17 Free Washington Life & Health Practice Questions: Medical Plans, Group Health and Senior Coverage (2026)
How to Use This Medical Plans, Group Health and Senior Coverage Set
Three outline sections feed this set: Medical Plans with 6 items, Group Health Insurance with 4, and Health Insurance for Senior Citizens and Special Needs Individuals with 5. Each is small, but the topics repeat across questions and the wrong options are built from the right answers to neighbouring questions.
The questions below cover group eligibility and enrollment, managed care plan types, coordination of benefits, stop-loss, COBRA, Medicare supplement and Medicare Advantage rules. Learn the plan types as a set: who needs a referral, who pays for out-of-network care, and who is primary when two plans overlap.
Medical Plans has 6 items, Group Health Insurance has 4 items and Health Insurance for Senior Citizens and Special Needs Individuals has 5 items on the PSI combined Life and Disability outline.
Practice Questions 1-6: Group Enrollment, Managed Care, Coordination and Stop-Loss
Late enrollment in a non-contributory group, HMO against PPO, which plan pays first, what a stop-loss provision does, outpatient benefits and open enrollment.
Question 1 (Chapter 8)
A Washington employer offers a group health plan that is non-contributory, meaning the employer pays 100% of the premiums. An employee declines coverage when first eligible but later wants to enroll during the plan year. What is the most likely requirement for the employee to enroll?
- A) The employee can enroll immediately without any restrictions.
- B) The employee can enroll only if they experience a qualifying life event.
- C) The employee must wait until the next open enrollment period to enroll.
- D) The employee must provide evidence of insurability to enroll mid-year.
Show answer & explanation
Answer: B
In a non-contributory group health plan, employees who decline coverage when first eligible can only enroll later if they experience a qualifying life event (such as marriage, birth of a child, or loss of other coverage) or during the annual open enrollment period. Mid-year enrollment without a qualifying event is not permitted, and evidence of insurability is not typically required for group health enrollment. Option A is incorrect because enrollment is not immediate; Option C is incomplete because it ignores qualifying life events; Option D is incorrect because group health plans do not require evidence of insurability for enrollment.
Question 2 (Chapter 8)
A Washington resident is comparing an HMO and a PPO plan. Which statement accurately describes a key difference between these two types of managed care plans?
- A) Both HMOs and PPOs require a referral from a primary care physician to see a specialist.
- B) HMOs require members to use in-network providers except in emergencies, while PPOs allow out-of-network use at a higher cost.
- C) PPOs typically have lower premiums than HMOs because they have more restrictive provider networks.
- D) HMOs do not have deductibles, while PPOs always have high deductibles to offset flexibility.
Show answer & explanation
Answer: B
HMOs generally require members to receive care from in-network providers and use a gatekeeper (primary care physician) for specialist referrals, with coverage typically unavailable for out-of-network care except in emergencies. PPOs offer more flexibility, allowing members to see out-of-network providers, albeit at a higher cost-sharing rate, and usually do not require referrals for specialists. Option A is incorrect because PPOs do not require referrals; Option C is incorrect because PPOs usually have higher premiums than HMOs due to greater flexibility; Option D is incorrect because both plan types can have deductibles, and HMOs are not deductible-free by design.
Question 3 (Chapter 8)
A Washington employer offers a group health plan with a coordination of benefits (COB) provision. An employee is covered under both their employer's plan and their spouse's employer's plan. If the employee incurs a medical claim, which plan is typically considered the primary payer under standard COB rules?
- A) The plan that has covered the employee for the longer period of time is primary.
- B) The plan with the higher annual benefit limit is primary.
- C) The plan that the employee enrolled in most recently is primary.
- D) The plan where the employee is the main policyholder (not as a dependent) is primary.
Show answer & explanation
Answer: D
Under standard coordination of benefits rules, the plan that covers the individual as an employee (or policyholder) is primary, while the plan that covers them as a dependent is secondary. This is known as the 'non-dependent' or 'primary subscriber' rule. Options A, B, and C are incorrect because length of coverage, benefit limits, and enrollment timing do not determine primary status under standard COB guidelines.
Question 4 (Chapter 8)
A Washington resident is reviewing their group health plan's summary of benefits and sees a 'stop-loss' provision. What is the purpose of this provision?
- A) To limit the amount the insurance company pays for a single claim.
- B) To eliminate the deductible after a certain number of hospitalizations.
- C) To reduce the premium if the insured remains claim-free for a year.
- D) To cap the insured's out-of-pocket expenses for covered services in a given period.
Show answer & explanation
Answer: D
A stop-loss provision in a health plan sets a maximum limit on the insured's out-of-pocket payments (such as deductibles and coinsurance) for covered services during a specified period (usually a year). Once this limit is reached, the plan pays 100% of covered services for the remainder of the period. It does not limit the insurer's payments (that would be a lifetime or annual maximum), nor does it eliminate deductibles or reduce premiums based on claims history.
Question 5 (Chapter 8)
A Washington resident has a health insurance policy that includes outpatient benefits. Which of the following services would most likely be covered under the outpatient benefits provision?
- A) Same-day colonoscopy performed at an ambulatory surgical center
- B) Inpatient surgery requiring a 3-day hospital stay
- C) Skilled nursing facility care after a hip fracture
- D) Hospice care in a dedicated facility
Show answer & explanation
Answer: A
Outpatient benefits cover medical services that do not require an overnight hospital stay, such as same-day procedures, diagnostic tests, and treatments performed at ambulatory surgical centers, clinics, or physician offices. A same-day colonoscopy at an ambulatory surgical center is a classic example of an outpatient service. Options B, C, and D describe inpatient or residential care that requires an overnight stay and would be covered under inpatient or extended care benefits, not outpatient benefits.
Question 6 (Chapter 8)
A Washington employer with 50 employees offers a contributory group health plan where employees pay 30% of the premium. An employee who waived coverage during initial eligibility wants to enroll during the annual open enrollment period. What must the employee do to enroll?
- A) Enroll during the open enrollment period without evidence of insurability.
- B) Provide evidence of insurability.
- C) Wait until a qualifying life event occurs.
- D) Pay the full premium for the first year as a penalty for late enrollment.
Show answer & explanation
Answer: A
During the annual open enrollment period, eligible employees may enroll in or change their group health plan coverage without providing evidence of insurability, regardless of prior waiver. Option B is incorrect because evidence of insurability is not required during open enrollment. Option C is incorrect because open enrollment is a specific period that does not require a qualifying event. Option D is incorrect; there is no penalty premium for late enrollment during open enrollment.
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Practice Questions 7-12: Medigap, COBRA, End-Stage Renal Disease and Medicare Advantage
Medicare supplement benefits, COBRA duration after divorce, Medicare and employer plans for ESRD, out-of-network reimbursement, Medicare Advantage drug coverage and stop-loss.
Question 7 (Chapter 8)
A Washington resident with Original Medicare (Parts A and B) is considering enrolling in a Medicare Supplement (Medigap) Plan G. Which of the following statements about Plan G is accurate?
- A) Plan G covers the Medicare Part B deductible.
- B) Plan G covers the Medicare Part A deductible and 100% of Part B coinsurance after the deductible is met.
- C) Plan G includes prescription drug coverage under Part D.
- D) Plan G is only available to individuals under age 65 who qualify for Medicare due to disability.
Show answer & explanation
Answer: B
B is correct. Medigap Plan G pays the Part A hospital deductible, Part A coinsurance, Part B coinsurance and copayments in full once the Part B deductible has been met, Part B excess charges, blood and foreign-travel emergency care. A is wrong because no plan sold to people newly eligible after 2020 covers the Part B deductible. C is wrong because drug coverage comes from Part D, never a Medigap plan. D is wrong because Plan G is available to anyone enrolled in Parts A and B, whatever their age.
Question 8 (Chapter 8)
Under HIPAA's portability provisions, a Washington resident loses group health coverage due to divorce. They have 60 days to elect continuation coverage under COBRA. If they elect COBRA, how long can they maintain coverage?
- A) 18 months
- B) 24 months
- C) 36 months
- D) Until they remarry or obtain other coverage
Show answer & explanation
Answer: C
Under COBRA, divorce is a qualifying event that allows the spouse to elect continuation coverage. The maximum duration of COBRA coverage due to divorce is 36 months. Options A and B are incorrect durations for this qualifying event. Option D is incorrect; COBRA coverage has a fixed maximum duration and is not contingent on remarriage or obtaining other coverage (though coverage may be terminated early if those events occur).
Question 9 (Chapter 8)
A Washington resident is eligible for Medicare due to end-stage renal disease (ESRD). They enroll in Medicare and also have employer group health coverage from a job with 25 employees. Which statement about coordination of benefits is correct?
- A) The employer group health plan is primary for the first 30 months of eligibility.
- B) Medicare is always the primary payer for ESRD patients.
- C) The employer group health plan is primary, and Medicare is secondary.
- D) Medicare is secondary only if the employer has fewer than 20 employees.
Show answer & explanation
Answer: A
A is correct. For a person entitled to Medicare because of end-stage renal disease, the employer group health plan pays first during a coordination period of up to 30 months, after which Medicare becomes primary. This rule applies regardless of the employer's size. B ignores the coordination period, C makes the group plan primary permanently, and D applies the 20-employee test that governs age-based Medicare, not ESRD.
Question 10 (Chapter 8)
A Washington resident is enrolled in a Preferred Provider Organization (PPO) plan. They receive care from an out-of-network provider and submit a claim for reimbursement. Which statement accurately describes how the plan typically processes this claim?
- A) The plan reimburses the full amount charged by the provider.
- B) The plan reimburses based on the negotiated in-network rate, and the resident is responsible for the difference.
- C) The plan denies the claim because out-of-network care is not covered.
- D) The plan reimburses based on the usual, customary, and reasonable (UCR) rate for the service in the geographic area.
Show answer & explanation
Answer: D
In a PPO plan, out-of-network claims are typically reimbursed based on the usual, customary, and reasonable (UCR) rate for the service in the geographic area, not the actual charge or the in-network negotiated rate. The resident is responsible for any amount exceeding the UCR rate, plus any applicable cost-sharing (e.g., coinsurance based on the UCR rate). Option A is incorrect because plans do not reimburse the full charged amount. Option B describes a common misconception; reimbursement is not based on the in-network rate. Option C is incorrect because PPOs do cover out-of-network care, albeit at a lower level. Option D correctly describes the UCR-based reimbursement standard.
Question 11 (Chapter 8)
A Washington resident is enrolled in a Medicare Advantage (Part C) plan that does not include prescription drug coverage. The resident wants to add drug coverage. Which of the following is true about their options?
- A) They can add drug coverage by purchasing a Medicare Supplement (Medigap) policy.
- B) They can keep the Medicare Advantage plan and enroll in a Medicare Part D plan alongside it.
- C) They are not eligible for prescription drug coverage while enrolled in a Medicare Advantage plan.
- D) They can only add drug coverage by switching to a different Medicare Advantage plan that includes it.
Show answer & explanation
Answer: D
D is correct. A beneficiary in a Medicare Advantage HMO or PPO that has no drug benefit cannot add a stand-alone Part D plan; drug coverage comes only by switching to an Advantage plan that includes it (MA-PD). A is wrong because Medigap policies carry no drug benefit and cannot be combined with Advantage plans. B describes the rule for Original Medicare and for Advantage private fee-for-service or medical savings account plans, not for an HMO or PPO. C is wrong because drug coverage is available by changing plans.
Question 12 (Chapter 8)
A Washington employer offers a group health plan with a stop-loss provision. An employee incurs a large medical claim that exceeds the plan's stop-loss attachment point. What happens next?
- A) The employee must pay 100% of the costs above the attachment point.
- B) The employer must purchase additional insurance to cover the excess.
- C) The plan pays 100% of covered services for the remainder of the plan year after the attachment point is reached.
- D) The employee is automatically disenrolled from the plan.
Show answer & explanation
Answer: C
A stop-loss provision in a group health plan caps the employee's out-of-pocket expenses. Once the employee's paid amount (deductible + coinsurance) reaches the attachment point (stop-loss limit), the plan pays 100% of covered services for the remainder of the plan year. Options A, B, and D are incorrect: the employee does not pay excess costs, the employer does not need to buy additional insurance (unless it's a self-funded plan with specific stop-loss insurance, but the question refers to the plan provision), and enrollment is not terminated.
Practice Questions 13-17: Preventive Care, Moving, Gatekeepers, POS Plans and Self-Funding
No cost-sharing preventive services, a Medicare Advantage member who moves, the gatekeeper, POS referrals and individual stop-loss in a self-funded plan.
Question 13 (Chapter 8)
A Washington employer offers a group health plan with a summary of benefits that states preventive care services are covered with no cost-sharing. Which of the following services is most likely to be covered under this provision?
- A) Treatment for a broken leg
- B) Prescription medication for diabetes
- C) Emergency room visit for chest pain
- D) Annual mammogram for breast cancer screening
Show answer & explanation
Answer: D
Preventive care services are those aimed at preventing illness or detecting it early, before symptoms appear. Under the Affordable Care Act and standard group health plans, preventive services such as annual mammograms, colonoscopies, vaccinations, and wellness visits are covered with no cost-sharing (no deductible, copay, or coinsurance) when provided by an in-network provider. Treatment for a broken leg, prescription medication for diabetes, and an emergency room visit for chest pain are all treatments for existing conditions or symptoms and are not considered preventive care.
Question 14 (Chapter 8)
A Washington resident is enrolled in a Medicare Advantage (Part C) plan that includes prescription drug coverage (MA-PD). They move to a new state where their current plan is not available. Which of the following is true about their options?
- A) They can keep their current plan regardless of location, as Medicare Advantage plans are nationwide.
- B) They are eligible for a Special Enrollment Period to enroll in a new Medicare Advantage or Part D plan available in the new state.
- C) They must switch to Original Medicare and can then enroll in a standalone Part D plan in the new state.
- D) They are automatically enrolled in the Medicare Advantage plan with the lowest premium in the new state.
Show answer & explanation
Answer: B
When a Medicare Advantage plan enrollee moves out of their plan's service area, they lose eligibility for that plan due to geographic restrictions. This move triggers a Special Enrollment Period (SEP), during which the individual can enroll in a new Medicare Advantage plan (with or without drug coverage) or a standalone Medicare Part D plan that is available in their new state of residence. They are not allowed to keep their current plan if it does not serve the new area, nor are they automatically enrolled in any plan. They also do not have to go through Original Medicare first; they can directly enroll in a new MA-PD plan if available.
Question 15 (Chapter 8)
A Washington resident is reviewing their group health plan's summary of benefits and sees that the plan includes a 'gatekeeper' requirement. Which statement accurately describes the role of a gatekeeper in this context?
- A) The gatekeeper is responsible for negotiating discounted rates with hospitals and specialists.
- B) The gatekeeper, typically a primary care physician, must provide a referral for the enrollee to see a specialist.
- C) The gatekeeper must authorize all emergency room visits before they occur.
- D) The gatekeeper is an insurance company employee who reviews claims for medical necessity.
Show answer & explanation
Answer: B
In an HMO or POS plan, the gatekeeper is usually the enrollee's primary care physician who must provide a referral for the enrollee to see a specialist, helping to manage utilization and costs. Option A describes a network negotiator, not a gatekeeper. Option C is incorrect because emergency care does not typically require prior authorization. Option D describes utilization review, which is a function of the insurer, not the gatekeeper role as defined in managed care plans.
Question 16 (Chapter 8)
A Washington resident is enrolled in a Point-of-Service (POS) plan and uses an in-network specialist without obtaining a referral from their primary care physician. What is the most likely outcome regarding coverage?
- A) The service is not covered because a referral is always required for specialists in POS plans.
- B) The service is covered at the in-network benefit level, as POS plans allow in-network specialist visits without referrals.
- C) The service is covered only if the resident pays the full cost and submits for reimbursement.
- D) The service is covered at the out-of-network benefit level due to the lack of referral.
Show answer & explanation
Answer: D
D is correct. A point-of-service plan works like an HMO when the member goes through the primary care physician: in-network care with a referral is paid at the highest benefit level. Seeing a specialist without the referral, even an in-network one, is treated as going outside the gatekeeper system and is paid at the lower out-of-network level with higher cost-sharing. A is wrong because the service is still covered, B is wrong because the referral determines the benefit level, and C describes no POS rule.
Question 17 (Chapter 8)
A Washington employer with 100 employees offers a self-funded group health plan. The plan includes a stop-loss provision with an attachment point of $10,000 per individual. An employee incurs $25,000 in covered medical expenses in a year. What is the employer's financial responsibility for this claim?
- A) The employer pays the entire $25,000 because stop-loss only applies to aggregate claims.
- B) The employer pays the first $10,000, and the stop-loss insurer pays the remaining $15,000.
- C) The stop-loss insurer pays the entire $25,000 because it exceeds the attachment point.
- D) The employer pays nothing; the stop-loss insurer covers all claims above $5,000.
Show answer & explanation
Answer: B
In a self-funded plan with specific (individual) stop-loss coverage, the employer pays claims up to the attachment point ($10,000). The stop-loss insurer then reimburses the employer for amounts exceeding that point. Here, the employer pays $10,000 and the insurer pays $15,000. Option A is incorrect because stop-loss can apply to individual claims. Option C is incorrect as the employer retains responsibility up to the attachment point. Option D is incorrect due to the wrong threshold and employer responsibility.
The Mistakes That Cost Marks
Mixing up managed care plans. HMOs generally limit you to the network, PPOs pay out-of-network claims at a lower level, and POS plans work like an HMO when you go through the primary care physician and pay less when you do not.
Getting coordination of benefits backwards. The plan covering the person as an employee normally pays before the plan covering the person as a dependent.
Misplacing the stop-loss. In a self-funded plan, the employer pays up to the attachment point and the stop-loss insurer pays the rest.
Remembering the wrong COBRA length. Divorce is a qualifying event with a longer maximum than loss of employment.
Mixing Medigap with Medicare Advantage. Medigap supplements Original Medicare, while Medicare Advantage replaces it, so the options for adding drug coverage differ.
Your Next Step
You have worked through 17 questions on this part of the exam. Check the ones you missed against the explanations, then try the same topic again after a day. When you are ready for the full picture, start with the LanePrep course preview for audio lessons and quizzes, or return to the free Washington Life & Health practice question hub to choose your next topic.
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