AHIP EXAM
MEDICARE FUNDAMENTALS, ENROLLMENT &
COMPLIANCE
MODULE 1-4
2026;Q&A
CONTAINS:
✓ AHIP-style Medicare certification questions with answers
✓ CMS marketing & compliance scenarios
✓ Scope of Appointment (SOA) rules and violations
✓ Medicare Advantage (MA) eligibility & enrollment
✓ Part D coverage gap (donut hole) explanation
✓ Special Enrollment Period (SEP) qualifying events
✓ ESRD & Special Needs Plan (SNP) enrollment rules
✓ Fraud, Waste & Abuse (FWA) reporting requirements
✓ Grievances vs appeals procedures
✓ Agent conduct & prohibited sales practices
✓ Detailed rationales for exam preparation
✓ Updated for 2026
,Mr. Henderson has requested to meet with you to discuss his health coverage options for the
upcoming year. He is currently enrolled in a Medicare Advantage PPO plan but is interested in
switching to a Medicare Supplement (Medigap) plan and a standalone Part D prescription drug plan.
During your appointment, which of the following statements regarding the Scope of Appointment
(SOA) is accurate?
A) You must obtain a new SOA at the beginning of the marketing appointment, even if you met him
previously to discuss these exact topics.
B) Since Mr. Henderson initiated the contact, no Scope of Appointment form is required for this specific
meeting.
C) You may use the SOA signed during the previous year’s enrollment if it is still on file and covers the
same topics.
D) The SOA must be signed prior to the presentation of marketing information and can only be used
for the specific plan types discussed during that appointment.
Correct Answer: D) The SOA must be signed prior to the presentation of marketing information
and can only be used for the specific plan types discussed during that appointment.
Explanation / Rationale:
Federal regulations require that a Scope of Appointment (SOA) be completed and signed by the
beneficiary prior to any marketing presentation or discussion of specific plan benefits. The SOA serves
as a record of what products the beneficiary has agreed to discuss. It limits the scope of the
appointment to those specific products (e.g., MA and/or PDP). If a beneficiary wishes to discuss topics
outside the signed SOA, a new form must be completed. Using a SOA from a previous year is generally
not permitted because the beneficiary's interests may have changed. Furthermore, even if the
beneficiary initiated the contact, agents are still required to document the scope of the appointment
to ensure compliance with CMS marketing guidelines.
Mrs. Lopez, a Medicare beneficiary, calls you in a state of distress. She claims that an agent visited her
home unannounced, stayed for three hours, and refused to leave until she signed an enrollment
application for a Medicare Advantage plan. She also states the agent told her that her Original
Medicare would be cancelled if she did not sign. What is the most appropriate immediate action you
should take?
A) Advise Mrs. Lopez to contact the Medicare Advantage plan directly to report the agent and request a
disenrollment.
B) Report the incident to your Medicare marketing compliance department or the CMS Medicare Drug
Integrity Contractor (MEDIC) immediately.
,C) Explain to Mrs. Lopez that she likely misunderstood the agent's sales tactics and that she has 30 days
to cancel the enrollment anyway.
D) Contact the agent yourself to confront them about the violation and demand they retract the
application.
Correct Answer: B) Report the incident to your Medicare marketing compliance department or
the CMS Medicare Drug Integrity Contractor (MEDIC) immediately.
Explanation / Rationale:
The scenario describes potential marketing fraud and egregious compliance violations, including
"high-pressure" sales tactics and making false or misleading statements regarding the cancellation of
Original Medicare. These are serious offenses under CMS guidelines. As an agent, you have a duty to
report suspected fraud, waste, and abuse. While advising the beneficiary on her rights to disenroll is
helpful, the priority is reporting the violation to the appropriate compliance channels or CMS/MEDIC
to prevent the agent from victimizing others. Confronting the agent yourself is inappropriate and
outside the scope of your authority; it could lead to conflict or interference with an official
investigation.
You are marketing Medicare Advantage and Part D plans at a community center. You set up a table
with brochures and a sign that says "Free Medicare Information." A passerby asks for a specific
comparison of the monthly premiums for Plan A and Plan B. What must you do before providing this
specific comparative information?
A) You must ask the individual to fill out a Scope of Appointment form right there at the table.
B) You may provide the comparison immediately because it is considered general educational
information, not a specific marketing presentation.
C) You must obtain their contact information and schedule a formal in-home appointment to discuss
plan details.
D) You must first confirm they are eligible for Medicare by asking for their Medicare number.
Correct Answer: A) You must ask the individual to fill out a Scope of Appointment form right
there at the table.
, Explanation / Rationale:
According to CMS guidelines, any time a beneficiary requests specific plan information, or when an
agent intends to discuss specific plan benefits or enroll a beneficiary, a Scope of Appointment (SOA)
must be completed. Setting up a table in a public area is considered a marketing/sales event. While
general educational information (like "What is Medicare?") can be shared without an SOA, providing
specific plan comparisons (e.g., premium amounts) crosses the line into marketing. Therefore, the SOA
is required before discussing the specifics of Plan A versus Plan B.
Which of the following statements accurately describes the limitations on marketing materials used
by agents for Medicare Advantage and Part D plans?
A) Agents may create their own flyers and brochures as long as they include the CMS disclaimer and are
approved by their carrier.
B) All marketing materials must be approved by the plan sponsor (carrier) and CMS before use, and
agents are prohibited from using materials that have not been approved.
C) Agents are allowed to use any materials provided by CMS, but they cannot use materials created by
the carrier without first getting a beneficiary's signature.
D) Marketing materials can be distributed door-to-door without restriction as long as they are placed in
the mailbox.
Correct Answer: B) All marketing materials must be approved by the plan sponsor (carrier) and
CMS before use, and agents are prohibited from using materials that have not been approved.
Explanation / Rationale:
CMS has strict rules to ensure beneficiaries receive accurate and consistent information. All marketing
materials used by agents to promote MA and PDP plans must be reviewed and approved by both the
plan sponsor (insurance company) and CMS. Agents are strictly forbidden from creating their own
marketing materials, such as homemade flyers or business cards with plan details, as these may
contain non-compliant language or errors. Furthermore, placing materials in a mailbox is a violation
of federal law (tampering with a mailbox is reserved for U.S. Mail).
MEDICARE FUNDAMENTALS, ENROLLMENT &
COMPLIANCE
MODULE 1-4
2026;Q&A
CONTAINS:
✓ AHIP-style Medicare certification questions with answers
✓ CMS marketing & compliance scenarios
✓ Scope of Appointment (SOA) rules and violations
✓ Medicare Advantage (MA) eligibility & enrollment
✓ Part D coverage gap (donut hole) explanation
✓ Special Enrollment Period (SEP) qualifying events
✓ ESRD & Special Needs Plan (SNP) enrollment rules
✓ Fraud, Waste & Abuse (FWA) reporting requirements
✓ Grievances vs appeals procedures
✓ Agent conduct & prohibited sales practices
✓ Detailed rationales for exam preparation
✓ Updated for 2026
,Mr. Henderson has requested to meet with you to discuss his health coverage options for the
upcoming year. He is currently enrolled in a Medicare Advantage PPO plan but is interested in
switching to a Medicare Supplement (Medigap) plan and a standalone Part D prescription drug plan.
During your appointment, which of the following statements regarding the Scope of Appointment
(SOA) is accurate?
A) You must obtain a new SOA at the beginning of the marketing appointment, even if you met him
previously to discuss these exact topics.
B) Since Mr. Henderson initiated the contact, no Scope of Appointment form is required for this specific
meeting.
C) You may use the SOA signed during the previous year’s enrollment if it is still on file and covers the
same topics.
D) The SOA must be signed prior to the presentation of marketing information and can only be used
for the specific plan types discussed during that appointment.
Correct Answer: D) The SOA must be signed prior to the presentation of marketing information
and can only be used for the specific plan types discussed during that appointment.
Explanation / Rationale:
Federal regulations require that a Scope of Appointment (SOA) be completed and signed by the
beneficiary prior to any marketing presentation or discussion of specific plan benefits. The SOA serves
as a record of what products the beneficiary has agreed to discuss. It limits the scope of the
appointment to those specific products (e.g., MA and/or PDP). If a beneficiary wishes to discuss topics
outside the signed SOA, a new form must be completed. Using a SOA from a previous year is generally
not permitted because the beneficiary's interests may have changed. Furthermore, even if the
beneficiary initiated the contact, agents are still required to document the scope of the appointment
to ensure compliance with CMS marketing guidelines.
Mrs. Lopez, a Medicare beneficiary, calls you in a state of distress. She claims that an agent visited her
home unannounced, stayed for three hours, and refused to leave until she signed an enrollment
application for a Medicare Advantage plan. She also states the agent told her that her Original
Medicare would be cancelled if she did not sign. What is the most appropriate immediate action you
should take?
A) Advise Mrs. Lopez to contact the Medicare Advantage plan directly to report the agent and request a
disenrollment.
B) Report the incident to your Medicare marketing compliance department or the CMS Medicare Drug
Integrity Contractor (MEDIC) immediately.
,C) Explain to Mrs. Lopez that she likely misunderstood the agent's sales tactics and that she has 30 days
to cancel the enrollment anyway.
D) Contact the agent yourself to confront them about the violation and demand they retract the
application.
Correct Answer: B) Report the incident to your Medicare marketing compliance department or
the CMS Medicare Drug Integrity Contractor (MEDIC) immediately.
Explanation / Rationale:
The scenario describes potential marketing fraud and egregious compliance violations, including
"high-pressure" sales tactics and making false or misleading statements regarding the cancellation of
Original Medicare. These are serious offenses under CMS guidelines. As an agent, you have a duty to
report suspected fraud, waste, and abuse. While advising the beneficiary on her rights to disenroll is
helpful, the priority is reporting the violation to the appropriate compliance channels or CMS/MEDIC
to prevent the agent from victimizing others. Confronting the agent yourself is inappropriate and
outside the scope of your authority; it could lead to conflict or interference with an official
investigation.
You are marketing Medicare Advantage and Part D plans at a community center. You set up a table
with brochures and a sign that says "Free Medicare Information." A passerby asks for a specific
comparison of the monthly premiums for Plan A and Plan B. What must you do before providing this
specific comparative information?
A) You must ask the individual to fill out a Scope of Appointment form right there at the table.
B) You may provide the comparison immediately because it is considered general educational
information, not a specific marketing presentation.
C) You must obtain their contact information and schedule a formal in-home appointment to discuss
plan details.
D) You must first confirm they are eligible for Medicare by asking for their Medicare number.
Correct Answer: A) You must ask the individual to fill out a Scope of Appointment form right
there at the table.
, Explanation / Rationale:
According to CMS guidelines, any time a beneficiary requests specific plan information, or when an
agent intends to discuss specific plan benefits or enroll a beneficiary, a Scope of Appointment (SOA)
must be completed. Setting up a table in a public area is considered a marketing/sales event. While
general educational information (like "What is Medicare?") can be shared without an SOA, providing
specific plan comparisons (e.g., premium amounts) crosses the line into marketing. Therefore, the SOA
is required before discussing the specifics of Plan A versus Plan B.
Which of the following statements accurately describes the limitations on marketing materials used
by agents for Medicare Advantage and Part D plans?
A) Agents may create their own flyers and brochures as long as they include the CMS disclaimer and are
approved by their carrier.
B) All marketing materials must be approved by the plan sponsor (carrier) and CMS before use, and
agents are prohibited from using materials that have not been approved.
C) Agents are allowed to use any materials provided by CMS, but they cannot use materials created by
the carrier without first getting a beneficiary's signature.
D) Marketing materials can be distributed door-to-door without restriction as long as they are placed in
the mailbox.
Correct Answer: B) All marketing materials must be approved by the plan sponsor (carrier) and
CMS before use, and agents are prohibited from using materials that have not been approved.
Explanation / Rationale:
CMS has strict rules to ensure beneficiaries receive accurate and consistent information. All marketing
materials used by agents to promote MA and PDP plans must be reviewed and approved by both the
plan sponsor (insurance company) and CMS. Agents are strictly forbidden from creating their own
marketing materials, such as homemade flyers or business cards with plan details, as these may
contain non-compliant language or errors. Furthermore, placing materials in a mailbox is a violation
of federal law (tampering with a mailbox is reserved for U.S. Mail).
