Medicare Basics
20%of exam
Medicare Advantage Plans
20%of exam
Part D Drug Plans
15%of exam
Marketing & Sales Compliance
25%of exam
Fraud, Waste & Abuse
20%of exam
Quick Facts
- Exam
- AHIP Medicare
- Plan year
- 2026
- Questions
- 50 open-book
- Pass
- 90% (45/50)
- Time
- 2 hours
- Fee
- $175
- Attempts
- 3 included
- Renewal
- Annual, every plan year
Enrollment Period Order
IEP then AEP then MA OEP then SEP
IEP: turning 65AEP: Oct-Dec switchMA OEP: MA-only Jan-MarSEP: life event trigger
AEP vs MA OEP
AEP
- Oct 15-Dec 7
- Any plan switch
- OM to MA allowed
MA OEP
- Jan 1-Mar 31
- MA plan only
- No OM to MA
All beneficiaries vs MA enrollees
Enrollment Window Picker
- Turning 65 soon→IEP(7-month window)
- Switch Oct 15-Dec 7→AEP(Any plan change)
- Already in MA plan→MA OEP(Jan-Mar only)
- Moved out of area→SEP(Life event)
- Lost employer coverage→SEP(60-day window)
- Newly Medicare eligible via MA→ICEP(Aligns with IEP)
Medicare Parts
- Part A
- Hospital, SNF, hospice
- Part B
- Medical + outpatient care
- Part C
- Medicare Advantage alternative
- Part D
- Prescription drug coverage
- Medigap
- Fills Original Medicare gaps
- Original Medicare
- Parts A+B only
- IRMAA
- Income-based premium surcharge
- Work credits
- 40 quarters = premium-free A
Medigap vs Medicare Advantage
Medigap
- Works with Original Medicare
- Pays cost-sharing gaps
- Cannot pair with MA
Medicare Advantage
- Replaces Original Medicare
- Uses provider networks
- Caps yearly out-of-pocket
Supplement vs replacement plan
Enrollment Windows
- IEP
- 7-month window at 65
- AEP
- Oct 15-Dec 7 switch
- MA OEP
- Jan 1-Mar 31, MA only
- SEP
- Triggered by life event
- ICEP
- Initial MA coverage window
- SSDI wait
- 24 months, then Medicare
- ESRD
- Immediate dialysis eligibility
- ALS
- No waiting period
Penalties + Costs
- Part B LEP
- 10% per 12 months late
- Part D LEP
- 63+ day coverage gap
- 2026 Part B premium
- $202.90 per month
- 2026 Part B deductible
- $283 per year
- Creditable coverage
- Delays Part D penalty
- Guaranteed issue
- No underwriting, limited window
SNP Types Memory Line
D dual, C chronic, I institutional
D-SNP: Medicare + MedicaidC-SNP: one chronic conditionI-SNP: long-term care facility
HMO vs PPO
HMO
- In-network only care
- Referral required
- Lower premium
PPO
- Out-of-network allowed
- No referral needed
- Higher premium
Network strict vs flexible
MA Plan Type Picker
- Wants lowest premium→HMO(Network required)
- Wants no referrals→PPO(Higher premium)
- Wants flexible providers→PFFS(No fixed network)
- Wants HSA-like account→MSA(High deductible)
- Dual Medicare + Medicaid→D-SNP(Coordinates benefits)
- Has chronic condition→C-SNP(Condition-specific)
- Lives in nursing facility→I-SNP(90+ days)
MA Plan Types
- HMO
- Network + referral required
- HMO-POS
- HMO + limited out-of-network
- PPO
- Out-of-network allowed, no referral
- PFFS
- Insurer sets own terms
- MSA
- High deductible + savings account
SNPs + MOOP
- D-SNP
- Dual Medicare + Medicaid
- C-SNP
- Chronic condition restricted
- I-SNP
- Institutional, nursing-home level
- Model of Care
- Required SNP care plan
- MOOP
- Annual in-network cost cap
2026 Part D Numbers
Deductible 615 then cap 2100 then free
$615 max deductible$2,100 out-of-pocket cap$0 after cap hit
PDP vs MA-PD
PDP
- Stand-alone drug plan
- Pairs with Original Medicare
- Separate premium
MA-PD
- Bundled into MA plan
- One combined premium
- Includes medical + drug
Separate vs bundled coverage
Part D Basics
- Formulary
- Plan's covered drug list
- Drug tiers
- Cost-sharing levels by drug
- LIS / Extra Help
- Income-based Part D subsidy
- PDP
- Stand-alone drug plan
- MA-PD
- MA plan + drug coverage
- Prior authorization
- Pre-approval before plan pays
- Step therapy
- Try cheaper drug first
2026 Part D Redesign
- OOP cap
- $2,100 max in 2026
- Deductible cap
- $615 maximum in 2026
- M3P
- Spreads costs into monthly payments
- Donut hole
- Eliminated by IRA redesign
- Catastrophic phase
- $0 after OOP cap
Educational vs Sales Event
Educational
- Objective plan information only
- No applications collected
- No follow-up scheduling
Sales
- Can take applications
- Can schedule follow-ups
- Stricter marketing rules apply
Applications define the event
Marketing Compliance Picker
- Scheduling a home visit→SOA form(48 hours ahead)
- Beneficiary walks in same day→SOA exception(No 48-hr wait)
- No beneficiary contact yet→Stop, no outreach(Unsolicited contact banned)
- Wants to discuss life insurance too→Separate SOA(No cross-selling)
- Offering a thank-you gift→$15 item limit($75 yearly cap)
- Hosting a public seminar→Educational rules(No enrollment forms)
Marketing Rules
- SOA
- Form naming products to discuss
- 48-hour rule
- Advance notice before appointment
- SOA exceptions
- Last 4 days, walk-ins
- Unsolicited contact
- Banned without beneficiary permission
- Cross-selling
- Needs a separate appointment/SOA
- Gift limit
- $15 per item cap
- Gift aggregate
- $75 per person yearly
- PEC
- Pre-enrollment costs/network checklist
- Call recording
- Full call must record
- Personal appointment
- One-on-one or small household
Events + Disclaimers
- Educational event
- No enrollment forms allowed
- Sales event
- Can take applications
- TPMO
- Compensated third-party marketer
- TPMO disclaimer
- Required on materials/calls
FWA Triangle
Fraud is intent, Waste is carelessness, Abuse is unsound
Fraud: intentional deceptionWaste: careless overuseAbuse: unsound but unintentional
Fraud vs Abuse
Fraud
- Intentional deception
- Personal financial gain
- Requires proof of intent
Abuse
- No intent needed
- Unsound business practices
- Still costs programs money
Intent is the difference
FWA Definitions
- Fraud
- Intentional deception for gain
- Waste
- Careless overuse of resources
- Abuse
- Unsound practice, no intent
- Reporting duty
- Mandatory for all agents
- Compliance training
- Required annually for agents
Anti-Kickback vs Stark Law
Anti-Kickback
- Any referral source
- Requires intent to induce
- Criminal + civil penalties
Stark Law
- Physician self-referral only
- Strict liability, no intent
- Civil penalties only
Intent required vs strict liability
Compliance Laws
- False Claims Act
- Treble damages, false claims
- Anti-Kickback Statute
- Bars payment for referrals
- Stark Law
- Self-referral ban, no intent
- HIPAA
- Protects health information privacy
- OIG exclusion list
- Barred providers registry
- Compliance elements
- 7 required CMS program parts
Common Traps
Fraud vs abuse
Fraud needs intent ≠ Abuse needs no intent
AEP vs MA OEP
AEP is open to all ≠ MA OEP is MA-only
Educational vs sales event
Educational cannot enroll ≠ Sales event can enroll
Part B LEP vs Part D LEP
Part B penalty is 10% year ≠ Part D penalty is per-gap
SOA required vs SOA exception
Most appointments need 48-hr SOA ≠ Walk-ins skip the 48-hr wait
Anti-Kickback vs Stark Law
Anti-Kickback needs intent ≠ Stark Law is strict liability
Original Medicare vs Medicare Advantage
Original Medicare has no network ≠ Medicare Advantage uses networks
Last Minute
- 1.Pass score is 90%, not lower
- 2.Only 3 attempts included per purchase
- 3.Exam is open-book, use your notes
- 4.SOA form needed 48 hours ahead
- 5.Gift cap: $15 item, $75 year
- 6.2026 Part D cap: $2,100
- 7.AHIP recertification is required every year
- 8.Fraud requires intent; abuse does not
- 9.Educational events cannot collect applications
- 10.MA OEP switches MA plans only
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