Free South Carolina Health Insurance Practice Exam Online

Correct answer: B. A PPO typically allows members to see out-of-network providers at a higher cost-sharing level, and generally does not require a referral to see a specialist

Correct. PPO plans generally offer more flexibility than HMOs: members can usually see out-of-network providers (at higher cost-sharing) and typically do not need a PCP referral to see a specialist.

• A: PPOs typically do provide some level of out-of-network benefit, just at reduced reimbursement compared to in-network care, rather than excluding it entirely.
• C: The strict gatekeeper/referral requirement is characteristic of HMO plans, not the defining feature of a PPO.
• D: PPO plans are sold in both the individual and group markets, not exclusively as a group product.

Correct answer: B. Group health insurance covers members of a defined group (such as employees) under a single master contract, with underwriting typically done at the group level rather than for each member individually

Correct. A group health plan is written under a single master contract covering eligible members of a defined group, with underwriting generally focused on the group as a whole (group size, industry, experience) rather than medically underwriting each individual member.

• A: Cost depends on risk pooling, plan design, and market factors; group coverage is not automatically more expensive than individual coverage, and the comparison varies.
• C: Group coverage is available to many types of employer and association groups, not solely government employees.
• D: Individual major medical policies commonly include prescription drug coverage as an essential health benefit under the ACA.

Correct answer: B. The PCP generally acts as a gatekeeper, coordinating care and providing referrals to specialists within the network

Correct. HMO plans typically require members to select a primary care physician who coordinates care and provides referrals to in-network specialists, helping manage cost and continuity of care.

• A: HMO structure specifically relies on the PCP for care coordination, unlike more open-access plan designs.
• C: Members generally select their own PCP from the plan's network, rather than having one assigned with no ability to change.
• D: The PCP is a treating physician providing and coordinating medical care, not merely a billing function.

Correct answer: B. The percentage split of covered costs between the insurer and the insured after the deductible is met (for example, the plan pays 80% and the insured pays 20%)

Correct. Coinsurance is the percentage-based cost-sharing arrangement between insurer and insured that applies to covered expenses after the deductible has been satisfied.

• A: A flat dollar amount per visit describes a copayment, not coinsurance.
• C: The amount paid before coverage begins describes the deductible, a separate cost-sharing feature from coinsurance.
• D: Coinsurance is a cost-sharing mechanism for covered claims, not a late-payment penalty.

Correct answer: B. Insurers offering ACA-compliant individual and small-group plans generally cannot deny coverage or charge higher premiums based on an applicant's pre-existing health conditions

Correct. The ACA requires guaranteed issue and prohibits medical underwriting based on pre-existing conditions for ACA-compliant individual and small-group major medical plans; premiums may vary only by limited factors such as age, tobacco use, geography, and family size.

• A: This describes the pre-ACA underwriting practice that guaranteed-issue and community rating rules under the ACA were specifically designed to eliminate for ACA-compliant plans.
• C: There is no five-year pre-existing condition waiting period under ACA-compliant plans; coverage applies from the effective date without such exclusions.
• D: The ACA's pre-existing condition protections apply broadly, not solely to children.