AHIP Final Exam 2026– Verified Edition with
Complete Answers and Rationales
Questions with Answers
Below are 50 verified questions from the 2026 AHIP Final Exam, covering Medicare
basics, enrollment, plan types, fraud/abuse, and compliance. Each includes the correct
answer and a detailed rationale based on CMS guidelines and AHIP content.
1. Mr. Davis is 52 years old and has recently been diagnosed with -stage
end 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 is not eligible until age 65.
B) He may sign up for Medicare at any time; coverage begins on the fourth month
after dialysis starts.
C) He must wait 24 months from diagnosis.
D) ESRD does not qualify for Medicare.
Answer: B) He may sign up for Medicare at any time; coverage begins on the
fourth month after dialysis starts.
Rationale: Medicare eligibility for ESRD allows enrollment at any time, with Part A
coverage starting the first month of dialysis, but full benefits (Parts A, B, D) begin
after the third month, per CMS ESRD rules.
2. Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is
being successfully treated for that condition. She is concerned about whether or
not Medicare will cover her doctor's office visits for follow
-up care. What should
you tell her?
A) Original Medicare covers follow -up visits.
B) Follow-up visits are not covered under Original Medicare.
C) She needs a Medicare Advantage plan for coverage.
D) Coverage depends on the doctor's network.
Answer: A) Original Medicare covers follow -up visits.
Rationale: Original Medicare (Parts A and B) covers medically necessary-up follow
, care for conditions like fractures, including doctor visits, with applicable deductibles
and co-insurance.
3. Mr. Zachow has a condition for which three drugs are available. He has tried two
but had an allergic reaction to them. Only the third drug works for him and it is
not on his Part D plan's formulary. What could you tell him to do?
A) Switch to a different Part D plan.
B) He can request an exception from the plan to cover the drug.
C) The plan must cover it regardless.
D) He cannot get coverage for it.
Answer: B) He can request an exception from the plan to cover the drug.
Rationale: Part D plans must cover formulary exceptions for medically necessary
non-formulary drugs if documented by the prescriber, per CMS guidelines on
coverage determinations.
4. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is
considering enrollment in a Medicare Advantage plan (Part C). What should you
advise her to do before she can enroll in a Medicare Advantage plan?
A) Enroll in Part B first.
B) Wait for Open Enrollment.
C) No action needed.
D) Enroll in Part D only.
Answer: A) Enroll in Part B first.
Rationale: Medicare Advantage plans require enrollment in both Parts A and B, as
they replace Original Medicare but do not substitute for Part B coverage.
5. Mr. Anderson wants to know whether he is eligible to sign up for a Private - Fee
for-Service (PFFS) plan. What questions would you need to ask to determine his
eligibility?
A) His income level.
B) Whether he has Parts A and B and lives in the plan's service area.
C) His employment status.
D) His marital status.
Answer: B) Whether he has Parts A and B and lives in the plan's service area.
Rationale: PFFS eligibility requires Parts A and B enrollment and residence in the
plan's service area, per CMS MA enrollment rules.
Complete Answers and Rationales
Questions with Answers
Below are 50 verified questions from the 2026 AHIP Final Exam, covering Medicare
basics, enrollment, plan types, fraud/abuse, and compliance. Each includes the correct
answer and a detailed rationale based on CMS guidelines and AHIP content.
1. Mr. Davis is 52 years old and has recently been diagnosed with -stage
end 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 is not eligible until age 65.
B) He may sign up for Medicare at any time; coverage begins on the fourth month
after dialysis starts.
C) He must wait 24 months from diagnosis.
D) ESRD does not qualify for Medicare.
Answer: B) He may sign up for Medicare at any time; coverage begins on the
fourth month after dialysis starts.
Rationale: Medicare eligibility for ESRD allows enrollment at any time, with Part A
coverage starting the first month of dialysis, but full benefits (Parts A, B, D) begin
after the third month, per CMS ESRD rules.
2. Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is
being successfully treated for that condition. She is concerned about whether or
not Medicare will cover her doctor's office visits for follow
-up care. What should
you tell her?
A) Original Medicare covers follow -up visits.
B) Follow-up visits are not covered under Original Medicare.
C) She needs a Medicare Advantage plan for coverage.
D) Coverage depends on the doctor's network.
Answer: A) Original Medicare covers follow -up visits.
Rationale: Original Medicare (Parts A and B) covers medically necessary-up follow
, care for conditions like fractures, including doctor visits, with applicable deductibles
and co-insurance.
3. Mr. Zachow has a condition for which three drugs are available. He has tried two
but had an allergic reaction to them. Only the third drug works for him and it is
not on his Part D plan's formulary. What could you tell him to do?
A) Switch to a different Part D plan.
B) He can request an exception from the plan to cover the drug.
C) The plan must cover it regardless.
D) He cannot get coverage for it.
Answer: B) He can request an exception from the plan to cover the drug.
Rationale: Part D plans must cover formulary exceptions for medically necessary
non-formulary drugs if documented by the prescriber, per CMS guidelines on
coverage determinations.
4. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is
considering enrollment in a Medicare Advantage plan (Part C). What should you
advise her to do before she can enroll in a Medicare Advantage plan?
A) Enroll in Part B first.
B) Wait for Open Enrollment.
C) No action needed.
D) Enroll in Part D only.
Answer: A) Enroll in Part B first.
Rationale: Medicare Advantage plans require enrollment in both Parts A and B, as
they replace Original Medicare but do not substitute for Part B coverage.
5. Mr. Anderson wants to know whether he is eligible to sign up for a Private - Fee
for-Service (PFFS) plan. What questions would you need to ask to determine his
eligibility?
A) His income level.
B) Whether he has Parts A and B and lives in the plan's service area.
C) His employment status.
D) His marital status.
Answer: B) Whether he has Parts A and B and lives in the plan's service area.
Rationale: PFFS eligibility requires Parts A and B enrollment and residence in the
plan's service area, per CMS MA enrollment rules.
