Definition of Terms
Amount paid out-of-pocket before insurance starts covering costs
Deductible
What is the minimum age for automatic Medicare eligibility if receiving Social Security?
65
Mario is a retired mechanic who started receiving Social Security benefits at age 62. He just turned 65. What type of health insurance is he now eligible for, and how did he receive it?
Mario is eligible for Medicare, the federal health insurance program for individuals aged 65 and older. Because he was already receiving Social Security benefits, he was automatically enrolled and received his Medicare card a few months before his 65th birthday.
What is the difference between a deductible and a co-payment in a health insurance plan?
A deductible is the amount a person must pay out-of-pocket before the insurance starts covering costs. A co-payment (or co-pay) is a fixed fee paid for specific services, such as a doctor’s visit, even after the deductible is met.
Monthly payment for insurance
Premium
Which of the following is a joint federal and state program for low-income individuals?
Medicaid
Eve is a 44-year-old woman from California with a low income. She recently applied for health coverage. What program is she likely eligible for, and how is it funded?
Eve is likely eligible for Medicaid, a joint federal and state program that provides health coverage to low-income individuals. It is funded by both the federal government and the state of California.
What type of plan requires referrals and limits care to a network of providers?
A. PPO
B. EPO
C. HMO
D. POS
C. HMO
Fixed fee for specific services
Co-payment (Co-pay)
Who pays first when someone is dually eligible for Medicare and Medicaid?
Medicare
A patient qualifies for both Medicare and Medicaid. How are their healthcare costs typically managed between the two programs?
For individuals who are dually eligible, Medicare pays first for covered services. Medicaid then covers the remaining costs, such as co-pays or services not fully covered by Medicare.
Veronica is a U.S. Navy officer stationed in Virginia. What type of health insurance does she likely have?
Veronica is covered by TRICARE, a healthcare program for military personnel, retirees, and their dependents. It operates similarly to private insurance.
Percentage of costs shared after deductible is met
Co-insurance
Which program provides health coverage for children and pregnant women with income too high for Medicaid?
CHIP
Jade is a 5-year-old child whose family income is too high for Medicaid but still limited. What government-funded program might provide her with health insurance?
Jade may be eligible for the Children’s Health Insurance Program (CHIP), which provides coverage to children and pregnant women in families with incomes too high for Medicaid but still within a limited range.
Samantha is a freelance graphic designer in Oregon. She doesn’t have employer-provided insurance. How does she obtain health coverage?
Samantha purchases her health insurance through the Health Insurance Marketplace, using her state’s website to compare and select plans based on her ZIP code and income.
Cap on total spending in a year
MOOP (Maximum Out-of-Pocket)
James is concerned about how much he might have to spend on healthcare in a year. His plan mentions a MOOP of $6,000. What does this mean for him?
MOOP stands for Maximum Out-of-Pocket. It means that once James has paid $6,000 in deductibles, co-pays, and co-insurance for covered services within the plan year, his insurance will cover 100% of any additional covered healthcare costs for the rest of the year.
Carl is a software engineer working for a mid-sized tech company in Texas. He receives health insurance as part of his employment benefits. What type of insurance does he have?
Carl has private health insurance through an employer-sponsored plan, which is the most common form of coverage in the U.S.
Lena is comparing two health insurance plans: one is an HMO and the other is a PPO. She wants to keep her current doctor, who is not part of the HMO network. What should she consider when making her decision?
Lena should consider choosing the PPO plan, as it offers more flexibility in choosing healthcare providers, including those outside the network. While PPOs typically have higher premiums and out-of-pocket costs, they do not require referrals and allow her to continue seeing her current doctor.