Free AHIP Medicare Exam Flashcards

Hospital insurance covering inpatient stays, skilled nursing facility care, hospice, and some home health. Most people get it premium-free based on 40 quarters of Medicare-taxed work; those with fewer quarters pay a monthly premium.

Medical insurance covering physician visits, outpatient care, durable medical equipment, and preventive services. Requires a monthly premium ($202.90 standard in 2026) and an annual deductible ($283 in 2026); late enrollment triggers a permanent premium penalty.

A private-plan alternative to Original Medicare that must cover everything Parts A and B cover (hospice stays under Part A) plus usually Part D and extra benefits. Beneficiaries still pay their Part B premium plus any plan premium.

Optional outpatient prescription drug coverage delivered through stand-alone plans (PDPs) or bundled into MA plans (MA-PD). Going 63+ continuous days without creditable drug coverage after your Initial Enrollment Period triggers the late enrollment penalty.

A private policy that pays some of the cost-sharing gaps left by Original Medicare, such as deductibles and coinsurance. It only works alongside Original Medicare — it cannot be paired with a Medicare Advantage plan.

Original Medicare (A+B) is fee-for-service with no network restrictions and no built-in annual out-of-pocket cap unless paired with Medigap. Medicare Advantage plans use networks (except PFFS), often bundle Part D, and must cap yearly out-of-pocket spending.

Automatic eligibility begins at 65 for most U.S. citizens/permanent residents who qualify for Social Security. Enrollment is not automatic for everyone — anyone not yet collecting Social Security benefits must actively sign up during their Initial Enrollment Period.

People under 65 qualify through disability after receiving Social Security Disability Insurance for 24 months, or immediately upon diagnosis of End-Stage Renal Disease or ALS — ALS has no waiting period at all.

A 7-month window centered on a beneficiary's 65th birthday (3 months before, the birth month, and 3 months after) to enroll in Parts A and B without a late enrollment penalty.

Runs October 15 - December 7 every year. Beneficiaries can switch between Original Medicare and Medicare Advantage, change MA plans, or change Part D plans, with changes taking effect January 1.

Runs January 1 - March 31, but only for people already enrolled in an MA plan. They can switch MA plans or drop MA for Original Medicare — they cannot use this window to switch from Original Medicare into MA.

A triggered window opened by a qualifying life event — moving out of a plan's service area, losing employer coverage, gaining/losing Medicaid, or a plan's contract non-renewal — that lets a beneficiary enroll or change plans outside AEP/OEP.

A permanent 10% premium increase for each full 12-month period a beneficiary was eligible for Part B but didn't enroll and lacked creditable coverage (like current employer coverage). The penalty lasts as long as the person has Part B.

Applies when a beneficiary goes 63+ consecutive days without Part D or other creditable drug coverage after their Initial Enrollment Period ends. It's added to the Part D premium for as long as they keep Part D coverage.

Drug coverage — often through an employer plan — expected to pay, on average, at least as much as standard Medicare Part D. Having it lets a beneficiary delay Part D enrollment without triggering the late enrollment penalty.

Situations — like losing MA coverage involuntarily or being within your 6-month Medigap open enrollment window — where an insurer must sell you a Medigap policy regardless of health status, with no medical underwriting or pre-existing condition waiting period.

Requires members to use in-network providers and get a primary care physician referral for specialist care, except in emergencies. Typically the lowest-premium MA option because of tight network control.

An HMO variant that allows limited out-of-network coverage for specific services, usually at a higher cost-share than staying in-network — a middle ground between standard HMO restrictions and PPO flexibility.

Allows members to see out-of-network providers without a referral, though out-of-network care costs more. Offers more flexibility than HMO but usually carries a higher premium.

Sets its own payment terms for providers on a claim-by-claim basis; any provider willing to accept those terms can treat the member. Unlike HMO/PPO, PFFS is not required to build a contracted provider network.

Pairs a high-deductible MA plan with a CMS-funded bank account. The plan pays nothing until the deductible is met; the account can be used tax-free for qualified medical expenses. MSA plans cannot include Part D drug coverage.

An MA Special Needs Plan restricted to beneficiaries eligible for both Medicare and Medicaid. It coordinates benefits between the two programs and often requires a state-specific Model of Care.

An MA Special Needs Plan limited to people with a CMS-specified severe or disabling chronic condition, such as diabetes or chronic heart failure, tailoring provider networks and benefits to that condition.

An MA Special Needs Plan for beneficiaries who live in, or require the level of care of, a long-term care facility such as a nursing home for 90+ days.

The CMS-mandated annual cap on a member's in-network cost-sharing under a Medicare Advantage plan. Once met, the plan pays 100% of covered services for the rest of the year — a protection Original Medicare alone doesn't have.

A plan's list of covered drugs, organized into cost tiers. Plans must cover at least two drugs in most therapeutic categories and can change formularies mid-year with proper notice to affected members.

Formularies group covered drugs into cost tiers — typically preferred generic, generic, preferred brand, non-preferred, and specialty. Higher tiers carry higher copays or coinsurance, with specialty-tier drugs the most expensive.

Federal assistance that reduces or eliminates Part D premiums, deductibles, and copays for beneficiaries with limited income and resources. It also removes the late-enrollment-penalty impact for eligible members.

The IRA-created annual out-of-pocket cap on covered Part D drug costs rose to $2,100 for 2026 (from $2,000 in 2025). Once a member hits the cap, they pay $0 for covered Part D drugs the rest of the year.

Lets any Part D or MA-PD enrollee spread their out-of-pocket drug costs into monthly payments across the plan year instead of paying the full amount at the pharmacy. It doesn't lower total cost — only smooths the payment timing.

The maximum allowable Part D deductible for 2026 is $615. Plans may set a lower deductible or none at all, but cannot charge members more than this CMS-set ceiling.

Largely eliminated under the IRA redesign — beneficiaries now move directly from initial coverage into catastrophic coverage once they hit the annual out-of-pocket cap, instead of facing a separate high-cost gap phase.

A preferred pharmacy offers lower member cost-sharing under the plan's contract terms; a standard (non-preferred) in-network pharmacy still fills the prescription but at a higher copay or coinsurance for the same drug.

A utilization management tool requiring the prescriber to get plan approval before certain drugs are covered, used to confirm medical necessity and appropriate use before the plan pays a claim.

A required form, or documented verbal agreement for phone appointments, specifying which products an agent may discuss with a beneficiary during a marketing appointment. Must generally be completed at least 48 hours before the appointment.

The 48-hour advance SOA requirement does not apply during the last 4 days of a valid enrollment period, or when the beneficiary walks into an agent's office and initiates the appointment — same-day SOAs are allowed in those cases.

Agents may not initiate marketing contact — calls, texts, emails, or door-to-door visits — with a beneficiary who hasn't given permission or requested information. Responding to a beneficiary-initiated inquiry is permitted.

Agents cannot market non-health-related products, like life insurance or annuities, during a Medicare Advantage or Part D sales appointment. A separate appointment with its own SOA is required to discuss unrelated products.

CMS caps promotional gifts to Medicare prospects at nominal value — no more than $15 per item and $75 aggregate per person per year — and bars offering meals as part of marketing activities regardless of value.

A CMS-required document agents must review with beneficiaries before completing an enrollment application, confirming they understand the plan's costs, provider network, and other key features before they sign up.

CMS requires plans and agents to record marketing and sales calls with beneficiaries in their entirety, including the enrollment process, to support compliance oversight and dispute resolution.

Any organization or individual, other than the plan itself, compensated to perform lead generation, marketing, or sales activities on the plan's behalf. TPMOs must include a required CMS disclaimer on their materials and calls.

An educational event may only provide objective plan information and cannot collect enrollment applications, schedule follow-up appointments, or distribute plan-specific marketing materials — doing any of that reclassifies it as a sales event with stricter rules.

Knowingly and willfully executing, or attempting to execute, a scheme to defraud a health care program. Intent to deceive for personal or financial gain is the key distinction that separates fraud from abuse.

Practices inconsistent with sound medical, business, or fiscal practices that result in unnecessary cost to a health care program. Unlike fraud, abuse does not require proof of intent to deceive.

Overutilization or misuse of resources, such as unnecessary tests or services, that involves neither the intent of fraud nor the knowing disregard of abuse — simply inefficient or careless use of resources.

Federal law imposing civil liability on anyone who knowingly submits, or causes the submission of, false or fraudulent claims for payment to a federal program like Medicare, with penalties that can include treble damages.

Prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce referrals for services reimbursable by a federal health care program — it applies even if the referred service was medically necessary.

Prohibits a physician from referring Medicare patients for certain designated health services to an entity in which the physician or an immediate family member has a financial relationship, unless an exception applies. Unlike the Anti-Kickback Statute, Stark is strict-liability and does not require intent.

A registry maintained by the HHS Office of Inspector General listing individuals and entities barred from participating in federal health care programs. Agents and their organizations must screen employees and vendors against it on a regular basis.