GBA3 EXAM 2025 QUESTIONS AND
ANSWERS
Indemnity plan / traditioanl / fee for service - ANS originally covered catastrophic (inpatient)
then added outpatient, diagnostic, physican services no permission needed.. pay a % of
treatment.
managed care - ANS insurance carriers have a role in steering health services and care while
prepaying some portion of health care services., all but replaced indemnities
common types of health plans: - ANS hmo, ppo, pos, hdhp
HMO description - ANS pcp, he chooses speciality care, copays for oop and specialist visits,
no claim for reimbursement, no oon except for emergency
ppo vs pos - ANS primary care provider requirement by a POS but not by a PPO, lower copay
amounts for preferred care in a POS than in a PPO, and a smaller network of providers to
choose from in a POS than in a PPO.
ppo description - ANS limited beneifts outside of network, no referral or pcp requirement,
sometimes have tiers within preferred network
pos plan - ANS hybrid of ppo hmo, individual may need to select pcp to obtain referrals , no
reimbursent file, oop is copays in netork, oon is %
1 COPYRIGHT © 2025 SIRJOEL ALL RIGHTS RESERVED
, hdhp plan - ANS catastrophic insurance, lower premium costs for higher deductible, by
paying after insured has lot of oop expenses, high deductible with lots of
fsa, hra and hsa - ANS fsa: select $ from pre tax basis for IRS-qualified medical expenses. can
enroll regardless of health plan insurance and employers may contribute, usually lost $
hra: employer funded to pay health care expenses as determined by employer, rarely roll over
contribution
hsa: owned by employer, grows and keeps with you, tax free until 65 when take out for non
medical expenses its for income tax
deductible, coinsurance, copay, pcp, referral - ANS you know these.. but referral is An
authorization or prior approval from a primary care provider to receive medical care from
another provider
in network provider vs oon provider (preferred vs nonpreferred) - ANS some plans may have
tiered network with varying oop expenses , but in network provider has contract with
insurance, oon doesn't
Out-of-pocket expense maximum - ANS most a member can pay during the plan year (or CY)
before health insurance pays 100% (never includes insurance premiums paid, balance-billed
charges or expenses for care services not covered by the health plan.)
ucr & allowed amount - ANS terms used by health plans to determine the maximum amount
the plan will pay for covered health care service, also "eligible expense, payment allowance or
negotiated rate
For OON, if the provider charges more than the allowed amount by the health plan, the
provider can charge the member for the difference.
2 COPYRIGHT © 2025 SIRJOEL ALL RIGHTS RESERVED
ANSWERS
Indemnity plan / traditioanl / fee for service - ANS originally covered catastrophic (inpatient)
then added outpatient, diagnostic, physican services no permission needed.. pay a % of
treatment.
managed care - ANS insurance carriers have a role in steering health services and care while
prepaying some portion of health care services., all but replaced indemnities
common types of health plans: - ANS hmo, ppo, pos, hdhp
HMO description - ANS pcp, he chooses speciality care, copays for oop and specialist visits,
no claim for reimbursement, no oon except for emergency
ppo vs pos - ANS primary care provider requirement by a POS but not by a PPO, lower copay
amounts for preferred care in a POS than in a PPO, and a smaller network of providers to
choose from in a POS than in a PPO.
ppo description - ANS limited beneifts outside of network, no referral or pcp requirement,
sometimes have tiers within preferred network
pos plan - ANS hybrid of ppo hmo, individual may need to select pcp to obtain referrals , no
reimbursent file, oop is copays in netork, oon is %
1 COPYRIGHT © 2025 SIRJOEL ALL RIGHTS RESERVED
, hdhp plan - ANS catastrophic insurance, lower premium costs for higher deductible, by
paying after insured has lot of oop expenses, high deductible with lots of
fsa, hra and hsa - ANS fsa: select $ from pre tax basis for IRS-qualified medical expenses. can
enroll regardless of health plan insurance and employers may contribute, usually lost $
hra: employer funded to pay health care expenses as determined by employer, rarely roll over
contribution
hsa: owned by employer, grows and keeps with you, tax free until 65 when take out for non
medical expenses its for income tax
deductible, coinsurance, copay, pcp, referral - ANS you know these.. but referral is An
authorization or prior approval from a primary care provider to receive medical care from
another provider
in network provider vs oon provider (preferred vs nonpreferred) - ANS some plans may have
tiered network with varying oop expenses , but in network provider has contract with
insurance, oon doesn't
Out-of-pocket expense maximum - ANS most a member can pay during the plan year (or CY)
before health insurance pays 100% (never includes insurance premiums paid, balance-billed
charges or expenses for care services not covered by the health plan.)
ucr & allowed amount - ANS terms used by health plans to determine the maximum amount
the plan will pay for covered health care service, also "eligible expense, payment allowance or
negotiated rate
For OON, if the provider charges more than the allowed amount by the health plan, the
provider can charge the member for the difference.
2 COPYRIGHT © 2025 SIRJOEL ALL RIGHTS RESERVED
