AHIP Medicare study plan

Define the four parts of Medicare (A, B, C, D) and state what each covers

Distinguish Original Medicare from Medicare Advantage in terms of network rules and cost-sharing structure

List the standard eligibility criteria for Medicare (age, disability, ESRD/ALS) and enrollment periods (IEP, GEP, SEPs)

Explain how late enrollment penalties for Parts B and D are calculated and when they apply

Compare the different Medicare Advantage plan types (HMO, PPO, PFFS, SNP) on network and referral requirements

Identify the core consumer protections and required plan elements of MA plans (e.g., MOOP, coverage of emergency care)

Describe how SNPs differ from general MA plans, including C-SNP, D-SNP, and I-SNP eligibility

Explain how MA plans coordinate with Part D and what a MA-PD plan is

Explain MA enrollment periods (ICEP, AEP, OEP) and the rules governing when a beneficiary may switch plans

Summarize how MA plans are paid (capitation, risk adjustment, Star Ratings) and why Star Ratings matter

Describe the appeals and grievance process available to MA enrollees

Distinguish MA from Medicare Supplement (Medigap) in terms of what each covers and when it can be purchased

Explain the structure of Part D (standalone PDPs vs MA-PD) and the role of formularies and tiers

Describe the coverage phases of Part D, including deductible, initial coverage, and the catastrophic phase, and how the out-of-pocket cap works

Identify what drugs are excluded from Part D and the exceptions/appeals process for formulary and tiering

Explain the Part D late enrollment penalty and the low-income subsidy (Extra Help)

List the required elements of compliant Medicare marketing materials (e.g., required disclaimers, CMS approval where applicable)

Distinguish permitted marketing activities from prohibited ones (e.g., unsolicited door-to-door, cold-calling rules, gifts/meals limits)

Explain the rules for scope of appointment (SOA) and consent before a sales appointment

Describe the TPRA and how agents must handle beneficiary personal information

Explain the enrollment process rules, including the role of the enrollment form, confirmation, and disenrollment

Describe agent/broker compensation rules and the prohibition on steering or incentivizing improper plan choices

Identify the consequences of non-compliance for agents and agencies (CMS sanctions, terminations, civil money penalties)

Explain the beneficiary's right to change plans and the rules around plan-initiated disenrollment

Define fraud, waste, and abuse and distinguish each with concrete Medicare examples

Identify common FWA schemes in Medicare (e.g., billing for services not rendered, upcoding, identity theft)

Describe the False Claims Act, Anti-Kickback Statute, and Civil Monetary Penalties Law at a high level

Explain the mandatory compliance program elements and the role of the compliance officer

Complete a full-length timed practice exam covering all five domains

Review every missed question and write a corrected rationale for each

Re-drill the two weakest domains identified by the practice exam

Recite the key rules for marketing, enrollment, and FWA from memory without notes