AHIP questions and answers 2025\2026
A+ Grade
Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is not sure about
what type of plan designs are available through this program. What should you tell him about the types
of health plans that are available through the Medicare Advantage program?
- correct answer They are Medicare health plans such as HMOs, PPOs, PFFS, SNPs, and MSAs
(W) Mr. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be a correct description?
- correct answer Medicare Advantage is a way of covering all of the Original Medicare benefits through
private health insurance companies.
During a sales presentation in Ms. Sullivan's home, she tells you that she has heard about a type of
Medicare health plan known as Private Fee-for-Service (PFFS). She wants to know if this would be
available to her. What should you tell her about PFFS plans?
- correct answer A PFFS plan is one of various types of Medicare Advantage plans offered by private
entities and she may enroll in one if it is available in her area.
(W) Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage.
What should you tell her?
- correct answer Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare
Advantage
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying
his Part B premium. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by
Part A. What should you tell him?
- correct answer He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare
Part B
,(W) Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor
recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Billings have
in regard to her MA plan during the next open enrollment season?
- correct answer She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for
individuals suffering from ESRD if one is available in her area
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access
providers. What should you tell him?
- correct answer In most Medicare Advantage HMOs, Mr. Kumar must obtain his services only from
providers who have a contractual relationship with the plan (except in an emergency).
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can
go to for her health care. What should you tell her?
- correct answer Mrs. Ramos can obtain care from any provider who participates in Original Medicare,
but generally will be charged a lower co-payment if she goes to one of the plan's preferred providers.
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under
Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans
(SNPs). What could you tell him?
- correct answer SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and
they provide prescription drug coverage that could be very helpful as well
(W) Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his
investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has
mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that
plan. What should you tell him?
- correct answer SNPs limit enrollment to certain sub-populations of beneficiaries. Given his current
situation, he is unlikely to qualify and would not be able to enroll in the SNP.
(W) 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?
- correct answer 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.
(W) Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security
Administration and has been receiving disability payments. He is wondering whether he can obtain
,coverage under Medicare. What should you tell him?
- correct answer After receiving such disability payments for 24 months, he will be automatically
enrolled in Medicare, regardless of age.
(W) Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security
Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug
policy?
- correct answer No, he cannot purchase a Medicare Advantage or Part D policy because he has not
received Social Security or Railroad Retirement disability benefits for 24 months.
(W) Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, without
paying any premiums, because she has been working for 40 years and paying Medicare taxes. What
should you tell her?
- correct answer In order to obtain Part B coverage, she must pay a standard monthly premium, though
it is higher for individuals with higher incomes
(W) Mr. Diaz continued working with his company and was insured under his employer's group plan
until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for
Part B when first eligible and wants to know how much he will have to pay. What should you tell him?
- correct answer Mr. Diaz will not pay any penalty because he had continuous coverage under his
employer's plan.
(W) Mrs. Peňa is 66 years old, has coverage under an employer plan and will retire next year. She heard
she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell
her?
- correct answer She may enroll at any time while she is covered under her employer plan, but she will
have a special eight-month enrollment period that differs from the standard general enrollment period,
during which she may enroll in Medicare Part B
(W) Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enrollment in a
Medicare health plan. What should you advise her to do before she will be able to enroll into a Medicare
health plan?
- correct answer In order to join a Medicare health plan, she also must enroll in Part B
Mrs. Park has a low, fixed income. What could you tell her that might be of assistance?
- correct answer She should contact her state Medicaid agency to see if she qualifies for one of several
programs that can help with Medicare costs for which she is responsible
, (W) Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some
type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what
the assistance could do for him if he qualifies. What could you tell him?
- correct answer He might qualify for help with Part D prescription drug costs and help paying Part A
and/or Part B premiums, deductibles, and/or cost sharing.
(W) Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns
66. He wants to understand the health care costs he might be exposed to under Medicare if he were to
require hospitalization as a result of an illness. In general terms, what could you tell him about his costs
for inpatient hospital services under Original Medicare?
- correct answer Under Original Medicare, there is a single deductible amount due for the first 60 days
of any inpatient hospital stay, after which it converts into a per-day amount through day 90. After day
90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for
all costs
(W) Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized.
What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric
hospital stay that Medicare will cover?
- correct answer Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's
entire lifetime.
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully
treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she
will need a month or two of nursing and rehabilitative care. What should you tell them about Original
Medicare's coverage of care in a skilled nursing facility?
- correct answer Medicare will cover Mrs. Shields' skilled nursing services provided during the first 20
days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days.
Mrs. Quinn has just turned 65 and received a letter informing her that she has been automatically
enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs.
Quinn?
- correct answer Part B primarily covers physician services. She will be paying a monthly premium and,
with the exception of many preventive and screening tests, generally will have 20% co-payments for
these services, in addition to an annual deductible.
(W) Mr. Buck has several family members who died from different cancers. He wants to know if
Medicare covers cancer screening. What should you tell him?
A+ Grade
Mr. Lopez has heard that he can sign up for a product called "Medicare Advantage" but is not sure about
what type of plan designs are available through this program. What should you tell him about the types
of health plans that are available through the Medicare Advantage program?
- correct answer They are Medicare health plans such as HMOs, PPOs, PFFS, SNPs, and MSAs
(W) Mr. Wells is trying to understand the difference between Original Medicare and Medicare
Advantage. What would be a correct description?
- correct answer Medicare Advantage is a way of covering all of the Original Medicare benefits through
private health insurance companies.
During a sales presentation in Ms. Sullivan's home, she tells you that she has heard about a type of
Medicare health plan known as Private Fee-for-Service (PFFS). She wants to know if this would be
available to her. What should you tell her about PFFS plans?
- correct answer A PFFS plan is one of various types of Medicare Advantage plans offered by private
entities and she may enroll in one if it is available in her area.
(W) Mrs. Radford asks whether there are any special eligibility requirements for Medicare Advantage.
What should you tell her?
- correct answer Mrs. Radford must be entitled to Part A and enrolled in Part B to enroll in Medicare
Advantage
Mr. Castillo, a naturalized citizen, previously enrolled in Medicare Part B but has recently stopped paying
his Part B premium. He would like to enroll in a Medicare Advantage (MA) plan and is still covered by
Part A. What should you tell him?
- correct answer He is not eligible to enroll in a Medicare Advantage plan until he re-enrolls in Medicare
Part B
,(W) Mrs. Billings enrolled in the ABC Medicare Advantage (MA) plan several years ago. Her doctor
recently confirmed a diagnosis of end-stage renal disease (ESRD). What options does Mrs. Billings have
in regard to her MA plan during the next open enrollment season?
- correct answer She may remain in her ABC MA plan or enroll in a Special Needs Plan (SNP) for
individuals suffering from ESRD if one is available in her area
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access
providers. What should you tell him?
- correct answer In most Medicare Advantage HMOs, Mr. Kumar must obtain his services only from
providers who have a contractual relationship with the plan (except in an emergency).
Mrs. Ramos is considering a Medicare Advantage PPO and has questions about which providers she can
go to for her health care. What should you tell her?
- correct answer Mrs. Ramos can obtain care from any provider who participates in Original Medicare,
but generally will be charged a lower co-payment if she goes to one of the plan's preferred providers.
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under
Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans
(SNPs). What could you tell him?
- correct answer SNPs have special programs for enrollees with chronic conditions, like Mr. Sinclair, and
they provide prescription drug coverage that could be very helpful as well
(W) Mr. Greco is in excellent health, lives in his own home, and has a sizeable income from his
investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has
mentioned that the SNP charges very low cost-sharing amounts and Mr. Greco would like to join that
plan. What should you tell him?
- correct answer SNPs limit enrollment to certain sub-populations of beneficiaries. Given his current
situation, he is unlikely to qualify and would not be able to enroll in the SNP.
(W) 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?
- correct answer 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.
(W) Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security
Administration and has been receiving disability payments. He is wondering whether he can obtain
,coverage under Medicare. What should you tell him?
- correct answer After receiving such disability payments for 24 months, he will be automatically
enrolled in Medicare, regardless of age.
(W) Mr. Davis is 49 years old and has been receiving disability benefits from the Social Security
Administration for 12 months. Can you sell him a Medicare Advantage or Part D Prescription Drug
policy?
- correct answer No, he cannot purchase a Medicare Advantage or Part D policy because he has not
received Social Security or Railroad Retirement disability benefits for 24 months.
(W) Ms. Henderson believes that she will qualify for Medicare coverage when she turns 65, without
paying any premiums, because she has been working for 40 years and paying Medicare taxes. What
should you tell her?
- correct answer In order to obtain Part B coverage, she must pay a standard monthly premium, though
it is higher for individuals with higher incomes
(W) Mr. Diaz continued working with his company and was insured under his employer's group plan
until he reached age 68. He has heard that there is a premium penalty for those who did not sign up for
Part B when first eligible and wants to know how much he will have to pay. What should you tell him?
- correct answer Mr. Diaz will not pay any penalty because he had continuous coverage under his
employer's plan.
(W) Mrs. Peňa is 66 years old, has coverage under an employer plan and will retire next year. She heard
she must enroll in Part B at the beginning of the year to ensure no gap in coverage. What can you tell
her?
- correct answer She may enroll at any time while she is covered under her employer plan, but she will
have a special eight-month enrollment period that differs from the standard general enrollment period,
during which she may enroll in Medicare Part B
(W) Mrs. Kelly is entitled to Part A, but is not yet enrolled in Part B. She is considering enrollment in a
Medicare health plan. What should you advise her to do before she will be able to enroll into a Medicare
health plan?
- correct answer In order to join a Medicare health plan, she also must enroll in Part B
Mrs. Park has a low, fixed income. What could you tell her that might be of assistance?
- correct answer She should contact her state Medicaid agency to see if she qualifies for one of several
programs that can help with Medicare costs for which she is responsible
, (W) Mr. Yu has limited income and resources so you have encouraged him to see if he qualifies for some
type of financial assistance. Mr. Yu is not sure it is worth the trouble to apply and wants to know what
the assistance could do for him if he qualifies. What could you tell him?
- correct answer He might qualify for help with Part D prescription drug costs and help paying Part A
and/or Part B premiums, deductibles, and/or cost sharing.
(W) Mr. Patel is in good health and is preparing a budget in anticipation of his retirement when he turns
66. He wants to understand the health care costs he might be exposed to under Medicare if he were to
require hospitalization as a result of an illness. In general terms, what could you tell him about his costs
for inpatient hospital services under Original Medicare?
- correct answer Under Original Medicare, there is a single deductible amount due for the first 60 days
of any inpatient hospital stay, after which it converts into a per-day amount through day 90. After day
90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for
all costs
(W) Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be hospitalized.
What should you tell Mr. Rainey (or his representative) about the length of an inpatient psychiatric
hospital stay that Medicare will cover?
- correct answer Medicare will cover a total of 190 days of inpatient psychiatric care during Mr. Rainey's
entire lifetime.
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being successfully
treated for that condition. However, she and her physicians feel that after her lengthy hospital stay she
will need a month or two of nursing and rehabilitative care. What should you tell them about Original
Medicare's coverage of care in a skilled nursing facility?
- correct answer Medicare will cover Mrs. Shields' skilled nursing services provided during the first 20
days of her stay, after which she would have a coinsurance until she has been in the facility for 100 days.
Mrs. Quinn has just turned 65 and received a letter informing her that she has been automatically
enrolled in Medicare Part B. She wants to understand what this means. What should you tell Mrs.
Quinn?
- correct answer Part B primarily covers physician services. She will be paying a monthly premium and,
with the exception of many preventive and screening tests, generally will have 20% co-payments for
these services, in addition to an annual deductible.
(W) Mr. Buck has several family members who died from different cancers. He wants to know if
Medicare covers cancer screening. What should you tell him?
