America's Health Insurance Plans (AHIP) | Medicare Certification Preparation
Q1. What is Medicare?
Answer: Medicare is the federal health insurance program primarily for
people age 65 and older, as well as certain younger people with disabilities,
and people with End-Stage Renal Disease (ESRD) or ALS.
Q2. At what age does a person generally become eligible for Medicare?
Answer: Age 65. However, people under 65 may qualify if they have received
Social Security Disability Insurance (SSDI) for 24 months, have ALS, or have
ESRD.
Q3. Who administers the Medicare program?
Answer: The Centers for Medicare & Medicaid Services (CMS), a federal
agency within the Department of Health and Human Services (HHS).
Q4. What are the four parts of Medicare?
Answer: Part A (Hospital Insurance), Part B (Medical Insurance), Part C
(Medicare Advantage), and Part D (Prescription Drug Coverage).
Q5. What does Medicare Part A cover?
Answer: Part A covers inpatient hospital stays, skilled nursing facility (SNF)
care, hospice care, and some home health care.
Q6. What does Medicare Part B cover?
Answer: Part B covers outpatient services, doctor visits, preventive services,
lab tests, x-rays, durable medical equipment (DME), and some home health
care.
Q7. What is Original Medicare?
Answer: Original Medicare refers to Medicare Parts A and B, administered
directly by the federal government. Beneficiaries can see any provider who
accepts Medicare.
,Q8. Is Medicare Part A premium-free for most people?
Answer: Yes. Most people do not pay a premium for Part A because they or
their spouse paid Medicare taxes while working for at least 40 quarters (10
years).
Q9. What is the standard Medicare Part B premium in 2026?
Answer: The standard Part B premium is set annually by CMS. For 2026,
beneficiaries should verify the current amount at Medicare.gov, as it is
adjusted each year based on income.
Q10. What is the Medicare Initial Enrollment Period (IEP)?
Answer: The IEP is a 7-month window: the 3 months before the month you
turn 65, your birthday month, and the 3 months after. It is when most people
first enroll in Medicare.
Q11. What is the Medicare General Enrollment Period (GEP)?
Answer: The GEP runs from January 1 through March 31 each year.
Coverage begins July 1 for those who enroll during this period. It is for people
who missed their IEP.
Q12. What is a Special Enrollment Period (SEP) for Medicare?
Answer: An SEP allows people to enroll in Medicare outside normal
enrollment windows due to qualifying events such as losing employer
coverage, moving, or gaining/losing Medicaid eligibility.
Q13. What happens if someone delays Medicare Part B enrollment without
qualifying coverage?
Answer: They may face a late enrollment penalty of 10% of the Part B
premium for each 12-month period they were eligible but did not enroll.
Q14. What is the Medicare Part A deductible?
Answer: The Part A deductible applies per benefit period and covers the first
60 days of an inpatient hospital stay. The exact amount changes annually;
check CMS resources for the current amount.
Q15. What is a Medicare benefit period for Part A?
Answer: A benefit period begins the day a beneficiary is admitted to a
hospital or SNF and ends when they have been out of the hospital/SNF for 60
consecutive days.
Section 2: Medicare Advantage (Part C)
Q16. What is Medicare Advantage (Part C)?
, Answer: Medicare Advantage plans are offered by private, CMS-approved
insurers as an alternative to Original Medicare. They must cover all Part A and
Part B services and often include extra benefits.
Q17. What additional benefits may Medicare Advantage plans include
beyond Original Medicare?
Answer: MA plans may include dental, vision, hearing, fitness benefits,
transportation, over-the-counter allowances, and prescription drug coverage
(MAPD plans).
Q18. What is a Health Maintenance Organization (HMO) Medicare
Advantage plan?
Answer: An HMO plan requires members to use a network of providers and
typically requires referrals to see specialists. Care outside the network is
generally not covered except in emergencies.
Q19. What is a Preferred Provider Organization (PPO) Medicare Advantage
plan?
Answer: A PPO plan allows members to see any provider, but at lower cost
when using in-network providers. Referrals are generally not required, and
out-of-network care is covered at higher cost-sharing.
Q20. What is a Private Fee-for-Service (PFFS) Medicare Advantage plan?
Answer: A PFFS plan determines how much it pays providers and how much
the member pays. Members can see any Medicare-approved provider who
accepts the plan's payment terms.
Q21. What is a Special Needs Plan (SNP)?
Answer: SNPs are a type of Medicare Advantage plan designed for specific
populations: Dual Eligible SNPs (D-SNPs) for dual Medicare/Medicaid
beneficiaries, Chronic Condition SNPs (C-SNPs), and Institutional SNPs (I-
SNPs).
Q22. What is the Medicare Advantage Annual Enrollment Period (AEP)?
Answer: The AEP runs from October 15 through December 7 each year.
During this time, Medicare beneficiaries can enroll in, switch, or disenroll from
Medicare Advantage or Part D plans. Coverage begins January 1.
Q23. What is the Medicare Advantage Open Enrollment Period (OEP)?
Answer: The MA OEP runs from January 1 through March 31. Beneficiaries
already enrolled in an MA plan can switch to another MA plan or return to
Original Medicare and enroll in a standalone Part D plan.
, Q24. What is a Maximum Out-of-Pocket (MOOP) limit in Medicare
Advantage?
Answer: The MOOP is the maximum amount a member pays in a plan year
for covered Part A and B services. Once the MOOP is reached, the plan pays
100% of covered costs. CMS sets an upper limit on MOOP each year.
Q25. Can Medicare Advantage plans charge more than the Part B
premium?
Answer: MA plans can charge an additional plan premium on top of the Part
B premium. Some plans have a $0 additional premium. Some plans offer a
Part B premium reduction benefit.
Q26. What is a network in the context of Medicare Advantage?
Answer: A network is the group of doctors, hospitals, and other providers that
have agreed to provide services to plan members, often at negotiated rates.
Q27. What is a Medicare Advantage Medical Savings Account (MSA) plan?
Answer: An MSA plan combines a high-deductible health plan with a bank
account that Medicare deposits money into. Members use the account funds
to pay for health services until the deductible is met.
Q28. Are emergency services covered out-of-network in Medicare
Advantage plans?
Answer: Yes. All Medicare Advantage plans are required to cover emergency
care anywhere in the United States, even if the provider is not in the plan's
network.
Q29. What is a benchmark in Medicare Advantage?
Answer: The benchmark is a county-level payment rate set by CMS. It is the
maximum amount CMS will pay a plan for each enrollee. Plans that bid below
the benchmark may offer rebates as supplemental benefits.
Q30. What does a Medicare Advantage plan's Star Rating measure?
Answer: The Star Rating (1–5 stars) measures plan quality and performance
across categories including preventive care, managing chronic conditions,
member experience, customer service, and drug plan performance.
Section 3: Medicare Part D – Prescription Drug Coverage
Q31. What is Medicare Part D?
Answer: Part D is the voluntary Medicare prescription drug benefit offered
through private insurers approved by CMS. It helps cover the cost of
outpatient prescription drugs.
Q1. What is Medicare?
Answer: Medicare is the federal health insurance program primarily for
people age 65 and older, as well as certain younger people with disabilities,
and people with End-Stage Renal Disease (ESRD) or ALS.
Q2. At what age does a person generally become eligible for Medicare?
Answer: Age 65. However, people under 65 may qualify if they have received
Social Security Disability Insurance (SSDI) for 24 months, have ALS, or have
ESRD.
Q3. Who administers the Medicare program?
Answer: The Centers for Medicare & Medicaid Services (CMS), a federal
agency within the Department of Health and Human Services (HHS).
Q4. What are the four parts of Medicare?
Answer: Part A (Hospital Insurance), Part B (Medical Insurance), Part C
(Medicare Advantage), and Part D (Prescription Drug Coverage).
Q5. What does Medicare Part A cover?
Answer: Part A covers inpatient hospital stays, skilled nursing facility (SNF)
care, hospice care, and some home health care.
Q6. What does Medicare Part B cover?
Answer: Part B covers outpatient services, doctor visits, preventive services,
lab tests, x-rays, durable medical equipment (DME), and some home health
care.
Q7. What is Original Medicare?
Answer: Original Medicare refers to Medicare Parts A and B, administered
directly by the federal government. Beneficiaries can see any provider who
accepts Medicare.
,Q8. Is Medicare Part A premium-free for most people?
Answer: Yes. Most people do not pay a premium for Part A because they or
their spouse paid Medicare taxes while working for at least 40 quarters (10
years).
Q9. What is the standard Medicare Part B premium in 2026?
Answer: The standard Part B premium is set annually by CMS. For 2026,
beneficiaries should verify the current amount at Medicare.gov, as it is
adjusted each year based on income.
Q10. What is the Medicare Initial Enrollment Period (IEP)?
Answer: The IEP is a 7-month window: the 3 months before the month you
turn 65, your birthday month, and the 3 months after. It is when most people
first enroll in Medicare.
Q11. What is the Medicare General Enrollment Period (GEP)?
Answer: The GEP runs from January 1 through March 31 each year.
Coverage begins July 1 for those who enroll during this period. It is for people
who missed their IEP.
Q12. What is a Special Enrollment Period (SEP) for Medicare?
Answer: An SEP allows people to enroll in Medicare outside normal
enrollment windows due to qualifying events such as losing employer
coverage, moving, or gaining/losing Medicaid eligibility.
Q13. What happens if someone delays Medicare Part B enrollment without
qualifying coverage?
Answer: They may face a late enrollment penalty of 10% of the Part B
premium for each 12-month period they were eligible but did not enroll.
Q14. What is the Medicare Part A deductible?
Answer: The Part A deductible applies per benefit period and covers the first
60 days of an inpatient hospital stay. The exact amount changes annually;
check CMS resources for the current amount.
Q15. What is a Medicare benefit period for Part A?
Answer: A benefit period begins the day a beneficiary is admitted to a
hospital or SNF and ends when they have been out of the hospital/SNF for 60
consecutive days.
Section 2: Medicare Advantage (Part C)
Q16. What is Medicare Advantage (Part C)?
, Answer: Medicare Advantage plans are offered by private, CMS-approved
insurers as an alternative to Original Medicare. They must cover all Part A and
Part B services and often include extra benefits.
Q17. What additional benefits may Medicare Advantage plans include
beyond Original Medicare?
Answer: MA plans may include dental, vision, hearing, fitness benefits,
transportation, over-the-counter allowances, and prescription drug coverage
(MAPD plans).
Q18. What is a Health Maintenance Organization (HMO) Medicare
Advantage plan?
Answer: An HMO plan requires members to use a network of providers and
typically requires referrals to see specialists. Care outside the network is
generally not covered except in emergencies.
Q19. What is a Preferred Provider Organization (PPO) Medicare Advantage
plan?
Answer: A PPO plan allows members to see any provider, but at lower cost
when using in-network providers. Referrals are generally not required, and
out-of-network care is covered at higher cost-sharing.
Q20. What is a Private Fee-for-Service (PFFS) Medicare Advantage plan?
Answer: A PFFS plan determines how much it pays providers and how much
the member pays. Members can see any Medicare-approved provider who
accepts the plan's payment terms.
Q21. What is a Special Needs Plan (SNP)?
Answer: SNPs are a type of Medicare Advantage plan designed for specific
populations: Dual Eligible SNPs (D-SNPs) for dual Medicare/Medicaid
beneficiaries, Chronic Condition SNPs (C-SNPs), and Institutional SNPs (I-
SNPs).
Q22. What is the Medicare Advantage Annual Enrollment Period (AEP)?
Answer: The AEP runs from October 15 through December 7 each year.
During this time, Medicare beneficiaries can enroll in, switch, or disenroll from
Medicare Advantage or Part D plans. Coverage begins January 1.
Q23. What is the Medicare Advantage Open Enrollment Period (OEP)?
Answer: The MA OEP runs from January 1 through March 31. Beneficiaries
already enrolled in an MA plan can switch to another MA plan or return to
Original Medicare and enroll in a standalone Part D plan.
, Q24. What is a Maximum Out-of-Pocket (MOOP) limit in Medicare
Advantage?
Answer: The MOOP is the maximum amount a member pays in a plan year
for covered Part A and B services. Once the MOOP is reached, the plan pays
100% of covered costs. CMS sets an upper limit on MOOP each year.
Q25. Can Medicare Advantage plans charge more than the Part B
premium?
Answer: MA plans can charge an additional plan premium on top of the Part
B premium. Some plans have a $0 additional premium. Some plans offer a
Part B premium reduction benefit.
Q26. What is a network in the context of Medicare Advantage?
Answer: A network is the group of doctors, hospitals, and other providers that
have agreed to provide services to plan members, often at negotiated rates.
Q27. What is a Medicare Advantage Medical Savings Account (MSA) plan?
Answer: An MSA plan combines a high-deductible health plan with a bank
account that Medicare deposits money into. Members use the account funds
to pay for health services until the deductible is met.
Q28. Are emergency services covered out-of-network in Medicare
Advantage plans?
Answer: Yes. All Medicare Advantage plans are required to cover emergency
care anywhere in the United States, even if the provider is not in the plan's
network.
Q29. What is a benchmark in Medicare Advantage?
Answer: The benchmark is a county-level payment rate set by CMS. It is the
maximum amount CMS will pay a plan for each enrollee. Plans that bid below
the benchmark may offer rebates as supplemental benefits.
Q30. What does a Medicare Advantage plan's Star Rating measure?
Answer: The Star Rating (1–5 stars) measures plan quality and performance
across categories including preventive care, managing chronic conditions,
member experience, customer service, and drug plan performance.
Section 3: Medicare Part D – Prescription Drug Coverage
Q31. What is Medicare Part D?
Answer: Part D is the voluntary Medicare prescription drug benefit offered
through private insurers approved by CMS. It helps cover the cost of
outpatient prescription drugs.
