CES Benefits Plans and Coverage 1 — Questions and Answers
Question 1: Which health plan type requires members to choose a primary care physician (PCP) and get referrals to see specialists?
- PPO
- HMO (Correct answer)
- EPO
- POS
Correct answer: HMO
HMO (Health Maintenance Organization) plans require members to designate a PCP who coordinates care and provides referrals to in-network specialists.
Question 2: What does PPO stand for in health insurance?
- Primary Provider Option
- Preferred Provider Organization (Correct answer)
- Participating Plan Option
- Premium Payment Obligation
Correct answer: Preferred Provider Organization
PPO stands for Preferred Provider Organization, offering flexibility to see in-network or out-of-network providers without referrals.
Question 3: An EPO plan differs from a PPO primarily because an EPO:
- Requires a PCP referral
- Covers out-of-network care at higher costs
- Does not cover out-of-network care except emergencies (Correct answer)
- Has no deductible
Correct answer: Does not cover out-of-network care except emergencies
An EPO (Exclusive Provider Organization) restricts coverage to in-network providers, with no out-of-network benefits except for true emergencies.
Question 4: A High Deductible Health Plan (HDHP) is typically paired with which savings vehicle?
- Flexible Spending Account (FSA)
- Health Savings Account (HSA) (Correct answer)
- Health Reimbursement Arrangement (HRA)
- 401(k)
Correct answer: Health Savings Account (HSA)
HDHPs are designed to be paired with HSAs, allowing members to save pre-tax dollars for qualified medical expenses.
Question 5: Under the ACA, which metal tier plan covers approximately 80% of expected healthcare costs on average?
- Bronze
- Silver
- Gold (Correct answer)
- Platinum
Correct answer: Gold
Gold plans have an actuarial value of about 80%, meaning the plan pays 80% of covered costs on average, leaving the member to pay 20%.
Question 6: A formulary in a health insurance plan refers to:
- The network of approved hospitals
- The list of covered prescription drugs (Correct answer)
- The schedule of copayments
- The plan's deductible structure
Correct answer: The list of covered prescription drugs
A formulary is the plan's list of covered prescription drugs, typically organized into tiers with different cost-sharing amounts.
CES Benefits Plans and Coverage 1
Which health plan type requires members to choose a primary care physician (PCP) and get referrals to see specialists?