2026 AHIP Final Exam Questions with
100% Correct Answers – Verified
Edition with Rationales
### Overview of the 2026 AHIP Final Exam
The 2026 AHIP (America's Health Insurance Plans) Final Exam is part of
the mandatory Medicare + Fraud, Waste, and Abuse (MFWA)
certification required by the Centers for Medicare & Medicaid Services
(CMS) for agents selling Medicare Advantage (MA) and Part D
prescription drug plans in 2026. The training opened on June 23, 2025,
and is valid for sales through the end of 2025 and all of 2026. It's an
open-book exam, but time constraints (2 hours) make preparation
essential. Completing it early ensures you're "Ready to Sell" for the
Annual Enrollment Period (AEP, October 15–December 7, 2026).
1. *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?*
*Answer*: Mr. Zachow has a right to request a formulary exception to
obtain coverage for his Part D drug.
, Rationale: Part D plans must allow exceptions for medically necessary
non-formulary drugs if alternatives fail or cause adverse effects (CMS
guideline).
2. *Mrs. Shields is covered by Original Medicare. She sustained a hip
fracture and is being successfully treated for that condition. However,
she has developed a severe case of dry eye and wants Medicare to
cover a surgical procedure. What can you tell her?*
*Answer*: Medicare does not cover dry eye surgical procedures.
Rationale: Original Medicare covers hip fracture treatment but
excludes most vision-related surgeries unless cataract-related.
3. *What is the standard Part D coverage gap (donut hole) phase for
2026?*
*Answer*: After initial coverage limit ($590 in 2025; adjusted
annually), beneficiary pays 25% on brands until out-of-pocket reaches
$8,000 (2025 threshold; IRA-reduced).
Rationale: Inflation Reduction Act caps out-of-pocket at $2,000
starting 2025, eliminating true "hole" but retaining discount phase.
4. *When can an individual with employer group health coverage enroll
in Part A and/or Part B?*
*Answer*: Anytime while on group coverage during a Special
Enrollment Period (SEP).
, Rationale: SEP avoids late penalties if group coverage ends; differs
from Initial Enrollment Period (IEP).
5. *Which of the following best describes costs under standard Part D
coverage?*
*Answer*: Deductible (up to $590 in 2025), then copays/coinsurance
until initial limit; 25% on brands in coverage gap; $0 after $2,000 out-of-
pocket (2025+).
Rationale: IRA eliminates 5% coinsurance post-gap; all plans must
offer equivalent to standard.
6. *Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but
accepts the plan's terms and conditions for payment. Mary Rodgers
sees Dr. Brennan for treatment. How is Dr. Brennan classified for the
PFFS plan?*
*Answer*: Deemed provider.
Rationale: PFFS plans allow non-contracted providers if they accept
plan terms at time of service.
7. *What steps may a Part D sponsor take for beneficiaries at risk of
misusing opioids?*
*Answer*: Identify at-risk via prescription/prescriber criteria;
implement lock-in or pre-authorization.
, Rationale: CMS allows drug management programs for frequently
abused drugs.
8. *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?*
*Answer*: Medicare covers acupuncture for chronic low back pain (up
to 12 visits/year) but not glasses or dentures.
Rationale: Part B covers limited acupuncture since 2020; vision/dental
exclusions apply.
9. *Mr. Davis is 52 years old and has recently been diagnosed with end-
stage renal disease (ESRD) and will soon begin dialysis. He is wondering
if he can obtain coverage under Medicare. What should you tell him?*
*Answer*: He may sign up for Medicare at any time; coverage begins
the fourth month of dialysis.
Rationale: ESRD entitles immediate Part A/B eligibility; waiting period
for onset.
10. *What is the Annual Election Period (AEP) for MA/PDP changes?*
*Answer*: October 15 to December 7, with January 1 effective date.
Rationale: Allows switches between Original Medicare, MA, PDPs; no
other periods for non-qualifying changes.
100% Correct Answers – Verified
Edition with Rationales
### Overview of the 2026 AHIP Final Exam
The 2026 AHIP (America's Health Insurance Plans) Final Exam is part of
the mandatory Medicare + Fraud, Waste, and Abuse (MFWA)
certification required by the Centers for Medicare & Medicaid Services
(CMS) for agents selling Medicare Advantage (MA) and Part D
prescription drug plans in 2026. The training opened on June 23, 2025,
and is valid for sales through the end of 2025 and all of 2026. It's an
open-book exam, but time constraints (2 hours) make preparation
essential. Completing it early ensures you're "Ready to Sell" for the
Annual Enrollment Period (AEP, October 15–December 7, 2026).
1. *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?*
*Answer*: Mr. Zachow has a right to request a formulary exception to
obtain coverage for his Part D drug.
, Rationale: Part D plans must allow exceptions for medically necessary
non-formulary drugs if alternatives fail or cause adverse effects (CMS
guideline).
2. *Mrs. Shields is covered by Original Medicare. She sustained a hip
fracture and is being successfully treated for that condition. However,
she has developed a severe case of dry eye and wants Medicare to
cover a surgical procedure. What can you tell her?*
*Answer*: Medicare does not cover dry eye surgical procedures.
Rationale: Original Medicare covers hip fracture treatment but
excludes most vision-related surgeries unless cataract-related.
3. *What is the standard Part D coverage gap (donut hole) phase for
2026?*
*Answer*: After initial coverage limit ($590 in 2025; adjusted
annually), beneficiary pays 25% on brands until out-of-pocket reaches
$8,000 (2025 threshold; IRA-reduced).
Rationale: Inflation Reduction Act caps out-of-pocket at $2,000
starting 2025, eliminating true "hole" but retaining discount phase.
4. *When can an individual with employer group health coverage enroll
in Part A and/or Part B?*
*Answer*: Anytime while on group coverage during a Special
Enrollment Period (SEP).
, Rationale: SEP avoids late penalties if group coverage ends; differs
from Initial Enrollment Period (IEP).
5. *Which of the following best describes costs under standard Part D
coverage?*
*Answer*: Deductible (up to $590 in 2025), then copays/coinsurance
until initial limit; 25% on brands in coverage gap; $0 after $2,000 out-of-
pocket (2025+).
Rationale: IRA eliminates 5% coinsurance post-gap; all plans must
offer equivalent to standard.
6. *Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but
accepts the plan's terms and conditions for payment. Mary Rodgers
sees Dr. Brennan for treatment. How is Dr. Brennan classified for the
PFFS plan?*
*Answer*: Deemed provider.
Rationale: PFFS plans allow non-contracted providers if they accept
plan terms at time of service.
7. *What steps may a Part D sponsor take for beneficiaries at risk of
misusing opioids?*
*Answer*: Identify at-risk via prescription/prescriber criteria;
implement lock-in or pre-authorization.
, Rationale: CMS allows drug management programs for frequently
abused drugs.
8. *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?*
*Answer*: Medicare covers acupuncture for chronic low back pain (up
to 12 visits/year) but not glasses or dentures.
Rationale: Part B covers limited acupuncture since 2020; vision/dental
exclusions apply.
9. *Mr. Davis is 52 years old and has recently been diagnosed with end-
stage renal disease (ESRD) and will soon begin dialysis. He is wondering
if he can obtain coverage under Medicare. What should you tell him?*
*Answer*: He may sign up for Medicare at any time; coverage begins
the fourth month of dialysis.
Rationale: ESRD entitles immediate Part A/B eligibility; waiting period
for onset.
10. *What is the Annual Election Period (AEP) for MA/PDP changes?*
*Answer*: October 15 to December 7, with January 1 effective date.
Rationale: Allows switches between Original Medicare, MA, PDPs; no
other periods for non-qualifying changes.
