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Question 1. Which of the following is the primary federal agency that administers the Medicare program? A) Department of Health and Human Services (HHS) B) Centers for Medicare & Medicaid Services (CMS) C) Federal Insurance Office (FIO) D) National Institutes of Health (NIH) Answer: B Explanation: CMS is the agency within HHS that oversees Medicare, Medicaid, and the Health Insurance Marketplace. Question 2. A beneficiary who is 68 years old and has end-stage renal disease (ESRD) is eligible for Medicare because: A) ESRD automatically grants eligibility regardless of age B) He must wait until age 65 to become eligible C) He must have worked 10 years in Medicare-taxed employment D) ESRD eligibility only applies to those under 65 Answer: A Explanation: ESRD is a special eligibility condition that provides Medicare coverage regardless of the beneficiary’s age. Question 3. The initial enrollment period (IEP) for Medicare begins: A) Three months before the month of the beneficiary’s 65th birthday and ends three months after B) The first day of the month the beneficiary turns 65 and lasts for 12 months C) Only after the beneficiary files a claim for hospital services D) When the beneficiary’s disability benefits start Answer: A Explanation: The IEP is a 7-month window that starts three months before the 65th birthday month, includes the birthday month, and ends three months after. Question 4. Which of the following services is NOT covered by Medicare Part A?
A) Inpatient hospital stays B) Skilled nursing facility care after a hospital stay C) Routine dental cleanings D) Hospice care Answer: C Explanation: Medicare Part A covers inpatient hospital, skilled nursing, hospice, and home health services, but not routine dental care. Question 5. A Medicare beneficiary who enrolls in a Medicare Advantage (MA) plan must: A) Have only Part A and can decline Part B B) Have both Part A and Part B C) Have a Medicare Supplement (Medigap) policy D) Be enrolled in a Medicaid program Answer: B Explanation: To enroll in a Medicare Advantage plan, a beneficiary must be enrolled in both Part A and Part B. Question 6. In a Medicare Advantage HMO plan, which statement is true regarding provider access? A) Beneficiaries can see any provider nationwide without referral B) Beneficiaries must receive care from providers within the HMO’s network except in emergencies C) Beneficiaries can see out-of-network specialists without prior authorization D) Beneficiaries are required to pay the full Part B deductible for all services Answer: B Explanation: HMO plans require beneficiaries to use network providers for non-emergency care; out-of-network care is generally not covered except for emergencies. Question 7. The maximum out-of-pocket (MOOP) limit in a Medicare Advantage plan applies to:
A) Tier 0 – Over-the-counter only B) Tier 1 – Preferred generic C) Tier 5 – Experimental medication D) Tier 7 – Unlimited supply Answer: B Explanation: Tier 1 typically represents preferred generic drugs, which have the lowest cost-sharing. Question 11. A beneficiary who qualifies for “Extra Help” under Medicare Part D receives: A) Free dental coverage B) Reduced premiums, deductibles, and copayments for prescription drugs C) Automatic enrollment in a Medicare Advantage plan D) Unlimited hospital stays without cost sharing Answer: B Explanation: “Extra Help” (Low-Income Subsidy) lowers the cost of Part D premiums, deductibles, and copayments for eligible low-income beneficiaries. Question 12. Late enrollment penalties (LEP) for Medicare Part D are calculated based on: A) The beneficiary’s current income level B) The number of months the beneficiary was eligible but not enrolled, multiplied by a percentage of the national base beneficiary premium C) The total number of prescriptions filled in the previous year D) The beneficiary’s age at the time of enrollment Answer: B Explanation: LEP is assessed for each month a beneficiary was eligible for Part D but did not enroll, using a percentage (usually 1%) of the national base premium. Question 13. Under CMS marketing rules, which term is prohibited when describing Medicare Advantage plans? A) “Free”
B) “Comprehensive” C) “Low-cost” D) “Convenient” Answer: A Explanation: The term “free” is prohibited because it can be misleading; Medicare plans always involve some cost sharing. Question 14. The “Scope of Appointment” (SOA) requirement mandates that: A) An agent must obtain written consent from the beneficiary before discussing any Medicare product B) An agent must confirm the type of Medicare product the beneficiary wishes to discuss and document that confirmation C) An agent must schedule a minimum 30-minute meeting for every enrollment D) An agent can discuss any Medicare product without prior notice as long as it is in person Answer: B Explanation: SOA requires agents to document that beneficiaries have agreed to discuss specific Medicare products, ensuring transparency and compliance. Question 15. Which of the following actions would be considered a violation of the “cooling-off” period rules for a Medicare Advantage enrollment? A) Sending a follow-up email 24 hours after the initial appointment B) Calling the beneficiary 48 hours after the appointment to confirm enrollment C) Contacting the beneficiary by phone within 24 hours to remind them of the enrollment deadline D) Waiting 72 hours before sending any additional information Answer: C Explanation: The cooling-off period requires a minimum of 48 hours after the appointment before any sales contact is made. Question 16. In the context of unsolicited contact, which activity is expressly prohibited by CMS? A) Sending a mailed brochure to a beneficiary who has opted in to receive mailings
Answer: B Explanation: The FCA imposes liability on anyone who knowingly submits false or fraudulent claims to the federal government, including Medicare. Question 20. Which of the following is an example of “billing for services not rendered”? A) Submitting a claim for a lab test that was ordered but never performed B) Charging a higher co-pay than listed in the plan’s formulary C) Providing a beneficiary with an inaccurate estimate of out-of-pocket costs D) Referring a beneficiary to a specialist outside the network Answer: A Explanation: Billing for a service that was never actually provided is a classic form of fraud. Question 21. Under the Anti-Kickback Statute, a health-care provider may receive: A) Direct cash payments for referring patients to a Medicare-covered service B) A modest gift of a branded pen if it is of nominal value and not tied to referrals C) A commission for each prescription filled for a Medicare beneficiary D) Free lodging in exchange for patient referrals Answer: B Explanation: The statute prohibits remuneration tied to referrals, but nominal items of minimal value that are not linked to referrals are permissible. Question 22. A “dual-eligible” beneficiary is someone who qualifies for both Medicare and: A) Private health insurance B) Medicaid C) Veterans Affairs (VA) benefits D) Tricare Answer: B
Explanation: Dual-eligible beneficiaries receive benefits from both Medicare and Medicaid. Question 23. Which of the following best describes a Private Fee-for-Service (PFFS) Medicare Advantage plan? A) It requires beneficiaries to obtain referrals for specialist care B) It contracts with a network of providers but does not require beneficiaries to stay in-network C) It pays providers on a per-service basis without a network, allowing any Medicare-accepting provider to treat the beneficiary D) It only covers hospital services and excludes outpatient care Answer: C Explanation: PFFS plans have no network; beneficiaries can see any provider who accepts Medicare, and the plan pays on a fee-for-service basis. Question 24. Which of the following is NOT a requirement for a beneficiary to enroll in a Special Needs Plan (SNP)? A) Having a specific chronic condition for a C-SNP B) Living within the plan’s service area C) Being age 65 or older only D) Being dual-eligible for Medicare and Medicaid for a D-SNP Answer: C Explanation: Age 65 is not a requirement; eligibility is based on the specific needs (chronic condition, dual-eligibility, or institutional status). Question 25. The “donut hole” coverage gap in Part D was partially closed by the Inflation Reduction Act. Which change contributed to the closure? A) Increasing the deductible to $ B) Eliminating the coverage gap entirely for all beneficiaries C) Reducing beneficiary cost-sharing in the gap to 25% of drug cost D) Removing all specialty drugs from Part D formularies Answer: C
Explanation: High-income beneficiaries may be assessed an additional IRMAA based on their modified adjusted gross income. Question 29. In Medicare Part D, “step therapy” is a utilization management technique that: A) Requires a beneficiary to try lower-cost drugs before approving a higher-cost alternative B) Allows unlimited refills of any medication after the first 30 days C) Automatically enrolls beneficiaries in the most expensive tier drug D) Provides a discount for bulk purchases of medication Answer: A Explanation: Step therapy requires the use of preferred or lower-cost drugs before a higher-cost drug is approved. Question 30. The “Evidence of Coverage” (EOC) document must be provided to beneficiaries: A) Only after they have signed the enrollment application B) At least 30 days before the start of the plan year C) Before enrollment, so they can review plan benefits and rules D) Only if the beneficiary requests it in writing Answer: C Explanation: CMS requires that the EOC be disclosed before enrollment to ensure beneficiaries understand plan details. Question 31. Which of the following best describes the “General Enrollment Period” (GEP) for Medicare? A) A period that allows beneficiaries to enroll in Medicare Part A only B) A time window from January 1 to March 31 for those who missed their IEP C) A 7-day window for beneficiaries to change plans during the AEP D) An enrollment period exclusive to individuals with end-stage renal disease Answer: B
Explanation: The GEP runs from January 1 to March 31 each year, allowing those who missed their IEP to enroll in Parts A and B. Question 32. Which of the following is considered a “non-compliant” marketing activity? A) Hosting an educational webinar with a neutral title and providing plan information after a signed SOA B) Sending a postcard that mentions “free Medicare coverage” to a list of names purchased from a third party C) Posting a plan’s benefit summary on a public website with a disclaimer that the information is for educational purposes only D) Providing a beneficiary with a comparative chart of plan costs after they request it Answer: B Explanation: Advertising “free Medicare coverage” is prohibited, and using purchased lists for unsolicited contact is non-compliant. Question 33. A Medicare beneficiary who is eligible for both Medicare and Medicaid is most likely to be enrolled in which type of Medicare Advantage plan? A) HMO B) D-SNP (Dual-eligible Special Needs Plan) C) PFFS D) C-SNP Answer: B Explanation: D-SNPs are specifically designed for dual-eligible beneficiaries, integrating both Medicare and Medicaid benefits. Question 34. Under the Stark Law, physicians are prohibited from: A) Referring patients to any Medicare-covered service for which they receive a fee B) Referring patients to a health-care entity in which they have a financial relationship, unless an exception applies C) Discussing Medicare plan options with patients during office visits D) Receiving a salary from a Medicare Advantage plan sponsor
Explanation: MA plans may offer supplemental benefits like fitness programs, but these are optional and not required by Medicare. Question 38. Which of the following actions would constitute a violation of the Medicare “Cold Calling” prohibition? A) Calling a beneficiary who previously requested information about a plan B) Calling a beneficiary after receiving a signed SOA C) Calling a beneficiary who is on the Do-Not-Call Registry without prior consent D) Sending a text message reminder after an appointment has been scheduled Answer: C Explanation: Cold calling a beneficiary on the Do-Not-Call list without prior consent is prohibited. Question 39. The “medicare drug integrity contractor” (MEDIC) is primarily responsible for: A) Auditing Medicare Advantage plan marketing materials B) Monitoring Part D prescription drug claims for fraud, waste, and abuse C) Setting premium rates for Medicare Part B D) Providing legal representation to beneficiaries in disputes Answer: B Explanation: MEDIC focuses on detecting and preventing fraud, waste, and abuse in Medicare Part D prescription drug claims. Question 40. Which of the following best describes the “Open Enrollment Period” (OEP) for Medicare Advantage? A) A period from January 1–March 31 for beneficiaries to join a new plan B) A 2-month window from April 1–May 31 for beneficiaries who are already enrolled in an MA plan to change plans C) The same as the Annual Enrollment Period (AEP) in October D) A 30-day period after a beneficiary’s birthday to enroll in Part B Answer: B
Explanation: The OEP runs from January 1 to March 31 (or sometimes April 1–May 31 depending on year) and allows current MA enrollees to switch plans. Question 41. Which of the following is a required disclosure before a beneficiary can enroll in a Medicare Advantage plan? A) The plan’s profit margin B) The plan’s network of hospitals and physicians C) The agent’s personal health history D) The number of claims the plan has processed in the past year Answer: B Explanation: Beneficiaries must be informed about the plan’s provider network before enrollment. Question 42. A Medicare beneficiary who is enrolled in a Medicare Advantage plan with a prescription drug component (MAPD) must: A) Also enroll in a separate stand-alone Part D plan B) Pay separate Part B premiums for the MAPD plan C) Receive drug coverage through the MAPD plan, not a stand-alone PDP D) Lose eligibility for the Extra Help program Answer: C Explanation: MAPD plans combine Medicare Advantage medical coverage with prescription drug coverage; beneficiaries do not need a separate PDP. Question 43. The “coverage gap” in Medicare Part D is also known as: A) The “deductible phase” B) The “initial coverage phase” C) The “donut hole” D) The “catastrophic phase” Answer: C Explanation: The coverage gap is commonly referred to as the “donut hole.”
Question 47. Which of the following is NOT a permissible reason for a Medicare Advantage plan to deny a claim? A) The service was provided by an out-of-network provider without emergency circumstances B. The beneficiary failed to meet the deductible for the plan’s benefit category C. The service was not medically necessary as defined by the plan’s clinical guidelines D. The beneficiary chose to receive care at a facility that is not covered under the plan’s network, even though it is a Medicare-approved hospital Answer: D Explanation: Medicare-approved hospitals are covered under Original Medicare; however, MA plans can restrict coverage to network facilities, so denial is permissible. The correct answer is actually A. Correction: The correct answer is A – denying a claim because the provider is out-of-network without emergency circumstances is permissible, but the question asked for NOT permissible. The correct “not permissible” reason is D because MA plans must cover services at any Medicare-approved hospital in an emergency; denying based solely on network status for non-emergency is permissible, making D permissible. Therefore the question is ambiguous. Revised Answer: D – The plan cannot deny a claim solely because the beneficiary chose a Medicare-approved hospital if the service is covered under the plan’s terms. Question 48. Which of the following is a requirement for an agent to discuss Medicare Advantage plans with a beneficiary? A) The agent must be a licensed insurance producer in the state where the beneficiary resides B) The agent must have a medical degree C) The agent must be a current Medicare beneficiary themselves D) The agent must be employed by the CMS Answer: A Explanation: Agents must hold a valid insurance license in the state of the beneficiary to discuss and sell Medicare plans. Question 49. Under the Medicare Part D “standard benefit design,” the deductible is: A) Mandatory for all plans and set at $445 (2024 amount)
B) Optional; plans may choose to have no deductible C) Only applicable to specialty drugs D) Paid entirely by the federal government Answer: B Explanation: While many Part D plans include a deductible, it is not required; plans can offer a $0 deductible option. Question 50. Which of the following actions would be considered a “kickback” under the Anti-Kickback Statute? A) Providing a modest promotional item of nominal value to a provider unrelated to referrals B) Paying a physician a percentage of the amount billed to Medicare for each referral they make to a specific pharmacy C) Offering a free health-screening event to the public D) Giving a beneficiary a free tote bag after enrollment Answer: B Explanation: Paying a percentage of the Medicare claim amount in exchange for referrals is a prohibited kickback. Question 51. A Medicare beneficiary who moves to a new state and wishes to remain in the same Medicare Advantage plan must: A) Wait until the next AEP to change to a new plan B) Enroll in a Special Enrollment Period due to a change in residence C) Remain in the original plan regardless of coverage area D. Automatically lose all Medicare benefits Answer: B Explanation: Changing residence triggers an SEP, allowing the beneficiary to enroll in a new MA plan that serves the new address. Question 52. Which of the following best describes “utilization management” in Medicare Part D? A) The process of setting premium rates for drug plans
A) Beneficiary’s full name and Social Security number B) Beneficiary’s diagnosis of hypertension C) Beneficiary’s favorite color D) Beneficiary’s Medicare claim numbers Answer: C Explanation: Favorite color is not considered PHI under HIPAA. Question 56. A Medicare Advantage plan that includes dental, vision, and hearing benefits is offering: A) Mandatory Medicare benefits B) Supplemental benefits that are optional for the plan to provide C) Benefits that replace Part B coverage D) Illegal benefits prohibited by CMS Answer: B Explanation: MA plans may add supplemental benefits like dental, vision, and hearing, but these are optional and not required by Medicare. Question 57. Under the “Medicare Part B” coverage, which of the following services is covered without a deductible? A) Routine dental cleanings B) Annual wellness visit (AWV) C) Cosmetic surgery D) Over-the-counter medications Answer: B Explanation: The Annual Wellness Visit is a covered preventive service under Part B with no deductible. Question 58. Which of the following is the correct order of the four phases of Medicare Part D coverage? A) Initial Coverage → Deductible → Catastrophic → Coverage Gap B) Deductible → Initial Coverage → Coverage Gap → Catastrophic
C) Coverage Gap → Deductible → Initial Coverage → Catastrophic D) Catastrophic → Coverage Gap → Initial Coverage → Deductible Answer: B Explanation: The sequence is Deductible, Initial Coverage, Coverage Gap (donut hole), then Catastrophic. Question 59. A Medicare beneficiary who is enrolled in a Medicare Advantage plan and wishes to obtain a service not covered by the plan must: A) Pay the full cost out-of-pocket and submit a claim to Medicare B) Switch to Original Medicare to obtain the service C) Request a special exception from the plan’s medical director D) Nothing; the service will be automatically covered under Part D Answer: C Explanation: Beneficiaries can request a special exception or appeal the plan’s denial for services not covered under the plan’s formulary. Question 60. Which of the following best describes the “Annual Notice of Change” (ANOC) that Medicare Advantage plans must send to beneficiaries? A) A document that outlines any changes to the plan’s benefits, premiums, and cost-sharing for the upcoming year B) A marketing flyer promoting new plan options C) A reminder to renew the beneficiary’s Part D coverage only D. A notice that the plan is being discontinued Answer: A Explanation: The ANOC informs beneficiaries of any changes to the plan for the next benefit year. Question 61. The “Medicare Advantage Prescription Drug (MAPD) plan” differs from a stand-alone Part D plan primarily because: A) MAPD plans are only available to beneficiaries under age 65 B) MAPD plans combine medical and drug coverage under a single contract C) MAPD plans do not have a deductible
