Health Insurance and Employee Benefits
Core concepts
Health coverage questions turn on cost-sharing mechanics: deductible, coinsurance, copayment, and out-of-pocket maximum. Managed care models-HMO, PPO, POS-differ on network use, referrals, and out-of-network benefits. Contrast individual medical underwriting with group experience rating. Know HIPAA portability, creditable coverage, special enrollment, and privacy rules; COBRA continuation; ERISA and Section 125 cafeteria plans; and the HSA (which requires a qualifying high-deductible plan), FSA, and HRA. Disability income focuses on own-occupation versus any-occupation, elimination period, benefit period, and the typical 60–70% income replacement cap. Long-term care triggers on ADL deficits or cognitive impairment. Medicare Parts A–D and Medigap basics round it out.
Traps
COBRA generally applies to employers with 20 or more employees; beneficiaries may pay up to 102% of premium; 18 months for termination or reduction, 29 months with the disability extension, and 36 months for certain events. An HSA is disqualified by Medicare enrollment or other non-HDHP coverage. FSA funds are generally use-it-or-lose-it, with only a limited carryover. "Own occupation" is broader and more expensive than "any occupation." Out-of-pocket maximums exclude premiums.
Worked example
$1,000 deductible, then 80/20 coinsurance, on an $11,000 claim: $10,000 remains after the deductible; the plan pays $8,000; the insured pays $2,000 coinsurance plus the $1,000 deductible, or $3,000, subject to the out-of-pocket maximum.