Q: Which formula represents the calculation for a premium under experience rating?

Premium = $$\text{Average cost of claims for the group} + \text{Administrative costs}$$

Question 1

Which of the following best describes the relationship between health care financing and access to health services?

Accepted Answer

Access to health services is largely dependent on the method and adequacy of health care financing.

Question 2

Which tax is considered a 'prepayment' for services you will receive through Medicare at age 65?

Accepted Answer

Payroll tax (FICA)

Question 3

What is the primary purpose of insurance at its core?

Accepted Answer

To mitigate/protect against financial risk

Question 4

Which of the following is NOT one of the four principles of insurance?

Accepted Answer

Guaranteed profit

Question 5

A patient has a health insurance plan with a $$500 deductible, 20% co-insurance, and an out-of-pocket maximum of 2$$,000. If the patient incurs $3,000 in covered medical expenses, how much will the patient pay out-of-pocket?

Accepted Answer

The patient pays $$500 deductible plus 20% of the remaining 2$$,500: $$500 + (0.20 	imes 2$$,500) = $$500 + 500$$ = $1,000.

Question 6

Which formula represents the calculation for a premium under experience rating?

Accepted Answer

Premium = $$	ext{Average cost of claims for the group} + 	ext{Administrative costs}$$

Question 7

Which of the following best describes the difference between an HMO and a PPO?

Accepted Answer

HMOs require members to use network providers and obtain referrals for specialists, while PPOs allow more flexibility in provider choice and do not require referrals.

Question 8

High-Deductible Health Plans (HDHPs) are designed to:

Accepted Answer

Decrease premiums and increase out-of-pocket costs.

Question 9

HDHPs can be paired with which type of account to help cover out-of-pocket/high deductible costs?

Accepted Answer

Health Savings Account (HSA)

Question 10

Medicare was established under which Act and Title?

Accepted Answer

Social Security Act, Title XVIII

Question 11

Medicaid was established under which Act and Title?

Accepted Answer

Social Security Act, Title XIX

Question 12

Which of the following statements correctly distinguishes Medicare from Medicaid?

Accepted Answer

Medicare is federally funded and administered for the elderly and disabled; Medicaid is state-administered and federally funded for low-income individuals.

Question 13

Which service is covered under Medicare Part A?

Accepted Answer

Inpatient hospital care

Question 14

What is MediGap insurance?

Accepted Answer

A private insurance policy that helps cover costs not paid by Medicare

Question 15

CHIP provides health coverage for children in families with incomes too high to qualify for ______ but too low to afford ______ coverage.

Accepted Answer

Medicaid; private

Question 16

What is the primary health insurance program for military personnel, retirees, and their families?

Accepted Answer

TRICARE

Question 17

The Veterans Health Administration (VHA) operates the largest integrated health system in the U.S., offering services to veterans through a network of facilities and programs. Which Act aims to improve access to care for veterans by allowing them to seek services outside of the VA system when necessary?

Accepted Answer

Veterans Access, Choice, and Accountability Act

Question 18

Which trend has been observed in employment-based health insurance among small employers?

Accepted Answer

A decline in offering health insurance, with many workers preferring higher wages over benefits.

Question 19

If a group insurance plan uses community rating, which formula best describes how premiums are calculated?

Accepted Answer

Premium = $$	ext{Total cost for all insured in the community} \div 	ext{Number of insured}$$

Question 20

A patient is covered by a private insurance plan with a $$1,000 deductible, 10% co-insurance, and an out-of-pocket maximum of 5$$,000. If the patient has $10,000 in medical expenses, how much will the insurance pay?

Accepted Answer

Insurance pays $$10,000 - 1$$,000 = $$9,000$$; patient pays 10% of $$9,000 = 900$, so insurance pays 9$$,000 - $$900 = 8$$,100$

Medical Terminology Study Guide: Health Insurance & Financing Concepts

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