PEARSON VUE NATIONAL HEALTH INSURANCE EXAM
ACTUAL EXAM 2025/2026 | COMPLETE QUESTIONS AND
CORRECT ANSWERS | BRAND NEW VERSION!
Question 1
Which of the following terms refers to the amount an insured person must
pay out-of-pocket before their health insurance plan begins to pay for
medical expenses?
A) Premium
B) Co-payment
C) Deductible
D) Co-insurance
E) Out-of-pocket maximum
Correct Answer: C) Deductible
Rationale: A deductible is the specific amount of money an insured
individual must pay for covered medical services before their
insurance plan starts to pay.
Question 2
What is a fixed amount that an insured person pays for a covered health care
service after they've paid their deductible, often paid at the time of service?
A) Premium
B) Co-payment
C) Co-insurance
D) Deductible
E) Out-of-pocket maximum
Correct Answer: B) Co-payment
Rationale: A co-payment, or co-pay, is a fixed amount for a covered
service, paid by the patient to the provider at the time the service is
rendered, after the deductible has been met.
Question 3
Which term describes the percentage of costs an insured person pays for
covered healthcare services after they've met their deductible?
A) Premium
,B) Co-payment
C) Co-insurance
D) Deductible
E) Out-of-pocket maximum
Correct Answer: C) Co-insurance
Rationale: Co-insurance is the percentage of a covered healthcare
service's cost that the insured person pays after their deductible
has been met, with the insurance company paying the remaining
percentage.
Question 4
The highest amount a health insurance plan will pay for a covered service in
a plan year is known as the:
A) Deductible
B) Co-payment limit
C) Co-insurance cap
D) Out-of-pocket maximum
E) Annual premium
Correct Answer: D) Out-of-pocket maximum
Rationale: The out-of-pocket maximum is the most an insured person
will have to pay for covered services in a plan year. Once this limit is
reached, the insurance company typically pays 100% of additional
covered costs.
Question 5
What is the regular amount paid by the insured to the insurance company in
exchange for health insurance coverage?
A) Deductible
B) Co-payment
C) Co-insurance
D) Premium
E) Claim
,Correct Answer: D) Premium
Rationale: A premium is the amount of money an individual or
business pays for an insurance policy. Health insurance premiums
are typically paid monthly or annually.
Question 6
Which type of health insurance plan typically requires members to choose a
primary care physician (PCP) and obtain referrals to see specialists?
A) Preferred Provider Organization (PPO)
B) Health Maintenance Organization (HMO)
C) Exclusive Provider Organization (EPO)
D) Point of Service (POS)
E) Indemnity Plan
Correct Answer: B) Health Maintenance Organization (HMO)
Rationale: Health Maintenance Organizations (HMOs) are known for
requiring members to select a PCP, who then acts as a gatekeeper
for referrals to specialists and other services within the network.
Question 7
A health insurance plan that offers a larger network of providers than an
HMO and allows members to see specialists without a referral, but may have
higher out-of-pocket costs for out-of-network care, is a:
A) Health Maintenance Organization (HMO)
B) Exclusive Provider Organization (EPO)
C) Point of Service (POS)
D) Preferred Provider Organization (PPO)
E) Indemnity Plan
Correct Answer: D) Preferred Provider Organization (PPO)
Rationale: Preferred Provider Organizations (PPOs) offer flexibility in
choosing providers, including specialists without referrals, and
generally have broader networks than HMOs. However, out-of-
network care typically incurs higher costs.
, Question 8
Which health insurance plan combines features of both HMOs and PPOs,
allowing members to choose between a restricted network with lower costs
or a broader network with higher out-of-pocket expenses?
A) Health Maintenance Organization (HMO)
B) Exclusive Provider Organization (EPO)
C) Point of Service (POS)
D) Preferred Provider Organization (PPO)
E) High-Deductible Health Plan (HDHP)
Correct Answer: C) Point of Service (POS)
Rationale: Point of Service (POS) plans offer a choice at the "point of
service" between using the plan's network (similar to an HMO, often
with a PCP and referrals) or going outside the network (similar to a
PPO, but with higher out-of-pocket costs).
Question 9
Under the Affordable Care Act (ACA), which of the following is NOT
considered an Essential Health Benefit (EHB)?
A) Maternity and newborn care
B) Prescription drugs
C) Dental care for adults
D) Mental health and substance use disorder services
E) Preventive and wellness services
Correct Answer: C) Dental care for adults
Rationale: While dental care for children is an EHB, adult dental care
is not mandated as an EHB under the Affordable Care Act. EHBs
include categories like hospitalization, ambulatory patient services,
emergency services, maternity/newborn care, mental
health/substance use, prescription drugs, rehabilitative/habilitative
services, lab services, preventive/wellness services, and pediatric
services (including oral and vision care).
ACTUAL EXAM 2025/2026 | COMPLETE QUESTIONS AND
CORRECT ANSWERS | BRAND NEW VERSION!
Question 1
Which of the following terms refers to the amount an insured person must
pay out-of-pocket before their health insurance plan begins to pay for
medical expenses?
A) Premium
B) Co-payment
C) Deductible
D) Co-insurance
E) Out-of-pocket maximum
Correct Answer: C) Deductible
Rationale: A deductible is the specific amount of money an insured
individual must pay for covered medical services before their
insurance plan starts to pay.
Question 2
What is a fixed amount that an insured person pays for a covered health care
service after they've paid their deductible, often paid at the time of service?
A) Premium
B) Co-payment
C) Co-insurance
D) Deductible
E) Out-of-pocket maximum
Correct Answer: B) Co-payment
Rationale: A co-payment, or co-pay, is a fixed amount for a covered
service, paid by the patient to the provider at the time the service is
rendered, after the deductible has been met.
Question 3
Which term describes the percentage of costs an insured person pays for
covered healthcare services after they've met their deductible?
A) Premium
,B) Co-payment
C) Co-insurance
D) Deductible
E) Out-of-pocket maximum
Correct Answer: C) Co-insurance
Rationale: Co-insurance is the percentage of a covered healthcare
service's cost that the insured person pays after their deductible
has been met, with the insurance company paying the remaining
percentage.
Question 4
The highest amount a health insurance plan will pay for a covered service in
a plan year is known as the:
A) Deductible
B) Co-payment limit
C) Co-insurance cap
D) Out-of-pocket maximum
E) Annual premium
Correct Answer: D) Out-of-pocket maximum
Rationale: The out-of-pocket maximum is the most an insured person
will have to pay for covered services in a plan year. Once this limit is
reached, the insurance company typically pays 100% of additional
covered costs.
Question 5
What is the regular amount paid by the insured to the insurance company in
exchange for health insurance coverage?
A) Deductible
B) Co-payment
C) Co-insurance
D) Premium
E) Claim
,Correct Answer: D) Premium
Rationale: A premium is the amount of money an individual or
business pays for an insurance policy. Health insurance premiums
are typically paid monthly or annually.
Question 6
Which type of health insurance plan typically requires members to choose a
primary care physician (PCP) and obtain referrals to see specialists?
A) Preferred Provider Organization (PPO)
B) Health Maintenance Organization (HMO)
C) Exclusive Provider Organization (EPO)
D) Point of Service (POS)
E) Indemnity Plan
Correct Answer: B) Health Maintenance Organization (HMO)
Rationale: Health Maintenance Organizations (HMOs) are known for
requiring members to select a PCP, who then acts as a gatekeeper
for referrals to specialists and other services within the network.
Question 7
A health insurance plan that offers a larger network of providers than an
HMO and allows members to see specialists without a referral, but may have
higher out-of-pocket costs for out-of-network care, is a:
A) Health Maintenance Organization (HMO)
B) Exclusive Provider Organization (EPO)
C) Point of Service (POS)
D) Preferred Provider Organization (PPO)
E) Indemnity Plan
Correct Answer: D) Preferred Provider Organization (PPO)
Rationale: Preferred Provider Organizations (PPOs) offer flexibility in
choosing providers, including specialists without referrals, and
generally have broader networks than HMOs. However, out-of-
network care typically incurs higher costs.
, Question 8
Which health insurance plan combines features of both HMOs and PPOs,
allowing members to choose between a restricted network with lower costs
or a broader network with higher out-of-pocket expenses?
A) Health Maintenance Organization (HMO)
B) Exclusive Provider Organization (EPO)
C) Point of Service (POS)
D) Preferred Provider Organization (PPO)
E) High-Deductible Health Plan (HDHP)
Correct Answer: C) Point of Service (POS)
Rationale: Point of Service (POS) plans offer a choice at the "point of
service" between using the plan's network (similar to an HMO, often
with a PCP and referrals) or going outside the network (similar to a
PPO, but with higher out-of-pocket costs).
Question 9
Under the Affordable Care Act (ACA), which of the following is NOT
considered an Essential Health Benefit (EHB)?
A) Maternity and newborn care
B) Prescription drugs
C) Dental care for adults
D) Mental health and substance use disorder services
E) Preventive and wellness services
Correct Answer: C) Dental care for adults
Rationale: While dental care for children is an EHB, adult dental care
is not mandated as an EHB under the Affordable Care Act. EHBs
include categories like hospitalization, ambulatory patient services,
emergency services, maternity/newborn care, mental
health/substance use, prescription drugs, rehabilitative/habilitative
services, lab services, preventive/wellness services, and pediatric
services (including oral and vision care).
