Life & Health Insurance Health Insurance Fundamentals Questions and Answers

Question 1

An insured has a health insurance plan with a $1,000 deductible and 20% coinsurance. If the insured incurs a covered medical expense of $5,000, how much will the insurance company pay?

Accepted Answer

$3,200

Answer

$3,000

Answer

$4,000

Answer

$5,000

Question 2

Which of the following health insurance plans typically requires the policyholder to select a Primary Care Physician (PCP) and obtain a referral to see a specialist?

Accepted Answer

Health Maintenance Organization (HMO)

Answer

Preferred Provider Organization (PPO)

Answer

Exclusive Provider Organization (EPO)

Answer

Indemnity Plan

Question 3

A couple has a child covered under both of their group health insurance plans. The father's birthday is March 15th, and the mother's birthday is July 22nd. According to the 'birthday rule' for coordination of benefits, which plan is considered primary for the child's claims?

Accepted Answer

The father's plan, because his birthday occurs earlier in the calendar year.

Answer

The mother's plan, because she is the female parent.

Answer

The plan that has been in effect the longest.

Answer

The parents can choose which plan is primary.

Question 4

Which provision in a health insurance policy prevents the insurer from denying a claim due to misstatements on the application after the policy has been in force for a specific period, typically two years?

Accepted Answer

Incontestable Clause

Answer

Grace Period

Answer

Reinstatement

Answer

Entire Contract Clause

Question 5

The Affordable Care Act (ACA) requires that most health insurance plans cover a set of 'Essential Health Benefits.' Which of the following is NOT considered one of the ten essential health benefits?

Accepted Answer

Cosmetic surgery

Answer

Prescription drugs

Answer

Maternity and newborn care

Answer

Mental health and substance use disorder services

Question 6

An individual has a health plan with a feature that allows them to see providers both in and out-of-network, but with higher cost-sharing for out-of-network services. They are not required to have a PCP or get referrals. What type of plan does this most likely describe?

Accepted Answer

Preferred Provider Organization (PPO)

Answer

Health Maintenance Organization (HMO)

Answer

Exclusive Provider Organization (EPO)

Answer

Point of Service (POS)