Medical Plans, Disability Income, and Group Health Insurance
Medical plans
Major medical combines a deductible, coinsurance, and a high maximum. A comprehensive plan adds first-dollar coverage for some services. HMOs are closed-panel plans using capitation and a primary care gatekeeper, with no nonemergency out-of-network benefits. PPOs pay more in network and less out of network; POS plans combine a gatekeeper with an out-of-network option; EPOs cover network only without referrals. HDHPs paired with an HSA offer tax-advantaged savings.
Medicare and Medicaid
Medicare Part A covers inpatient hospital care (premium free with enough work quarters); Part B covers physician and outpatient services; Part C is Medicare Advantage; Part D covers prescriptions. Medigap supplements original Medicare. Medicaid is a joint federal-state program for low-income individuals.
Disability income
Key terms: own occupation versus any occupation (own-occupation is more favorable), elimination period, benefit period, benefit percentage (often 60–70% of income), residual/partial benefits, and Social Security integration or offset. Business coverage includes business overhead expense and key person disability. If the employer pays the premium, benefits are taxable; if the employee pays with after-tax dollars, benefits are tax free.
Group health
A master policy with certificates; eligibility rules including a probationary period and actively-at-work requirements; contributory plans typically require 75% participation and noncontributory plans 100%. Group plans must offer conversion and portability rights, and COBRA continuation runs 18 months for termination/reduction of hours, 29 months for disability, and 36 months for dependents or other qualifying events.
Traps
Do not confuse HMO capitation with PPO fee-for-service arrangements, and remember that Medicare Advantage is Part C, not a supplement.