AHIP Final Exam Test Questions and
Answers (2025-2026) (Verified
Answers)GRADED A LATEST VERSION
Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of
misusing or abusing frequently abused drugs? - I. Identifying at risk individuals by using criteria
that includes the number of opioid prescriptions the beneficiary has and the number of
prescribers who have written those prescriptions.
II. Locking an at-risk beneficiary into one pharmacy.
III. Locking an at-risk beneficiary into one prescriber.
Mrs. Wolf wears glasses and dentures and has enjoyed considerable pain relief from arthritis
through acupuncture. She is concerned about whether or not Medicare will cover these items
and services. What should you tell her? - Medicare does not cover acupuncture, or, in general,
glasses or dentures.
Which statement best describes PACE plans? - It includes comprehensive medical and social
service delivery systems using an interdisciplinary team approach in an adult day health center,
supplemented by in-home and referral services.
Mr. Shultz was still working when he first qualified for Medicare. At that time, he had employer
group coverage that was creditable. During his initial Part D eligibility period, he decided not to
enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has
lost his employer group coverage. How would you advise him? - Mr. Schultz should enroll in a
Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.
For which of the following individuals would a Cost Plan be most appropriate? - Ms. Baker who
is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan
premiums.
Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug
coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what
circumstances can she do this? - If the Medicare Advantage plan is a Private Fee-for-Service
(PFFS) plan that does not offer drug coverage or a Medical Savings Account, Mrs. Berkowitz can
do this.
Ms. Goldstein is required by the plan she represents to obtain enrollment forms that have
carbon copies in the back. She gives one to the beneficiary, sends another to the plan and
retains the third. What should she do with her copies of the enrollment forms? - She should
make every effort to safeguard the beneficiary information on those enrollment forms.
,Mr. Lopez takes several high cost prescription drugs. He would like to enroll in a standalone
Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan
can he enroll? - Private Fee-for-Service (PFFS) plan that does not include drug coverage.
Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He
found a stand-alone Medicare prescription drug plan in his area that offers better coverage
than that available through his MA-PD plan and in addition has a low premium. It won't cost
him much more and, because he has the means to do so, he wishes to enroll in the stand-alone
prescription drug plan in addition to his MA-PD plan. What should you tell him? - If Mr. Block
enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the
Medicare Advantage plan.
Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and
paid taxes during that entire period. She is concerned that she will not qualify for coverage
under part A because she was not born in the United States. What should you tell her? - Most
individuals who are citizens and over age 65 are covered under Part A by virtue of having paid
Medicare taxes while working, though some may be covered as a result of paying monthly
premiums.
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable
coverage previously available through her husband's employer. She is interested in enrolling in
a Medicare Part D prescription drug plan (PDP). What should you tell her? - If a Part D benefit is
offered through her plan she must enroll in this plan.
Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original
Fee-for-Service (FFS) Medicare? What could you tell him? - Part A, which covers hospital, skilled
nursing facility, hospice and home health services and Part B, which covers professional services
such as those provided by a doctor are covered under Original Medicare.
Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that
there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On
January 15 she comes to you for advice as to what options, if any, she has. What should you say
regarding special enrollment periods (SEPs)? - Mrs. Wellington is eligible for a SEP that may be
used once until November 30 to enroll in the five-star plan.
Mr. Shapiro gets by on a very small fixed income. He has heard there may be extra help paying
for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know
whether he might qualify. What should you tell him? - The extra help is available to
beneficiaries whose income and assets do not exceed annual limits specified by the
government.
,A client wants to give you an enrollment application on October 1 prior to the beginning of the
Annual Election Period because he is leaving on vacation for two weeks and does not want to
forget about turning it in. What should you tell him? - You must tell him you are not permitted
to take the form. If he sends the form directly to the plan, the plan will process the enrollment
on the day the Annual Election Period begins.
Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare
health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also
enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation
rules apply to this situation? - This situation is considered a "dual enrollment," and CMS
compensation rules are applied to the two plans at once and independently of each other.
You are meeting with Mrs. Hall in her home. On her scope of appointment form she asked to
discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone
prescription drug plan. She is leaving the next day to visit her family for a week in another state,
so it is important to her to make a decision before she leaves. What must happen before that
additional discussion can take place? - Since Mrs. Hall specifically asked that you discuss the
stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form
first, indicating that she wants to discuss the Part D plan.
You have come to Mrs. Midler's home for a sales presentation. At the beginning of the
presentation, Mrs. Midler tells you that she has a copy of her medical record available because
she thinks this will help you understand her needs. She suggests that you will know which
questions to ask her about her health status in order to best assist her in selecting a plan. What
should you do? - You can only ask Mrs. Midler questions about conditions that affect eligibility,
specifically, whether she has end stage renal disease or one of the conditions that would qualify
her for a special needs plan.
Another agent working for your agency claims that because you are not employed by the
Medicare Advantage plans that you represent, you are not subject to the same requirements as
the plans themselves. How should you respond to such a statement? - Your coworker is not
correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all
contracted and employed agents comply with all Medicare marketing rules.
Ms. Jensen has heard about "Original Fee-for-Service Medicare" and "Private Fee-for-Service"
plans. She wants to know what the difference is, if any. What should you tell her? - PFFS plans
are a type of Medicare Advantage plan offered by private companies.
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the
Part D low-income subsidy. Where might he turn for help with his prescription drug costs? - Mr.
, Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance
Program.
Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual
checkups for the past 15 years, likes these yearly visits, and would like to continue obtaining
these services as a Medicare beneficiary. What should you tell him about annual check-ups? -
Medicare will cover an annual wellness visit, even if he has no illnesses or injuries.
Mr. Lopez, who is fairly well off, would like to enroll in a Medicare prescription drug plan you
represent and simply give you a check to cover his premiums for the entire year. What should
you tell him? - He will need to mail in his payment with his enrollment form.
Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and
is interested in that product. She wants to be sure she also has coverage for prescription drugs.
Would she be able to obtain drug coverage if she enrolled in the SNP? - Yes. All SNPs are
required to provide Part D coverage for prescription drugs.
Agent Higgins helps Mrs. O'Malley to enroll in AB Medicare Advantage (MA) plan during the
Annual Open Enrollment Period. Mrs. O'Malley's effective enrollment date is January 1st.
Subsequently, Mrs. O'Malley disenrolls on February 12th following a move outside the plan's
service area. What impact will this have on Agent Higgins compensation? - Agent Higgins entire
compensation must be recouped because Mrs. O'Malley has disenrolled within 3 months of
enrollment.
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like
to know which of the following services Original Medicare will cover if the appropriate criteria
are met? What could you tell her? - Original Medicare covers ambulance services.
Which of the following statements is correct about the appeal and grievance processes?
I. Enrollees have a right to obtain a review (appeal) of certain decisions about
prescription drug coverage.
II. The grievance process is used for reviews of coverage decisions on plan benefits. III.
Plans must provide a link to the Medicare.gov website where an enrollee can enter a
complaint.
IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of
their care. - I. Enrollees have a right to obtain a review (appeal) of certain decisions about
prescription drug coverage.
III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a
complaint.
Answers (2025-2026) (Verified
Answers)GRADED A LATEST VERSION
Which of the following steps may a Part D sponsor adopt for beneficiaries who are at risk of
misusing or abusing frequently abused drugs? - I. Identifying at risk individuals by using criteria
that includes the number of opioid prescriptions the beneficiary has and the number of
prescribers who have written those prescriptions.
II. Locking an at-risk beneficiary into one pharmacy.
III. Locking an at-risk beneficiary into one prescriber.
Mrs. Wolf wears glasses and dentures and has enjoyed considerable pain relief from arthritis
through acupuncture. She is concerned about whether or not Medicare will cover these items
and services. What should you tell her? - Medicare does not cover acupuncture, or, in general,
glasses or dentures.
Which statement best describes PACE plans? - It includes comprehensive medical and social
service delivery systems using an interdisciplinary team approach in an adult day health center,
supplemented by in-home and referral services.
Mr. Shultz was still working when he first qualified for Medicare. At that time, he had employer
group coverage that was creditable. During his initial Part D eligibility period, he decided not to
enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Shultz has
lost his employer group coverage. How would you advise him? - Mr. Schultz should enroll in a
Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.
For which of the following individuals would a Cost Plan be most appropriate? - Ms. Baker who
is enrolled in Medicare Part B and is willing to continue paying Part B premiums plus any plan
premiums.
Mrs. Berkowitz wants to enroll in a Medicare Advantage plan that does not include drug
coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what
circumstances can she do this? - If the Medicare Advantage plan is a Private Fee-for-Service
(PFFS) plan that does not offer drug coverage or a Medical Savings Account, Mrs. Berkowitz can
do this.
Ms. Goldstein is required by the plan she represents to obtain enrollment forms that have
carbon copies in the back. She gives one to the beneficiary, sends another to the plan and
retains the third. What should she do with her copies of the enrollment forms? - She should
make every effort to safeguard the beneficiary information on those enrollment forms.
,Mr. Lopez takes several high cost prescription drugs. He would like to enroll in a standalone
Part D prescription drug plan that is available in his area. In what type of Medicare Health Plan
can he enroll? - Private Fee-for-Service (PFFS) plan that does not include drug coverage.
Mr. Block is currently enrolled in a Medicare Advantage plan that includes drug coverage. He
found a stand-alone Medicare prescription drug plan in his area that offers better coverage
than that available through his MA-PD plan and in addition has a low premium. It won't cost
him much more and, because he has the means to do so, he wishes to enroll in the stand-alone
prescription drug plan in addition to his MA-PD plan. What should you tell him? - If Mr. Block
enrolls in the stand-alone Medicare prescription drug plan, he will be disenrolled from the
Medicare Advantage plan.
Mrs. Chen will be 65 soon, has been a citizen for twelve years, has been employed full time, and
paid taxes during that entire period. She is concerned that she will not qualify for coverage
under part A because she was not born in the United States. What should you tell her? - Most
individuals who are citizens and over age 65 are covered under Part A by virtue of having paid
Medicare taxes while working, though some may be covered as a result of paying monthly
premiums.
Mrs. Lopez is enrolled in a Medicare Advantage cost plan. She has recently lost creditable
coverage previously available through her husband's employer. She is interested in enrolling in
a Medicare Part D prescription drug plan (PDP). What should you tell her? - If a Part D benefit is
offered through her plan she must enroll in this plan.
Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original
Fee-for-Service (FFS) Medicare? What could you tell him? - Part A, which covers hospital, skilled
nursing facility, hospice and home health services and Part B, which covers professional services
such as those provided by a doctor are covered under Original Medicare.
Mrs. Wellington is enrolled in Parts A and B of Original Medicare. A friend recently told her that
there is an excellent Medicare Advantage (MA) plan with a five-star rating serving her area. On
January 15 she comes to you for advice as to what options, if any, she has. What should you say
regarding special enrollment periods (SEPs)? - Mrs. Wellington is eligible for a SEP that may be
used once until November 30 to enroll in the five-star plan.
Mr. Shapiro gets by on a very small fixed income. He has heard there may be extra help paying
for Part D prescription drugs for Medicare beneficiaries with limited income. He wants to know
whether he might qualify. What should you tell him? - The extra help is available to
beneficiaries whose income and assets do not exceed annual limits specified by the
government.
,A client wants to give you an enrollment application on October 1 prior to the beginning of the
Annual Election Period because he is leaving on vacation for two weeks and does not want to
forget about turning it in. What should you tell him? - You must tell him you are not permitted
to take the form. If he sends the form directly to the plan, the plan will process the enrollment
on the day the Annual Election Period begins.
Agent Roderick enrolls retiree Mrs. Martinez in a medical savings account (MSA) Medicare
health plan. The MSA plan does not offer prescription drug coverage, so Agent Roderick also
enrolls Mrs. Martinez in a standalone prescription drug plan (PDP). What CMS compensation
rules apply to this situation? - This situation is considered a "dual enrollment," and CMS
compensation rules are applied to the two plans at once and independently of each other.
You are meeting with Mrs. Hall in her home. On her scope of appointment form she asked to
discuss Medicare Advantage plans. During the meeting, she asks to discuss a stand-alone
prescription drug plan. She is leaving the next day to visit her family for a week in another state,
so it is important to her to make a decision before she leaves. What must happen before that
additional discussion can take place? - Since Mrs. Hall specifically asked that you discuss the
stand-alone Part D plan, you may do so, as long as she signs a new scope of appointment form
first, indicating that she wants to discuss the Part D plan.
You have come to Mrs. Midler's home for a sales presentation. At the beginning of the
presentation, Mrs. Midler tells you that she has a copy of her medical record available because
she thinks this will help you understand her needs. She suggests that you will know which
questions to ask her about her health status in order to best assist her in selecting a plan. What
should you do? - You can only ask Mrs. Midler questions about conditions that affect eligibility,
specifically, whether she has end stage renal disease or one of the conditions that would qualify
her for a special needs plan.
Another agent working for your agency claims that because you are not employed by the
Medicare Advantage plans that you represent, you are not subject to the same requirements as
the plans themselves. How should you respond to such a statement? - Your coworker is not
correct. Marketing on behalf of a plan is considered marketing by the plan and requires that all
contracted and employed agents comply with all Medicare marketing rules.
Ms. Jensen has heard about "Original Fee-for-Service Medicare" and "Private Fee-for-Service"
plans. She wants to know what the difference is, if any. What should you tell her? - PFFS plans
are a type of Medicare Advantage plan offered by private companies.
Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the
Part D low-income subsidy. Where might he turn for help with his prescription drug costs? - Mr.
, Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance
Program.
Mr. Jackson just turned 65. He has been seeing the same general practitioner for annual
checkups for the past 15 years, likes these yearly visits, and would like to continue obtaining
these services as a Medicare beneficiary. What should you tell him about annual check-ups? -
Medicare will cover an annual wellness visit, even if he has no illnesses or injuries.
Mr. Lopez, who is fairly well off, would like to enroll in a Medicare prescription drug plan you
represent and simply give you a check to cover his premiums for the entire year. What should
you tell him? - He will need to mail in his payment with his enrollment form.
Ms. Stuart has heard about a special needs plan (SNP) that one of her friends is enrolled in and
is interested in that product. She wants to be sure she also has coverage for prescription drugs.
Would she be able to obtain drug coverage if she enrolled in the SNP? - Yes. All SNPs are
required to provide Part D coverage for prescription drugs.
Agent Higgins helps Mrs. O'Malley to enroll in AB Medicare Advantage (MA) plan during the
Annual Open Enrollment Period. Mrs. O'Malley's effective enrollment date is January 1st.
Subsequently, Mrs. O'Malley disenrolls on February 12th following a move outside the plan's
service area. What impact will this have on Agent Higgins compensation? - Agent Higgins entire
compensation must be recouped because Mrs. O'Malley has disenrolled within 3 months of
enrollment.
Mrs. Turner is comparing her employer's retiree insurance to Original Medicare and would like
to know which of the following services Original Medicare will cover if the appropriate criteria
are met? What could you tell her? - Original Medicare covers ambulance services.
Which of the following statements is correct about the appeal and grievance processes?
I. Enrollees have a right to obtain a review (appeal) of certain decisions about
prescription drug coverage.
II. The grievance process is used for reviews of coverage decisions on plan benefits. III.
Plans must provide a link to the Medicare.gov website where an enrollee can enter a
complaint.
IV. Enrollees have a right to file complaints (sometimes called grievances) about the quality of
their care. - I. Enrollees have a right to obtain a review (appeal) of certain decisions about
prescription drug coverage.
III. Plans must provide a link to the Medicare.gov website where an enrollee can enter a
complaint.
