AHIP Final Exam Question Bank (Latest 2026/2027
Edition) – 100% Correct Questions, Answers & Detailed
Rationales
Q1
A 68-year-old beneficiary with End-Stage Renal Disease (ESRD) enrolls in a Medicare
Advantage plan during the Annual Election Period. Under what circumstance may the
plan terminate his enrollment before the end of the calendar year?
A) If he moves outside the plan's service area and fails to notify the plan within 30 days
B) If he develops a chronic condition that requires expensive specialty medications
C) If he exceeds the plan's annual dollar limit on inpatient hospital services
D) If he receives care from an out-of-network specialist without obtaining a referral
Answer: A
Rationales:
● A: Medicare Advantage plans must terminate enrollment when a beneficiary
permanently moves out of the service area, as continuous residence within the
service area is a fundamental eligibility requirement for plan membership.
, ● B: Medicare Advantage plans are prohibited from disenrolling beneficiaries based
on health status or utilization of covered services, as this would violate federal
nondiscrimination protections.
● C: Original Medicare and Medicare Advantage plans do not impose annual dollar
limits on inpatient hospital services, so this scenario cannot trigger
disenrollment.
● D: While out-of-network care without prior authorization may result in higher
cost-sharing or non-coverage, it does not constitute grounds for involuntary plan
disenrollment.
Q2
During a marketing appointment, a prospective enrollee asks an agent whether her
specific brand-name diabetes medication is covered under the Medicare Advantage
plan being discussed. The agent does not have the plan's formulary available. What is
the agent's appropriate course of action?
A) Assure the prospective enrollee that all diabetes medications are covered under
Medicare Advantage plans
B) Inform the prospective enrollee that she must contact the plan directly after
enrollment to verify formulary coverage
C) Provide the plan's customer service number and explain that formulary verification
must occur before enrollment
D) Promise to submit a formulary exception request on her behalf immediately after the
appointment
Answer: C
Rationales:
, ● A: Medicare Advantage formularies vary significantly by plan, and agents cannot
make blanket assurances about drug coverage without verifying the specific
plan's formulary.
● B: Requiring the prospective enrollee to verify coverage after enrollment violates
CMS marketing guidelines, which mandate that agents provide accurate
information to facilitate informed decision-making prior to enrollment.
● C: Directing the prospective enrollee to the plan's customer service for formulary
verification before enrollment ensures compliance with CMS requirements for
accurate pre-enrollment information and protects the beneficiary from
inappropriate enrollment.
● D: Formulary exception requests can only be submitted by enrolled members or
their prescribing physicians, not by agents during a marketing appointment, and
cannot be promised before enrollment.
Q3
A beneficiary eligible for both Medicare and Medicaid (dual eligible) enrolls in a Dual
Eligible Special Needs Plan (D-SNP). Which statement accurately describes how his
cost-sharing responsibilities are typically handled for Medicare-covered services?
A) He must pay all Medicare cost-sharing amounts out-of-pocket and seek
reimbursement from his state Medicaid agency
B) His state Medicaid program generally pays the Medicare cost-sharing on his behalf,
minimizing or eliminating his out-of-pocket expenses
C) He is responsible for full Medicare Part A and Part B premiums but receives reduced
copayments for prescription drugs
D) His D-SNP is prohibited from covering any services that Medicaid would otherwise
cover
Answer: B
, Rationales:
● A: Dual eligible beneficiaries do not pay Medicare cost-sharing upfront and seek
reimbursement; rather, Medicaid automatically covers these amounts through
coordination of benefits.
● B: State Medicaid programs are required to pay Medicare cost-sharing for
full-benefit dual eligible individuals, which is the primary financial protection
mechanism that makes D-SNPs attractive to this population.
● C: Dual eligible beneficiaries typically have their Medicare Part B premiums paid
by Medicaid through the Medicare Savings Programs, and their prescription drug
costs are heavily subsidized through the Low Income Subsidy.
● D: D-SNPs are specifically designed to integrate Medicare and Medicaid benefits,
and they are required to coordinate with state Medicaid programs rather than
exclude Medicaid-covered services.
Q4
An agent is conducting a sales presentation for a Medicare Advantage plan at a
community center. A 64-year-old attendee who will turn 65 in three months asks to
complete an enrollment application. How should the agent respond?
A) Accept the application and submit it to the plan immediately to secure the earliest
effective date
B) Explain that enrollment applications can only be accepted during the 90 days prior to
the month of the individual's 65th birthday
C) Refuse to accept the application and instruct the attendee to contact Social Security
directly
D) Collect the application but hold it until the first day of the attendee's Initial Enrollment
Period
Edition) – 100% Correct Questions, Answers & Detailed
Rationales
Q1
A 68-year-old beneficiary with End-Stage Renal Disease (ESRD) enrolls in a Medicare
Advantage plan during the Annual Election Period. Under what circumstance may the
plan terminate his enrollment before the end of the calendar year?
A) If he moves outside the plan's service area and fails to notify the plan within 30 days
B) If he develops a chronic condition that requires expensive specialty medications
C) If he exceeds the plan's annual dollar limit on inpatient hospital services
D) If he receives care from an out-of-network specialist without obtaining a referral
Answer: A
Rationales:
● A: Medicare Advantage plans must terminate enrollment when a beneficiary
permanently moves out of the service area, as continuous residence within the
service area is a fundamental eligibility requirement for plan membership.
, ● B: Medicare Advantage plans are prohibited from disenrolling beneficiaries based
on health status or utilization of covered services, as this would violate federal
nondiscrimination protections.
● C: Original Medicare and Medicare Advantage plans do not impose annual dollar
limits on inpatient hospital services, so this scenario cannot trigger
disenrollment.
● D: While out-of-network care without prior authorization may result in higher
cost-sharing or non-coverage, it does not constitute grounds for involuntary plan
disenrollment.
Q2
During a marketing appointment, a prospective enrollee asks an agent whether her
specific brand-name diabetes medication is covered under the Medicare Advantage
plan being discussed. The agent does not have the plan's formulary available. What is
the agent's appropriate course of action?
A) Assure the prospective enrollee that all diabetes medications are covered under
Medicare Advantage plans
B) Inform the prospective enrollee that she must contact the plan directly after
enrollment to verify formulary coverage
C) Provide the plan's customer service number and explain that formulary verification
must occur before enrollment
D) Promise to submit a formulary exception request on her behalf immediately after the
appointment
Answer: C
Rationales:
, ● A: Medicare Advantage formularies vary significantly by plan, and agents cannot
make blanket assurances about drug coverage without verifying the specific
plan's formulary.
● B: Requiring the prospective enrollee to verify coverage after enrollment violates
CMS marketing guidelines, which mandate that agents provide accurate
information to facilitate informed decision-making prior to enrollment.
● C: Directing the prospective enrollee to the plan's customer service for formulary
verification before enrollment ensures compliance with CMS requirements for
accurate pre-enrollment information and protects the beneficiary from
inappropriate enrollment.
● D: Formulary exception requests can only be submitted by enrolled members or
their prescribing physicians, not by agents during a marketing appointment, and
cannot be promised before enrollment.
Q3
A beneficiary eligible for both Medicare and Medicaid (dual eligible) enrolls in a Dual
Eligible Special Needs Plan (D-SNP). Which statement accurately describes how his
cost-sharing responsibilities are typically handled for Medicare-covered services?
A) He must pay all Medicare cost-sharing amounts out-of-pocket and seek
reimbursement from his state Medicaid agency
B) His state Medicaid program generally pays the Medicare cost-sharing on his behalf,
minimizing or eliminating his out-of-pocket expenses
C) He is responsible for full Medicare Part A and Part B premiums but receives reduced
copayments for prescription drugs
D) His D-SNP is prohibited from covering any services that Medicaid would otherwise
cover
Answer: B
, Rationales:
● A: Dual eligible beneficiaries do not pay Medicare cost-sharing upfront and seek
reimbursement; rather, Medicaid automatically covers these amounts through
coordination of benefits.
● B: State Medicaid programs are required to pay Medicare cost-sharing for
full-benefit dual eligible individuals, which is the primary financial protection
mechanism that makes D-SNPs attractive to this population.
● C: Dual eligible beneficiaries typically have their Medicare Part B premiums paid
by Medicaid through the Medicare Savings Programs, and their prescription drug
costs are heavily subsidized through the Low Income Subsidy.
● D: D-SNPs are specifically designed to integrate Medicare and Medicaid benefits,
and they are required to coordinate with state Medicaid programs rather than
exclude Medicaid-covered services.
Q4
An agent is conducting a sales presentation for a Medicare Advantage plan at a
community center. A 64-year-old attendee who will turn 65 in three months asks to
complete an enrollment application. How should the agent respond?
A) Accept the application and submit it to the plan immediately to secure the earliest
effective date
B) Explain that enrollment applications can only be accepted during the 90 days prior to
the month of the individual's 65th birthday
C) Refuse to accept the application and instruct the attendee to contact Social Security
directly
D) Collect the application but hold it until the first day of the attendee's Initial Enrollment
Period
