AHIP Medicare Training Exam 2025/2026 –
Verified Questions with 100% Correct
Answers and Explanations
Question 1: Medicare Basics and Eligibility
Mr. Vasquez, a 65-year-old retiree in good health, is preparing a budget for healthcare costs. He
asks about potential expenses under Original Medicare if he requires hospitalization due to an
illness. What should you tell him regarding Part A coverage for inpatient hospital stays in 2026?
A. Medicare Part A covers 90 days per benefit period with a $1,632 deductible per benefit
period. B. Medicare Part A covers unlimited days with no deductible after the first 60. C.
Medicare Part A has no coverage for hospitalization; he needs Part B only. D. Medicare Part A
covers 100 days per year regardless of benefit periods.
Correct Answer: A. Medicare Part A covers 90 days per benefit period with a $1,632
deductible per benefit period.
Explanation: Under Original Medicare, Part A covers inpatient hospital stays for up to 90 days
per benefit period in 2026, with a deductible of $1,632 (updated annually for inflation). After 90
days, lifetime reserve days (60 total) apply with higher coinsurance. This ensures Mr. Vasquez
understands costs: $0 after deductible for days 1–60, $408/day for days 61–90. Reference: CMS
Medicare Part A Benefits (2026 updates). Agents must provide accurate cost-sharing info to
avoid misleading beneficiaries (CMS MCMG Section 30.1).
Question 2: Medicare Basics and Eligibility
Mrs. Quinn, age 66, recently retired and began receiving Social Security benefits. She received a
letter stating she was automatically enrolled in Medicare Part B. She calls you confused about
what this means and if she can opt out. What is the best response?
A. Automatic enrollment occurs for those receiving Social Security at age 65; she must pay Part
B premiums or face penalties if she declines. B. She can ignore the letter; Part B is optional and
has no penalties. C. Automatic enrollment is only for Part A; Part B requires separate
application. D. She must enroll in a Medicare Advantage plan to activate Part B.
Correct Answer: A. Automatic enrollment occurs for those receiving Social Security at age
65; she must pay Part B premiums or face penalties if she declines.
,Explanation: For beneficiaries turning 65 and receiving Social Security, Parts A and B
enrollment is automatic. Part B is voluntary; declining incurs a 10% permanent premium penalty
per year delayed. Advise her to contact Social Security within 3 months to decline without
penalty if she has creditable coverage. This promotes compliance with enrollment rules (CMS
Eligibility Guide, 2026). Agents should not pressure enrollment (MCMG Section 20.2).
Question 3: Medicare Basics and Eligibility
Mr. Davis, 52 years old, has been diagnosed with end-stage renal disease (ESRD) and will start
dialysis soon. He asks if he can enroll in Medicare now. What do you advise?
A. He can enroll at any time, but coverage begins the fourth month of dialysis. B. ESRD patients
are ineligible until age 65. C. He must wait for his 65th birthday for eligibility. D. Coverage
starts immediately upon diagnosis.
Correct Answer: A. He can enroll at any time, but coverage begins the fourth month of
dialysis.
Explanation: ESRD entitles individuals under 65 to Medicare regardless of age, but Part A/B
coverage starts the first month of the fourth month of dialysis. This "waiting period" allows
planning. Reference: CMS ESRD Medicare Coverage (2026). Agents must explain timelines
accurately to prevent disenrollment issues (42 CFR § 406.21).
Question 4: Medicare Basics and Eligibility
Juan Perez, turning 65 next month, plans to continue working at Smallcap Inc. (15 employees)
with employer-sponsored coverage. As a naturalized citizen with 20+ years of contributions, he
asks if he needs Medicare now. What is correct?
A. He can delay Parts A and B without penalty due to creditable employer coverage. B. He must
enroll in Part B immediately or face a penalty. C. Smallcap's plan makes him ineligible for
Medicare. D. He qualifies only for Part A premium-free.
Correct Answer: A. He can delay Parts A and B without penalty due to creditable
employer coverage.
Explanation: Active employees with group health plan coverage from employers with 20+
employees can delay Medicare without penalty. Smallcap has <20, so verify if creditable (meets
or exceeds Medicare). Advise checking with HR. Reference: CMS Coordination of Benefits
(2026). This avoids IRMAA surcharges (MCMG Section 10.1).
, Question 5: Medicare Basics and Eligibility
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She reviews her Medicare Summary
Notice (MSN) and disputes a partial claim denial for outpatient therapy. What should she do
next?
A. Contact the provider or file a redetermination request with her MAC within 120 days. B.
Switch to a Medicare Advantage plan to avoid denials. C. Ignore it; MSNs are not appealable. D.
Call you to file the appeal on her behalf.
Correct Answer: A. Contact the provider or file a redetermination request with her MAC
within 120 days.
Explanation: Beneficiaries can appeal claim denials via the MAC (e.g., Noridian) within 120
days of MSN. Start with a redetermination. Agents cannot file appeals (CMS Appeals Process,
2026). Educate on rights to ensure transparency (42 CFR § 405.906).
Question 6: Plan Types
Mr. Capadona wants a Medicare Advantage (MA) plan and a Medigap plan to cover MA gaps.
What do you tell him?
A. Medigap cannot be sold with MA plans; it only supplements Original Medicare. B. He can
buy both; Medigap covers MA cost-sharing. C. MA plans include Medigap benefits
automatically. D. Recommend switching to Original Medicare for both.
Correct Answer: A. Medigap cannot be sold with MA plans; it only supplements Original
Medicare.
Explanation: Medigap policies are prohibited for MA enrollees (42 CFR § 403.221). They
coordinate only with Original Medicare. This prevents misleading sales. Reference: CMS
Medigap Guide (2026). Agents must disclose incompatibilities (MCMG Section 30.7).
Question 7: Plan Types
Mr. Kelly asks about eligibility for a Private Fee-for-Service (PFFS) MA plan. What key
questions do you ask?
A. Does he have Parts A and B? Is he in the plan's service area? B. Is he under 65? Does he have
employer coverage? C. What is his income for low-income subsidies? D. Has he used a PFFS
plan before?
Verified Questions with 100% Correct
Answers and Explanations
Question 1: Medicare Basics and Eligibility
Mr. Vasquez, a 65-year-old retiree in good health, is preparing a budget for healthcare costs. He
asks about potential expenses under Original Medicare if he requires hospitalization due to an
illness. What should you tell him regarding Part A coverage for inpatient hospital stays in 2026?
A. Medicare Part A covers 90 days per benefit period with a $1,632 deductible per benefit
period. B. Medicare Part A covers unlimited days with no deductible after the first 60. C.
Medicare Part A has no coverage for hospitalization; he needs Part B only. D. Medicare Part A
covers 100 days per year regardless of benefit periods.
Correct Answer: A. Medicare Part A covers 90 days per benefit period with a $1,632
deductible per benefit period.
Explanation: Under Original Medicare, Part A covers inpatient hospital stays for up to 90 days
per benefit period in 2026, with a deductible of $1,632 (updated annually for inflation). After 90
days, lifetime reserve days (60 total) apply with higher coinsurance. This ensures Mr. Vasquez
understands costs: $0 after deductible for days 1–60, $408/day for days 61–90. Reference: CMS
Medicare Part A Benefits (2026 updates). Agents must provide accurate cost-sharing info to
avoid misleading beneficiaries (CMS MCMG Section 30.1).
Question 2: Medicare Basics and Eligibility
Mrs. Quinn, age 66, recently retired and began receiving Social Security benefits. She received a
letter stating she was automatically enrolled in Medicare Part B. She calls you confused about
what this means and if she can opt out. What is the best response?
A. Automatic enrollment occurs for those receiving Social Security at age 65; she must pay Part
B premiums or face penalties if she declines. B. She can ignore the letter; Part B is optional and
has no penalties. C. Automatic enrollment is only for Part A; Part B requires separate
application. D. She must enroll in a Medicare Advantage plan to activate Part B.
Correct Answer: A. Automatic enrollment occurs for those receiving Social Security at age
65; she must pay Part B premiums or face penalties if she declines.
,Explanation: For beneficiaries turning 65 and receiving Social Security, Parts A and B
enrollment is automatic. Part B is voluntary; declining incurs a 10% permanent premium penalty
per year delayed. Advise her to contact Social Security within 3 months to decline without
penalty if she has creditable coverage. This promotes compliance with enrollment rules (CMS
Eligibility Guide, 2026). Agents should not pressure enrollment (MCMG Section 20.2).
Question 3: Medicare Basics and Eligibility
Mr. Davis, 52 years old, has been diagnosed with end-stage renal disease (ESRD) and will start
dialysis soon. He asks if he can enroll in Medicare now. What do you advise?
A. He can enroll at any time, but coverage begins the fourth month of dialysis. B. ESRD patients
are ineligible until age 65. C. He must wait for his 65th birthday for eligibility. D. Coverage
starts immediately upon diagnosis.
Correct Answer: A. He can enroll at any time, but coverage begins the fourth month of
dialysis.
Explanation: ESRD entitles individuals under 65 to Medicare regardless of age, but Part A/B
coverage starts the first month of the fourth month of dialysis. This "waiting period" allows
planning. Reference: CMS ESRD Medicare Coverage (2026). Agents must explain timelines
accurately to prevent disenrollment issues (42 CFR § 406.21).
Question 4: Medicare Basics and Eligibility
Juan Perez, turning 65 next month, plans to continue working at Smallcap Inc. (15 employees)
with employer-sponsored coverage. As a naturalized citizen with 20+ years of contributions, he
asks if he needs Medicare now. What is correct?
A. He can delay Parts A and B without penalty due to creditable employer coverage. B. He must
enroll in Part B immediately or face a penalty. C. Smallcap's plan makes him ineligible for
Medicare. D. He qualifies only for Part A premium-free.
Correct Answer: A. He can delay Parts A and B without penalty due to creditable
employer coverage.
Explanation: Active employees with group health plan coverage from employers with 20+
employees can delay Medicare without penalty. Smallcap has <20, so verify if creditable (meets
or exceeds Medicare). Advise checking with HR. Reference: CMS Coordination of Benefits
(2026). This avoids IRMAA surcharges (MCMG Section 10.1).
, Question 5: Medicare Basics and Eligibility
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She reviews her Medicare Summary
Notice (MSN) and disputes a partial claim denial for outpatient therapy. What should she do
next?
A. Contact the provider or file a redetermination request with her MAC within 120 days. B.
Switch to a Medicare Advantage plan to avoid denials. C. Ignore it; MSNs are not appealable. D.
Call you to file the appeal on her behalf.
Correct Answer: A. Contact the provider or file a redetermination request with her MAC
within 120 days.
Explanation: Beneficiaries can appeal claim denials via the MAC (e.g., Noridian) within 120
days of MSN. Start with a redetermination. Agents cannot file appeals (CMS Appeals Process,
2026). Educate on rights to ensure transparency (42 CFR § 405.906).
Question 6: Plan Types
Mr. Capadona wants a Medicare Advantage (MA) plan and a Medigap plan to cover MA gaps.
What do you tell him?
A. Medigap cannot be sold with MA plans; it only supplements Original Medicare. B. He can
buy both; Medigap covers MA cost-sharing. C. MA plans include Medigap benefits
automatically. D. Recommend switching to Original Medicare for both.
Correct Answer: A. Medigap cannot be sold with MA plans; it only supplements Original
Medicare.
Explanation: Medigap policies are prohibited for MA enrollees (42 CFR § 403.221). They
coordinate only with Original Medicare. This prevents misleading sales. Reference: CMS
Medigap Guide (2026). Agents must disclose incompatibilities (MCMG Section 30.7).
Question 7: Plan Types
Mr. Kelly asks about eligibility for a Private Fee-for-Service (PFFS) MA plan. What key
questions do you ask?
A. Does he have Parts A and B? Is he in the plan's service area? B. Is he under 65? Does he have
employer coverage? C. What is his income for low-income subsidies? D. Has he used a PFFS
plan before?
