17 Free Utah Life & Health Practice Questions: Medical Plans (2026)

Answer: D

D is correct because HMOs require a primary care physician (PCP) to act as a gatekeeper; the PCP must issue a referral before a specialist visit is covered. A is incorrect because indemnity reimbursement describes a fee-for-service model, not an HMO's managed-care approach. B is incorrect because verifying network participation is a PPO/EPO concept; HMOs generally require referrals even for in-network specialists. C is incorrect because precertification is a utilization review function typically initiated by the provider, not a substitute for the HMO's referral requirement.

Answer: B

B is correct: Both HIPAA and the ACA provide a 60-day special enrollment period following loss of minimum essential coverage, including job-based coverage. A is incorrect because 30 days applies to some HIPAA special enrollment triggers (e.g., birth/adoption) but not loss of coverage. C is incorrect because 90 days is not the standard SEP window. D is incorrect because loss of job-based coverage is a qualifying life event that triggers a special enrollment period.

Answer: A

A is correct: The ACA's guaranteed issue requirement (effective 2014) prohibits insurers from denying coverage or charging higher premiums based on health status in the individual market. B is incorrect because HIPAA's portability provisions primarily addressed group-to-group and group-to-individual portability with limited individual market protections; the ACA superseded and expanded these. C is incorrect because HIPUtah was Utah's high-risk pool mechanism for otherwise-uninsurable individuals, largely supplanted by ACA guaranteed issue. D is incorrect because § 31A-22-605 addresses standard policy provisions, not guaranteed issue.

Answer: A

A is correct. An applicable large employer whose plan fails the minimum-value standard owes the shared-responsibility payment once at least one full-time employee receives a premium tax credit on the marketplace. B is wrong because offering coverage that fails minimum value does not avoid the payment. C is wrong because failing minimum value alone triggers it; affordability is a separate test. D is wrong because the mandate is federal and applies in every state.

Answer: A

A is correct: HIPAA's privacy rule strictly limits a group health plan's disclosure of protected health information (PHI) to the plan sponsor (employer). The plan may only disclose summary information (e.g., enrollment counts, aggregate claims data) without authorization. Detailed claims history is PHI and requires the individual's written authorization. B is incorrect because plan sponsorship does not grant unlimited PHI access. C is incorrect because even plan administration functions do not permit disclosure of individual-level PHI without authorization or a qualified firewall certification. D is incorrect because it describes a separate disclosure from the physician, not the health plan's obligations.

Answer: A

EPOs (Exclusive Provider Organizations) require members to use network providers for all non-emergency care; there is no coverage for out-of-network services except in true emergencies. Option B incorrectly describes EPOs as allowing out-of-network access with higher cost-sharing, which is a PPO feature. Option C incorrectly applies PPO-style out-of-network coverage to an EPO. Option D incorrectly assigns a referral requirement to EPOs, which is characteristic of HMOs, not EPOs.

Answer: A

The ACA defines ten categories of essential health benefits that non-grandfathered individual and small group plans must cover. Pediatric services, including oral and vision care, is one of these ten categories. Option B (vision care for adults) is not a standalone EHB category; adult vision is not required. Option C (long-term care services) is explicitly excluded from EHB requirements. Option D (chiropractic maintenance care) is not specified as an EHB category, though spinal manipulation may fall under rehabilitative services if medically necessary.

Answer: A

Case management focuses on coordinating care for individuals with complex or chronic conditions to improve health outcomes, enhance quality of life, and reduce costs associated with avoidable complications or hospitalizations. Option B confuses case management with administrative cost containment; while it may reduce costs, it does so through improved health outcomes, not by reducing claims processing expenses. Option C describes network steering, which is a function of preferred-provider arrangements, not case management. Option D describes concurrent utilization review, which evaluates the necessity and appropriateness of ongoing inpatient care, not the longitudinal coordination characteristic of case management.

Answer: D

The requirement to obtain a referral from a primary care physician before seeing a specialist is a defining characteristic of Health Maintenance Organizations (HMOs), which use gatekeeping to control access to specialty care and manage costs. While Point-of-Service (POS) plans also typically have a PCP and may require referrals for out-of-network specialist visits, the scenario describes a requirement for the specialist visit to be covered at all, which aligns with the HMO model where out-of-network specialist care is generally not covered without a referral (and often not covered even with one, except in emergencies). PPOs and EPOs do not require referrals for specialist visits; PPOs allow out-of-network access at higher cost, and EPOs allow in-network specialist access without referrals but exclude out-of-network care except in emergencies.

Answer: C

Under a POS plan, in-network specialist visits typically require a referral from the primary care physician and have lower cost-sharing (e.g., lower copay/coinsurance). Out-of-network visits do not require a referral but result in higher cost-sharing for the insured (e.g., higher coinsurance rate or balance billing). Option C correctly captures this: referral required in-network for lower cost-sharing, no referral needed out-of-network but with higher cost-sharing. Option A reverses the cost-sharing. Option B incorrectly states out-of-network does not require a referral (true) but falsely claims it has lower cost-sharing. Option D incorrectly states in-network does not require a referral.

Answer: C

Under the ACA, essential health benefits (EHB) must be covered by all non-grandfathered health plans in the individual and small group markets, both inside and outside the Health Insurance Marketplace (exchange). Utah follows this federal rule. Option C correctly states that EHB requirements apply to both individual and small group non-grandfathered plans. Option A is incorrect because small group plans are not exempt. Option B is incorrect because EHB applies regardless of marketplace participation. Option D is incorrect because large group plans are not required to cover EHB (though they have other requirements), and individual/small group plans are required to do so.

Answer: A

Prior authorization is a utilization review technique where the health plan evaluates whether a prescribed service or drug is medically necessary and appropriate before providing coverage. It is a key tool for managing utilization and costs. Option A correctly identifies this as utilization review. Option B (case management) involves coordinating care for individuals with chronic conditions. Option C (disease management) focuses on managing specific diseases across a population. Option D (provider network contracting) refers to negotiating rates with providers, not reviewing individual service requests.

Answer: B

A hospital confinement requirement is a common provision in health insurance policies that stipulates that benefits for skilled nursing facility (SNF) care, home health care, or other services are only payable if the insured has first undergone a minimum inpatient hospital stay (often 3 days). This is not a pre-existing condition exclusion, elimination period (which refers to a time period before benefits begin, common in disability insurance), or coordination of benefits (which determines primary payer when multiple plans cover an individual). Option B correctly identifies this as a hospital confinement requirement.

Answer: B

The primary goal of case management in health insurance is to improve health outcomes, enhance quality of care, and reduce healthcare costs by preventing complications and hospitalizations, particularly for members with chronic conditions like diabetes. This is achieved through patient education, care coordination, and support for self-management. Option B correctly identifies improving health outcomes and reducing complications as the goal. Option A is incorrect because case management focuses on clinical and member outcomes, not primarily administrative expense reduction. Option C is incorrect because case management does not aim to increase provider reimbursement rates. Option D is incorrect because case management aims to reduce overall costs through better care, not to shift costs to members.

Answer: C

Loss of minimum essential coverage (MEC) is a qualifying life event that triggers a special enrollment period (SEP) in the individual market (both on and off the marketplace). Divorce resulting in loss of coverage under a group health plan — whether fully insured or self-funded — constitutes loss of MEC. The SEP is generally 60 days from the loss of coverage. HIPAA's portability provisions apply to both fully insured and self-funded group health plans (ERISA plans are subject to HIPAA). The ACA preserved and expanded these special enrollment rights. A is incorrect because self-funded plans are subject to HIPAA's portability and special enrollment rules. B is incorrect because divorce with loss of coverage is a qualifying event. D is incorrect because the SEP is 60 days (not 30) and applies regardless of whether the plan is fully insured or self-funded.

Answer: C

POS plans, like HMOs, require a primary care physician and referrals for specialist care, but they allow members to seek care outside the network for a higher cost-sharing amount. HMOs generally do not cover out-of-network care except in emergencies. POS plans do not eliminate the PCP requirement, and both POS and HMOs are managed care models, not indemnity.

Answer: B

Plans use formularies to encourage cost-effective prescribing by assigning different cost-sharing levels to drugs based on therapeutic equivalence and cost. A non-preferred brand drug typically incurs higher cost-sharing (e.g., 40% coinsurance) than a preferred generic (e.g., 10% coinsurance). If the resident chooses the brand-name drug when a generic is available, they pay the higher cost-sharing associated with that tier. The plan does not reduce the cost-sharing to match the generic's rate (A), nor does it automatically deny coverage simply because a generic exists (C). While the resident pays more, the plan still covers a portion (so D is incorrect); they are responsible for 40% of the allowed cost, not 100%.