Question 1

A health maintenance organization (HMO) pays each contracted primary care physician a fixed monthly amount for every enrolled member, regardless of how many times those members are actually treated. What is this reimbursement method called?

Accepted Answer

Capitation pays providers a set per-member, per-month amount regardless of the volume of services rendered, which is the hallmark prepaid financing method used by HMOs to control costs.

Question 2

Under a traditional HMO, before an enrollee can see a dermatologist or other specialist, what must generally happen first?

Accepted Answer

In an HMO the primary care physician acts as a gatekeeper, and a referral from that PCP is normally required before the member can receive care from a specialist.

Question 3

Which statement best distinguishes a Preferred Provider Organization (PPO) from a traditional HMO?

Accepted Answer

A PPO lets members use out-of-network providers while paying more out of pocket, and unlike an HMO it does not require a gatekeeper or referrals to see specialists.

Question 4

A point-of-service (POS) plan is best described as which of the following?

Accepted Answer

A POS plan is a hybrid: it uses a primary care physician/gatekeeper and lowest costs in-network like an HMO, but also allows members to seek out-of-network care at higher cost like a PPO.

Question 5

How does an Exclusive Provider Organization (EPO) typically differ from a PPO?

Accepted Answer

An EPO restricts covered care to its network and, aside from emergencies, does not pay for out-of-network services, though it usually does not require PCP referrals like an HMO.

Question 6

To be eligible to open and contribute to a Health Savings Account (HSA), an individual must be covered by what type of plan?

Accepted Answer

HSA eligibility requires enrollment in a qualifying high-deductible health plan (HDHP) and that the person not have other disqualifying coverage or be enrolled in Medicare.

Question 7

The "triple tax advantage" of a Health Savings Account refers to which combination of benefits?

Accepted Answer

An HSA offers a triple tax benefit: contributions are tax-deductible, earnings grow tax-deferred, and distributions used for qualified medical expenses are tax-free.

Question 8

Which of the following is a key advantage an HSA has over a typical Flexible Spending Account (FSA)?

Accepted Answer

HSAs are owned by the individual, are fully portable, and unused balances roll over each year, whereas a traditional FSA is subject to a use-it-or-lose-it rule and unused funds are generally forfeited.

Question 9

Under the Affordable Care Act, a plan covering essential health benefits may NOT do which of the following?

Accepted Answer

The ACA prohibits lifetime and annual dollar limits on essential health benefits, though plans may still use networks, age-based premiums within limits, and normal cost-sharing.

Question 10

Under the Affordable Care Act, until what age must a group or individual health plan that offers dependent coverage allow an adult child to remain on a parent's policy?

Accepted Answer

The ACA requires plans offering dependent coverage to allow adult children to stay on a parent's plan until age 26, regardless of the child's marital, student, or residency status.

Question 11

The ACA metal tiers (Bronze, Silver, Gold, Platinum) primarily categorize marketplace plans according to what?

Accepted Answer

Metal tiers reflect actuarial value, the percentage of total covered medical costs a plan is expected to pay on average, with Bronze paying the least and Platinum the most, while all tiers cover the same essential health benefits.

Question 12

Outside of a qualifying life event, when can an individual generally enroll in an ACA marketplace health plan?

Accepted Answer

Enrollment in a marketplace plan is normally limited to the annual open enrollment period; outside that window a person needs a qualifying life event to trigger a special enrollment period, and the ACA bars preexisting-condition exclusions.

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