14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training

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

14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training

Key Takeaways Explain This Topic AI

CMS requires seven core compliance elements for every MA/PDP Sponsor: written policies, a compliance officer and committee with board oversight, training, communication lines, disciplinary standards, monitoring and auditing, and prompt-response procedures.

FWA training must occur within 90 days of hire and annually thereafter, with a narrow exception for DMEPOS-accredited suppliers and Medicare Part A/B enrollees.

Non-discrimination training, grounded in ACA Section 1557, prohibits marketing, enrollment, or communication practices that disadvantage beneficiaries by race, color, national origin, sex, age, or disability.

OIG's 2025 modernized compliance guidance flags AI overreliance in risk adjustment as a new enforcement risk area, alongside access-to-care and marketing oversight.

"Prompt response to compliance issues," element seven, is the regulatory hook for corrective action plans.

Last updated: July 2026

Why This Topic Matters on the AHIP Exam

Every Medicare Advantage Organization and Part D Sponsor is legally required, under 42 CFR Section 422.503(b)(4)(vi) and Section 423.504(b)(4)(vi), to operate an "effective compliance program." AHIP tests two things from this requirement: whether you can name and describe the seven core elements CMS mandates, and whether you understand the non-discrimination training obligation that sits alongside them. Because Module 5 is 20% of the final and this is the backbone requirement underneath everything else in the module (FWA reporting, corrective action, sanctions), expect at least one or two direct "which of the following is one of the seven core elements" questions.

The Seven Core Elements of an Effective Compliance Program

CMS requires every Sponsor's compliance program to include, at minimum, these seven elements, drawn from Chapter 21 of the Medicare Managed Care Manual and Chapter 9 of the Prescription Drug Benefit Manual:

# Element What It Means in Practice

1 Written Policies, Procedures & Standards of Conduct Documented commitment to comply with federal and state law; describes expectations for ethical behavior

2 Compliance Officer, Compliance Committee & Board Oversight A designated compliance officer and committee accountable for the program; senior management and the governing body must actively oversee it, not just sign off

3 Effective Training & Education FWA and general compliance training within 90 days of hire and at least annually thereafter, for employees, governing body members, and FDRs

4 Effective Lines of Communication Hotlines, anonymous reporting channels, and a documented non-retaliation policy

5 Well-Publicized Disciplinary Standards Consistent, known consequences for noncompliance, applied fairly at every level of the organization

6 Effective System for Routine Monitoring & Auditing Ongoing, risk-based auditing, such as of claims, risk-adjustment submissions, and marketing materials

7 Procedures for Prompt Response to Compliance Issues Investigate promptly, correct the underlying problem, and prevent recurrence, which is exactly where Chapter 14.3's corrective action plans come from

A useful memory device is Policies, Officer, Training, Communication, Discipline, Monitoring, Response . If an exam option lists something that isn't one of these seven, such as "annual sales bonus structure" or "marketing budget approval," it is a distractor, not a core element.

FWA Training Requirement Details

Two specific numbers show up often on the exam: FWA and general compliance training must occur within 90 days of initial hire and at least annually thereafter . There is one narrow training exception : FDRs who already meet FWA training and education requirements through accreditation as a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier , or through enrollment in Medicare Part A or Part B , are deemed to have satisfied the FWA training obligation without repeating it separately.

Non-Discrimination Training

Alongside the seven core elements, Sponsors must also train employees and FDRs on non-discrimination obligations, most directly grounded in Section 1557 of the Affordable Care Act (ACA) , which prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in any health program receiving federal funds, squarely including Medicare Advantage and Part D. In practice, this means:

Marketing and enrollment materials cannot be designed, targeted, or withheld in a way that discourages enrollment by any protected group, such as steering healthier populations away from a plan or avoiding outreach in areas with higher disability populations;

Materials must be available in accessible formats, including large print and audio, and in languages spoken by a threshold share of the plan's service-area population, with required taglines in the top languages spoken locally;

Agents may not make assumptions about a beneficiary's needs, cognitive capacity, or preferences based on protected characteristics during a sales appointment.

A 2026 Update Worth Knowing: OIG's Modernized Compliance Guidance

In 2025, the HHS Office of Inspector General released its first major update to Medicare Advantage compliance program guidance in more than two decades, consolidating over 25 years of audit and enforcement experience into a single modernized framework. It does not replace the seven core elements, which remain the regulatory floor, but it sharpens what CMS and the OIG expect a "good" compliance program to actually do. It flags risk areas including access-to-care monitoring, such as quarterly provider-directory checks and prior-authorization turnaround times, marketing and broker-payment oversight, overreliance on artificial intelligence tools in risk-adjustment coding as a new enforcement priority, Star Ratings data integrity, and continued responsibility for vendor (FDR) conduct even when work is outsourced. Expect the exam to frame this as "which of the following is a growing compliance risk area" rather than asking you to recite the guidance verbatim.

Exam Scenario

A Sponsor's compliance officer wants to know which core element requires the plan to investigate a reported issue and fix the underlying cause, not just discipline the one employee involved. The answer is element seven, Procedures for Prompt Response to Compliance Issues , which is exactly what feeds into the corrective action plan process covered next in 14.3.

Key Takeaways

FWA training must occur within 90 days of hire and annually thereafter, with a narrow exception for DMEPOS-accredited suppliers and Medicare Part A/B enrollees.

OIG's 2025 modernized compliance guidance flags AI overreliance in risk adjustment as a new enforcement risk area, alongside access-to-care and marketing oversight.

"Prompt response to compliance issues," element seven, is the regulatory hook for corrective action plans.