6.4 MA Benefits, MOOP & Supplemental Benefits

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

6.4 MA Benefits, MOOP & Supplemental Benefits

Key Takeaways Explain This Topic AI

Every Medicare Advantage plan must cover, at minimum, everything Original Medicare Part A and Part B cover (excluding hospice, which generally remains billed through Original Medicare even for MA enrollees).

For 2026, the CMS-mandated maximum out-of-pocket (MOOP) limit is $9,250 for in-network services; PPO plans must also set a combined in-network/out-of-network MOOP no higher than $13,900.

Part D cost-sharing does NOT count toward the MA plan's MOOP — only Part A/B in-network cost-sharing applies.

Standard supplemental benefits must be 'primarily health related' and offered to all enrollees in a plan, while Special Supplemental Benefits for the Chronically Ill (SSBCI) can be limited to enrollees with qualifying chronic conditions.

The VBID (Value-Based Insurance Design) demonstration model ended after CY2025 — benefits it used to fund (like grocery allowances) are increasingly offered through SSBCI instead for 2026.

Last updated: July 2026

Why This Topic Matters

Beyond plan type (HMO, PPO, SNP, etc.), every Medicare Advantage plan operates under the same floor of required benefits and the same cost-protection guardrail: the maximum out-of-pocket (MOOP) limit. This is one of the most concrete, numbers-driven parts of Module 2 — the exam wants agents to know exactly what a plan must cover, what a client's worst-case annual cost exposure looks like, and which extra benefits a plan can restrict to specific enrollees versus which it must offer to everyone.

Quick Answer: MA plans must cover everything Original Medicare Parts A and B cover (except hospice), and must cap in-network cost-sharing at a CMS-mandated MOOP — $9,250 for 2026. Supplemental benefits beyond that floor are either open to all enrollees (if "primarily health related") or, for chronically ill enrollees only, offered as Special Supplemental Benefits for the Chronically Ill (SSBCI).

The Minimum Benefit Floor

Every MA plan must provide, at minimum, all benefits covered under Original Medicare Part A (hospital insurance) and Part B (medical insurance) — this is the core statutory promise of Medicare Advantage: an enrollee cannot receive less coverage than Original Medicare provides. There is one well-known and heavily tested exception: hospice care generally continues to be billed through Original Medicare Part A even for a beneficiary enrolled in an MA plan, rather than through the MA plan itself. This trips up agents who assume the MA plan handles every Part A/B service without exception — hospice is the standard carve-out to memorize.

Beyond that floor, plans commonly add:

Reduced cost-sharing (lower copays than Original Medicare for some services)

Extra benefits Original Medicare doesn't cover at all , such as routine dental, vision, and hearing exams and hardware

Care coordination extras , like a nurse hotline or case management for complex conditions
Maximum Out-of-Pocket (MOOP): The 2026 Numbers

CMS requires every MA plan to set an annual cap on in-network cost-sharing — once an enrollee hits that number, the plan pays 100% of covered Part A/B services for the rest of the year. This is a real, quantifiable protection Original Medicare alone does not have (Original Medicare has no cap; a Medigap policy is the traditional way to protect against that gap).

MOOP Component 2026 Mandatory Maximum
In-network MOOP (all MA plan types) $9,250
Combined in-network + out-of-network MOOP (PPO plans only) $13,900

Two details the exam likes to test:

Plans can set a lower MOOP than the mandatory maximum (and most do — the average in-network MOOP across MA enrollees is well below $9,250), but no plan can set one higher.

Only Part A/B in-network cost-sharing counts toward the MOOP. Part D drug cost-sharing (deductibles, copays in the coverage phases) does not count toward the MA plan's MOOP — Part D has its own separate out-of-pocket cap, covered in Chapter 7.

For a PPO, out-of-network spending only counts toward the higher combined limit, not the in-network limit — so a PPO enrollee who exclusively sees in-network providers will hit the $9,250 ceiling and stop paying, while one who mixes in- and out-of-network care tracks against the $13,900 combined ceiling.

Supplemental Benefits: Two Different Rulebooks

Not every extra benefit follows the same rule, and this distinction is a common source of exam confusion:

Benefit Category Who Can Receive It Standard
Standard supplemental benefits Every enrollee in the plan Must be "primarily health related"

Special Supplemental Benefits for the Chronically Ill (SSBCI) Only enrollees with a qualifying chronic condition and evidence the benefit will improve/maintain health or function Can include some non-medical benefits (like healthy food, home modifications, or pest control) tied to a documented health need

SSBCI exists because Congress recognized (via the CHRONIC Care Act of 2018) that certain non-traditional benefits — home-delivered meals, transportation, healthy food, home safety modifications — can measurably improve outcomes for high-risk chronically ill members specifically, even though they wouldn't qualify as "primarily health related" benefits for the general population.

The 2026 Shift: VBID Sunset, SSBCI Expansion

A detail agents recertifying from a prior year's AHIP training will want to update: the Value-Based Insurance Design (VBID) demonstration model — which many plans used to fund benefits like grocery or utility allowances — ended after CY2025 . For 2026, plans are increasingly shifting those same kinds of benefits into the SSBCI framework instead, meaning access is now tied to a documented qualifying chronic condition rather than being available demonstration-wide. One other 2026 guardrail worth remembering: SSBCI cannot be used to offer $0 cost-sharing on prescription drugs — that restriction is new for plan year 2026.

Exam Scenario

A client without any chronic condition asks whether her MA plan's $0-copay grocery allowance (which she saw advertised last year) still applies to her. Because that benefit was funded through the now-ended VBID demonstration and has likely been restructured as an SSBCI benefit for 2026, she would need a qualifying chronic condition and documented health need to access it — it is no longer a benefit available to the general enrolled population the way it may have been under VBID.