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Latest 2026 / 202 7 AHIP - Modules 1-5 Midterm
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- Mr. Capadona would like to purchase a Medicare Advantage (MA) plan and a Medigap plan to pick up costs not covered by that plan. What should you tell him? - ANSWER >>It is illegal for you to sell Mr. Capadona a Medigap plan if he is enrolled in an MA plan, and besides, Medigap only works with Original Medicare.
- Agent John Miller is meeting with Jerry Smith, a new prospect. Jerry is currently enrolled in Medicare Parts A and B. Jerry has also purchased a Medicare
Supplement (Medigap) plan which he has had for several years. However, the plan does not provide drug benefits. How would you advise Agent John Miller to proceed? - ANSWER >>Tell prospect Jerry Smith that he should consider adding a standalone Part D prescription drug coverage policy to his present coverage.
- Mr. Wu is eligible for Medicare. He has limited financial resources but failed to qualify for the Part D low-income subsidy. Where might he turn for help with his prescription drug costs? - ANSWER >>Mr. Wu may still qualify for help in paying Part D costs through his State Pharmaceutical Assistance Program (SPAP).
- Mr. Vasquez is in good health and is preparing a budget in anticipation of his retirement when he turns 66. He wants to understand the health care costs he might be exposed to under Medicare if he were to require hospitalization because of an illness. In general terms, what could you tell him about his costs for inpatient hospital services under Original Medicare? - ANSWER >>Under Original Medicare, there is a single deductible amount due for the first 60 days of any inpatient hospital stay, after which it converts into a per-day coinsurance amount through day 90. After day 90, he would pay a daily amount up to 60 days over his lifetime, after which he would be responsible for all costs.
- Mr. Moy will soon turn age 65. He is slightly younger than his wife. Mr. Moy's wife has a Medicare Advantage plan, but he wants to understand what coverage Medicare Supplemental Insurance provides since his health care needs are different from his wife's needs. What could you tell Mr. Moy? - ANSWER >>Medicare Supplemental Insurance would help cover his Part A deductible and Part B coinsurance or copayments in Original Fee-for-Service (FFS) Medicare as well as possibly some services that Medicare does not cover.
- Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employersponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer- sponsored healthcare coverage. How would you respond? - ANSWER >>Juan is likely to be eligible for Medicare once he turns age 65 and if he enrolls, Medicare
- Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without paying any premiums, because she has been working for 40 years and paying Medicare taxes. What should you tell her? - ANSWER >>To obtain Part B coverage, she must pay a standard monthly premium, though it is higher for individuals with higher incomes.
- Mr. Bauer is 49 years old, but eighteen months ago he was declared disabled by the Social Security Administration and has been receiving disability payments. He is wondering whether he can obtain coverage under Medicare. What should you tell him? - ANSWER >>After receiving such disability payments for 24 months, he will be automatically enrolled in Medicare, regardless of age.
- Mr. Schmidt would like to plan for retirement and has asked you what is covered under Original Fee-for-Service (FFS) Medicare. What could you tell him? - ANSWER >>Part A, which covers hospital, skilled nursing facility, hospice, and home health services and Part B, which covers professional services such as those provided by a doctor are covered under Original Medicare.
- Anthony Boniface turned 65 in 2024. He was not receiving Social Security or Railroad Retirement Benefits on his 65th birthday. He was interested in obtaining Medicare coverage and is eligible for premium-free Part A. Before he could enroll in Medicare, his entire area was impacted by a hurricane causing massive flooding and severe wind damage. The Federal government declared this to be a natural disaster which has recently ended. During this period Anthony's initial enrollment period expired. Anthony asks you how he can now obtain Medicare coverage. What should you say? - ANSWER >>Anthony is eligible for a special enrollment period (SEP) because he missed an enrollment period due to the impact of the Federally declared disaster. This SEP will allow Anthony to enroll in Part B up to six months after the end of the emergency declaration. Anthony may enroll in premium-free Part A at any time and his Part A coverage will be retroactive for up to 6 months.
- Ms. Lewis has aggressive cancer and would like to know if Medicare will cover hospice services in case she needs them. What should you tell her? - ANSWER >>Medicare covers hospice services, and they will be available for her.
- Edward suffered from serious kidney disease. As a result, Edward became eligible for Medicare coverage due to end-stage renal disease (ESRD). A close relative donated their kidney and Edward successfully underwent transplant surgery 12 months ago. Edward is now age 50 and asks you if his Medicare coverage will continue, what should you say? - ANSWER >>Individuals eligible for Medicare based on ESRD generally lose eligibility 36 months after the month in which the individual receives a kidney transplant unless they are eligible for Medicare on another basis such as age or disability. Edward may, however, remain enrolled in Part B but solely for coverage of immunosuppressive drugs if he has no other health care coverage that would cover the drugs.
- Mrs. Foster is covered by Original Medicare. She sustained a hip fracture and is being successfully treated for that condition. However, she and her physicians feel that after her lengthy hospital stay, she will need a month or two of nursing and rehabilitative care. What should you tell them about Original Medicare's coverage of care in a skilled nursing facility? - ANSWER >>Medicare will cover Mrs. Foster's skilled nursing services provided during the first 20 days of her stay, after which she would have a copay until she has been in the facility for 100 days.
- Madeline Martinez was widowed several years ago. Her husband worked for many years and contributed into the Medicare system. He also left a substantial estate which provides Madeline with an annual income of approximately $130,000. Madeline, who has only worked part-time for the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to you for advice. What should you tell her? - ANSWER >>You should tell Madeline that she will be able to enroll in Medicare Part A without paying monthly premiums due to her husband's long work record and participation in the Medicare system. You should also tell Madeline that she will pay Part B premiums at more than the standard lowest rate but less than the highest rate due her substantial income.
- Mrs. Lester is age 75 and enjoys a comfortable but not extremely high-income level. She wishes to enroll in an MA MSA plan that she heard about from her neighbor. She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Lester? - ANSWER >>Mrs. Lester may enroll in an MA MSA plan and remain in her current standalone Part D prescription drug plan.
- Herber Noble is turning 65 next month, Herber legally entered the United States over twenty years ago but is not a citizen. Since his entry into the country, Herber has worked at Smallcap Incorporated and contributed to the Medicare system. Herber suffers from diabetes. He will soon retire and asks you if he can enroll in a Medicare Advantage plan that you represent. How would you respond? - ANSWER >>Herber is eligible to enroll in Medicare Advantage as long as he is entitled to Part A and enrolled in Part B. Herber should go to the Social Security website to enroll in Medicare Part A and B if he has not done so already. Once he is enrolled, he can choose a Medicare Advantage plan.
- Mr. Bryant enjoys a comfortable retirement income. He recently had surgery and expected that he would have certain services and items covered by the plan with minimal out-of-pocket costs because his MA-PD coverage has been very good. However, when he received the bill, he was surprised to see large charges in excess of his maximum out-of-pocket limit that included some services and items he thought would be fully covered. He called you to ask what he could do? What could you tell him? - ANSWER >>You can offer to review the plans appeal process to help him ask the plan to review the coverage decision.
- Mr. Dalton is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a Medicare Advantage Special Needs Plan (SNP). His friend has mentioned that the SNP charges very low cost-sharing amounts and Mr. Dalton would like to join that plan. What should you tell him? - ANSWER >>SNPs limit enrollment to certain subpopulations of beneficiaries. Given his current situation, he is unlikely to qualify and would not be able to enroll in the SNP.
- Mr. Kumar is considering a Medicare Advantage HMO and has questions about his ability to access providers. What should you tell him? - ANSWER >>In most Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network).
- Mr. Anderson wants to know whether he is eligible to sign up for a Private fee- forservice (PFFS) plan. What questions would you need to ask to determine his eligibility? - ANSWER >>You would need to ask Mr. Anderson if he is entitled to Part A, enrolled in Part B, and if he lives in the PFFS plan's service area.
- Mr. Abbott has heard that he can sign up for a product called "Medicare Advantage" but is not sure about what type of plan designs are available through this program. What should you tell him about the types of health plans that are available through the Medicare Advantage program? - ANSWER >>There are Medicare health plans such as HMOs, PPOs, PFFS, and MSAs.
- Mr. Trevino notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? - ANSWER >>He may receive health care services from any doctor allowed to bill Medicare, if he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing.
- Mrs. Robles is considering a Medicare Advantage PPO and has questions about which providers she can go to for her health care. What should you tell her? - ANSWER >>Mrs. Robles can obtain care from any provider who participates in Original Medicare, but generally will have a higher cost-sharing amount if she sees a provider who/that is not a part of the PPO network.
- Tariq is a Medicare beneficiary who is considering switching to a Medicare Advantage plan during this year's open enrollment season. He has read about prior authorization and the need for referrals in the newspapers and asks you what type of plans can require prior authorization. What do you say? -
treatment. How much may Dr. Morgan charge? - ANSWER >>Dr. Morgan can charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15% of the Medicare rate.
- Mr. Pham is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare Advantage HMO. Shortly thereafter, Mr. Pham visits his primary care provider (PCP), Dr. Maria Sanchez. Mr. Pham complains of a bad cold and receives care - a Medicarecovered service. The normal copayment is $40. How much may Dr. Sanchez collects? - ANSWER >>The minimal copayment that would apply under Medicaid, regardless of what the plan requires of other enrollees.
- Raymond is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning. Which type of SNP is likely to be most appropriate for him? - ANSWER >>C-SNP
- Mrs. Nelson likes a Private Fee-for-Service (PFFS) plan available in her area that does not include drug coverage. She wants to enroll in the plan and enroll in a stand-alone prescription drug plan. What should you tell her? - ANSWER >>She could enroll in a PFFS plan and a stand-alone Medicare prescription drug plan.
- Mrs. Nguyen is a retired federal worker with coverage under a Federal Employee Health Benefits (FEHB) plan that includes creditable drug coverage. She is ready to turn 65 and become Medicare eligible for the first time. What issues might she consider about whether to enroll in a Medicare prescription drug plan? - ANSWER >>She could compare the coverage to see if the Medicare Part D plan offers better benefits and coverage than the FEHB plan for the specific medications she needs and whether any additional benefits are worth the Part D premium costs on top of her FEHB contribution.
- Mrs. Duran is enrolled in a prescription drug plan. She has heard about something called True-Out-Pocket costs or "TrOOP" and asks you if any of the
following count toward reaching the catastrophic coverage phase. What do you say? I. Her annual PDP deductible II. Supplemental coverage provided by an employer group waiver plan III. The off formulary drug her doctor prescribed but she pays for because the plan denied her exception request IV. Her over-the-counter (OTC) allergy medication. - ANSWER >>I and II only
- Mrs. Castro has just turned 65, is in excellent health and has a relatively high income. She uses no medications and sees no reason to spend money on a Medicare prescription drug plan if she does not need the coverage. She currently does not have creditable coverage. What could you tell her about the implications of such a decision? - ANSWER >>If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, and if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered.
- Which of the following individuals is most likely to be eligible to enroll in a Part D Plan? - ANSWER >>Jose, a grandfather who was granted asylum and has worked in the United States for many years.
- Mrs. Esmeralda Avila is a Medicare beneficiary enrolled in a MA-PD plan you represent. Her neighbor recently suffered from a painful case of shingles. Mrs. Avila hopes to avoid such an illness through vaccination. She asks you whether the cost of the shingles vaccination will be covered under the plan you represent. What should you say? - ANSWER >>Yes, there is no cost sharing for the shingles vaccine even in the deductible phase of her prescription drug plan because it is an adult vaccine recommended by the Advisory Committee on Immunization Practices (AICP).
- Mrs. Russo is entitled to Part A and has medical coverage without drug coverage through an employer retiree plan. She is not enrolled in Part B. Since the employer plan does not cover prescription drugs, she wants to enroll in a Medicare prescription drug plan. Will she be able to? - ANSWER >>Yes. Mrs.
- Mr. and Mrs. Cole both take a specialized multivitamin prescription each day. Mr. Cole takes a prescription to help regrow his hair. They are anxious to have their Medicare prescription drug plan cover these drug needs. What should you tell them? - ANSWER >>Medicare prescription drug plans are not permitted to cover the prescription medications the Coles are interested in under Part D coverage, however, plans may cover them as supplemental benefits and the Coles could look into that possibility.
- Ms. Ramos is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her? - ANSWER >>She may fill prescriptions for covered drugs at non-network pharmacies, but likely at a higher cost than paid at an in-network pharmacy.
- Mr. Chen was still working when he first qualified for Medicare. At that time, he had employer group coverage that was creditable. During his initial Part D eligibility period, he decided not to enroll because he was satisfied with his drug coverage. It is now a year later and Mr. Chen has lost his employer group coverage within the last two weeks. How would you advise him? - ANSWER >>Mr. Chen should enroll in a Part D plan before he has a 63-day break in coverage in order to avoid a premium penalty.
- Mrs. Kelly wants to enroll in a Medicare Advantage plan that does not include drug coverage and also enroll in a stand-alone Medicare prescription drug plan. Under what circumstances can she do this? - ANSWER >>If the Medicare Advantage plan is a Private Fee-for-Service (PFFS) plan that does not offer drug coverage or a Medical Savings Account plan, Mrs. Kelly can do this.
- John Cohen is a Medicare beneficiary who suffers from diabetes. Mr. Cohen is considering enrollment in an MA-PD plan that you represent. He asks you whether his insulin costs will be covered. What should you say? - ANSWER >>Mr. Cohen's insulin costs for a one-month supply cannot be more than $35 in any coverage phase.
- Mrs. Strickland is a new Medicare beneficiary who has just retired from retail work. She is interested in selecting a Medicare Part D prescription drug plan. She takes several medications and is concerned that she has not been able to identify a plan that covers all of her medications. She does not want to make an abrupt change to new drugs that would be covered and asks what she should do. What should you tell her? - ANSWER >>Every Part D drug plan is required to cover a single one-month fill of her existing medications sometime during a 90-day transition period.
- What types of tools can Medicare Part D prescription drug plans use that affect the way their enrollees can access medications? - ANSWER >>Part D plans do not have to cover all medications. As a result, their formularies, or lists of covered drugs, will vary from plan to plan. In addition, they can use cost containment techniques such as tiered copayments and step therapy.
- Which of the following statements about Medicare Part D is/are correct? I. Part D plans must enroll any eligible beneficiary who applies, regardless of health status, except in limited circumstances. II. Private fee-for-service (PFFS) plans are not required to use a pharmacy network but may choose to have one. III. Beneficiaries enrolled in an MA-Medical Savings Account (MSA) plan may only obtain Part D benefits through a standalone PDP. IV. Beneficiaries enrolled in an MA-PPO may obtain Part D benefits through a standalone PDP or through their plan. - ANSWER >>I, II, and III only
- Mrs. Sharma has Original Medicare and would like to enroll in a Private Fee-for- Service (PFFS) plan. All types of PFFS plans are available in her area. Which options could Mrs. Sharma consider before selecting a PFFS plan? - ANSWER >>A Medicare Advantage Prescription Drug (MA-PD) PFFS plan that combines medical benefits and Part D prescription drug coverage, a PFFS plan offering only medical benefits, or a PFFS plan in combination with a stand-alone prescription drug plan.
- Mr. Aguilar is a newly enrolled Medicare Part D beneficiary and one of your clients. In addition to drugs on his plan's formulary, he takes several other
with an effective date of July 1st. Which statement best describes how Agent Chan may be compensated under CMS rules? - ANSWER >>FeelBetter will pay Agent Chan initial year compensation for July through December. The renewal amounts will be paid starting in January if Ms. King remains enrolled the following year.
- Agent Lopez helps Ralph to enroll in Top Choice Medicare Advantage plan during the Annual Open Enrollment Period. Ralph's effective enrollment date is January 1st. Ralph disenrolls on February 12th because he discovers that the plan does not cover services furnished by several of his longtime providers. Which of the following statements best describes the impact of Ralph's action upon Agent Lopez's compensation? - ANSWER >>Agent Lopez's entire compensation must be recouped because Ralph disenrolled within 3 months of enrollment.
- Alice is a marketing representative employed by a health plan. Betty is a captive agent of a health plan who markets for multiple plans and sponsors. Carl is a captive agent who markets for only one plan/sponsor. Denise is an independent agent who markets to different types of groups. Edward is an independent agent who markets only to employer and union groups. CMS marketing representative compensation rules generally apply to: - ANSWER >>Betty and Denise, but not Alice (the employee) or Carl or Edward (to whom exceptions apply).
- Mrs. Lewis is turning 65 in November and called to ask for your help deciding on a Medicare Advantage plan. She agreed to sign a scope of appointment form and meet with you on October 15. During the appointment, what are you permitted to do? - ANSWER >>You may provide her with the required enrollment materials and take her completed enrollment application.
- Angel is new to the Medicare marketplace having previously been focused on life insurance and disability income protection products. He intends to conduct an educational seminar during the AEP at a local hotel and then invite those who attend to a subsequent marketing meeting to discuss the benefits of next year's plans. How would you advise Angel? - ANSWER >>Angel should conduct the education seminar as an early morning meeting and the marketing meeting on
the following day in the late afternoon so that there are at least 12 hours between the two meetings.
- You have approached a hospital administrator about marketing in her facility. The administrator is uncomfortable with the suggestion. How could you address her concerns? - ANSWER >>Tell her that Medicare guidelines allow you to conduct marketing activities in common areas of a provider's facility.
- Mr. Lynn, an agent for Acme Insurance, Inc. thinks that, since state laws are preempted concerning the marketing of Medicare health plans, he doesn't have much to worry about. What might you, as his colleague, advise him concerning the type of scrutiny he will be under? - ANSWER >>Organizations sponsoring Medicare health plans are responsible for the behavior of their contracted representatives and will be conducting monitoring activities to ensure compliance with all applicable federal law and guidance and plan policies. Furthermore, state agent licensure laws are not preempted and he must abide by their requirements.
- You have been providing a pre-Thanksgiving meal during sales presentations in November for many years, and your clients look forward to attending this annual event. When marketing Medicare Advantage and Part D plans, what are you permitted to do concerning meals? - ANSWER >>You may provide light snacks, but a Thanksgiving style meal would be prohibited, regardless of the total value of the meal.
- BestCare Health Plan has received a request from a state insurance department in connection with the investigation of several marketing representatives licensed by the state who sell Medicare Advantage plans. What action(s) should BestCare take in response? - ANSWER >>Cooperate with the state and supply requested information.
- Another agent you know has engaged in misconduct that has been verified by the plan she represented. What sort of penalty might the plan impose on this individual? - ANSWER >>The plan may withhold commission, require retraining,
recoup Agent Higgins' compensation because she has moved away from its service area.
- Agent Mendez wishes to solicit Medicare Advantage prospects through e-mail and asks you for advice as to whether this is possible. What should you tell her? - ANSWER >>Marketing representatives may initiate electronic contact through e-mail but an opt-out process must be provided.
- This year you have decided to focus your efforts on marketing to employer group plans. One employer provides you with a list of their retirees and asks you to contact them to explain the characteristics of the plan they have selected. What should you do? - ANSWER >>You may go ahead and call them.
- Miles is a licensed agent who represents Colgate Health and its Medicare Advantage (MA) plans. Miles has several clients who have recently come to him for help. They are in their initial coverage periods) (ICEP) and are interested in enrolling in one of Colgate Health's MA plans. Adam will soon turn 68 and has decided to retire. Betty is about to turn 65 and has also decided to retire. Adam and Betty both currently have coverage through Colgate Health. Charles had health coverage through Colgate but dropped the coverage when he retired early to travel to Europe. Charles has just turned age 65 and is now back in the United States. Diedre, who will turn 65 next month, currently has coverage through Ditmas Health - a company that Miles also represents. Who qualifies for the opt- in simplified enrollment mechanism? - ANSWER >>Adam and Betty because each of them will not have a break between their non-Medicare and Medicare coverage through Colgate Health Plan.
- A client wants to give you an enrollment application on October 1 before the beginning of the Annual Election Period because he is leaving on vacation for two weeks and does not want to forget about turning it in. What should you tell him? - ANSWER >>You must tell him you are not permitted to take the form. If he sends the form directly to the plan, the plan will process the enrollment on the day the Annual Election Period begins.
- Mr. Bean has just entered his MA Initial Coverage Election Period (ICEP). What action could you help him take during this time? - ANSWER >>He will have one opportunity to enroll in a Medicare Advantage plan.
- You are doing a sales presentation for Mrs. Mayo. You know that Medicare marketing guidelines prohibit certain types of statements. Apply those guidelines to the following statements and identify which would be prohibited. - ANSWER >>"If you're not in very good health, you will probably do better with a different product."
- Mr. Solomon is enrolled in an MA plan. He recently suffered complications following hip replacement surgery. As a result, he has spent the last three months in Resthaven, a skilled nursing facility. Mr. Solomon is about to be discharged. What advice would you give him regarding his health coverage options? - ANSWER >>His open enrollment period as an institutionalized individual will continue for two months after the month he moves out of the facility.
- Archer works as a representative focused on the senior marketplace. What would be considered prohibited activity by Archer? - ANSWER >>Implying that only seniors can enroll in a Medicare Advantage plan when meeting with Mr. Lynn, who is 58 but qualifies for Medicare because he is disabled.
- Mrs. Green calls to tell you she has not received her new plan ID card yet, but she needs to see a doctor. What can she expect to receive from the plan after the plan has received her enrollment form? - ANSWER >>Evidence of plan membership, information on how to obtain services, and the effective date of coverage.
- Melina Giles recently suffered a stroke while visiting her daughter and grandchildren. As a result, Melina has been admitted to a rehabilitation hospital where she is expected to reside for several months. The rehabilitation hospital is located outside the geographic area served by her current Medicare Advantage (MA) plan. What options are available to Melina regarding her health plan coverage? - ANSWER >>Melina may make an unlimited number of MA enrollment requests and may disenroll from her current MA plan.
