AHIP Medicare Fraud, Waste and Abuse (MFWA)
Certification Exam New 2026 Version with All 50
Questions, 100% Correct Answers and Rationales
Section 1: Medicare Basics (Questions 1–5)
1. What is the primary coverage provided by Medicare Part A?
A) Doctor visits and outpatient services
B) Inpatient hospital stays, skilled nursing facility care, hospice, and some home health
care
C) Prescription drug coverage
D) Preventive services like annual wellness visits Correct Answer: B) Inpatient hospital
stays, skilled nursing facility care, hospice, and some home health care
Rationale: Medicare Part A, often called "Hospital Insurance," covers inpatient hospital
care, skilled nursing facilities (after a qualifying hospital stay), hospice care, and certain
home health services. Most people get Part A premium-free if they or their spouse paid
Medicare taxes while working.
2. When does Medicare Part B coverage typically begin for someone who enrolls during
their Initial Enrollment Period (IEP)?
A) The month after enrollment
B) The first day of the month of enrollment
C) The first day of the month after the month of enrollment
D) Immediately upon application approval Correct Answer: C) The first day of the month
after the month of enrollment
Rationale: For Part B, coverage starts the first day of the month following the month of
enrollment during the IEP (which spans the 3 months before the month of the 65th
birthday, the birthday month, and 3 months after). This ensures timely but not retroactive
coverage.
3. Which of the following individuals is eligible for Medicare based on age?
A) A 62-year-old retiree who has not yet claimed Social Security
B) A 65-year-old U.S. citizen who has paid Medicare taxes for at least 10 years
C) A 70-year-old permanent resident who has lived in the U.S. for 5 years
D) A 65-year-old who works full-time and has employer-sponsored health insurance
Correct Answer: B) A 65-year-old U.S. citizen who has paid Medicare taxes for at least
10 years
Rationale: Medicare eligibility at age 65 requires U.S. citizenship or lawful permanent
residency for at least 5 continuous years, plus sufficient work credits (40 quarters, or
about 10 years) for premium-free Part A. Working or other insurance does not disqualify
eligibility, but enrollment may be delayed.
4. What is the standard monthly premium for Medicare Part B in 2026 for most
beneficiaries?
A) $0 (free for all)
B) $174.70 (subject to income-related adjustments)
C) Varies by state
D) $185.00 fixed for all Correct Answer: B) $174.70 (subject to income-related
, adjustments)
Rationale: The standard Part B premium for 2026 is $174.70, but higher-income
beneficiaries pay an Income-Related Monthly Adjustment Amount (IRMAA). Premiums
are deducted from Social Security benefits or billed directly.
5. Mrs. Lopez has End-Stage Renal Disease (ESRD). How long can she remain eligible for
Medicare after a successful kidney transplant?
A) Indefinitely
B) 12 months
C) 24 months
D) 36 months Correct Answer: D) 36 months
Rationale: Individuals eligible for Medicare due to ESRD generally lose coverage 36
months after the month of a successful kidney transplant, unless they qualify on another
basis (e.g., age 65 or disability). This is per CMS rules to ensure continued access during
recovery.
Section 2: Medicare Advantage and Part D Enrollment (Questions 6–10)
6. What is the Annual Enrollment Period (AEP) for Medicare Advantage and Part D plans?
A) January 1–March 31
B) June 1–September 30
C) October 15–December 7
D) All year round Correct Answer: C) October 15–December 7
Rationale: The AEP allows beneficiaries to enroll in, switch, or disenroll from Medicare
Advantage (Part C) and Part D plans. Changes take effect January 1 of the following
year. Other periods like the Medicare Advantage Open Enrollment Period (OEP) apply
for specific switches.
7. Mr. Patel is turning 65 next month and wants to enroll in a Medicare Advantage plan.
What enrollment period should he use?
A) Annual Enrollment Period (AEP)
B) Initial Enrollment Period (IEP)
C) Special Enrollment Period (SEP)
D) Open Enrollment Period (OEP) Correct Answer: B) Initial Enrollment Period (IEP)
Rationale: The IEP for new Medicare beneficiaries is the 7-month period around the
birthday month (3 months before, the month of, and 3 months after turning 65). During
IEP, they can enroll in Original Medicare or Medicare Advantage without penalty.
8. Can a beneficiary enrolled in a Medicare Advantage HMO plan see an out-of-network
provider for routine care?
A) Yes, at the same cost as in-network
B) No, unless it's an emergency
C) Yes, but only for specialist care
D) Yes, if they pay the full cost Correct Answer: B) No, unless it's an emergency
Rationale: HMOs require use of in-network providers for non-emergency care. Out-of-
network services are generally not covered except in emergencies or for urgent care when
out of the plan's service area.
9. What is the maximum out-of-pocket limit for in-network services in a Medicare
Advantage plan for 2026?
A) There is no limit
B) $8,850
Certification Exam New 2026 Version with All 50
Questions, 100% Correct Answers and Rationales
Section 1: Medicare Basics (Questions 1–5)
1. What is the primary coverage provided by Medicare Part A?
A) Doctor visits and outpatient services
B) Inpatient hospital stays, skilled nursing facility care, hospice, and some home health
care
C) Prescription drug coverage
D) Preventive services like annual wellness visits Correct Answer: B) Inpatient hospital
stays, skilled nursing facility care, hospice, and some home health care
Rationale: Medicare Part A, often called "Hospital Insurance," covers inpatient hospital
care, skilled nursing facilities (after a qualifying hospital stay), hospice care, and certain
home health services. Most people get Part A premium-free if they or their spouse paid
Medicare taxes while working.
2. When does Medicare Part B coverage typically begin for someone who enrolls during
their Initial Enrollment Period (IEP)?
A) The month after enrollment
B) The first day of the month of enrollment
C) The first day of the month after the month of enrollment
D) Immediately upon application approval Correct Answer: C) The first day of the month
after the month of enrollment
Rationale: For Part B, coverage starts the first day of the month following the month of
enrollment during the IEP (which spans the 3 months before the month of the 65th
birthday, the birthday month, and 3 months after). This ensures timely but not retroactive
coverage.
3. Which of the following individuals is eligible for Medicare based on age?
A) A 62-year-old retiree who has not yet claimed Social Security
B) A 65-year-old U.S. citizen who has paid Medicare taxes for at least 10 years
C) A 70-year-old permanent resident who has lived in the U.S. for 5 years
D) A 65-year-old who works full-time and has employer-sponsored health insurance
Correct Answer: B) A 65-year-old U.S. citizen who has paid Medicare taxes for at least
10 years
Rationale: Medicare eligibility at age 65 requires U.S. citizenship or lawful permanent
residency for at least 5 continuous years, plus sufficient work credits (40 quarters, or
about 10 years) for premium-free Part A. Working or other insurance does not disqualify
eligibility, but enrollment may be delayed.
4. What is the standard monthly premium for Medicare Part B in 2026 for most
beneficiaries?
A) $0 (free for all)
B) $174.70 (subject to income-related adjustments)
C) Varies by state
D) $185.00 fixed for all Correct Answer: B) $174.70 (subject to income-related
, adjustments)
Rationale: The standard Part B premium for 2026 is $174.70, but higher-income
beneficiaries pay an Income-Related Monthly Adjustment Amount (IRMAA). Premiums
are deducted from Social Security benefits or billed directly.
5. Mrs. Lopez has End-Stage Renal Disease (ESRD). How long can she remain eligible for
Medicare after a successful kidney transplant?
A) Indefinitely
B) 12 months
C) 24 months
D) 36 months Correct Answer: D) 36 months
Rationale: Individuals eligible for Medicare due to ESRD generally lose coverage 36
months after the month of a successful kidney transplant, unless they qualify on another
basis (e.g., age 65 or disability). This is per CMS rules to ensure continued access during
recovery.
Section 2: Medicare Advantage and Part D Enrollment (Questions 6–10)
6. What is the Annual Enrollment Period (AEP) for Medicare Advantage and Part D plans?
A) January 1–March 31
B) June 1–September 30
C) October 15–December 7
D) All year round Correct Answer: C) October 15–December 7
Rationale: The AEP allows beneficiaries to enroll in, switch, or disenroll from Medicare
Advantage (Part C) and Part D plans. Changes take effect January 1 of the following
year. Other periods like the Medicare Advantage Open Enrollment Period (OEP) apply
for specific switches.
7. Mr. Patel is turning 65 next month and wants to enroll in a Medicare Advantage plan.
What enrollment period should he use?
A) Annual Enrollment Period (AEP)
B) Initial Enrollment Period (IEP)
C) Special Enrollment Period (SEP)
D) Open Enrollment Period (OEP) Correct Answer: B) Initial Enrollment Period (IEP)
Rationale: The IEP for new Medicare beneficiaries is the 7-month period around the
birthday month (3 months before, the month of, and 3 months after turning 65). During
IEP, they can enroll in Original Medicare or Medicare Advantage without penalty.
8. Can a beneficiary enrolled in a Medicare Advantage HMO plan see an out-of-network
provider for routine care?
A) Yes, at the same cost as in-network
B) No, unless it's an emergency
C) Yes, but only for specialist care
D) Yes, if they pay the full cost Correct Answer: B) No, unless it's an emergency
Rationale: HMOs require use of in-network providers for non-emergency care. Out-of-
network services are generally not covered except in emergencies or for urgent care when
out of the plan's service area.
9. What is the maximum out-of-pocket limit for in-network services in a Medicare
Advantage plan for 2026?
A) There is no limit
B) $8,850
