GH 101 BENEFITS AND PRICING NEWEST 2025-
2026 UPDATE 100 QUESTIONS & 100% CORRECT
ANSWERS GRADED A+ (BRAND NEW!!)
MOST TESTED TOPICS:
• Group health plan structures and funding methods
• Premium rating methodologies
• Cost-sharing provisions (deductibles, copayments, coinsurance)
• Regulatory requirements affecting benefits
• Pricing factors and underwriting considerations
1. An employer chooses a self-funded health plan primarily to:
A. Transfer all financial risk to the insurer
B. Reduce administrative responsibilities
C. Assume claim risk while potentially lowering long-term costs
D. Avoid compliance with federal regulations
Self-funded plans place claim risk on the employer but may reduce premium costs
and taxes.
2. Community rating requires insurers to:
A. Set premiums based on individual health status
B. Charge the same rate to all members within a defined group
C. Adjust rates monthly based on claims
D. Exclude high-risk individuals
Community rating prohibits pricing based on health factors within the rating pool.
3. A deductible is best described as:
A. A fixed fee per service
B. The maximum out-of-pocket limit
, C. The amount paid by the insured before benefits begin
D. A penalty for out-of-network care
Deductibles must be satisfied before the plan pays most covered expenses.
4. Coinsurance refers to:
A. A flat dollar payment per visit
B. A percentage of costs shared after the deductible
C. Premium contributions by the employer
D. The annual maximum benefit
Coinsurance splits costs between insurer and insured as a percentage.
5. An HMO typically requires members to:
A. Pay full price upfront
B. Submit claims manually
C. Use a network and obtain referrals for specialists
D. Choose any provider worldwide
HMOs emphasize coordinated care within a closed network.
6. Experience rating bases premiums on:
A. Industry averages only
B. Employee salaries
C. Geographic location only
D. Past claims history of the group
Experience-rated plans reflect the group’s own utilization.
7. A copayment is:
A. A deductible replacement
B. A fixed amount paid at the time of service
C. A percentage after claims processing
D. Paid only for hospital care
Copayments are flat fees for specific services.
, 8. Stop-loss insurance protects:
A. Employees from high premiums
B. Providers from malpractice claims
C. Self-funded employers from catastrophic claims
D. Insurers from underwriting losses
Stop-loss limits the employer’s financial exposure.
9. A PPO differs from an HMO because a PPO:
A. Requires referrals
B. Has no network
C. Allows out-of-network use at higher cost
D. Eliminates cost sharing
PPOs offer flexibility with financial incentives for network use.
10.The out-of-pocket maximum limits:
A. Employer contributions
B. Annual premiums
C. Insurer profits
D. Total member cost sharing for covered services
Once reached, the plan pays 100% of covered in-network costs.
11.Guaranteed issue means:
A. Premiums cannot change
B. Coverage lasts forever
C. Insurers must offer coverage regardless of health status
D. Claims cannot be denied
This rule prevents denial based on medical conditions.
12.Preventive services are often covered:
A. Only after deductible
B. At higher coinsurance
C. With prior hospitalization
D. Without cost sharing in compliant plans
2026 UPDATE 100 QUESTIONS & 100% CORRECT
ANSWERS GRADED A+ (BRAND NEW!!)
MOST TESTED TOPICS:
• Group health plan structures and funding methods
• Premium rating methodologies
• Cost-sharing provisions (deductibles, copayments, coinsurance)
• Regulatory requirements affecting benefits
• Pricing factors and underwriting considerations
1. An employer chooses a self-funded health plan primarily to:
A. Transfer all financial risk to the insurer
B. Reduce administrative responsibilities
C. Assume claim risk while potentially lowering long-term costs
D. Avoid compliance with federal regulations
Self-funded plans place claim risk on the employer but may reduce premium costs
and taxes.
2. Community rating requires insurers to:
A. Set premiums based on individual health status
B. Charge the same rate to all members within a defined group
C. Adjust rates monthly based on claims
D. Exclude high-risk individuals
Community rating prohibits pricing based on health factors within the rating pool.
3. A deductible is best described as:
A. A fixed fee per service
B. The maximum out-of-pocket limit
, C. The amount paid by the insured before benefits begin
D. A penalty for out-of-network care
Deductibles must be satisfied before the plan pays most covered expenses.
4. Coinsurance refers to:
A. A flat dollar payment per visit
B. A percentage of costs shared after the deductible
C. Premium contributions by the employer
D. The annual maximum benefit
Coinsurance splits costs between insurer and insured as a percentage.
5. An HMO typically requires members to:
A. Pay full price upfront
B. Submit claims manually
C. Use a network and obtain referrals for specialists
D. Choose any provider worldwide
HMOs emphasize coordinated care within a closed network.
6. Experience rating bases premiums on:
A. Industry averages only
B. Employee salaries
C. Geographic location only
D. Past claims history of the group
Experience-rated plans reflect the group’s own utilization.
7. A copayment is:
A. A deductible replacement
B. A fixed amount paid at the time of service
C. A percentage after claims processing
D. Paid only for hospital care
Copayments are flat fees for specific services.
, 8. Stop-loss insurance protects:
A. Employees from high premiums
B. Providers from malpractice claims
C. Self-funded employers from catastrophic claims
D. Insurers from underwriting losses
Stop-loss limits the employer’s financial exposure.
9. A PPO differs from an HMO because a PPO:
A. Requires referrals
B. Has no network
C. Allows out-of-network use at higher cost
D. Eliminates cost sharing
PPOs offer flexibility with financial incentives for network use.
10.The out-of-pocket maximum limits:
A. Employer contributions
B. Annual premiums
C. Insurer profits
D. Total member cost sharing for covered services
Once reached, the plan pays 100% of covered in-network costs.
11.Guaranteed issue means:
A. Premiums cannot change
B. Coverage lasts forever
C. Insurers must offer coverage regardless of health status
D. Claims cannot be denied
This rule prevents denial based on medical conditions.
12.Preventive services are often covered:
A. Only after deductible
B. At higher coinsurance
C. With prior hospitalization
D. Without cost sharing in compliant plans
