CEBS GBA 1 ACTUAL 2026 EXAM QUESTIONS AND
ANSWERS GRADED A+
✔✔Deductible - ✔✔Amount paid by the insured before the plan pays
✔✔Coinsurance - ✔✔Insured's cost share of the covered health care service.
✔✔Copay (Copayment) - ✔✔A fixed amount the insured pays when receiving a health
care service.
✔✔PCP (Primary Care Physician) - ✔✔Main physician that manages the care of the
insured. (Can be general, family, internal medicine, or OB/GYN doctor).
✔✔Referral - ✔✔PCP authorization to receive medical care from another provider -
generally a specialist.
✔✔In Network - ✔✔Has a contract with the plan to provide service for a discounted rate.
✔✔Out of Network - ✔✔Does not have a contract for provided services, and thus can
be considerably more expensive.
✔✔Allowed Amount - ✔✔Maximum amount the plan will pay for a service. May be
called 'eligible expense', 'payment allowance', or 'negotiated rate'. Generally computed
based on the common rate for a service in a geographical area.
✔✔Preventative Care - ✔✔Designated services such as immunizations, mammogram,
and cholesterol screenings covered without having a copay, deductible, or coinsurance.
✔✔PBM (Pharmaceutical Benefits Manager) - ✔✔Prescription drug coverage is carved
out and managed by _______________, who administer the plan and engage in cost
containment and disease management.
✔✔MBHO (Managed Behavioral Health Care Organization) - ✔✔Became popular in the
1980's to manage Mental Health/Substance Abuse benefits in a carve out basis.
✔✔ACA Reforms - ✔✔Expanded eligibility for medical benefits under the federal
government's program for low-income individuals, prohibited denial of benefits for
preexisting mental health conditions and placed restrictions on premium rates for low-
income coverage.
✔✔Per time Period - ✔✔Bulge and Salary - physicians are paid salary and government
hospitals are paid by budget.
✔✔Per recipient - ✔✔Contact capitation - A physician is paid for specialist services.
, ✔✔Per Beneficiary - ✔✔Capitation - Managed care organization pays a physician that is
not their employee.
✔✔Per episode - ✔✔Case rates, payment per stay, and bundled payments - the plan
pays according to doctors for a hospital stay or various services such as resource-
based providers such as a surgeon.
✔✔Per day - ✔✔Per diem, per visit - Nursing facility, outpatient services.
✔✔Per service - ✔✔Fee for service - payments are made for each service rendered in
one day. Doctors, anesthesiologists, etc.
✔✔Per dollar of cost - ✔✔Cost reimbursement - percentage of cost allowed by payer is
allowed to critical access hospital, nursing facilities, etc.
✔✔Per dollar of charges - ✔✔Payment is used for any type of provider and is
determined by the charges billed by the provider.
✔✔ACO (Accountable Care Organization) - ✔✔Generally are comprised of physicians
and hospitals that get paid a fee-for service; get paid by physician care; and have
quality and performance standards.
✔✔Medical Homes - ✔✔May be paid using traditional payment methods, but under
performance standards. May also be paid by capitation or episode.
✔✔Payment Adjustments - ✔✔Does not change basic payment method, but does apply
penalties and bonuses for readmission rates, use of electronic records, and reporting
quality measures.
✔✔Bundling - ✔✔Broadening the unit of payment by including different types of
providers and lengthening the time period for such processes and inpatient episodes
and re-admissions.
✔✔Global Payment - ✔✔Synonym for fixed budget, capitation, or payment per episode.
✔✔Patient Cost Share - ✔✔Usually allowed costs are shared by payers and patients.
The basic payment method stays in tact, but the cost sharing is restructured to
encourage cost-conscious choices.
✔✔Increased transparency - ✔✔More accessibility to the cost of services.
✔✔CDHP - ✔✔The basic philosophy was that lower premiums would be exchanged for
greater cost-sharing, which would be more attractive to low-risk enrollees.
ANSWERS GRADED A+
✔✔Deductible - ✔✔Amount paid by the insured before the plan pays
✔✔Coinsurance - ✔✔Insured's cost share of the covered health care service.
✔✔Copay (Copayment) - ✔✔A fixed amount the insured pays when receiving a health
care service.
✔✔PCP (Primary Care Physician) - ✔✔Main physician that manages the care of the
insured. (Can be general, family, internal medicine, or OB/GYN doctor).
✔✔Referral - ✔✔PCP authorization to receive medical care from another provider -
generally a specialist.
✔✔In Network - ✔✔Has a contract with the plan to provide service for a discounted rate.
✔✔Out of Network - ✔✔Does not have a contract for provided services, and thus can
be considerably more expensive.
✔✔Allowed Amount - ✔✔Maximum amount the plan will pay for a service. May be
called 'eligible expense', 'payment allowance', or 'negotiated rate'. Generally computed
based on the common rate for a service in a geographical area.
✔✔Preventative Care - ✔✔Designated services such as immunizations, mammogram,
and cholesterol screenings covered without having a copay, deductible, or coinsurance.
✔✔PBM (Pharmaceutical Benefits Manager) - ✔✔Prescription drug coverage is carved
out and managed by _______________, who administer the plan and engage in cost
containment and disease management.
✔✔MBHO (Managed Behavioral Health Care Organization) - ✔✔Became popular in the
1980's to manage Mental Health/Substance Abuse benefits in a carve out basis.
✔✔ACA Reforms - ✔✔Expanded eligibility for medical benefits under the federal
government's program for low-income individuals, prohibited denial of benefits for
preexisting mental health conditions and placed restrictions on premium rates for low-
income coverage.
✔✔Per time Period - ✔✔Bulge and Salary - physicians are paid salary and government
hospitals are paid by budget.
✔✔Per recipient - ✔✔Contact capitation - A physician is paid for specialist services.
, ✔✔Per Beneficiary - ✔✔Capitation - Managed care organization pays a physician that is
not their employee.
✔✔Per episode - ✔✔Case rates, payment per stay, and bundled payments - the plan
pays according to doctors for a hospital stay or various services such as resource-
based providers such as a surgeon.
✔✔Per day - ✔✔Per diem, per visit - Nursing facility, outpatient services.
✔✔Per service - ✔✔Fee for service - payments are made for each service rendered in
one day. Doctors, anesthesiologists, etc.
✔✔Per dollar of cost - ✔✔Cost reimbursement - percentage of cost allowed by payer is
allowed to critical access hospital, nursing facilities, etc.
✔✔Per dollar of charges - ✔✔Payment is used for any type of provider and is
determined by the charges billed by the provider.
✔✔ACO (Accountable Care Organization) - ✔✔Generally are comprised of physicians
and hospitals that get paid a fee-for service; get paid by physician care; and have
quality and performance standards.
✔✔Medical Homes - ✔✔May be paid using traditional payment methods, but under
performance standards. May also be paid by capitation or episode.
✔✔Payment Adjustments - ✔✔Does not change basic payment method, but does apply
penalties and bonuses for readmission rates, use of electronic records, and reporting
quality measures.
✔✔Bundling - ✔✔Broadening the unit of payment by including different types of
providers and lengthening the time period for such processes and inpatient episodes
and re-admissions.
✔✔Global Payment - ✔✔Synonym for fixed budget, capitation, or payment per episode.
✔✔Patient Cost Share - ✔✔Usually allowed costs are shared by payers and patients.
The basic payment method stays in tact, but the cost sharing is restructured to
encourage cost-conscious choices.
✔✔Increased transparency - ✔✔More accessibility to the cost of services.
✔✔CDHP - ✔✔The basic philosophy was that lower premiums would be exchanged for
greater cost-sharing, which would be more attractive to low-risk enrollees.
