Week5 Health Insurance Payers

Which factor is not permitted to affect a person's premium under the ACA's community‑rating rules?

A - Health status

B - Geographic location

C - Age

D - Tobacco use

A - Health status

Which term describes the situation where healthier individuals leave the risk pool, causing premiums to rise for the remaining, higher‑risk members?

A - Capitation

B - Moral hazard

C - Information asymmetry

D - Adverse selection

D - Adverse selection

In a staff‑model HMO, which statement best describes the relationship between physicians, the insurer, and facilities?

A - Physicians belong to a multispecialty group that contracts with the insurer and retains separate ownership of clinics

B - Physicians are employed by the insurer and facilities are owned by the insurer

C - Physicians are paid per service but the insurer does not own any facilities

D - Physicians are independent contractors who may see non-HMO patients for a fee

B - Physicians are employed by the insurer and facilities are owned by the insurer

A 70‑year‑old retiree enrolls in Medicare. Which Medicare part specifically covers physician services and outpatient preventive care?

A - Part B

B - Part A

C - Part C

D - Part D

A - Part B

Under the ACA, what is the minimum Medical Loss Ratio (MLR) that large‑group health plans must meet?

A - 75%

B - 80%

C - 90%

D - 85%

D - 85%

A large employer contracts with an insurer that pays a fixed $500 per employee each month regardless of the amount of medical care each employee actually uses. Which term best describes this payment arrangement?

A - Capitation

B - Fee-for-service

C - Co-payment

D - Risk adjustment

A - Capitation

A state Medicaid agency plans to add dental coverage for adult enrollees. Under Medicaid rules, this dental coverage would be classified as what type of benefit?

A - An optional (state-specific) benefit

B - A supplemental private-insurance benefit

C - A federal entitlement benefit

D - A mandatory (required) benefit

A - An optional (state-specific) benefit

What is the typical federal matching rate for a state's Medicaid expenditures?

A - 85%

B - 57%

C - 45%

D - 70%

B - 57%

Which type of consumer‑driven health plan pairs a high‑deductible health plan with a tax‑advantaged savings account that rolls over unused funds year‑to‑year?

A - Medical Savings Trust (MST)

B - Flexible Spending Account (FSA)

C - Health Savings Account (HSA)

D - Health Reimbursement Arrangement (HRA)

C - Health Savings Account (HSA)

A healthy employee enrolls in a plan that covers all preventive visits with no co‑pay, so he begins to schedule extra check‑ups each month. Which economic concept best explains this increased utilization?

A - Moral hazard

B - Information asymmetry

C - Adverse selection

D - Risk pooling

A - Moral hazard

Which of the following services is not included in the mandatory Medicaid benefit package?

A - Nursing facility services

B - Clinic services

C - Physician services

D - Inpatient hospital services

B - Clinic services

Three small employers, each with 100 low‑risk employees, join together to purchase a single health‑insurance group. What is the most likely effect on each employee's premium?

A - Premiums will stay the same; risk is unchanged for each individual

B - Premiums will become variable, reflecting each employee's individual health status

C - Premiums will decrease because the larger risk pool reduces the average cost per person

D - Premiums will increase because the insurers face higher administrative complexity

C - Premiums will decrease because the larger risk pool reduces the average cost per person

An HMO contracts with an Integrated Delivery Network (IDN) that includes hospitals, physicians, and ancillary services, and requires members to stay within that network for full coverage. Which HMO structural model is this?

A - Staff Model

B - Group Model

C - Open-Panel Model

D - Network Model

D - Network Model

After satisfying the annual deductible, a patient pays 20% of each subsequent medical bill while the insurer pays the remaining 80%. Which cost‑sharing mechanism is this?

A - Out-of-pocket maximum

B - Deductible

C - Co-pay

D - Co-insurance

D - Co-insurance

Emily, a 68‑year‑old Medicare beneficiary, wants coverage for her prescription cholesterol medication. Which Medicare component should she enroll in to obtain drug coverage?

A - Medicare Part B

B - Medicare Part D

C - Medicare Part A

D - Medicare Part C

B - Medicare Part D

Which of the following consumer-driven health plans is typically paired with a high-deductible health plan but does not allow funds to roll over from year to year?

A - Health Savings Account (HSA)

B - Health Reimbursement Arrangement (HRA)

C - Flexible Spending Account (FSA)

D - Medicare Advantage (MA)

C - Flexible Spending Account (FSA)

A Fortune 500 company with 5,000 employees secures a health‑plan premium that is 15 % lower than the premium offered to a small firm with 100 employees, even though the benefit design is identical. Which economic concept best explains this lower premium?

A - Adverse selection

B - Risk-pooling

C - Buying power

D - Moral hazard

C - Buying power

Which of the following is not a mandatory eligibility requirement for Medicaid?

A - Elderly individuals below 75% FPL

B - Pregnant women below 133% FPL

C - Elderly individuals below 133% FPL

C - Pregnant women below 75%% FPL

C - Elderly individuals below 133% FPL