This chapter has ten units and 25 focused lessons on medical coverage, disability, public programs, and supplemental policies. Start with health-plan costs and provisions, then apply those basics to group coverage, accounts, Medicare, Medicaid, Social Security, long-term care, and supplemental products.
When reading a health policy, separate:
- Covered services: What the plan can pay for.
- Access rules: How networks, referrals, and the plan's advance medical-necessity review (preauthorization) affect care.
- Cost sharing: The member's share of covered expenses. Deductibles, copayments, and coinsurance apply in different ways.
- Claim payment: An authorization alone does not guarantee payment; the contract and claim facts control.
The Chapter Map
Common abbreviations are accidental death and dismemberment (AD&D), the Consolidated Omnibus Budget Reconciliation Act (COBRA), and Health Savings Account (HSA).
| Unit | Lessons | What You'll Learn |
|---|---|---|
| Health Policy Basics and Cost Sharing | 2 | Cost sharing, exclusions, benefit limits, and renewability |
| Medical Plans and Managed Care | 3 | Medical expense designs, managed care, coordination of benefits, and cost containment |
| Health Provisions and Field Underwriting | 4 | Policy clauses, claims, application duties, underwriting, and consumer information |
| Disability Income | 3 | Disability definitions, benefit timing, riders, and claim requirements |
| Accidental Death and Dismemberment (AD&D) and Workers' Compensation | 2 | Accidental death and dismemberment and occupational injury coverage |
| Group Health, COBRA, and Marketplace Coverage | 3 | Group contracts, continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA), Marketplace plans, and federal protections |
| Health Accounts | 2 | Health Savings Account (HSA), Flexible Spending Arrangement, and Health Reimbursement Arrangement: eligibility, ownership, and funding |
| Medicare and Medigap | 2 | Medicare Parts A through D, Medicare Advantage, and Medigap |
| Medicaid and Social Security | 2 | Medicaid, Social Security Disability Insurance, and Supplemental Security Income |
| Long-Term Care and Supplemental Coverage | 2 | Long-term care, dental, vision, accident, hospital-indemnity, and specified-disease coverage |
A Useful Way to Organize the Material
First, understand the policy
- Identify the insured, covered events or services, exclusions, benefit limits, and member cost sharing.
- Separate renewability provisions from claim rules.
- For a payment scenario, identify the eligible expense and apply contract terms before calculating the member's share.
Next, understand access and administration
- Health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans: Compare provider choice, referrals, and out-of-network costs.
- Coordination of benefits: Determines how more than one plan responds to a loss.
- Utilization management: Includes review, case management, and preauthorization; approval does not guarantee later claim payment.
Then, compare income and public programs
- Disability income: Replaces part of earnings after the policy's definition is met.
- Workers' compensation: Addresses qualifying occupational injuries under the applicable program.
- Medicare, Medicaid, Social Security Disability Insurance, and Supplemental Security Income: Have different eligibility and benefit rules; none is interchangeable with private insurance.
Finally, compare coverage combinations
- Health accounts: Health Savings Accounts, Flexible Spending Arrangements, and Health Reimbursement Arrangements differ in eligibility, ownership, funding, and plan rules.
- Medicare paths: Medigap supplements Original Medicare; Medicare Advantage provides Medicare benefits through a different plan structure.
- Defined benefits: Long-term care and supplemental policies address specified needs and do not replace comprehensive medical coverage.
Exam Tip: Gotchas
- Medicare Advantage and Medigap are different coverage paths; Medigap supplements Original Medicare.
- An HSA is an account arrangement, not health insurance.
How to Study This Chapter
- Read the first three units for the vocabulary of policies, claims, and member costs.
- Compare concepts that look similar: deductible versus coinsurance, elimination versus benefit period, the three health-account types, and Medigap versus Medicare Advantage.
- After each unit, use its Study Quiz and Flashcard Session.
- Take the Health General-Knowledge Diagnostic after your first pass, then revisit units tied to missed or guessed questions.
State-mandated provisions, continuation laws, licensing rules, and exam procedures require current materials for your state.
Exam Tip: Gotchas
- A deductible, copayment, coinsurance, and premium describe different amounts.
- Preauthorization, a provider network, and claim payment answer different questions.
Start the Chapter
Begin with Health Policy Basics and Cost Sharing. If a contract term feels unfamiliar, revisit Shared Foundations before continuing.