GBA Group Benefits Associate

Which type of managed care plan requires members to receive all non-emergency care from in-network providers but does NOT require a primary care physician referral to see a specialist?

• AHealth Maintenance Organization (HMO)
• BPreferred Provider Organization (PPO)
• CExclusive Provider Organization (EPO)
• DPoint-of-Service (POS) plan

An employer with 300 employees is considering moving from a fully-insured health plan to a self-insured arrangement. Which of the following is the PRIMARY financial advantage of self-insurance?

• AThe employer is exempt from all federal healthcare regulations
• BThe employer retains underwriting savings and avoids state premium taxes and mandated ben…
• CThe employer transfers all claims risk to a stop-loss carrier
• DThe employer can deny claims for pre-existing conditions

In a self-insured health plan, specific stop-loss insurance provides protection against which type of loss?

• ATotal aggregate claims exceeding a threshold for the entire plan year
• BIndividual claims exceeding a specified dollar amount per covered person
• CAdministrative costs exceeding the plan's operating budget
• DPrescription drug costs for the entire plan

A Consumer-Directed Health Plan (CDHP) typically combines which two components?

• AAn HMO plan and a pension fund
• BA High Deductible Health Plan (HDHP) and a tax-advantaged savings account (HSA or HRA)
• CA dental plan and a vision plan
• DA life insurance policy and a disability plan

Which pharmacy benefit management strategy requires a patient to try a less expensive drug before the plan will cover a more expensive alternative?

• APrior authorization
• BStep therapy
• CQuantity limits
• DSpecialty pharmacy carve-out

An employer's PPO plan allows members to see out-of-network providers but at higher cost-sharing. Which feature distinguishes a PPO from an HMO?

• APPOs require members to select a primary care physician
• BPPOs provide coverage for out-of-network services at reduced benefit levels
• CPPOs do not use networks of contracted providers
• DPPOs have no deductibles or copays

What is the primary purpose of aggregate stop-loss insurance in a self-insured health plan?

• ATo cover individual claims above a specific dollar threshold
• BTo cap the total plan claims liability for the contract period if claims exceed a predete…
• CTo replace the employer's obligation to pay any claims
• DTo provide coverage for pharmacy benefits exclusively

Which of the following is a key advantage of a POS (Point-of-Service) plan from an employee's perspective?

• ALower premiums than all other plan types
• BThe ability to seek out-of-network care while still having in-network HMO-style benefits…
• CNo need for any referrals under any circumstances
• DAll services are covered at 100% with no cost-sharing

In the context of pharmacy benefit design, what is a formulary?

• AA legal contract between the employer and the pharmacy benefit manager
• BA list of prescription drugs covered by the plan, organized into tiers with different cos…
• CA government database of all FDA-approved medications
• DAn employee's prescription history maintained by the plan

An employer is choosing between fully-insured and self-insured health plan funding. In a fully-insured arrangement, which party bears the claims risk?

• AThe employer
• BThe employees
• CThe insurance carrier
• DThe third-party administrator

Which of the following BEST describes a minimum premium plan as a health plan funding arrangement?

• AThe employer pays the lowest possible premium for a fully-insured plan
• BA hybrid arrangement where the employer pays most claims directly but the carrier covers…
• CA plan with no employee premium contributions
• DA government-subsidized plan for low-income employers

An HSA-qualified HDHP for 2026 must have a minimum deductible of at least what amount for self-only coverage?

• A$1,000
• B$1,650
• C$2,000
• D$3,300

Which type of provider reimbursement method pays hospitals a predetermined fixed amount per patient admission regardless of the actual services provided during the stay?

• AFee-for-service
• BPer diem
• CDiagnosis-Related Group (DRG) payment
• DCapitation

Which of the following prescription drug strategies uses tiered copays to incentivize employees to choose generic medications over brand-name alternatives?

• AMandatory generic substitution
• BTiered formulary with lowest copay for generics
• CMail-order pharmacy with 90-day supply
• DSpecialty pharmacy prior authorization

An employer wants to carve out its pharmacy benefits from the medical plan. What does a pharmacy carve-out arrangement involve?

• AEliminating prescription drug coverage entirely
• BSeparating pharmacy benefit management from the medical plan carrier and contracting with…
• CRequiring employees to pay 100% of prescription costs
• DLimiting coverage to generic drugs only

Under self-insured plan design, what does an Administrative Services Only (ASO) contract provide?

• AFull insurance coverage with the carrier assuming all claims risk
• BClaims processing, network access, and administrative services without the carrier assumi…
• CEmployee enrollment management only, with no claims processing
• DStop-loss insurance bundled with premium-based coverage

Which factor MOST significantly affects the premium renewal rate for a fully-insured group health plan?

• AThe number of conference rooms in the employer's office
• BThe group's claims experience and utilization trends
• CThe employer's stock price
• DEmployee tenure length

Which CDHP account type allows the employer to set a maximum annual benefit, rolls unused funds into the next year at the employer's discretion, and is funded solely by the employer?

• AHealth Savings Account (HSA)
• BHealth Reimbursement Arrangement (HRA)
• CFlexible Spending Account (FSA)
• DArcher Medical Savings Account (MSA)

A self-insured employer's specific stop-loss policy has an attachment point of $200,000. An employee incurs $350,000 in claims during the plan year. How much does the stop-loss carrier reimburse?

• A$200,000
• B$150,000
• C$350,000
• D$0

Which network model uses a panel of independent physicians who contract with the health plan to provide services on a discounted fee-for-service basis?

• AStaff model HMO
• BGroup model HMO
• CIndependent Practice Association (IPA) model HMO
• DNetwork model HMO

What is the typical coverage amount of employer-provided basic group term life insurance?

• AA flat $10,000 for all employees
• BOne to two times the employee's annual base salary
• CFive times the employee's annual salary
• DThe employee's total net worth

Which type of supplemental group life insurance provides a benefit specifically for death resulting from an accident, often at double the base life insurance amount?

• AWhole life insurance
• BAccidental Death and Dismemberment (AD&D) insurance
• CUniversal life insurance
• DKey person life insurance

Under IRC Section 79, employer-paid group term life insurance coverage exceeding what amount creates taxable imputed income for the employee?

• A$25,000
• B$50,000
• C$100,000
• D$250,000

An employee is unable to work due to a serious illness. The employer provides short-term disability (STD) coverage. What is the typical benefit duration for STD plans?

• A1-2 weeks
• BUp to 13-26 weeks
• C1-2 years
• DUntil normal retirement age

Which of the following BEST describes the definition of disability used in most long-term disability (LTD) plans?

• AUnable to perform any work whatsoever
• B"Own occupation" for an initial period (typically 24 months), then "any occupation" for t…
• CUnable to commute to the workplace
• DAny medical condition requiring ongoing treatment

What is the typical income replacement percentage provided by a long-term disability plan?

• A30-40% of pre-disability earnings
• B50-70% of pre-disability earnings
• C80-90% of pre-disability earnings
• D100% of pre-disability earnings

An employer provides dental coverage under a DHMO plan. Which of the following is characteristic of a DHMO?

• AMembers can see any dentist without restrictions
• BMembers must select a primary care dentist and receive all care from that dentist or thro…
• CAll dental services are covered at 100% with no cost-sharing
• DThe plan only covers emergency dental services

Which of the following benefits provides employees with confidential assessment, short-term counseling, and referral services for personal and work-related problems?

• ALong-term disability insurance
• BEmployee Assistance Program (EAP)
• CWorkers' compensation
• DSupplemental health insurance

Which vision plan benefit typically includes an annual allowance for corrective lenses, frames, or contact lenses?

• AMedical plan ophthalmology benefit
• BRoutine vision plan materials benefit
• CWorkers' compensation vision coverage
• DCOBRA vision continuation

An employee receiving LTD benefits also receives Social Security Disability Insurance (SSDI). Most LTD plans reduce the LTD benefit by the SSDI amount through which provision?

• ASubrogation clause
• BOffset (integration) provision
• CCoordination of benefits (COB)
• DContribution clause

Which of the following supplemental benefits pays a fixed daily, weekly, or monthly cash benefit to the insured if they are hospitalized, regardless of actual hospital charges?

• AMajor medical insurance
• BHospital indemnity insurance
• CStop-loss insurance
• DCritical illness insurance

Under the elimination period in a disability plan, what happens during this waiting period?

• AThe employee receives full disability benefits
• BThe employee must satisfy the waiting period before benefits begin
• CThe insurance carrier investigates the claim
• DThe employer continues paying the employee's full salary

A dental plan categorizes services into types. Which service type typically has the highest coinsurance rate (lowest plan payment percentage)?

• AType I: Preventive (cleanings, exams)
• BType II: Basic (fillings, extractions)
• CType III: Major (crowns, bridges, dentures)
• DAll types are paid at the same rate

Which disability insurance feature allows an employee to return to work part-time while receiving a reduced disability benefit?

• AWaiver of premium
• BResidual or partial disability benefit
• CCost-of-living adjustment (COLA)
• DConversion privilege

Under ACA rules, which preventive dental service must be covered without cost-sharing for children as an essential health benefit?

• AAll dental services for children under 18
• BPediatric dental services including oral exams and fluoride
• COrthodontic treatment for all children
• DDental implants for children

Under the ACA, which of the following individuals may NOT be excluded from group health plan coverage based on a pre-existing condition?

• AOnly children under age 19
• BOnly employees with prior creditable coverage
• CAny individual, regardless of health status or prior coverage
• DOnly employees who have been continuously employed for 12 months

Under ERISA, which of the following is the plan administrator required to provide to participants automatically?

• AA copy of the full plan document
• BA Summary Plan Description (SPD) and Summary of Benefits and Coverage (SBC)
• CThe insurance carrier's financial statements
• DThe employer's corporate tax return

HIPAA's privacy rule limits the use and disclosure of protected health information (PHI). Which of the following is a permitted use of PHI without individual authorization?

• ASharing PHI with the employer's marketing department for promotional purposes
• BUsing PHI for treatment, payment, or health care operations
• CSelling PHI to pharmaceutical companies for drug marketing
• DPosting PHI on the company intranet for transparency

Under COBRA, which employer size triggers the federal COBRA continuation coverage requirement?

• AAny employer with 1 or more employees
• BEmployers with 20 or more employees on more than 50% of typical business days
• CEmployers with 50 or more employees
• DOnly employers with 100 or more employees

Under the FMLA, an eligible employee is entitled to up to 12 weeks of job-protected leave. Which of the following is a qualifying reason for FMLA leave?

• AVoluntary cosmetic surgery
• BA serious health condition that makes the employee unable to perform job functions
• CPersonal vacation time
• DAttending a friend's wedding

Under Section 125 of the Internal Revenue Code, when can an employee change their benefit elections during the plan year?

• AAt any time for any reason
• BOnly during annual open enrollment or upon a qualifying life event
• COnly with the employer's permission
• DMonthly, upon written request to the insurance carrier

Which federal law requires group health plans to provide parity between mental health/substance use disorder benefits and medical/surgical benefits?

• AERISA
• BMental Health Parity and Addiction Equity Act (MHPAEA)
• CADA
• DHIPAA

Under USERRA, an employee returning from military service of 31 to 180 days must apply for reemployment within how many days?

• AImmediately upon return
• B14 days
• C30 days
• D90 days

The ACA requires applicable large employers to offer health coverage to employees working an average of how many hours per week to avoid the employer mandate penalty?

• A20 hours per week
• B25 hours per week
• C30 hours per week
• D40 hours per week

Under COBRA, a qualified beneficiary has how many days to elect continuation coverage after receiving the election notice?

• A30 days
• B45 days
• C60 days
• D90 days