America's Health Insurance Plans
LANIF • PIHA
✦ AHIP ✦
MEDICARE Medicare + Fraud, Waste & Abuse Training
G U I D I N G T H E F U T U R E O F H E A LT H C A R E
CERTIFICATION
AHIP Final Certification Exam 2025/2026 – Medicare &
FWA Training Study Guide
M E D I C A R E A D VA N TA G E · PA RT D · M E D I G A P · E L I G I B I L I TY · E N R O L L M E N T · CO M P L I A N C E
ORGANIZATION America's Health Insurance Plans (AHIP) CERTIFICATION Medicare + Fraud, Waste & Abuse Training
EXAM TYPE Final Certification Examination ACADEMIC YEAR
TOTAL QUESTIONS 250+ Verified Questions (Part 1 of 5) SUBJECT AREAS Medicare Parts A–D · MA Plans · Medigap ·
AEP · LIS · FWA Compliance
FORMAT Multiple Choice — Select the Single Best
Answer
FINAL CERTIFICATION EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question based on current Medicare regulations and AHIP curriculum.
▸ Content covers Medicare Parts A–D, Medicare Advantage plan types, Medigap, enrollment periods, eligibility, Low-Income
Subsidy, and Fraud, Waste & Abuse compliance.
▸ Each question includes the correct answer with a detailed rationale explaining the governing regulation or policy.
SECTION I — MEDICARE FUNDAMENTALS, MA PLANS & PART D Questions 1 – 50
1. What is the primary purpose of Medicare Advantage plans?
A. To replace Original Medicare entirely
B. To offer additional benefits beyond Original Medicare
C. To provide coverage only for prescription drugs
D. To serve only low-income beneficiaries
CORRECT ANSWER B — To offer additional benefits beyond Original Medicare
RATIONALE Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare. They
provide all Part A and Part B benefits and often include additional benefits not covered by Original Medicare,
such as vision, hearing, dental, wellness programs, and prescription drug coverage. They do not replace
Original Medicare — beneficiaries remain enrolled in Medicare while receiving benefits through the MA plan.
MA plans must cover all services that Original Medicare covers (except hospice care, which remains under Part
A).
, 2. Which of the following is a requirement for Medicare eligibility?
A. Having an annual income below the federal poverty level
B. Being employed full-time
C. Being a U.S. citizen or legal resident
D. Having a pre-existing chronic condition
CORRECT ANSWER C — Being a U.S. citizen or legal resident
RATIONALE Medicare eligibility requires individuals to be U.S. citizens or legal permanent residents who have lived in the
United States for at least five continuous years. Additionally, most beneficiaries qualify based on age (65 or
older), disability (receiving Social Security disability benefits for 24 months), or specific medical conditions
(ESRD or ALS). Income is not an eligibility factor for Medicare (unlike Medicaid). Employment status and pre-
existing conditions do not affect eligibility.
3. What is a key feature of Medicare Part D?
A. It covers all prescription drugs at no cost to the beneficiary
B. It replaces the need for Part A and Part B
C. It provides prescription drug coverage
D. It is automatically included with Original Medicare
CORRECT ANSWER C — It provides prescription drug coverage
RATIONALE Medicare Part D provides outpatient prescription drug coverage through private insurance plans approved by
Medicare. It is optional — not automatically included with Original Medicare. Beneficiaries must actively
enroll in either a stand-alone Prescription Drug Plan (PDP) or a Medicare Advantage plan that includes Part D
(MA-PD). Part D plans have formularies, cost-sharing tiers, and may have a coverage gap ("donut hole"). The
Part D late enrollment penalty applies if a beneficiary goes without creditable drug coverage for 63+
consecutive days.
4. What is the purpose of the Annual Enrollment Period (AEP) for Medicare?
A. To allow providers to update their Medicare certification
B. To enable beneficiaries to enroll in or change Medicare plans
C. To permit CMS to audit Medicare Advantage plans
D. To close enrollment for the remainder of the year
CORRECT ANSWER B — To enable beneficiaries to enroll in or change Medicare plans
RATIONALE The Annual Enrollment Period (AEP) runs from October 15 through December 7 each year. During this period,
Medicare beneficiaries can: switch from Original Medicare to a Medicare Advantage plan (or vice versa), switch
from one MA plan to another, enroll in or switch Part D plans, or drop Part D coverage entirely. Changes made
during AEP take effect January 1 of the following year. This is distinct from the Medicare Advantage Open
Enrollment Period (January 1–March 31) which has more limited options.
LANIF • PIHA
✦ AHIP ✦
MEDICARE Medicare + Fraud, Waste & Abuse Training
G U I D I N G T H E F U T U R E O F H E A LT H C A R E
CERTIFICATION
AHIP Final Certification Exam 2025/2026 – Medicare &
FWA Training Study Guide
M E D I C A R E A D VA N TA G E · PA RT D · M E D I G A P · E L I G I B I L I TY · E N R O L L M E N T · CO M P L I A N C E
ORGANIZATION America's Health Insurance Plans (AHIP) CERTIFICATION Medicare + Fraud, Waste & Abuse Training
EXAM TYPE Final Certification Examination ACADEMIC YEAR
TOTAL QUESTIONS 250+ Verified Questions (Part 1 of 5) SUBJECT AREAS Medicare Parts A–D · MA Plans · Medigap ·
AEP · LIS · FWA Compliance
FORMAT Multiple Choice — Select the Single Best
Answer
FINAL CERTIFICATION EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question based on current Medicare regulations and AHIP curriculum.
▸ Content covers Medicare Parts A–D, Medicare Advantage plan types, Medigap, enrollment periods, eligibility, Low-Income
Subsidy, and Fraud, Waste & Abuse compliance.
▸ Each question includes the correct answer with a detailed rationale explaining the governing regulation or policy.
SECTION I — MEDICARE FUNDAMENTALS, MA PLANS & PART D Questions 1 – 50
1. What is the primary purpose of Medicare Advantage plans?
A. To replace Original Medicare entirely
B. To offer additional benefits beyond Original Medicare
C. To provide coverage only for prescription drugs
D. To serve only low-income beneficiaries
CORRECT ANSWER B — To offer additional benefits beyond Original Medicare
RATIONALE Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare. They
provide all Part A and Part B benefits and often include additional benefits not covered by Original Medicare,
such as vision, hearing, dental, wellness programs, and prescription drug coverage. They do not replace
Original Medicare — beneficiaries remain enrolled in Medicare while receiving benefits through the MA plan.
MA plans must cover all services that Original Medicare covers (except hospice care, which remains under Part
A).
, 2. Which of the following is a requirement for Medicare eligibility?
A. Having an annual income below the federal poverty level
B. Being employed full-time
C. Being a U.S. citizen or legal resident
D. Having a pre-existing chronic condition
CORRECT ANSWER C — Being a U.S. citizen or legal resident
RATIONALE Medicare eligibility requires individuals to be U.S. citizens or legal permanent residents who have lived in the
United States for at least five continuous years. Additionally, most beneficiaries qualify based on age (65 or
older), disability (receiving Social Security disability benefits for 24 months), or specific medical conditions
(ESRD or ALS). Income is not an eligibility factor for Medicare (unlike Medicaid). Employment status and pre-
existing conditions do not affect eligibility.
3. What is a key feature of Medicare Part D?
A. It covers all prescription drugs at no cost to the beneficiary
B. It replaces the need for Part A and Part B
C. It provides prescription drug coverage
D. It is automatically included with Original Medicare
CORRECT ANSWER C — It provides prescription drug coverage
RATIONALE Medicare Part D provides outpatient prescription drug coverage through private insurance plans approved by
Medicare. It is optional — not automatically included with Original Medicare. Beneficiaries must actively
enroll in either a stand-alone Prescription Drug Plan (PDP) or a Medicare Advantage plan that includes Part D
(MA-PD). Part D plans have formularies, cost-sharing tiers, and may have a coverage gap ("donut hole"). The
Part D late enrollment penalty applies if a beneficiary goes without creditable drug coverage for 63+
consecutive days.
4. What is the purpose of the Annual Enrollment Period (AEP) for Medicare?
A. To allow providers to update their Medicare certification
B. To enable beneficiaries to enroll in or change Medicare plans
C. To permit CMS to audit Medicare Advantage plans
D. To close enrollment for the remainder of the year
CORRECT ANSWER B — To enable beneficiaries to enroll in or change Medicare plans
RATIONALE The Annual Enrollment Period (AEP) runs from October 15 through December 7 each year. During this period,
Medicare beneficiaries can: switch from Original Medicare to a Medicare Advantage plan (or vice versa), switch
from one MA plan to another, enroll in or switch Part D plans, or drop Part D coverage entirely. Changes made
during AEP take effect January 1 of the following year. This is distinct from the Medicare Advantage Open
Enrollment Period (January 1–March 31) which has more limited options.
