AHIP MEDICARE CERTIFICATION 2026/2027
350 PRACTICE QUESTIONS • ANSWERS • DETAILED RATIONALES
1. Why should a beneficiary's medications be checked against the plan's formulary?
A. It helps determine coverage and potential out-of-pocket cost
B. It guarantees all drugs are free
C. It replaces the need for a prescription
D. It determines Medicare Part A eligibility
CORRECT ANSWER: A. It helps determine coverage and potential out-of-pocket cost
RATIONALE: The plan's formulary can affect whether and how a prescription is covered and
what the beneficiary may pay.
2. Why should a beneficiary's medications be checked against the plan's formulary?
A. It helps determine coverage and potential out-of-pocket cost
B. It guarantees all drugs are free
C. It replaces the need for a prescription
D. It determines Medicare Part A eligibility
CORRECT ANSWER: A. It helps determine coverage and potential out-of-pocket cost
RATIONALE: The plan's formulary can affect whether and how a prescription is covered and
what the beneficiary may pay. Page 3 MODULE 2 — ENROLLMENT PERIODS & ELECTIONS
Page 1
,3. For a beneficiary with employer coverage, what should be verified before advising
about enrollment?
A. The applicable election period, eligibility, current coverage, and effective-date rules
B. Only the beneficiary's favorite hospital
C. Only the plan's television advertisement
D. Only the beneficiary's preferred pharmacy
CORRECT ANSWER: A. The applicable election period, eligibility, current coverage, and
effective-date rules
RATIONALE: Enrollment advice should be based on eligibility, the applicable election period,
current coverage, and effective-date rules. ADDITIONAL MIXED REVIEW
4. Which statement best reflects the role of age 65 in Medicare eligibility?
A. It can be a basis for Medicare eligibility when applicable federal requirements are met
B. It automatically creates Medicaid eligibility
C. It guarantees Part D enrollment
D. It eliminates all enrollment rules
CORRECT ANSWER: A. It can be a basis for Medicare eligibility when applicable federal
requirements are met
RATIONALE: Medicare eligibility can arise through age, disability, or certain qualifying
conditions, but specific federal requirements apply.
Page 2
,5. Why is it important to identify the beneficiary's Initial Enrollment Period?
A. It determines which enrollment opportunity and timing rules may apply
B. It determines the beneficiary's blood type
C. It guarantees a specific plan
D. It replaces the need to verify eligibility
CORRECT ANSWER: A. It determines which enrollment opportunity and timing rules may
apply
RATIONALE: Identifying the applicable enrollment period is essential because each period
has different eligibility and effective-date rules.
6. Which action best protects beneficiary privacy?
A. Follow applicable protections, communicate accurately, and respect the beneficiary's rights
B. Withhold information
C. Use stereotypes
D. Pressure the beneficiary
CORRECT ANSWER: A. Follow applicable protections, communicate accurately, and
respect the beneficiary's rights
RATIONALE: Protecting beneficiary privacy requires accurate, respectful, nondiscriminatory
service and compliance with applicable protections.
Page 3
, 7. Which situation is a potential false claims compliance concern?
A. Knowingly billing for services not provided
B. Accurately documenting a service
C. Correcting a typo through the approved process
D. Providing an authorized benefit
CORRECT ANSWER: A. Knowingly billing for services not provided
RATIONALE: Knowingly submitting false information or claims can be a serious fraud
concern and should be handled through appropriate compliance processes.
8. Why should an agent review a plan's network before enrollment?
A. It can materially affect access, coverage, or beneficiary costs
B. It is unrelated to plan selection
C. It guarantees every service is covered
D. It determines Social Security eligibility
CORRECT ANSWER: A. It can materially affect access, coverage, or beneficiary costs
RATIONALE: A plan's network can materially affect the beneficiary's access, coverage, or
costs and should be reviewed using current plan information.
Page 4
350 PRACTICE QUESTIONS • ANSWERS • DETAILED RATIONALES
1. Why should a beneficiary's medications be checked against the plan's formulary?
A. It helps determine coverage and potential out-of-pocket cost
B. It guarantees all drugs are free
C. It replaces the need for a prescription
D. It determines Medicare Part A eligibility
CORRECT ANSWER: A. It helps determine coverage and potential out-of-pocket cost
RATIONALE: The plan's formulary can affect whether and how a prescription is covered and
what the beneficiary may pay.
2. Why should a beneficiary's medications be checked against the plan's formulary?
A. It helps determine coverage and potential out-of-pocket cost
B. It guarantees all drugs are free
C. It replaces the need for a prescription
D. It determines Medicare Part A eligibility
CORRECT ANSWER: A. It helps determine coverage and potential out-of-pocket cost
RATIONALE: The plan's formulary can affect whether and how a prescription is covered and
what the beneficiary may pay. Page 3 MODULE 2 — ENROLLMENT PERIODS & ELECTIONS
Page 1
,3. For a beneficiary with employer coverage, what should be verified before advising
about enrollment?
A. The applicable election period, eligibility, current coverage, and effective-date rules
B. Only the beneficiary's favorite hospital
C. Only the plan's television advertisement
D. Only the beneficiary's preferred pharmacy
CORRECT ANSWER: A. The applicable election period, eligibility, current coverage, and
effective-date rules
RATIONALE: Enrollment advice should be based on eligibility, the applicable election period,
current coverage, and effective-date rules. ADDITIONAL MIXED REVIEW
4. Which statement best reflects the role of age 65 in Medicare eligibility?
A. It can be a basis for Medicare eligibility when applicable federal requirements are met
B. It automatically creates Medicaid eligibility
C. It guarantees Part D enrollment
D. It eliminates all enrollment rules
CORRECT ANSWER: A. It can be a basis for Medicare eligibility when applicable federal
requirements are met
RATIONALE: Medicare eligibility can arise through age, disability, or certain qualifying
conditions, but specific federal requirements apply.
Page 2
,5. Why is it important to identify the beneficiary's Initial Enrollment Period?
A. It determines which enrollment opportunity and timing rules may apply
B. It determines the beneficiary's blood type
C. It guarantees a specific plan
D. It replaces the need to verify eligibility
CORRECT ANSWER: A. It determines which enrollment opportunity and timing rules may
apply
RATIONALE: Identifying the applicable enrollment period is essential because each period
has different eligibility and effective-date rules.
6. Which action best protects beneficiary privacy?
A. Follow applicable protections, communicate accurately, and respect the beneficiary's rights
B. Withhold information
C. Use stereotypes
D. Pressure the beneficiary
CORRECT ANSWER: A. Follow applicable protections, communicate accurately, and
respect the beneficiary's rights
RATIONALE: Protecting beneficiary privacy requires accurate, respectful, nondiscriminatory
service and compliance with applicable protections.
Page 3
, 7. Which situation is a potential false claims compliance concern?
A. Knowingly billing for services not provided
B. Accurately documenting a service
C. Correcting a typo through the approved process
D. Providing an authorized benefit
CORRECT ANSWER: A. Knowingly billing for services not provided
RATIONALE: Knowingly submitting false information or claims can be a serious fraud
concern and should be handled through appropriate compliance processes.
8. Why should an agent review a plan's network before enrollment?
A. It can materially affect access, coverage, or beneficiary costs
B. It is unrelated to plan selection
C. It guarantees every service is covered
D. It determines Social Security eligibility
CORRECT ANSWER: A. It can materially affect access, coverage, or beneficiary costs
RATIONALE: A plan's network can materially affect the beneficiary's access, coverage, or
costs and should be reviewed using current plan information.
Page 4
