ACA Essential Health Benefits & Plan Types 2 — Questions and Answers
Question 1: Which of the following is an Essential Health Benefit mandated by the ACA?
- Acupuncture and alternative medicine
- Prescription drug coverage (Correct answer)
- Long-term care services
- Vision care for adults
Correct answer: Prescription drug coverage
Prescription drugs are one of the 10 mandated EHBs; alternative medicine, long-term care, and adult vision care are not required EHBs.
Question 2: What does an HMO (Health Maintenance Organization) typically require of its members?
- Seeing any provider without referrals
- Choosing a primary care physician and obtaining referrals for specialists (Correct answer)
- Paying higher premiums for broader network access
- Equal coverage for out-of-network and in-network providers
Correct answer: Choosing a primary care physician and obtaining referrals for specialists
HMOs require members to select a primary care physician (PCP) who coordinates care and must provide referrals for specialist visits to be covered.
Question 3: What best describes an Exclusive Provider Organization (EPO)?
- A plan that covers out-of-network care at any cost level
- A plan requiring referrals for all specialist visits
- A plan that only covers in-network care except in emergencies (Correct answer)
- A plan exclusively offered to large employer groups
Correct answer: A plan that only covers in-network care except in emergencies
EPOs restrict coverage to in-network providers except for emergency care, but unlike HMOs, they typically do not require specialist referrals.
Question 4: What does 'actuarial value' represent in an ACA health plan?
- The maximum premium an insurer can charge
- The percentage of total covered healthcare costs the plan pays on average (Correct answer)
- The annual deductible a member must satisfy before coverage begins
- The standard copay amount for primary care visits
Correct answer: The percentage of total covered healthcare costs the plan pays on average
Actuarial value is the percentage of total covered healthcare expenses that the plan pays for a standard population of enrollees.
Question 5: Which plan type typically offers the MOST provider flexibility but usually has higher monthly premiums?
- HMO
- EPO
- PPO (Correct answer)
- HDHP
Correct answer: PPO
PPOs allow members to see any provider, including out-of-network providers, without a referral, offering the most flexibility at typically higher premium costs.
Question 6: A Health Savings Account (HSA) can be used in conjunction with which type of ACA health plan?
- Any Bronze plan
- An HSA-qualified High-Deductible Health Plan (HDHP) (Correct answer)
- Any HMO plan
- A Platinum plan
Correct answer: An HSA-qualified High-Deductible Health Plan (HDHP)
HSAs are only available to individuals enrolled in IRS-qualified HDHPs that meet the minimum deductible and maximum out-of-pocket thresholds set by the IRS.
Question 7: What is the primary advantage of a Bronze plan for a relatively healthy individual?
- Lower deductibles than other metal tiers
- Lower out-of-pocket maximums
- Lower monthly premiums (Correct answer)
- Access to a wider provider network
Correct answer: Lower monthly premiums
Bronze plans offer the lowest monthly premiums of all metal tiers, making them cost-effective for individuals who rarely use healthcare services.
ACA Essential Health Benefits & Plan Types 2
Which of the following is an Essential Health Benefit mandated by the ACA?