Page 1 of 43
NEW CERTIFIED ENROLLER EXAM|
COVERED CALIFORNIA NEW MODIFIED
EXAM STUDY GUIDEQUESTIONS WITH
CORRECT ANSWERS
How does a PPO health insurance plan work? -- ANSWER--It
contracts with participating doctors and hospitals to create a network.
Out-of-Network providers charge more than a plan's allowed amount,
and the member is responsible for 100% of all costs in excess of the
allowed amount.
What does EPO stand for in healthcare? -- ANSWER--Exclusive
Provider Organization
How are out-of-network services handled in an EPO? -- ANSWER-
Not covered except for emergency care, plan-approved care, or if a
needed specialist is not in network
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How is care provided in an EPO? -- ANSWER--By the EPO network
of doctors, specialists, and hospitals
Do EPO members need a referral from a PCP to see an in-network
specialist? -- ANSWER--No, they don't need a referral
What is coinsurance? -- ANSWER--A type of cost sharing in which a
member pays for a medical service after meeting a deductible.
What is considered Coinsurance? -- ANSWER--A consumer's share of
the cost of a covered health care service, as a percentage.
What is a copayment (copay)? -- ANSWER--The fixed dollar amount
the member pays for a covered health care service. Usually paid when
the service is received.
What document outlines both covered and excluded services, which
are benefits not covered by the health insurance plan? -- ANSWER--
Evidence of Coverage
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What is a Summary of Benefits and Coverage? -- ANSWER-provides
a description of the coverage, including any amount the member has
to pay for services they use, such as deductibles, coinsurance, and
copays. It also contains exceptions, reductions, or limitations under
the coverage.
What is a list of covered prescription drugs, also called a "drug list"? -
- ANSWER--Formulary
What is "Out-of-Pocket Maximum/Out-of-Pocket Limit"? --
ANSWER--The most a consumer pays during the year before their
insurance plans pays 100% of the allowed amount.
What does HMO stand for? -- ANSWER--Health Maintenance
Organization
, Page 4 of 43
What is a key characteristic of HMOs regarding member care? --
ANSWER--Members need to select a PCP to provide and coordinate
their care
What is the role of a PCP in an HMO? -- ANSWER--PCP issues
referrals for members to see other doctors, except in urgent or
emergency care situations
How does an HMO handle out-of-network care? -- ANSWER--HMOs
typically do not cover the cost of out-of-network care
What does PPO stand for? -- ANSWER--Preferred Provider
Organization
What to expect after enrollment? -- ANSWER--- Important benefit
information
- Provide instructions on how to use their health coverage
NEW CERTIFIED ENROLLER EXAM|
COVERED CALIFORNIA NEW MODIFIED
EXAM STUDY GUIDEQUESTIONS WITH
CORRECT ANSWERS
How does a PPO health insurance plan work? -- ANSWER--It
contracts with participating doctors and hospitals to create a network.
Out-of-Network providers charge more than a plan's allowed amount,
and the member is responsible for 100% of all costs in excess of the
allowed amount.
What does EPO stand for in healthcare? -- ANSWER--Exclusive
Provider Organization
How are out-of-network services handled in an EPO? -- ANSWER-
Not covered except for emergency care, plan-approved care, or if a
needed specialist is not in network
,Page 2 of 43
How is care provided in an EPO? -- ANSWER--By the EPO network
of doctors, specialists, and hospitals
Do EPO members need a referral from a PCP to see an in-network
specialist? -- ANSWER--No, they don't need a referral
What is coinsurance? -- ANSWER--A type of cost sharing in which a
member pays for a medical service after meeting a deductible.
What is considered Coinsurance? -- ANSWER--A consumer's share of
the cost of a covered health care service, as a percentage.
What is a copayment (copay)? -- ANSWER--The fixed dollar amount
the member pays for a covered health care service. Usually paid when
the service is received.
What document outlines both covered and excluded services, which
are benefits not covered by the health insurance plan? -- ANSWER--
Evidence of Coverage
,Page 3 of 43
What is a Summary of Benefits and Coverage? -- ANSWER-provides
a description of the coverage, including any amount the member has
to pay for services they use, such as deductibles, coinsurance, and
copays. It also contains exceptions, reductions, or limitations under
the coverage.
What is a list of covered prescription drugs, also called a "drug list"? -
- ANSWER--Formulary
What is "Out-of-Pocket Maximum/Out-of-Pocket Limit"? --
ANSWER--The most a consumer pays during the year before their
insurance plans pays 100% of the allowed amount.
What does HMO stand for? -- ANSWER--Health Maintenance
Organization
, Page 4 of 43
What is a key characteristic of HMOs regarding member care? --
ANSWER--Members need to select a PCP to provide and coordinate
their care
What is the role of a PCP in an HMO? -- ANSWER--PCP issues
referrals for members to see other doctors, except in urgent or
emergency care situations
How does an HMO handle out-of-network care? -- ANSWER--HMOs
typically do not cover the cost of out-of-network care
What does PPO stand for? -- ANSWER--Preferred Provider
Organization
What to expect after enrollment? -- ANSWER--- Important benefit
information
- Provide instructions on how to use their health coverage
