Health Insurance and Health Care Financing
What the exam tests
Health Insurance and Health Care Financing tests cost-sharing mechanics, managed-care networks, ACA market rules, HSA eligibility, and coordination of benefits. Expect calculations involving deductibles, coinsurance, and out-of-pocket maximums.
Core rules
- Cost sharing includes deductible, coinsurance, copayments, and the out-of-pocket maximum. Premiums are not part of the out-of-pocket maximum.
- In-network preventive care generally must be covered without cost sharing under ACA rules.
- HMO typically requires referrals and in-network care; PPO uses a network with higher out-of-network costs; EPO has no out-of-network coverage except emergencies; POS combines HMO and PPO features.
- ACA market plans must cover essential health benefits, guarantee issue, and cannot impose annual or lifetime dollar limits on essential benefits. Metal tiers reflect actuarial value, not quality.
- HSAs require a qualifying high-deductible health plan, no disqualifying coverage, and no Medicare enrollment.
- COBRA continuation, HIPAA special enrollment, and coordination of benefits determine which plan pays first.
Worked example
A claim is $12,000. The deductible is $2,000, coinsurance is 20%, and the out-of-pocket maximum is $6,000. The insured pays the $2,000 deductible, then 20% of the remaining $10,000 = $2,000. Total member cost is $4,000, below the $6,000 maximum, so the insurer pays $8,000. If the claim were $30,000, the 20% share would be $5,600, but the member total would cap at $6,000.
Traps that cost marks
Do not confuse a copay with coinsurance. Do not apply the deductible to preventive care that must be first-dollar. Do not assume an out-of-pocket maximum includes premiums. A general-purpose FSA can disqualify HSA contributions.