I85PREP
⌘ K
AHIP PHIAS study materials
AHIP PHIAS study resources

AHIP PHIAS: Medical Plans and Managed Care: Cost-Sharing, Networks, and Benefit Design

AHIP PHIAS · Work through your exam, one topic at a time.

All guide sections

Medical Plans and Managed Care: Cost-Sharing, Networks, and Benefit Design

The core framework

Advanced medical-plan questions test whether you can trace a claim through a plan's cost-sharing structure and network rules. Know the vocabulary precisely: deductible (member cost before the plan pays, excluding first-dollar services), coinsurance (a percentage of the allowed amount), copayment (a fixed dollar amount), and out-of-pocket maximum (the ceiling on in-network member cost-sharing, which typically excludes premiums and often excludes balance billing). Allowed amount is the contract rate; balance billing is the provider's charge above that rate, which network agreements generally prohibit for in-network care.

Network and delivery models

Distinguish HMO (closed panel, PCP gatekeeping, referral required, no non-emergency out-of-network coverage except urgent/emergency), PPO (in-network and out-of-network tiers with higher member cost out of network, no referral), POS (hybrid: gatekeeping in network, out-of-network benefit with referral), and EPO (network-only, no referral). Managed care tools include utilization management (prior authorization, concurrent review, retrospective review), case management, and disease management. Coordination of benefits determines primary/secondary payer order; subrogation lets a plan recover from a liable third party.

Traps to expect

  • Confusing the out-of-pocket maximum with the deductible, or assuming copayments never count toward the maximum (most plans count them).
  • Assuming preventive care is always free - it is first-dollar only when delivered in network by a network provider per plan terms.
  • Treating emergency care as subject to network rules; true emergencies are covered as in-network under prudent-layperson standards.
  • Mixing up creditable coverage and minimum essential coverage, or guaranteed renewability with guaranteed issue.

Worked example

A plan has a $2,000 deductible, 20% coinsurance, and a $6,000 out-of-pocket maximum. The member incurs a $12,000 allowed in-network charge. Member pays $2,000 deductible, then 20% of the remaining $10,000 = $2,000, for $4,000 total - under the maximum, so the plan pays $8,000. If charges had been $30,000, coinsurance would hit the $6,000 cap, and the plan pays the rest of covered allowed charges.