AHIP FINAL EXAM NEWEST VERSION 2026-2027
ACTUAL QUESTION AND CORRECT DETAILED
VERIFIED ANSWERS FROM VERIFIED SOURCES BY
EXPERT RATED A GRADE.( America's Health
Insurance Plans).
Mr. Davies is turning 65 next month. He would like to enroll in a Medicare
health plan, but does not want to be limited in terms of where he obtains
his care. What should you tell him about how a Medicare Cost Plan might fit
his needs?
a. Cost plan enrollees can choose to receive Medicare covered services under
the plan's benefits by going to plan network providers and paying plan cost
sharing, or may receive services from nonnetwork providers and pay cost-
sharing due under Original Medicare.
b. Cost plan enrollees must receive all Medicare covered services from plan
network providers or pay the full cost of services from nonnetwork providers.
c. Cost plan enrollees can only receive services from nonnetwork providers if
the plan approves the service in advance.
d. Cost plan enrollees are not permitted to receive services from nonnetwork
providers under any circumstances.
CORRECT ANS: a. Cost plan enrollees can choose to receive Medicare covered
services under the plan's benefits by going to plan network providers and
paying plan cost sharing, or may receive services from nonnetwork providers
and pay cost-sharing due under Original Medicare.
Expert Rationale: Medicare Cost Plans are a type of Medicare health plan that
offers beneficiaries the flexibility to choose between receiving services from
network providers under the plan's benefits or from nonnetwork providers
,under Original Medicare's fee-for-service structure. This flexibility allows
enrollees like Mr. Davies to maintain access to a broader range of providers
while still having the option to use plan network providers for potentially
lower cost-sharing. This dual-option structure distinguishes Cost Plans from
other Medicare Advantage plans that typically have more restrictive networks.
Ms. Lopez is an independent agent under contract with MarketCo, a third-
party marketing organization. MarketCo has a contract with BestCare health
plan, a Medicare Advantage (MA) organization, to offer marketing services
through its contracted agents and agencies. Ms. Lopez returns calls to
individuals who contact MarketCo in response to its mailers promoting
BestCare health plan. Which of the following best describes the
responsibilities of Ms. Lopez?
a. Ms. Lopez is considered a marketing representative of BestCare but is
exempt from the marketing rules regarding approved call scripts because she
works directly for MarketCo.
b. Ms. Lopez is considered a marketing representative of BestCare and thus is
obligated to comply with CMS marketing requirements, including those
regarding using only approved call scripts.
c. Ms. Lopez no longer needs to be concerned about state licensure since she
is marketing an MA product subject to federal rules.
d. Ms. Lopez needs to maintain state licensure, but because she is working for
a third-party marketing organization she is exempt from CMS training
requirements that apply to BestCare captive agents.
CORRECT ANS: b. Ms. Lopez is considered a marketing representative of
BestCare and thus is obligated to comply with CMS marketing requirements,
including those regarding using only approved call scripts.
Expert Rationale: When an agent acts on behalf of a Medicare Advantage
organization, even through a third-party marketing organization, they are
considered a marketing representative of that plan. As such, they are
,obligated to comply with all Centers for Medicare & Medicaid Services (CMS)
marketing requirements. This includes using only CMS-approved call scripts
during any telephonic marketing interactions. The fact that Ms. Lopez works
for MarketCo does not exempt her from these requirements. She must also
maintain state licensure and complete all required CMS training.
Mr. Edwards, a marketing representative of the ACME Insurance Company,
scheduled a marketing event and expects about 40 people to attend. He has
hired a magician at a cost of $200 to entertain attendees. Can he do this in a
way that complies with guidance from the Medicare agency?
a. He can do this because the estimated number of attendees is based on the
venue size and response rate and the value of the gift does not exceed $15.
b. He cannot do this because the value of the entertainment exceeds the $15
limit for nominal gifts.
c. He can do this because the event is educational and the entertainment is
incidental to the educational purpose.
d. He cannot do this because he is hiring a magician to entertain attendees.
CORRECT ANS: a. He can do this because the estimated number of attendees
is based on the venue size and response rate and the value of the gift does
not exceed $15.
Expert Rationale: CMS marketing guidelines permit nominal gifts or
refreshments at marketing events, provided the value does not exceed $15
per attendee. For entertainment such as a magician, the cost can be spread
across the estimated number of attendees to determine the per-person value.
If the total cost of the entertainment ($200) divided by the estimated
attendance (40) equals $5 per attendee, which is well below the $15 limit, it
would be permissible. The key is that the per-attendee value of any gift or
entertainment must not exceed $15.
, 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?
a. Mrs. Ramos can obtain care from any provider who participates in Original
Medicare, but generally will have a higher cost-sharing amount if she sees a
provider who/that is not a part of the PPO network.
b. Mrs. Ramos must obtain all of her care from providers within the PPO
network or she will have no coverage.
c. Mrs. Ramos can only see providers who are part of the PPO network.
d. Mrs. Ramos can see any provider, but only if the plan approves the service
in advance.
CORRECT ANS: a. Mrs. Ramos can obtain care from any provider who
participates in Original Medicare, but generally will have a higher cost-sharing
amount if she sees a provider who/that is not a part of the PPO network.
Expert Rationale: A Medicare Advantage Preferred Provider Organization
(PPO) plan offers flexibility in choosing providers. Enrollees can see any
provider who participates in Original Medicare. However, if they choose to see
a provider outside the plan's network, they will generally face higher cost-
sharing (e.g., higher copays, coinsurance, and deductibles). In-network
providers offer lower cost-sharing. This is a key feature of PPO plans,
distinguishing them from HMO plans, which typically do not cover out-of-
network services except in emergencies.
Julia Harris is turning 66 in July, at which time she will retire. She has
contacted your office and requested a meeting so that she can learn about
Medicare and the products you represent. How should you respond?
a. Tell Julia that you cannot meet with her until she is eligible to enroll.
b. Tell Julia that you will meet with her to explain Medicare, but you cannot
accept an enrollment request because she is not yet eligible.
c. Tell Julia that you will meet with her to explain Medicare and should she be
ACTUAL QUESTION AND CORRECT DETAILED
VERIFIED ANSWERS FROM VERIFIED SOURCES BY
EXPERT RATED A GRADE.( America's Health
Insurance Plans).
Mr. Davies is turning 65 next month. He would like to enroll in a Medicare
health plan, but does not want to be limited in terms of where he obtains
his care. What should you tell him about how a Medicare Cost Plan might fit
his needs?
a. Cost plan enrollees can choose to receive Medicare covered services under
the plan's benefits by going to plan network providers and paying plan cost
sharing, or may receive services from nonnetwork providers and pay cost-
sharing due under Original Medicare.
b. Cost plan enrollees must receive all Medicare covered services from plan
network providers or pay the full cost of services from nonnetwork providers.
c. Cost plan enrollees can only receive services from nonnetwork providers if
the plan approves the service in advance.
d. Cost plan enrollees are not permitted to receive services from nonnetwork
providers under any circumstances.
CORRECT ANS: a. Cost plan enrollees can choose to receive Medicare covered
services under the plan's benefits by going to plan network providers and
paying plan cost sharing, or may receive services from nonnetwork providers
and pay cost-sharing due under Original Medicare.
Expert Rationale: Medicare Cost Plans are a type of Medicare health plan that
offers beneficiaries the flexibility to choose between receiving services from
network providers under the plan's benefits or from nonnetwork providers
,under Original Medicare's fee-for-service structure. This flexibility allows
enrollees like Mr. Davies to maintain access to a broader range of providers
while still having the option to use plan network providers for potentially
lower cost-sharing. This dual-option structure distinguishes Cost Plans from
other Medicare Advantage plans that typically have more restrictive networks.
Ms. Lopez is an independent agent under contract with MarketCo, a third-
party marketing organization. MarketCo has a contract with BestCare health
plan, a Medicare Advantage (MA) organization, to offer marketing services
through its contracted agents and agencies. Ms. Lopez returns calls to
individuals who contact MarketCo in response to its mailers promoting
BestCare health plan. Which of the following best describes the
responsibilities of Ms. Lopez?
a. Ms. Lopez is considered a marketing representative of BestCare but is
exempt from the marketing rules regarding approved call scripts because she
works directly for MarketCo.
b. Ms. Lopez is considered a marketing representative of BestCare and thus is
obligated to comply with CMS marketing requirements, including those
regarding using only approved call scripts.
c. Ms. Lopez no longer needs to be concerned about state licensure since she
is marketing an MA product subject to federal rules.
d. Ms. Lopez needs to maintain state licensure, but because she is working for
a third-party marketing organization she is exempt from CMS training
requirements that apply to BestCare captive agents.
CORRECT ANS: b. Ms. Lopez is considered a marketing representative of
BestCare and thus is obligated to comply with CMS marketing requirements,
including those regarding using only approved call scripts.
Expert Rationale: When an agent acts on behalf of a Medicare Advantage
organization, even through a third-party marketing organization, they are
considered a marketing representative of that plan. As such, they are
,obligated to comply with all Centers for Medicare & Medicaid Services (CMS)
marketing requirements. This includes using only CMS-approved call scripts
during any telephonic marketing interactions. The fact that Ms. Lopez works
for MarketCo does not exempt her from these requirements. She must also
maintain state licensure and complete all required CMS training.
Mr. Edwards, a marketing representative of the ACME Insurance Company,
scheduled a marketing event and expects about 40 people to attend. He has
hired a magician at a cost of $200 to entertain attendees. Can he do this in a
way that complies with guidance from the Medicare agency?
a. He can do this because the estimated number of attendees is based on the
venue size and response rate and the value of the gift does not exceed $15.
b. He cannot do this because the value of the entertainment exceeds the $15
limit for nominal gifts.
c. He can do this because the event is educational and the entertainment is
incidental to the educational purpose.
d. He cannot do this because he is hiring a magician to entertain attendees.
CORRECT ANS: a. He can do this because the estimated number of attendees
is based on the venue size and response rate and the value of the gift does
not exceed $15.
Expert Rationale: CMS marketing guidelines permit nominal gifts or
refreshments at marketing events, provided the value does not exceed $15
per attendee. For entertainment such as a magician, the cost can be spread
across the estimated number of attendees to determine the per-person value.
If the total cost of the entertainment ($200) divided by the estimated
attendance (40) equals $5 per attendee, which is well below the $15 limit, it
would be permissible. The key is that the per-attendee value of any gift or
entertainment must not exceed $15.
, 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?
a. Mrs. Ramos can obtain care from any provider who participates in Original
Medicare, but generally will have a higher cost-sharing amount if she sees a
provider who/that is not a part of the PPO network.
b. Mrs. Ramos must obtain all of her care from providers within the PPO
network or she will have no coverage.
c. Mrs. Ramos can only see providers who are part of the PPO network.
d. Mrs. Ramos can see any provider, but only if the plan approves the service
in advance.
CORRECT ANS: a. Mrs. Ramos can obtain care from any provider who
participates in Original Medicare, but generally will have a higher cost-sharing
amount if she sees a provider who/that is not a part of the PPO network.
Expert Rationale: A Medicare Advantage Preferred Provider Organization
(PPO) plan offers flexibility in choosing providers. Enrollees can see any
provider who participates in Original Medicare. However, if they choose to see
a provider outside the plan's network, they will generally face higher cost-
sharing (e.g., higher copays, coinsurance, and deductibles). In-network
providers offer lower cost-sharing. This is a key feature of PPO plans,
distinguishing them from HMO plans, which typically do not cover out-of-
network services except in emergencies.
Julia Harris is turning 66 in July, at which time she will retire. She has
contacted your office and requested a meeting so that she can learn about
Medicare and the products you represent. How should you respond?
a. Tell Julia that you cannot meet with her until she is eligible to enroll.
b. Tell Julia that you will meet with her to explain Medicare, but you cannot
accept an enrollment request because she is not yet eligible.
c. Tell Julia that you will meet with her to explain Medicare and should she be
