Advanced AHIP Practice Questions with Answers/
Updated 2026 A+/Instant Download PDF
Table of Contents
1. Medicare Advantage and Part D Marketing Regulatory Compliance
2. Medicare Part D Prescription Drug Benefit Rules
3. Medicare Advantage (Part C) Enrollment and Eligibility Protocols
4. Compliance, Fraud, Waste, and Abuse (FWA) Detection
1. A licensed independent agent is preparing for the upcoming Annual Election Period
(AEP) and wants to distribute a self-developed marketing brochure detailing specific
cost-sharing benefits of a local Medicare Advantage Preferred Provider Organization
(PPO) plan. According to the Centers for Medicare & Medicaid Services (CMS)
Medicare Marketing Guidelines, what action must the agent take prior to distributing
this brochure? A. The agent may distribute the brochure immediately if it contains
standard summary of benefits data. B. The agent must submit the brochure through
the sponsoring plan's HPMS (Health Plan Management System) marketing module
for CMS review and generation of a material ID. C. The agent only needs written
approval from the insurance agency's compliance officer. D. The agent can use the
brochure without submission as long as it is distributed to fewer than 100
prospective enrollees.
Answer: B [Correct Answer] Rationale: CMS regulations require all marketing materials
developed by plans or their downstream downstream entities (like third-party agents) that
describe plan benefits, cost-sharing, or premiums to be submitted through the Health Plan
Management System (HPMS) for review and approval. Distributing unapproved or unfiled
material violates CMS marketing guidelines regardless of the audience size. Standard
summary data does not exempt custom-created materials from the required material ID
assignment.
2. During an educational event held at a local public library, an agent is approached by a
Medicare beneficiary who expresses an urgent interest in enrolling in a specific
Medicare Advantage Prescription Drug (MA-PD) plan. Which of the following actions
by the agent complies with CMS operational standards for educational events? A.
The agent must refuse to accept the enrollment application at the event but may
schedule a distinct, individual appointment for a later date and collect a Scope of
Appointment (SOA) form. B. The agent can assist the beneficiary in completing the
enrollment application immediately, provided they sit at a separate table away from
the main educational presentation. C. The agent may accept the application only if
the beneficiary signs a waiver indicating they requested the enrollment voluntarily. D.
, The agent can provide the enrollment form but must direct the beneficiary to mail it
directly to the plan sponsor themselves before the end of the day.
Answer: A [Correct Answer] Rationale: CMS strictly prohibits marketing activities, plan-
specific cross-selling, and the collection of enrollment applications at designated educational
events. To maintain compliance, the agent must keep educational and marketing activities
completely separate, meaning any individual enrollment discussion or form completion must
occur at a later, separate marketing appointment with a valid Scope of Appointment. Options
B, C, and D all violate this boundary by facilitating enrollment actions at or through the
educational venue.
3. A Medicare beneficiary who currently has standalone Medicare Part D prescription
drug coverage (PDP) relocates permanently from Ohio to a new primary residence in
Florida. The beneficiary contacts an advisor in November to understand their
enrollment options. Which of the following correctly describes the beneficiary's
enrollment rights under CMS guidelines? A. The beneficiary must wait until the next
General Enrollment Period (GEP) to make any changes to their prescription drug
coverage. B. The beneficiary is eligible for a Special Election Period (SEP) due to a
permanent change in residence, allowing them to enroll in a new PDP or MA-PD
plan available in their new service area. C. The beneficiary will be automatically
transitioned into a benchmark PDP plan in Florida by CMS without requiring a new
election. D. The beneficiary loses their Part D coverage entirely for the remainder of
the calendar year and must reapply during the next Annual Election Period (AEP).
Answer: B [Correct Answer] Rationale: A permanent change of residence outside of a plan's
service area triggers a Special Election Period (SEP) that generally begins the month prior to
the move and lasts for up to two months after the move. This allows the individual to select a
plan that services their new geographic region to avoid a gap in coverage. CMS does not
automatically transition individuals under these standard circumstances, nor does it force
them to wait for the GEP or cancel coverage for the year.
4. A Medicare Advantage plan sponsor is designing its formulary utilization
management rules for the upcoming contract year. The clinical team wants to
implement a step therapy requirement for a high-cost, single-source brand-name
drug where a clinical alternative exists in a lower tier. Under Part D regulations, which
condition must the plan meet to apply this requirement? A. The plan can implement
step therapy dynamically at any time during the plan year without giving prior notice
to current enrollees. B. The step therapy protocol must be explicitly approved by
the plan's Pharmacy and Therapeutics (P&T) Committee and clearly disclosed in the
plan's formulary documents. C. Step therapy can only be applied to generic
medications, never to single-source brand-name drugs. D. The plan must obtain a
separate written waiver from each individual prescriber before enforcing the step
therapy rule at the point of sale.
,Answer: B [Correct Answer] Rationale: Part D sponsors must utilize a Pharmacy and
Therapeutics (P&T) Committee to develop and approve all utilization management
strategies, including step therapy, prior authorization, and quantity limits, ensuring they are
based on clinical evidence. These requirements must be transparently published in the plan's
formulary. Unannounced mid-year changes targeting existing utilizers are heavily restricted,
and individual prescriber waivers are not required to establish the structural rule.
5. A compliance auditor discovers that a field marketing organization (FMO) has been
offering a $100 cash referral bonus to current Medicare Advantage members for
every new lead they provide that results in a successful enrollment. Which regulatory
threshold does this practice violate? A. The standard health plan retention marketing
allowance. B. The CMS nominal value initiative and anti-kickback statutes governing
member incentives and marketing behavior. C. The Medicare maximum out-of-
pocket (MOOP) annual calculation adjustments. D. The non-duplication of statutory
health benefits framework under Part C.
Answer: B [Correct Answer] Rationale: CMS sets a strict "nominal value" limit (typically $15
or less) on gifts or incentives provided to beneficiaries, and cash or cash equivalents (like gift
cards or checks) are strictly prohibited regardless of the amount. Offering a $100 cash
incentive for referrals constitutes a clear violation of CMS marketing rules and raises
significant federal Anti-Kickback Statute concerns. Options A, C, and D relate to entirely
different components of Medicare administration.
6. An individual qualifies for Medicare due to End-Stage Renal Disease (ESRD) and
wishes to enroll in a local Medicare Advantage plan during their Initial Coverage
Election Period (ICEP). Which of the following statements accurately reflects the
current statutory access rule for ESRD beneficiaries seeking Medicare Advantage
enrollment? A. ESRD beneficiaries are completely barred from enrolling in Medicare
Advantage plans unless they qualify for a Special Needs Plan (SNP). B. ESRD
beneficiaries have full statutory authority to enroll in any Medicare Advantage plan
available in their service area that is accepting new members. C. Enrollment is
permitted only if the individual agrees to pay an additional ESRD-specific premium
surcharge directly to the plan sponsor. D. The beneficiary can only enroll if they
completed a kidney transplant operations sequence within the preceding 12 calendar
months.
Answer: B [Correct Answer] Rationale: Since the passage of the 21st Century Cures Act, the
historical restriction blocking individuals with End-Stage Renal Disease (ESRD) from enrolling
in Medicare Advantage plans has been removed. ESRD beneficiaries now have the same
rights to enroll in standard Medicare Advantage plans as other Medicare-eligible individuals,
without premium surcharges or transplant prerequisites. Special Needs Plans (SNPs) remain
an option but are no longer a mandatory gatekeeper.
, 7. During a routine internal audit, a Medicare Advantage plan provider notices that
several claims for evaluation and management (E&M) services were submitted with a
higher level of complexity code than what was documented in the patients' medical
records. If left uncorrected, this pattern of billing could legally be classified as which
of the following? A. A standard coordination of benefits administrative variance. B.
Upcoding, which represents a form of healthcare fraud under the False Claims Act.
C. A permissible supplemental benefit adjustment under risk adjustment
methodology. D. An unbundled service delivery model exception.
Answer: B [Correct Answer] Rationale: Billing for a higher level of service than what was
actually rendered or documented is defined as "upcoding," which constitutes a fraudulent
practice under the federal False Claims Act. It does not qualify as an administrative variance,
a supplemental benefit, or an unbundled service model. Compliance programs are explicitly
designed to catch and self-report these errors to avoid severe statutory penalties.
8. A Medicare Advantage plan wishes to offer a new array of supplemental benefits
aimed at addressing social determinants of health for chronically ill members. Under
the Special Needs Plan (SNP) or Special Supplemental Benefits for the Chronically Ill
(SSBCI) guidelines, which of the following is an authorized design parameter? A. The
supplemental benefits must be offered equally to every single enrolled member in
the plan regardless of health status. B. The plan may offer non-primarily health-
related benefits (such as pest control or grocery allowances) exclusively to
members who meet specific chronic condition criteria and risk profiles. C. SSBCI
benefits cannot be detailed in the Evidence of Coverage (EOC) document due to
privacy rules. D. The benefits must be entirely funded by direct out-of-pocket
premium surcharges collected from the participating chronic patients.
Answer: B [Correct Answer] Rationale: SSBCI rules allow Medicare Advantage plans to offer
non-primarily health-related supplemental benefits tailored to chronically ill enrollees who
meet specific clinical thresholds. These benefits do not have to be offered uniformly across
the entire plan membership, which is an exception to the standard uniformity rule. They must
be documented clearly in plan materials, and they are funded via plan rebates or allocations,
not through targeted patient surcharges.
9. A Medicare beneficiary calls a customer service representative to lodge an expedited
appeal because the plan has decided to terminate their coverage for skilled nursing
facility (SNF) services. According to CMS adjudication timelines, how quickly must the
plan issue a determination on a valid expedited organization determination appeal?
A. Within 24 hours of receiving the request. B. Within 72 hours of receiving the
request. C. Within 14 calendar days of receiving the medical records. D. Within 30
working days from the date of service termination.
Updated 2026 A+/Instant Download PDF
Table of Contents
1. Medicare Advantage and Part D Marketing Regulatory Compliance
2. Medicare Part D Prescription Drug Benefit Rules
3. Medicare Advantage (Part C) Enrollment and Eligibility Protocols
4. Compliance, Fraud, Waste, and Abuse (FWA) Detection
1. A licensed independent agent is preparing for the upcoming Annual Election Period
(AEP) and wants to distribute a self-developed marketing brochure detailing specific
cost-sharing benefits of a local Medicare Advantage Preferred Provider Organization
(PPO) plan. According to the Centers for Medicare & Medicaid Services (CMS)
Medicare Marketing Guidelines, what action must the agent take prior to distributing
this brochure? A. The agent may distribute the brochure immediately if it contains
standard summary of benefits data. B. The agent must submit the brochure through
the sponsoring plan's HPMS (Health Plan Management System) marketing module
for CMS review and generation of a material ID. C. The agent only needs written
approval from the insurance agency's compliance officer. D. The agent can use the
brochure without submission as long as it is distributed to fewer than 100
prospective enrollees.
Answer: B [Correct Answer] Rationale: CMS regulations require all marketing materials
developed by plans or their downstream downstream entities (like third-party agents) that
describe plan benefits, cost-sharing, or premiums to be submitted through the Health Plan
Management System (HPMS) for review and approval. Distributing unapproved or unfiled
material violates CMS marketing guidelines regardless of the audience size. Standard
summary data does not exempt custom-created materials from the required material ID
assignment.
2. During an educational event held at a local public library, an agent is approached by a
Medicare beneficiary who expresses an urgent interest in enrolling in a specific
Medicare Advantage Prescription Drug (MA-PD) plan. Which of the following actions
by the agent complies with CMS operational standards for educational events? A.
The agent must refuse to accept the enrollment application at the event but may
schedule a distinct, individual appointment for a later date and collect a Scope of
Appointment (SOA) form. B. The agent can assist the beneficiary in completing the
enrollment application immediately, provided they sit at a separate table away from
the main educational presentation. C. The agent may accept the application only if
the beneficiary signs a waiver indicating they requested the enrollment voluntarily. D.
, The agent can provide the enrollment form but must direct the beneficiary to mail it
directly to the plan sponsor themselves before the end of the day.
Answer: A [Correct Answer] Rationale: CMS strictly prohibits marketing activities, plan-
specific cross-selling, and the collection of enrollment applications at designated educational
events. To maintain compliance, the agent must keep educational and marketing activities
completely separate, meaning any individual enrollment discussion or form completion must
occur at a later, separate marketing appointment with a valid Scope of Appointment. Options
B, C, and D all violate this boundary by facilitating enrollment actions at or through the
educational venue.
3. A Medicare beneficiary who currently has standalone Medicare Part D prescription
drug coverage (PDP) relocates permanently from Ohio to a new primary residence in
Florida. The beneficiary contacts an advisor in November to understand their
enrollment options. Which of the following correctly describes the beneficiary's
enrollment rights under CMS guidelines? A. The beneficiary must wait until the next
General Enrollment Period (GEP) to make any changes to their prescription drug
coverage. B. The beneficiary is eligible for a Special Election Period (SEP) due to a
permanent change in residence, allowing them to enroll in a new PDP or MA-PD
plan available in their new service area. C. The beneficiary will be automatically
transitioned into a benchmark PDP plan in Florida by CMS without requiring a new
election. D. The beneficiary loses their Part D coverage entirely for the remainder of
the calendar year and must reapply during the next Annual Election Period (AEP).
Answer: B [Correct Answer] Rationale: A permanent change of residence outside of a plan's
service area triggers a Special Election Period (SEP) that generally begins the month prior to
the move and lasts for up to two months after the move. This allows the individual to select a
plan that services their new geographic region to avoid a gap in coverage. CMS does not
automatically transition individuals under these standard circumstances, nor does it force
them to wait for the GEP or cancel coverage for the year.
4. A Medicare Advantage plan sponsor is designing its formulary utilization
management rules for the upcoming contract year. The clinical team wants to
implement a step therapy requirement for a high-cost, single-source brand-name
drug where a clinical alternative exists in a lower tier. Under Part D regulations, which
condition must the plan meet to apply this requirement? A. The plan can implement
step therapy dynamically at any time during the plan year without giving prior notice
to current enrollees. B. The step therapy protocol must be explicitly approved by
the plan's Pharmacy and Therapeutics (P&T) Committee and clearly disclosed in the
plan's formulary documents. C. Step therapy can only be applied to generic
medications, never to single-source brand-name drugs. D. The plan must obtain a
separate written waiver from each individual prescriber before enforcing the step
therapy rule at the point of sale.
,Answer: B [Correct Answer] Rationale: Part D sponsors must utilize a Pharmacy and
Therapeutics (P&T) Committee to develop and approve all utilization management
strategies, including step therapy, prior authorization, and quantity limits, ensuring they are
based on clinical evidence. These requirements must be transparently published in the plan's
formulary. Unannounced mid-year changes targeting existing utilizers are heavily restricted,
and individual prescriber waivers are not required to establish the structural rule.
5. A compliance auditor discovers that a field marketing organization (FMO) has been
offering a $100 cash referral bonus to current Medicare Advantage members for
every new lead they provide that results in a successful enrollment. Which regulatory
threshold does this practice violate? A. The standard health plan retention marketing
allowance. B. The CMS nominal value initiative and anti-kickback statutes governing
member incentives and marketing behavior. C. The Medicare maximum out-of-
pocket (MOOP) annual calculation adjustments. D. The non-duplication of statutory
health benefits framework under Part C.
Answer: B [Correct Answer] Rationale: CMS sets a strict "nominal value" limit (typically $15
or less) on gifts or incentives provided to beneficiaries, and cash or cash equivalents (like gift
cards or checks) are strictly prohibited regardless of the amount. Offering a $100 cash
incentive for referrals constitutes a clear violation of CMS marketing rules and raises
significant federal Anti-Kickback Statute concerns. Options A, C, and D relate to entirely
different components of Medicare administration.
6. An individual qualifies for Medicare due to End-Stage Renal Disease (ESRD) and
wishes to enroll in a local Medicare Advantage plan during their Initial Coverage
Election Period (ICEP). Which of the following statements accurately reflects the
current statutory access rule for ESRD beneficiaries seeking Medicare Advantage
enrollment? A. ESRD beneficiaries are completely barred from enrolling in Medicare
Advantage plans unless they qualify for a Special Needs Plan (SNP). B. ESRD
beneficiaries have full statutory authority to enroll in any Medicare Advantage plan
available in their service area that is accepting new members. C. Enrollment is
permitted only if the individual agrees to pay an additional ESRD-specific premium
surcharge directly to the plan sponsor. D. The beneficiary can only enroll if they
completed a kidney transplant operations sequence within the preceding 12 calendar
months.
Answer: B [Correct Answer] Rationale: Since the passage of the 21st Century Cures Act, the
historical restriction blocking individuals with End-Stage Renal Disease (ESRD) from enrolling
in Medicare Advantage plans has been removed. ESRD beneficiaries now have the same
rights to enroll in standard Medicare Advantage plans as other Medicare-eligible individuals,
without premium surcharges or transplant prerequisites. Special Needs Plans (SNPs) remain
an option but are no longer a mandatory gatekeeper.
, 7. During a routine internal audit, a Medicare Advantage plan provider notices that
several claims for evaluation and management (E&M) services were submitted with a
higher level of complexity code than what was documented in the patients' medical
records. If left uncorrected, this pattern of billing could legally be classified as which
of the following? A. A standard coordination of benefits administrative variance. B.
Upcoding, which represents a form of healthcare fraud under the False Claims Act.
C. A permissible supplemental benefit adjustment under risk adjustment
methodology. D. An unbundled service delivery model exception.
Answer: B [Correct Answer] Rationale: Billing for a higher level of service than what was
actually rendered or documented is defined as "upcoding," which constitutes a fraudulent
practice under the federal False Claims Act. It does not qualify as an administrative variance,
a supplemental benefit, or an unbundled service model. Compliance programs are explicitly
designed to catch and self-report these errors to avoid severe statutory penalties.
8. A Medicare Advantage plan wishes to offer a new array of supplemental benefits
aimed at addressing social determinants of health for chronically ill members. Under
the Special Needs Plan (SNP) or Special Supplemental Benefits for the Chronically Ill
(SSBCI) guidelines, which of the following is an authorized design parameter? A. The
supplemental benefits must be offered equally to every single enrolled member in
the plan regardless of health status. B. The plan may offer non-primarily health-
related benefits (such as pest control or grocery allowances) exclusively to
members who meet specific chronic condition criteria and risk profiles. C. SSBCI
benefits cannot be detailed in the Evidence of Coverage (EOC) document due to
privacy rules. D. The benefits must be entirely funded by direct out-of-pocket
premium surcharges collected from the participating chronic patients.
Answer: B [Correct Answer] Rationale: SSBCI rules allow Medicare Advantage plans to offer
non-primarily health-related supplemental benefits tailored to chronically ill enrollees who
meet specific clinical thresholds. These benefits do not have to be offered uniformly across
the entire plan membership, which is an exception to the standard uniformity rule. They must
be documented clearly in plan materials, and they are funded via plan rebates or allocations,
not through targeted patient surcharges.
9. A Medicare beneficiary calls a customer service representative to lodge an expedited
appeal because the plan has decided to terminate their coverage for skilled nursing
facility (SNF) services. According to CMS adjudication timelines, how quickly must the
plan issue a determination on a valid expedited organization determination appeal?
A. Within 24 hours of receiving the request. B. Within 72 hours of receiving the
request. C. Within 14 calendar days of receiving the medical records. D. Within 30
working days from the date of service termination.
