CES Benefits Plans and Coverage

Question 1

Which health plan type requires members to choose a primary care physician (PCP) and get referrals to see specialists?

Accepted Answer

HMO

Answer

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?

Accepted Answer

Preferred Provider Organization

Answer

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:

Accepted Answer

Does not cover out-of-network care except emergencies

Answer

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?

Accepted Answer

Health Savings Account (HSA)

Answer

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?

Accepted Answer

Gold

Answer

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%.

CES - Certified Enrollment Specialist Practice Test