3.1 Initial Enrollment Period (IEP)

AHIP Medicare Certification Exam

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1 Introduction

1.1 About the AHIP Medicare Certification Exam 1.2 How to Use This Study Guide

2 Chapter 2: Medicare Program Fundamentals

2.1 What Medicare Is: Program Structure & How Parts A–D Fit Together 2.2 Medicare Part A — Hospital Insurance 2.3 Medicare Part B — Medical Insurance 2.4 Medicare Eligibility Rules (Age 65, Disability, ESRD, ALS)

3 Chapter 3: Medicare Enrollment Periods

3.1 Initial Enrollment Period (IEP) 3.2 Annual Enrollment Period (AEP): October 15 – December 7 3.3 Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31 3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events 3.5 Late Enrollment Penalties (Part A, Part B, Part D)

4 Chapter 4: Medigap & Coordination of Coverage

4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights 4.2 Dual Eligibility & Medicare Savings Programs 4.3 How Original Medicare, MA, Part D & Medigap Interact

5 Chapter 5: Medicare Advantage Plan Types

5.1 Medicare Advantage (Part C) Overview: How MA Differs from Original Medicare 5.2 HMO & HMO-POS Plans 5.3 PPO Plans 5.4 PFFS Plans (Private Fee-for-Service) 5.5 MSA Plans (Medicare Medical Savings Accounts) 5.6 Cost Plans & Employer Group Waiver Plans (EGWPs)

6 Chapter 6: Special Needs Plans & MA Plan Design

6.1 Special Needs Plans (SNPs) Overview 6.2 D-SNP — Dual-Eligible Special Needs Plans 6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans 6.4 MA Benefits, MOOP & Supplemental Benefits 6.5 MA Star Ratings & Plan Quality

7 Chapter 7: Part D Structure & the 2026 Redesign

7.1 Part D Overview & Eligibility 7.2 Formularies & Drug Tiers 7.3 The 2026 Part D Benefit Redesign ($2,100 OOP Cap, $615 Max Deductible, Catastrophic Phase) 7.4 Medicare Prescription Payment Plan (Drug-Cost Smoothing)

8 Chapter 8: Part D Costs, Assistance & Appeals

8.1 Low-Income Subsidy (LIS) / Extra Help 8.2 Part D Late Enrollment Penalty & Creditable Coverage 8.3 Coverage Determinations, Exceptions & Appeals

9 Chapter 9: CMS Marketing Rules & Scope of Appointment

9.1 CMS Medicare Communications & Marketing Guidelines (MCMG) Overview 9.2 Scope of Appointment (SOA): the 48-Hour Rule & Exceptions 9.3 Permitted vs. Prohibited Marketing & Sales Activities 9.4 Marketing Events vs. Educational Events

10 Chapter 10: Enrollment & Disclosure Requirements

10.1 The Pre-Enrollment Checklist (PEC) 10.2 Enrollment Procedures & Application Requirements 10.3 Call Recording & Third-Party Marketing Organization (TPMO) Disclaimers 10.4 Agent & Broker Compensation Rules

11 Chapter 11: Marketing Conduct & Oversight

11.1 Cross-Selling Restrictions & Nominal Gift Value Rules 11.2 Marketing to Vulnerable Populations & Non-Discrimination in Sales 11.3 Website, Social Media & Advertising Compliance 11.4 Complaint Tracking Module (CTM) & Agent Oversight

12 Chapter 12: Understanding Fraud, Waste & Abuse

12.1 Defining Fraud, Waste & Abuse (and the Difference Between Them) 12.2 The False Claims Act 12.3 The Anti-Kickback Statute

13 Chapter 13: Compliance Laws & Screening

13.1 The Stark Law (Physician Self-Referral) 13.2 HIPAA Privacy & Security Basics 13.3 The OIG Exclusion List & Sanctioned-Provider Screening

14 Chapter 14: Reporting, Compliance Programs & Consequences

14.1 Detecting & Reporting FWA 14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training 14.3 Consequences & Corrective Action Plans

3.1 Initial Enrollment Period (IEP)

Key Takeaways Explain This Topic AI

The IEP is a 7-month window: 3 months before the 65th-birthday month, the birthday month itself, and 3 months after.

If a birthday falls on the 1st of the month, CMS treats the person as if born the prior month, shifting the whole window one month earlier.

Since the BENES Act took effect January 1, 2023, coverage now starts the first day of the month after enrollment for every month of the IEP — the old up-to-3-month delay for late sign-ups is gone.

People already collecting Social Security or Railroad Retirement Board benefits are enrolled in Parts A and B automatically; everyone else must actively apply.

Missing the IEP without a valid Special Enrollment Period pushes a beneficiary into the General Enrollment Period and can trigger permanent late-enrollment penalties.

Last updated: July 2026

Why the IEP Matters on the Exam

The Initial Enrollment Period (IEP) is the anchor point for every other enrollment rule tested on the AHIP exam. Before you can evaluate whether a beneficiary needs a Special Enrollment Period (SEP), owes a late-enrollment penalty, or is even eligible to buy a Medicare Advantage or Part D plan, you first have to determine whether they are inside or outside their IEP. AHIP scenario questions routinely give you a birth date and a "signed up on" date and ask you to calculate the enrollment window or the coverage effective date — get the math wrong and you get the whole question wrong.

What the IEP Is

The IEP is a 7-month window centered on the month a person turns 65:

• Window segment Length Timing
• Before 3 months Months 1-3 before the birthday month
• Birthday month 1 month The month containing the 65th birthday
• After 3 months Months 1-3 after the birthday month

Worked example: Maria turns 65 on September 20. Her IEP runs June 1 through December 31 — three months before September (June, July, August), September itself, and three months after (October, November, December).

The First-of-the-Month Trap

If a beneficiary's birthday falls on the first day of the month , CMS treats them as though they were born in the prior month for enrollment purposes. This shifts the entire 7-month window one month earlier and moves the effective coverage date up by a month for early sign-ups.

Worked example: David turns 65 on June 1. Because his birthday is the 1st, his IEP is treated as if he were born in May — so his window runs February 1 through August 31 , not March through September. If David enrolls in the first three months of that window, his coverage can start as early as May 1 , the month before he actually turns 65. This rule catches agents off guard constantly and is a favorite AHIP trap.

Coverage Start Dates: The BENES Act Fixed the Old Delay

Before 2023, signing up late in your IEP (in the birthday month or the three months after) could delay your coverage start by up to three additional months. The Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act , effective January 1, 2023 , eliminated that delay. Under current rules:

Enrolling before the birthday month: coverage starts the first day of the birthday month .

Enrolling during or after the birthday month (anywhere in the remaining IEP): coverage now starts the first day of the month after enrollment — no more multi-month wait.

This is a meaningful, current-year fact the exam expects you to know precisely, since older prep materials (and older agents) may still describe the pre-2023 delayed-start rule.

Automatic vs. Voluntary Enrollment

Whether a beneficiary must actively apply depends on whether they are already drawing retirement benefits:

Automatic enrollment: Anyone already receiving Social Security or Railroad Retirement Board (RRB) benefits when they turn 65 is automatically enrolled in Parts A and B. Their Medicare card arrives roughly 3 months before the 65th birthday.

Voluntary enrollment: Anyone who has not yet filed for Social Security (increasingly common as more people delay claiming benefits past 65) must actively apply for Medicare — online at ssa.gov, by phone, or in person. If they skip this step and have no other creditable coverage, they can trigger late-enrollment penalties.

Under-65 Disability IEP

Beneficiaries entitled to Medicare based on disability (not age) get an IEP built the same way, just anchored to a different milestone: 3 months before, including, and 3 months after the 25th month of Social Security Disability Insurance (SSDI) benefit entitlement (Medicare eligibility starts in month 25 after a 24-month waiting period). Agents will meet these under-65 disability cases regularly, and the underlying 3-1-3 structure of the window is identical to the age-65 IEP — only the anchor event changes.

Working Past 65: When the IEP Isn't the Deadline It Looks Like

A large share of AHIP exam scenarios (and real client conversations) involve someone still actively working at 65 with employer group health coverage. These beneficiaries are not required to use their IEP for Part B:

If the employer has 20 or more employees , the group plan is generally considered primary to Original Medicare's secondary role for as long as the person keeps working, and the beneficiary can delay Part B enrollment without ever owing a late-enrollment penalty.

Most of these beneficiaries still take premium-free Part A during their IEP, since it costs nothing and can pay secondary to the employer plan.

When the employer coverage eventually ends (retirement, job loss, etc.), the beneficiary gets an 8-month Special Enrollment Period to sign up for Part B penalty-free — a specific SEP category covered in Section 3.4.

This "delay now, SEP later" path is one reason the IEP is not automatically the single most urgent date on a client's calendar — but only when the 20-or-more-employees condition is met. Below that threshold, the group plan is typically secondary to Medicare, and delaying past the IEP risks a coverage gap and, eventually, the Part B penalty.

Quick Reference: IEP Effective Dates Under Current Rules

• When the beneficiary enrolls Coverage effective date
• Any of the 3 months before the birthday month First day of the birthday month
• The birthday month itself First day of the month after enrollment
• Any of the 3 months after the birthday month First day of the month after enrollment

Note that every row after the first now follows the same "next month" rule since the BENES Act took effect — there is no longer a scenario where enrolling in the IEP delays coverage by more than one month.

Common Exam Traps

Confusing the IEP with the General Enrollment Period (GEP) , which is for people who missed their IEP entirely (see Section 3.5) — the GEP has different penalty consequences.

Assuming the IEP window is always "birthday month plus surrounding months" without checking for the first-of-month exception.

Forgetting that the BENES Act coverage-start fix applies to all months of the IEP, not just the birthday month itself.

Assuming everyone who works past 65 must enroll in Part B during their IEP — that is only true when the employer has fewer than 20 employees.