HSA4109 KEY TERMS EVALUATION QUESTIONS WITH
SOLUTIONS 2025 GRADED A+
✔✔Copayment - ✔✔A fixed amount that you pay each time you get a medical service
after reaching your deductible.
✔✔Cost Sharing - ✔✔Out-of-pocket expenses that you pay including copayments,
coinsurance, and deductibles.
✔✔Deductible - ✔✔The amount an individual must spend out-of-pocket before an
insurance company will pay for services.
✔✔Death Spiral - ✔✔When adverse selection becomes a problem for an insurance
company, the members become sicker and sicker, eventually forcing the company out
of business.
✔✔Employer Mandate - ✔✔Affordable Care Act (ACA) requirement that all employers
with 50 or more employees must provide minimum essential health coverage to all full-
time employees (those who work 30 or more hours per week).
✔✔Essential Health Benefits (EHB) - ✔✔Set of 10 categories of healthcare services
that must be covered by health insurance plans, as required by the Affordable Care Act
(ACA). These include: inpatient and outpatient services; prescription drugs; mental
health services; and dental and vision services for children.
✔✔Exclusive Provider Organization (EPO) - ✔✔Type of managed care organization that
is a hybrid of a preferred provider organization (PPO) and a health maintenance
organization (HMO). Members must use in-network providers for services; but members
do not require referrals from primary care providers (PCPs) to see specialists.
✔✔Fee-for-Service - ✔✔Method of service delivery and financing where providers are
paid for each service performed, and patients have the freedom to choose the providers
they see. "Fee for service" plans are also known as "indemnity" plans.
✔✔Health Insurance Policy - ✔✔Contract between insured/member/policy holder and
the health plan/insurance company/insurer that the insurer will accept financial risk,
administer benefits, and pay claims on behalf of the member; and the member will
prepay a fixed amount to cover the healthcare costs in the event that a catastrophic
episode occurs.
✔✔In-Network (IN) - ✔✔Providers that have contracted with a managed care
organization. These providers may be also be called "preferred providers" or
"participating providers."
, ✔✔Individual Mandate - ✔✔Affordable Care Act (ACA) requirement that all individuals
must have health insurance coverage. The initial law included a penalty for individuals
who did not have health insurance. However, this penalty was eliminated beginning with
the 2019 coverage year.
✔✔Large Group - ✔✔Health insurance plans for large employers (those who have 51 or
more full-time employees).
✔✔Managed Care - ✔✔Method of service delivery and financing where the health plan
manages the cost, utilization, and quality of care. Patients are limited on the providers
that they can see, and the services they receive, to improve efficiencies and the cost of
healthcare.
✔✔Maximum Out-of-Pocket (MOOP) - ✔✔Once this limit on out-of-pocket spending is
met, the insurance company begins to pay 100% for covered services. Members no
longer have to pay any deductibles, coinsurance, copayments, or similar charges
beyond this amount.
✔✔Off-Exchange Insurance Products - ✔✔Health insurance products that are not
purchased through health insurance exchange; instead, these products can be
purchased through insurance agents, brokers, or directly from an insurance company.
✔✔On-Exchange Insurance Products - ✔✔Health insurance products that are
purchased through health insurance exchange.
✔✔Open Enrollment Period (OEP) - ✔✔The time period when individuals can enroll in a
health plan.
✔✔Out-of-Network (OON) - ✔✔Providers that have not contracted with a managed care
organization.
✔✔Payer - ✔✔An individual or organization (such as an individual, employer, health
insurance company, or the government) who pays for healthcare services.
✔✔Point-of-Service (POS) - ✔✔Type of managed care organization that is a hybrid of a
preferred provider organization (PPO) and a health maintenance organization (HMO).
Members may have some out-of-network coverage, but these plans require members to
designate a primary care provider (PCP).
✔✔Premium - ✔✔Monthly fixed payment to an insurance company for healthcare
coverage.
✔✔Preferred Provider Organization (PPO) - ✔✔Type of managed care organization
where members may receive care out-of-network without a referral for an additional
SOLUTIONS 2025 GRADED A+
✔✔Copayment - ✔✔A fixed amount that you pay each time you get a medical service
after reaching your deductible.
✔✔Cost Sharing - ✔✔Out-of-pocket expenses that you pay including copayments,
coinsurance, and deductibles.
✔✔Deductible - ✔✔The amount an individual must spend out-of-pocket before an
insurance company will pay for services.
✔✔Death Spiral - ✔✔When adverse selection becomes a problem for an insurance
company, the members become sicker and sicker, eventually forcing the company out
of business.
✔✔Employer Mandate - ✔✔Affordable Care Act (ACA) requirement that all employers
with 50 or more employees must provide minimum essential health coverage to all full-
time employees (those who work 30 or more hours per week).
✔✔Essential Health Benefits (EHB) - ✔✔Set of 10 categories of healthcare services
that must be covered by health insurance plans, as required by the Affordable Care Act
(ACA). These include: inpatient and outpatient services; prescription drugs; mental
health services; and dental and vision services for children.
✔✔Exclusive Provider Organization (EPO) - ✔✔Type of managed care organization that
is a hybrid of a preferred provider organization (PPO) and a health maintenance
organization (HMO). Members must use in-network providers for services; but members
do not require referrals from primary care providers (PCPs) to see specialists.
✔✔Fee-for-Service - ✔✔Method of service delivery and financing where providers are
paid for each service performed, and patients have the freedom to choose the providers
they see. "Fee for service" plans are also known as "indemnity" plans.
✔✔Health Insurance Policy - ✔✔Contract between insured/member/policy holder and
the health plan/insurance company/insurer that the insurer will accept financial risk,
administer benefits, and pay claims on behalf of the member; and the member will
prepay a fixed amount to cover the healthcare costs in the event that a catastrophic
episode occurs.
✔✔In-Network (IN) - ✔✔Providers that have contracted with a managed care
organization. These providers may be also be called "preferred providers" or
"participating providers."
, ✔✔Individual Mandate - ✔✔Affordable Care Act (ACA) requirement that all individuals
must have health insurance coverage. The initial law included a penalty for individuals
who did not have health insurance. However, this penalty was eliminated beginning with
the 2019 coverage year.
✔✔Large Group - ✔✔Health insurance plans for large employers (those who have 51 or
more full-time employees).
✔✔Managed Care - ✔✔Method of service delivery and financing where the health plan
manages the cost, utilization, and quality of care. Patients are limited on the providers
that they can see, and the services they receive, to improve efficiencies and the cost of
healthcare.
✔✔Maximum Out-of-Pocket (MOOP) - ✔✔Once this limit on out-of-pocket spending is
met, the insurance company begins to pay 100% for covered services. Members no
longer have to pay any deductibles, coinsurance, copayments, or similar charges
beyond this amount.
✔✔Off-Exchange Insurance Products - ✔✔Health insurance products that are not
purchased through health insurance exchange; instead, these products can be
purchased through insurance agents, brokers, or directly from an insurance company.
✔✔On-Exchange Insurance Products - ✔✔Health insurance products that are
purchased through health insurance exchange.
✔✔Open Enrollment Period (OEP) - ✔✔The time period when individuals can enroll in a
health plan.
✔✔Out-of-Network (OON) - ✔✔Providers that have not contracted with a managed care
organization.
✔✔Payer - ✔✔An individual or organization (such as an individual, employer, health
insurance company, or the government) who pays for healthcare services.
✔✔Point-of-Service (POS) - ✔✔Type of managed care organization that is a hybrid of a
preferred provider organization (PPO) and a health maintenance organization (HMO).
Members may have some out-of-network coverage, but these plans require members to
designate a primary care provider (PCP).
✔✔Premium - ✔✔Monthly fixed payment to an insurance company for healthcare
coverage.
✔✔Preferred Provider Organization (PPO) - ✔✔Type of managed care organization
where members may receive care out-of-network without a referral for an additional
