Health Insurance Principles, Products and Government Programs
Individual market
ACA plans are guaranteed issue, cannot exclude pre-existing conditions, must cover the ten essential health benefits, and must cap out-of-pocket spending. Metal tiers describe actuarial value: bronze about 60%, silver 70%, gold 80%, platinum 90%. Open enrollment runs November 1–January 15 through the federal marketplace, which North Dakota uses; a 60-day special enrollment period follows marriage, birth, loss of other coverage, or a move. Premium tax credits are available only through the marketplace.
Group coverage
Small-group rules (in North Dakota generally 2–50 employees - confirm the current threshold) require guarantee issue and bar individual underwriting. Waiting periods cannot exceed 90 days. COBRA continues group coverage 18 months after termination or reduced hours, and up to 36 months for dependents after death, divorce, or Medicare entitlement. HIPAA gives special enrollment rights for new dependents and loss of other coverage. Coordination of benefits rules set primary versus secondary when two plans cover the same person.
Public programs
Medicare: Part A hospital (premium-free with 40 quarters), Part B medical, Part C Medicare Advantage, Part D drugs. Medigap supplements Original Medicare but never includes drug coverage. Medicaid - not Medicare - pays for custodial long-term care. CHIP covers children in higher-income families. Disability income turns on own-occupation versus any-occupation, elimination period, benefit period, and residual benefits. LTC uses ADL triggers, an elimination period, and inflation riders. HSA funding requires a qualifying high-deductible plan and must stop when Medicare begins.
Worked example: $5,000 deductible, 20% coinsurance, $8,000 out-of-pocket maximum; a $30,000 claim means the patient owes 5,000 + 0.20 × 25,000 = $10,000, capped at $8,000.