the sale of Medigap policies to Medicare Advantage enrollees. If a
beneficiary is enrolled in a Medicare Advantage plan, they cannot also maintain a Medigap policy. The
Medigap policy would not cover the cost-sharing requirements (copayments, coinsurance, deductibles) of
the Medicare Advantage plan. If the beneficiary wants to return to Original Medicare later, they may have
limited rights to purchase a Medigap policy, depending on the situation (trial rights, guaranteed issue
rights). The beneficiary should carefully evaluate the benefits and costs of both options before making a
switch. Medicare Advantage plans often have networks and may restrict which providers the beneficiary
can use, which is different from Original Medicare with a Medigap policy.
QUESTION 4
A Medicare beneficiary is enrolled in a Medicare Part D prescription drug plan. The plan's formulary is
being updated, and a medication the beneficiary has been taking is being removed from the formulary.
What is the plan's obligation to the beneficiary?
Answer: The plan must provide a 60-day notice of the formulary change and offer a one-time, 30-day
supply of the affected medication at the same cost-sharing level
Rationale: Part D plans are required to provide written notice to beneficiaries at least 60 days before a
formulary change that removes a medication or makes it more restrictive. The plan must also allow the
beneficiary to request a formulary exception or request a one-time, 30-day supply of the affected
medication at the same cost-sharing level as if the medication were still on the formulary. This notice gives
the beneficiary time to work with their prescriber to switch to a covered alternative medication or request an
exception. The plan is not required to cover the medication after the 60-day notice period unless an
exception is approved. The beneficiary should contact the plan for information about the formulary change
and their options.
QUESTION 5
A Medicare beneficiary has an employer-sponsored retiree health plan that provides prescription drug
coverage. The beneficiary is considering enrolling in a Part D plan. Which statement is TRUE regarding
creditable coverage?
,Answer: The retiree plan must provide a notice each year indicating whether the coverage is creditable or
non-creditable
Rationale: Creditable coverage means that the coverage's expected value is at least equal to that of
standard Medicare Part D coverage. If the beneficiary's coverage is determined to be creditable, they can
delay enrolling in Part D without incurring a late enrollment penalty. If the coverage is non-creditable, the
beneficiary should enroll in Part D during their Initial Enrollment Period or during a Special Enrollment
Period (SEP) to avoid the penalty. The retiree plan is required to provide an annual notice to all Medicare-
eligible beneficiaries about the creditable status of their coverage. This notice is typically sent in September
each year. The beneficiary should carefully review the notice to determine their options. If the coverage is
non-creditable and they delay enrollment, they may face a penalty when they eventually enroll in Part D.
QUESTION 6
A Medicare beneficiary with Original Medicare is considering purchasing a Medigap policy. During the
Medigap Open Enrollment Period, what protections apply?
Answer: The beneficiary has guaranteed issue rights, meaning they cannot be denied a Medigap policy
based on health conditions or charged a higher premium due to health status
Rationale: The Medigap Open Enrollment Period is a 6-month period that begins the first day of the month
the beneficiary is 65 or older and enrolled in Medicare Part B. During this period, insurers are required to
offer any Medigap policy they sell at the same premium as they would to a healthy person, regardless of
the beneficiary's health status or pre-existing conditions. This is a guaranteed issue right. The insurer
cannot deny coverage or charge a higher premium based on health conditions. After the open enrollment
period, the beneficiary may be subject to medical underwriting and may be denied coverage or charged a
higher premium. There are limited exceptions to medical underwriting, including certain guaranteed issue
rights (such as when losing employer coverage or when a plan is discontinued).
QUESTION 7
A Medicare beneficiary is enrolled in a Medicare Advantage plan. The beneficiary has a chronic condition
and requires frequent specialist visits. Which statement is correct regarding referrals and prior
authorization?
Answer: The Medicare Advantage plan may require referrals from a primary care provider and prior
authorization for certain services
Rationale: Medicare Advantage plans may require beneficiaries to obtain referrals from a primary care
provider (PCP) and prior authorization for certain services, depending on the type of plan (HMO vs. PPO).
In HMO plans, the PCP typically coordinates all care and must provide referrals for specialist visits. In PPO
plans, beneficiaries can see any provider in the network without a referral, though they may pay higher
costs for out-of-network care. Prior authorization is a process where the plan reviews a requested service
or procedure to determine if it is medically necessary and covered. The plan must respond to prior
, authorization requests within a reasonable timeframe. The beneficiary should be aware of the plan's rules
and requirements. Failure to obtain necessary referrals or prior authorization may result in denial of
coverage.
QUESTION 8
A Medicare beneficiary is receiving a notice from their Part D plan regarding a coverage determination. The
plan has denied coverage for a prescribed medication. What is the beneficiary's first step in appealing this
decision?
Answer: File a redetermination request (first-level appeal) with the plan within 60 days of receiving the
denial notice
Rationale: Medicare beneficiaries have the right to appeal coverage decisions made by their Part D plan.
The first level of appeal is a redetermination request, which is filed directly with the plan. The request must
be filed within 60 calendar days of the date of the denial notice. The plan must respond within a specific
timeframe (7 days for standard requests, 72 hours for expedited requests if the beneficiary's life or health is
at risk). If the redetermination is denied, the beneficiary can appeal to the next level (reconsideration by an
independent review entity). The appeals process has five levels. Beneficiaries should keep copies of all
documents and communications related to the appeal. The beneficiary has the right to representation
during the appeals process.
QUESTION 9
A Medicare beneficiary is interested in enrolling in a Medicare Advantage plan for the first time. What is the
annual enrollment period for Medicare Advantage and Part D plans?
Answer: The Annual Enrollment Period (AEP) runs from October 15 to December 7 each year
Rationale: The Annual Enrollment Period (AEP), also known as the Fall Open Enrollment Period, runs from
October 15 to December 7 each year. During this period, Medicare beneficiaries can enroll in, switch, or
drop Medicare Advantage (Part C) and Part D prescription drug plans. Changes made during AEP take
effect on January 1 of the following year. The AEP is the primary opportunity for beneficiaries to review and
change their coverage for the upcoming year. Beneficiaries should compare plans annually because plan
benefits, formularies, premiums, and networks can change from year to year. There is also a Medicare
Advantage Open Enrollment Period (OEP) from January 1 to March 31, which allows beneficiaries enrolled
in a Medicare Advantage plan to switch to another Medicare Advantage plan or return to Original Medicare
(with or without a Part D plan).
QUESTION 10
A Medicare beneficiary is considering a Medicare Savings Program (MSP) to help with Medicare costs.
Which statement is correct about Medicare Savings Programs?
