4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights

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

4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights

Key Takeaways Explain This Topic AI

The one-time Medigap Open Enrollment Period is a 6-month window starting the month a person is both 65+ and enrolled in Part B — during it, insurers cannot medically underwrite or deny coverage.

Since January 1, 2020 (MACRA), Plans C, F, and High-Deductible F are closed to anyone newly eligible for Medicare — Plan G is now the most comprehensive plan new enrollees can buy.

Medigap only pairs with Original Medicare — it is illegal for an agent to sell a Medigap policy to someone the agent knows is enrolled in a Medicare Advantage plan.

Guaranteed issue rights (including the 12-month MA "trial right") let a beneficiary buy specific Medigap plans without underwriting outside the one-time OEP, but only within a limited window (usually 63 days) after the triggering event.

No Medigap policy sold after 2006 can include prescription drug coverage — a Medigap holder who wants drug coverage must enroll in a stand-alone Part D plan.

Last updated: July 2026

Why This Topic Matters

Medigap questions sit inside Module 1 (Medicare Basics, 20% of the exam), but they are some of the highest-stakes questions on the whole test because they intersect with Module 4's marketing rules. An agent who misunderstands Medigap can accidentally commit a compliance violation — for example, selling a Medigap policy to a client already enrolled in a Medicare Advantage (MA) plan without properly disenrolling them, or telling a client a Medigap plan "covers everything" when it never covers prescription drugs. AHIP exam writers love scenario questions that test whether you know which enrollment window applies and which products can legally be combined , so expect several questions built around a beneficiary's exact situation and timeline.

What a Medigap Policy Actually Is

A Medigap (Medicare Supplement) policy is a privately sold insurance product, regulated under federal and state law, that pays some or all of the cost-sharing gaps left by Original Medicare — deductibles, coinsurance, and copayments under Parts A and B. Medigap policies are standardized : in every state except Massachusetts, Minnesota, and Wisconsin (which use their own systems), each lettered plan (A, B, D, G, K, L, M, N, plus C and F for those grandfathered in) must offer identical benefits no matter which insurance company sells it. Only the premium, customer service, and financial strength of the carrier differ between two companies selling the same lettered plan.

A Medigap policy works only alongside Original Medicare . It cannot be paired with a Medicare Advantage plan, and federal law prohibits selling a new Medigap policy to someone the agent knows is currently enrolled in an MA plan, unless the sale is timed to coincide with the beneficiary disenrolling from MA and returning to Original Medicare.

The 2010 Standardization and the 2020 MACRA Cutoff

Two regulatory changes show up constantly on the exam:

2010 (Medicare Improvements for Patients and Providers Act, MIPPA): Plans E, H, I, and J were discontinued for new sales, and Plans M and N were introduced. This produced the current 10-plan standardized lineup (A, B, C, D, F, G, K, L, M, N).

January 1, 2020 (Medicare Access and CHIP Reauthorization Act, MACRA): Plans C, F, and High-Deductible F were closed to anyone newly eligible for Medicare on or after that date because they cover the Part B deductible, which Congress decided created first-dollar coverage that discouraged cost-conscious care. Beneficiaries who were already eligible for Medicare before 2020 can keep or still buy Plan C or F; anyone newly eligible on or after January 1, 2020 cannot.

Because Plan F is closing off to new entrants, Plan G (and High-Deductible G) is now the most comprehensive plan available to newly eligible beneficiaries — it covers everything Plan F does except the annual Part B deductible ($283 in 2026), which the beneficiary pays out of pocket before Plan G benefits begin.

Plan Who can still buy it Comprehensiveness

Plan F / High-Deductible F Only those Medicare-eligible before 1/1/2020 Most comprehensive (covers Part B deductible)

Plan G / High-Deductible G Anyone (including newly eligible) Covers everything F does except the Part B deductible

Plan N Anyone Lower premium; requires small copays for office visits/ER and does not cover Part B excess charges

• Plan A Anyone Core benefits only (Part A/B coinsurance, first 3 pints of blood)
• The Medigap Open Enrollment Period

The single most-tested Medigap concept is the Medigap Open Enrollment Period (OEP) — a one-time, 6-month window that starts the first day of the month in which a person is both age 65 or older and enrolled in Part B . During this window, an insurer must sell any Medigap policy it offers, at the best available rate, regardless of health history — no medical underwriting, no pre-existing condition exclusion.

Common exam trap: Do not confuse this with the Medicare Advantage Open Enrollment Period (MA OEP, January 1–March 31 every year) or the Annual Enrollment Period (AEP, October 15–December 7). All three use the word "enrollment," but the Medigap OEP happens only once, is tied to turning 65 and having Part B, and has nothing to do with switching MA plans.

Guaranteed Issue Rights Outside the OEP

Outside the one-time OEP, an insurer can generally medically underwrite a Medigap application — asking health questions and denying coverage or charging more based on the answers. However, federal law creates guaranteed issue (GI) rights in specific situations that force an insurer to sell a Medigap policy (usually Plan A, B, C, F, K, or L, depending on the state) without underwriting. The most tested GI triggers are:

Trial right: A beneficiary who enrolls in an MA plan for the first time at 65 and disenrolls within 12 months has a right to buy a Medigap policy as if returning from Original Medicare for the first time.

Involuntary loss of coverage: The MA plan or Medigap insurer leaves the area, becomes insolvent, commits fraud, or otherwise ends coverage through no fault of the beneficiary.

Move out of the plan's service area.

Each GI right comes with a strict application window, typically 63 days from the date coverage ends or the beneficiary is notified. Missing that window can mean losing the guaranteed issue right entirely and facing full medical underwriting.

Scenario

Mrs. Ito turns 65 and enrolls in Part B in April 2026. Her Medigap OEP runs April 1 – September 30, 2026. If she applies for Plan G in July, the insurer must issue the policy regardless of her health history. If she instead waits until November 2026 to apply — outside her OEP and without a qualifying GI event — the insurer may ask health questions and can deny her or charge a higher premium.