AHIP PHIAS cheat sheet

Indemnity (fee-for-service) plans pay claims based on usual, customary, and reasonable (UCR) charges and impose deductibles and coinsurance; they do not require network or PCP gatekeeping.

HMO model: members generally must use in-network providers, with a PCP acting as gatekeeper for specialist referrals; non-emergency out-of-network care is typically not covered except as required by emergency-access rules.

POS plans blend HMO and indemnity features: in-network care is managed through a PCP, while out-of-network care is covered with a deductible and higher coinsurance.

PPO plans pay more for in-network care and less for out-of-network care; members do not need referrals, and out-of-network providers may balance-bill above the allowed amount.

EPO plans cover only in-network providers (except emergencies) and typically require no PCP or referrals.

Coinsurance is the member's share of allowed charges expressed as a percentage; copayment is a fixed dollar amount per service; deductible is the amount paid before benefits begin (subject to preventive exceptions).

Out-of-pocket maximum limits member cost sharing for essential benefits; premiums, balance billing, and non-covered services generally do not count toward it.

Managed care cost controls include utilization review, prior authorization, case management, and provider network contracting with negotiated rates.

Under ACA market rules, non-grandfathered individual and small-group plans must cover essential health benefits, cannot deny or rate on health status, and must allow dependent coverage to age 26.

Medicare Part A covers inpatient hospital, skilled nursing facility (after a qualifying stay), hospice, and some home health; Part B covers physician, outpatient, and preventive services with a monthly premium.

Part A benefit periods: each period begins with a hospital stay and ends after 60 consecutive days without inpatient care; a per-period deductible applies, plus daily coinsurance for extended stays.

Part B generally pays 80% of the approved amount after the annual deductible; the beneficiary pays 20% with no cap unless other coverage applies.

Medicare Advantage (Part C) plans are private plans that must provide all Part A and Part B benefits, may include Part D, and commonly use networks, prior authorization, and copayments; they may offer extra benefits such as dental, vision, and fitness.

Part D covers outpatient prescription drugs through private plans; coverage includes a deductible (limited by CMS), an initial coverage phase, and catastrophic protection, with manufacturer discounts in the coverage gap.

Medigap (Medicare Supplement) plans are standardized in most states (Plans A, B, D, G, K, L, M, N); Plans C and F are closed to newly eligible beneficiaries, and Medigap cannot be sold with a Medicare Advantage plan.

Medicare Advantage enrollment periods include the Initial Enrollment Period (7 months around age 65), the Annual Election Period (October 15–December 7), and the Medicare Advantage Open Enrollment Period (January 1–March 31).

Medicare Secondary Payer rules: employer group health plans pay first for active workers and their spouses at employers with 20 or more employees; Medicare pays first for retirees and for small-employer active plans.

Under the 48-hour rule, a Medicare Advantage enrollee admitted to a hospital must be notified whether the stay is inpatient or observation, which affects skilled nursing facility eligibility.

Health Reimbursement Arrangements (HRAs) are employer-funded only; unused funds may roll over, and the employer sets the reimbursement rules for qualified medical expenses.

Health Savings Accounts (HSAs) require enrollment in a qualifying high-deductible health plan; contributions are pretax or tax-deductible, grow tax-free, and can be withdrawn tax-free for qualified medical expenses, with funds portable and no use-it-or-lose-it rule.

Flexible Spending Arrangements (FSAs) are employer-sponsored salary-reduction accounts; they are generally use-it-or-lose-it, though employers may offer a carryover or grace period, and the full election is available at the start of the year.

A qualifying high-deductible health plan for HSA eligibility requires a minimum deductible and maximum out-of-pocket limit set annually by the IRS; preventive care can be covered before the deductible.

Critical illness, accident, and hospital indemnity plans are supplemental fixed-benefit policies that pay a set amount upon a covered event; benefits are not coordinated with major medical coverage.

Dental and vision plans are supplemental benefits with their own deductibles, maximums, and waiting periods; they typically pay a percentage of allowed charges by service category.

Short-term medical plans are not ACA-compliant; they may exclude pre-existing conditions and essential benefits, and enrollment is limited to short durations under federal rules.

Consumer-directed health plans pair a high-deductible plan with a tax-advantaged account (HSA or HRA) and give members price transparency tools and discretion over spending.

COBRA lets qualified beneficiaries continue group coverage after a qualifying event for up to 18 months (longer in some cases) and generally requires payment of the full premium plus an administrative fee.

Short-term disability typically replaces about 50–70% of income for up to 6 months; long-term disability begins after that and may last to age 65 or for a stated period, with benefit percentages commonly 50–60%.

Own-occupation disability definitions pay if the insured cannot perform the duties of their own occupation; any-occupation definitions pay only if the insured cannot perform any occupation for which they are reasonably suited.

Elimination (waiting) period is the time between disability onset and when benefits begin; a longer elimination period lowers premium.

Long-term care services include skilled nursing care, custodial care (help with activities of daily living such as bathing, dressing, and eating), and home care; benefits are triggered when the insured cannot perform a set number of ADLs or has cognitive impairment.

LTC policies may be tax-qualified (benefits generally tax-free, with a per-diem limit) or non-tax-qualified; inflation protection riders and elimination periods affect premiums.

Worksite (voluntary) benefits are employer-sponsored but employee-paid products such as disability, critical illness, accident, and life coverage, often offered with guaranteed issue or simplified underwriting and payroll deduction.

Group life and disability rates are often experience-rated or pooled; portability and conversion rights allow employees to keep coverage after leaving employment, usually at higher individual rates.

Disability benefit offsets reduce the benefit by other income such as Social Security, workers' compensation, or employer sick pay; taxation depends on who paid the premium (employer-paid premiums produce taxable benefits).

LTC partnership programs allow policyholders to qualify for Medicaid asset protection when they exhaust qualifying long-term care coverage.