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AHIP 2025/2026 Final Exam –
Updated Questions and 100% Verified
Answers | Full Coverage for Modules
1–5 | Guarantee Pass
1. What is the primary purpose of Medicare Part A?
a) Cover prescription drugs
b) Provide inpatient hospital insurance
c) Offer outpatient medical services
d) Cover long-term care
Rationale: Medicare Part A covers inpatient hospital stays, skilled nursing facility care,
hospice, and some home health care. It does not cover prescription drugs (Part D),
outpatient services (Part B), or long-term care, per CMS guidelines.
2. Which of the following is a feature of Medicare Advantage (Part C) plans?
a) Available only to individuals under 65
b) Combines Part A, Part B, and often Part D benefits
c) Excludes hospital coverage
d) Requires a separate Medigap policy
Rationale: Medicare Advantage plans integrate Part A, Part B, and often Part D benefits
into a single plan, offered by private insurers. They are not limited to under 65, include
hospital coverage, and cannot be paired with Medigap, per CMS regulations.
3. True or False: Agents may offer gifts valued over $15 to potential enrollees to
encourage enrollment.
a) True
b) False
c) Only if approved by CMS
d) Only during open enrollment
Rationale: CMS prohibits offering gifts or incentives exceeding $15 in retail value to
influence enrollment, ensuring ethical marketing practices, per Medicare marketing
guidelines.
4. During which period can an individual enroll in a Medicare Part D plan without
penalty?
a) Initial Enrollment Period (IEP)
b) Annual Election Period (AEP)
c) Special Enrollment Period (SEP)
d) All of the above
Rationale: Individuals can enroll in Part D without penalty during IEP (around age 65),
AEP (October 15–December 7), or SEP (for qualifying events like moving or losing
coverage), per CMS enrollment rules.
5. What is a key requirement for marketing Medicare Advantage plans?
a) Agents must use only verbal presentations
, 2
b) Materials must be approved by CMS prior to use
c) Marketing can occur at any time without restrictions
d) Gifts are unlimited if disclosed
Rationale: CMS requires all marketing materials to be pre-approved to ensure
compliance with regulations, preventing misleading information, per Medicare marketing
guidelines.
6. Which action is considered fraud under Medicare guidelines?
a) Reporting accurate beneficiary information
b) Billing for services not rendered
c) Assisting with enrollment applications
d) Providing educational materials
Rationale: Billing for services not provided is fraud, as it misrepresents claims to CMS,
violating fraud, waste, and abuse (FWA) regulations, per AHIP training.
7. What is the maximum out-of-pocket limit for Medicare Advantage plans in 2025?
a) $5,000
b) $7,550
c) $10,000
d) No limit
Rationale: CMS sets the maximum out-of-pocket limit for Medicare Advantage plans at
$7,550 for in-network services in 2025, protecting beneficiaries from excessive costs.
8. True or False: Beneficiaries can change their Medicare Advantage plan during the
Open Enrollment Period (OEP).
a) True
b) False
c) Only if they move out of the plan’s service area
d) Only with CMS approval
Rationale: OEP (January 1–March 31) allows beneficiaries to switch Medicare
Advantage plans or return to Original Medicare, per CMS enrollment guidelines.
9. Which service is covered under Medicare Part B?
a) Routine dental care
b) Outpatient physician visits
c) Long-term nursing home care
d) Cosmetic surgery
Rationale: Part B covers outpatient services like physician visits, preventive care, and
diagnostic tests, but not dental, long-term care, or cosmetic procedures, per CMS
guidelines.
10. What must an agent do if a beneficiary requests to disenroll from a Medicare
Advantage plan?
a) Deny the request and suggest alternatives
b) Assist with the disenrollment process and notify the plan
c) Charge a fee for processing
d) Delay until the next AEP
Rationale: Agents must facilitate disenrollment and notify the plan promptly, respecting
the beneficiary’s choice, per CMS compliance requirements.
11. Which enrollment period allows switching from Original Medicare to a Medicare
Advantage plan?
AHIP 2025/2026 Final Exam –
Updated Questions and 100% Verified
Answers | Full Coverage for Modules
1–5 | Guarantee Pass
1. What is the primary purpose of Medicare Part A?
a) Cover prescription drugs
b) Provide inpatient hospital insurance
c) Offer outpatient medical services
d) Cover long-term care
Rationale: Medicare Part A covers inpatient hospital stays, skilled nursing facility care,
hospice, and some home health care. It does not cover prescription drugs (Part D),
outpatient services (Part B), or long-term care, per CMS guidelines.
2. Which of the following is a feature of Medicare Advantage (Part C) plans?
a) Available only to individuals under 65
b) Combines Part A, Part B, and often Part D benefits
c) Excludes hospital coverage
d) Requires a separate Medigap policy
Rationale: Medicare Advantage plans integrate Part A, Part B, and often Part D benefits
into a single plan, offered by private insurers. They are not limited to under 65, include
hospital coverage, and cannot be paired with Medigap, per CMS regulations.
3. True or False: Agents may offer gifts valued over $15 to potential enrollees to
encourage enrollment.
a) True
b) False
c) Only if approved by CMS
d) Only during open enrollment
Rationale: CMS prohibits offering gifts or incentives exceeding $15 in retail value to
influence enrollment, ensuring ethical marketing practices, per Medicare marketing
guidelines.
4. During which period can an individual enroll in a Medicare Part D plan without
penalty?
a) Initial Enrollment Period (IEP)
b) Annual Election Period (AEP)
c) Special Enrollment Period (SEP)
d) All of the above
Rationale: Individuals can enroll in Part D without penalty during IEP (around age 65),
AEP (October 15–December 7), or SEP (for qualifying events like moving or losing
coverage), per CMS enrollment rules.
5. What is a key requirement for marketing Medicare Advantage plans?
a) Agents must use only verbal presentations
, 2
b) Materials must be approved by CMS prior to use
c) Marketing can occur at any time without restrictions
d) Gifts are unlimited if disclosed
Rationale: CMS requires all marketing materials to be pre-approved to ensure
compliance with regulations, preventing misleading information, per Medicare marketing
guidelines.
6. Which action is considered fraud under Medicare guidelines?
a) Reporting accurate beneficiary information
b) Billing for services not rendered
c) Assisting with enrollment applications
d) Providing educational materials
Rationale: Billing for services not provided is fraud, as it misrepresents claims to CMS,
violating fraud, waste, and abuse (FWA) regulations, per AHIP training.
7. What is the maximum out-of-pocket limit for Medicare Advantage plans in 2025?
a) $5,000
b) $7,550
c) $10,000
d) No limit
Rationale: CMS sets the maximum out-of-pocket limit for Medicare Advantage plans at
$7,550 for in-network services in 2025, protecting beneficiaries from excessive costs.
8. True or False: Beneficiaries can change their Medicare Advantage plan during the
Open Enrollment Period (OEP).
a) True
b) False
c) Only if they move out of the plan’s service area
d) Only with CMS approval
Rationale: OEP (January 1–March 31) allows beneficiaries to switch Medicare
Advantage plans or return to Original Medicare, per CMS enrollment guidelines.
9. Which service is covered under Medicare Part B?
a) Routine dental care
b) Outpatient physician visits
c) Long-term nursing home care
d) Cosmetic surgery
Rationale: Part B covers outpatient services like physician visits, preventive care, and
diagnostic tests, but not dental, long-term care, or cosmetic procedures, per CMS
guidelines.
10. What must an agent do if a beneficiary requests to disenroll from a Medicare
Advantage plan?
a) Deny the request and suggest alternatives
b) Assist with the disenrollment process and notify the plan
c) Charge a fee for processing
d) Delay until the next AEP
Rationale: Agents must facilitate disenrollment and notify the plan promptly, respecting
the beneficiary’s choice, per CMS compliance requirements.
11. Which enrollment period allows switching from Original Medicare to a Medicare
Advantage plan?
