✅ AHIP Final Exam Latest (2025/2026) |
200 Verified Questions and Correct
Answers | A+ Graded
1. Which part of Medicare covers inpatient hospital services?
Answer: Part A
Rationale: Medicare Part A pays for inpatient stays, skilled nursing facility care, hospice, and
some home health.
2. A beneficiary turning 65 and already receiving Social Security benefits is
automatically enrolled in:
Answer: Part A and Part B
Rationale: Automatic enrollment occurs when receiving SSA benefits prior to 65.
3. The penalty for delaying Medicare Part B enrollment without creditable
coverage is:
Answer: 10% for every 12 months delayed
Rationale: CMS applies a 10% surcharge for each full uncovered year.
4. Medicare Advantage plans must cover:
Answer: All services covered by Original Medicare
Rationale: MA plans are required to provide equal or greater coverage than Parts A and B.
,5. What is the main requirement to join a Medicare Advantage plan?
Answer: Must have both Part A and Part B
Rationale: Enrollment in both parts is mandatory for MA.
6. The six protected drug classes under Part D ensure:
Answer: Broad access to critical medications
Rationale: Plans must cover all or nearly all drugs in these categories.
7. An agent must obtain a Scope of Appointment (SOA):
Answer: Before discussing specific plan benefits
Rationale: CMS requires SOA to document beneficiary permission.
8. LIS (Low-Income Subsidy) helps beneficiaries with:
Answer: Part D premium, deductible, and cost-sharing
Rationale: LIS reduces or eliminates drug plan costs for low-income enrollees.
9. What is considered marketing?
Answer: Materials intended to steer beneficiaries toward enrollment
Rationale: CMS defines marketing by intent and content.
10. Medicare Part B covers:
Answer: Outpatient services and preventive care
Rationale: Part B includes doctor visits, screenings, DME, and outpatient services.
11. A Special Enrollment Period (SEP) for Part B exists when:
,Answer: A beneficiary has creditable employer coverage and delays enrollment
Rationale: SEP avoids penalties when credible employer insurance exists.
12. Medicare Advantage plans receive payment from CMS through:
Answer: Monthly capitated payments
Rationale: Plans get a fixed per-member amount regardless of service use.
13. Upcoding by a provider is an example of:
Answer: Fraud
Rationale: Intentionally coding higher levels of service is deceptive and illegal.
14. Waste refers to:
Answer: Over-utilization of services
Rationale: Waste does not require intent to break rules.
15. Which program helps pay Medicare costs for individuals with limited
income?
Answer: Medicare Savings Programs (MSPs)
Rationale: MSPs cover Part A/B premiums and sometimes cost-sharing.
16. A marketing event allows an agent to:
Answer: Present plan-specific information
Rationale: Unlike educational events, marketing events permit discussing benefits.
17. A PPO Medicare Advantage plan allows members to:
Answer: See out-of-network providers at higher cost
Rationale: PPOs offer flexibility, but at increased OOP costs.
, 18. Which plan type restricts members to their network for all
non-emergency care?
Answer: HMO
Rationale: HMOs generally require in-network providers.
19. Which of the following is required for enrollment in a Special Needs
Plan (SNP)?
Answer: Must meet the SNP’s eligibility criteria
Rationale: SNPs require chronic conditions, institutional status, or dual eligibility.
20. The Medicare Part D coverage gap (“donut hole”) occurs after:
Answer: The initial coverage limit is reached
Rationale: After the limit, members pay a percentage of drug costs until catastrophic coverage.
21. A permissible activity at an educational event is:
Answer: Giving out general Medicare information
Rationale: No plan-specific info or enrollment forms allowed.
22. Which statement is true about MA plans and emergency care?
Answer: Emergency care must be covered everywhere in the U.S.
Rationale: CMS requires universal emergency coverage.
23. A drug formulary is:
Answer: The list of drugs a Part D plan covers
Rationale: Formularies categorize drugs by tiers and coverage rules.
200 Verified Questions and Correct
Answers | A+ Graded
1. Which part of Medicare covers inpatient hospital services?
Answer: Part A
Rationale: Medicare Part A pays for inpatient stays, skilled nursing facility care, hospice, and
some home health.
2. A beneficiary turning 65 and already receiving Social Security benefits is
automatically enrolled in:
Answer: Part A and Part B
Rationale: Automatic enrollment occurs when receiving SSA benefits prior to 65.
3. The penalty for delaying Medicare Part B enrollment without creditable
coverage is:
Answer: 10% for every 12 months delayed
Rationale: CMS applies a 10% surcharge for each full uncovered year.
4. Medicare Advantage plans must cover:
Answer: All services covered by Original Medicare
Rationale: MA plans are required to provide equal or greater coverage than Parts A and B.
,5. What is the main requirement to join a Medicare Advantage plan?
Answer: Must have both Part A and Part B
Rationale: Enrollment in both parts is mandatory for MA.
6. The six protected drug classes under Part D ensure:
Answer: Broad access to critical medications
Rationale: Plans must cover all or nearly all drugs in these categories.
7. An agent must obtain a Scope of Appointment (SOA):
Answer: Before discussing specific plan benefits
Rationale: CMS requires SOA to document beneficiary permission.
8. LIS (Low-Income Subsidy) helps beneficiaries with:
Answer: Part D premium, deductible, and cost-sharing
Rationale: LIS reduces or eliminates drug plan costs for low-income enrollees.
9. What is considered marketing?
Answer: Materials intended to steer beneficiaries toward enrollment
Rationale: CMS defines marketing by intent and content.
10. Medicare Part B covers:
Answer: Outpatient services and preventive care
Rationale: Part B includes doctor visits, screenings, DME, and outpatient services.
11. A Special Enrollment Period (SEP) for Part B exists when:
,Answer: A beneficiary has creditable employer coverage and delays enrollment
Rationale: SEP avoids penalties when credible employer insurance exists.
12. Medicare Advantage plans receive payment from CMS through:
Answer: Monthly capitated payments
Rationale: Plans get a fixed per-member amount regardless of service use.
13. Upcoding by a provider is an example of:
Answer: Fraud
Rationale: Intentionally coding higher levels of service is deceptive and illegal.
14. Waste refers to:
Answer: Over-utilization of services
Rationale: Waste does not require intent to break rules.
15. Which program helps pay Medicare costs for individuals with limited
income?
Answer: Medicare Savings Programs (MSPs)
Rationale: MSPs cover Part A/B premiums and sometimes cost-sharing.
16. A marketing event allows an agent to:
Answer: Present plan-specific information
Rationale: Unlike educational events, marketing events permit discussing benefits.
17. A PPO Medicare Advantage plan allows members to:
Answer: See out-of-network providers at higher cost
Rationale: PPOs offer flexibility, but at increased OOP costs.
, 18. Which plan type restricts members to their network for all
non-emergency care?
Answer: HMO
Rationale: HMOs generally require in-network providers.
19. Which of the following is required for enrollment in a Special Needs
Plan (SNP)?
Answer: Must meet the SNP’s eligibility criteria
Rationale: SNPs require chronic conditions, institutional status, or dual eligibility.
20. The Medicare Part D coverage gap (“donut hole”) occurs after:
Answer: The initial coverage limit is reached
Rationale: After the limit, members pay a percentage of drug costs until catastrophic coverage.
21. A permissible activity at an educational event is:
Answer: Giving out general Medicare information
Rationale: No plan-specific info or enrollment forms allowed.
22. Which statement is true about MA plans and emergency care?
Answer: Emergency care must be covered everywhere in the U.S.
Rationale: CMS requires universal emergency coverage.
23. A drug formulary is:
Answer: The list of drugs a Part D plan covers
Rationale: Formularies categorize drugs by tiers and coverage rules.
