HIM 400 Ch. 2 U.S. Health Insurance & Managed Care Exam: Individual Health
Insurance, Employer-Based Coverage, HSAs, FSAs, HRAs, Risk Pools, Adverse
Selection, Policyholders, Beneficiaries, Premiums, Cost-Sharing Provisions,
Deductibles, Copayments, Coinsurance, Tiered Benefits, Covered Conditions,
Exclusions, Medically Necessary Care, Prudent Layperson Standard, Eligibility,
Guaranteed Issue, Waiting Periods, Enrollment, Open Enrollment, Special
Enrollment Periods, Qualifying Life Events, Benefit Period, Maximum Out-of-
Pocket, Prior Authorization, Coordination of Benefits, Other Party Liability,
Appeals, Claims, Managed Care, HMOs, PPOs, POS, EPOs, Gatekeepers, Case
Management, Prescription Management, Formularies, Prospective
Reimbursement, Withhold Amounts, Positive and Negative Financial Incentives,
Utilization Review, and Cost-Effective Care Strategies Exam Questions Verified
and Provided with Complete A+ Graded Rationales Latest Updated 2026
individual health insurance
purchased by individual or family from an insurance agency
employer-based health insurance
individual or family obtains as part of an employment benefits package; plans that cover groups
(ex: farm bureau)
health savings account (HSA)
,like a savings account, but money deposited can only be used for healthcare expenses; the
employee and the employer may contribute; money at the end of the year can roll over
flexible spending account (FSA)
like and HSA and is pre-taxes, but unused money cannot be rolled over
healthcare, limited expense, and dependent
what are the three types of FSAs?
health reimbursement account (HRA)
health reimbursement arrangements; only employer-funded; unused amounts may roll over
risk pool
group of individual entities, (Indviduals, employers, associations) whose healthcare costs are
combined for evaluating financial history and estimating future costs
larger risk pool
higher expense generating individuals spread across many lower expense generating individuals
smaller risk pool
not a wide range of diversity so can't spread the expense, so are at risk for adverse selection
, adverse selection
enrollment of an excessive proportion of persons with poor health status
benefits
covered services; healthcare services for which the insurance company will pay as outlined in
the policy
policyholder
individual or entity that purchased the health insurance plan; alternative terminology includes
insured, certificate holder, member, subscriber, and beneficiary
premiums
payments that the policyholder must make to an insurer in return for healthcare coverage
cost sharing provisions
out-of-pocket expenses that the insured must pay
deductible
an annual amount of money that the policy holder must pay before the insurance will assume
its share of liability
Insurance, Employer-Based Coverage, HSAs, FSAs, HRAs, Risk Pools, Adverse
Selection, Policyholders, Beneficiaries, Premiums, Cost-Sharing Provisions,
Deductibles, Copayments, Coinsurance, Tiered Benefits, Covered Conditions,
Exclusions, Medically Necessary Care, Prudent Layperson Standard, Eligibility,
Guaranteed Issue, Waiting Periods, Enrollment, Open Enrollment, Special
Enrollment Periods, Qualifying Life Events, Benefit Period, Maximum Out-of-
Pocket, Prior Authorization, Coordination of Benefits, Other Party Liability,
Appeals, Claims, Managed Care, HMOs, PPOs, POS, EPOs, Gatekeepers, Case
Management, Prescription Management, Formularies, Prospective
Reimbursement, Withhold Amounts, Positive and Negative Financial Incentives,
Utilization Review, and Cost-Effective Care Strategies Exam Questions Verified
and Provided with Complete A+ Graded Rationales Latest Updated 2026
individual health insurance
purchased by individual or family from an insurance agency
employer-based health insurance
individual or family obtains as part of an employment benefits package; plans that cover groups
(ex: farm bureau)
health savings account (HSA)
,like a savings account, but money deposited can only be used for healthcare expenses; the
employee and the employer may contribute; money at the end of the year can roll over
flexible spending account (FSA)
like and HSA and is pre-taxes, but unused money cannot be rolled over
healthcare, limited expense, and dependent
what are the three types of FSAs?
health reimbursement account (HRA)
health reimbursement arrangements; only employer-funded; unused amounts may roll over
risk pool
group of individual entities, (Indviduals, employers, associations) whose healthcare costs are
combined for evaluating financial history and estimating future costs
larger risk pool
higher expense generating individuals spread across many lower expense generating individuals
smaller risk pool
not a wide range of diversity so can't spread the expense, so are at risk for adverse selection
, adverse selection
enrollment of an excessive proportion of persons with poor health status
benefits
covered services; healthcare services for which the insurance company will pay as outlined in
the policy
policyholder
individual or entity that purchased the health insurance plan; alternative terminology includes
insured, certificate holder, member, subscriber, and beneficiary
premiums
payments that the policyholder must make to an insurer in return for healthcare coverage
cost sharing provisions
out-of-pocket expenses that the insured must pay
deductible
an annual amount of money that the policy holder must pay before the insurance will assume
its share of liability
