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Under the Knox-Keene Health Care Service Plan Act, California HMOs are regulated by the Department of Managed Health Care (DMHC), not the CDI. The CDI regulates indemnity health insurance and PPO products, but full-service HMOs fall under DMHC.

Section 2713 of the Public Health Service Act, added by the ACA, requires non-grandfathered plans to cover certain preventive services (such as immunizations, screenings, and annual wellness visits) without imposing any deductible, copayment, or coinsurance when delivered in-network.

Voluntary or involuntary termination (other than for gross misconduct) and reduction in hours are 'qualifying events' that entitle a covered employee to up to 18 months of COBRA continuation. The 29-month period applies only when the qualified beneficiary becomes disabled, and 36 months applies to dependent events such as death, divorce, or loss of dependent status.

Federal COBRA applies only to employers with 20 or more employees. Cal-COBRA fills the gap by requiring continuation coverage from California group health plans of small employers with 2 to 19 employees, generally for up to 36 months total.

Section 223 of the Internal Revenue Code requires an HSA-eligible individual to be covered under a qualifying HDHP and to have no other disqualifying health coverage. Enrollment in Medicare disqualifies a person from making new HSA contributions.

The ACA defines four metal tiers by actuarial value: bronze at approximately 60%, silver at 70%, gold at 80%, and platinum at 90%. Catastrophic plans are separate and available only to certain enrollees.

Since 2014, the ACA has prohibited individual and group market insurers from denying coverage, charging higher premiums, or excluding benefits based on any pre-existing condition. Permitted rating factors are limited to age, geography, family size, and tobacco use.

The ACA requires plans offering dependent coverage to allow enrolled adult children to remain on a parent's plan until age 26, regardless of marital status, residency, financial dependence, or student status.

The ten Essential Health Benefits include ambulatory services, emergency services, hospitalization, maternity/newborn care, mental health/substance use, prescription drugs, rehabilitative services, lab services, preventive/chronic disease management, and pediatric (not adult) services including dental and vision. Adult dental and vision are not required.

The out-of-pocket maximum (sometimes called the MOOP) is the annual cap on a member's cost-sharing for in-network essential benefits. Once it is reached, the plan must pay 100% of covered in-network services for the remainder of the plan year.

A core HMO feature is the gatekeeper PCP who coordinates and authorizes referrals to specialists. HMOs typically only pay for in-network care, with emergencies as the main exception. PPOs allow direct access to specialists and pay reduced benefits for out-of-network care.

An EPO restricts non-emergency benefits to the in-network panel of providers, much like an HMO, but unlike a traditional HMO it generally does not require a PCP referral to see specialists. Out-of-network non-emergency care is usually not covered.

A Point of Service (POS) plan blends HMO and PPO features. The member selects a PCP who manages and refers care, but unlike a pure HMO the plan also pays a reduced benefit when the member uses out-of-network providers.

Coinsurance is the percentage share of covered expenses the insured pays (for example, 20%) after the deductible has been satisfied; the plan pays the remaining percentage. A deductible is the dollar amount paid before benefits start, and a copay is the fixed per-service charge.

HIPAA was enacted in 1996 to standardize electronic health transactions, protect the privacy and security of individually identifiable health information (PHI), and improve portability and continuity of group health coverage when workers change jobs.

Covered California is the state-operated Affordable Care Act exchange (marketplace) where individuals and small employers can compare and enroll in qualified health plans and where income-eligible enrollees receive federal and state premium assistance.

The federal individual mandate penalty was reduced to $0 starting in 2019, but California enacted its own Individual Shared Responsibility Penalty effective January 1, 2020. It is administered through the Franchise Tax Board and assessed on the state income tax return.

A health FSA established under an IRC §125 cafeteria plan is funded with pre-tax employee salary reductions (and any employer contributions). Unused balances are generally forfeited at year-end, although plans may allow a limited carryover or grace period.

An HRA is funded solely by the employer (not by employee salary reductions) and is owned by the employer. It reimburses employees, tax-free, for qualified medical expenses up to the amount the employer allocates, under rules in IRC §105 and IRS guidance.

Balance billing occurs when a provider bills the patient for the difference between the provider's total charge and the amount the insurer pays as the allowed amount. In-network providers typically agree not to balance bill; out-of-network or surprise-billing scenarios are addressed by laws like the federal No Surprises Act and California AB 72.

In a self-funded (self-insured) plan, the employer assumes the financial risk for claims and typically buys stop-loss (reinsurance) coverage that caps the employer's exposure per individual claim and on an aggregate annual basis. Self-funded plans are generally governed by ERISA at the federal level.

Major medical insurance provides broad coverage for hospital, surgical, physician, and outpatient care subject to plan design features such as a deductible, coinsurance, copayments, and an annual out-of-pocket maximum. Limited-benefit, accident-only, and indemnity policies are distinct product types.

A copayment (copay) is a fixed dollar amount the member pays at the time of service, regardless of total charges. Deductibles are paid before benefits begin, coinsurance is a percentage share after the deductible, and the out-of-pocket maximum is the annual cap on cost-sharing.

The ACA prohibits both annual and lifetime dollar limits on Essential Health Benefits. Non-essential benefits may still be subject to limits, but the ten categories of Essential Health Benefits (hospitalization, prescription drugs, maternity, etc.) must be offered without dollar caps.

Divorce or legal separation is a qualifying event that affects spouses and dependent children. The maximum COBRA continuation period for such 'dependent' qualifying events (including death of the covered employee or a child losing dependent status) is 36 months.

Under IRC §223, HSA eligibility requires that the individual (1) be covered by a qualifying HDHP with minimum deductibles and maximum out-of-pocket limits set annually by the IRS, (2) have NO other 'disqualifying' health coverage — this includes Medicare enrollment (any part), a general-purpose health FSA, a spouse's non-HDHP plan that covers them, or being entitled to VA benefits within the prior 3 months (with exceptions), and (3) not be claimed as a dependent on another taxpayer's return. The under-age-65 condition is implied by the Medicare disqualifier but is not the full rule. The 400%-of-federal-poverty-level ceiling does not apply here — HSA eligibility is income-blind, unlike ACA subsidies. And the self-employed-only restriction is wrong — HSAs are available to employees, self-employed, and the unemployed alike.

A hospital indemnity (or 'hospital cash') policy pays a flat, scheduled benefit — for example, $200 per day of hospital confinement or $1,500 per admission — without regard to the actual medical costs. This contrasts with a major medical or reimbursement policy, which pays based on the actual expenses incurred (subject to deductibles, coinsurance, and out-of-pocket maxima). Hospital indemnity benefits are typically considered SUPPLEMENTAL coverage and do NOT qualify as minimum essential coverage under the ACA; the consumer needs comprehensive coverage in addition. The description of paying only for catastrophic claims above a high dollar threshold describes catastrophic policies. The description of dollar-for-dollar reimbursement after the deductible and coinsurance describes reimbursement plans (the major medical model). And the claim that only the physician's professional fees are paid, with room and board excluded, is fabricated. Hospital indemnity is a 'valued' or 'indemnity-style' contract, paying a scheduled amount.

An Exclusive Provider Organization (EPO) is a managed-care hybrid: like an HMO, it provides coverage ONLY through in-network providers (except in genuine emergencies under the federal 'prudent layperson' standard); like a PPO, it generally does NOT require a primary-care-physician referral to see specialists. The EPO model is regulated as a health care service plan under Knox-Keene if it is a full-service plan. The plan that requires a PCP referral for every specialist visit describes a Point-of-Service (POS) plan. The plan with no provider network at all, paying every licensed provider on the same basis, describes a traditional fee-for-service indemnity plan. The government-run exchange-administered plan is fabricated; EPOs are private insurance products. The three key managed-care archetypes in California are HMO (PCP+narrow network), PPO (broader, no PCP, out-of-network covered at lower rate), and EPO (narrow, no PCP, no out-of-network).

Cost-sharing terms in California are defined under Insurance Code §10123 and managed-care regulations. A 'deductible' is the amount the member pays before the plan starts paying. A 'copay' is a fixed dollar amount per service. 'Coinsurance' is a percentage of the cost the member pays after the deductible. Most plan designs apply EITHER a copay OR coinsurance for a given visit — not both — and the Summary of Benefits & Coverage spells out which, so the correct statement is the one that makes the member owe the $30 copay OR 20% coinsurance ($100) per the plan's design, unless the schedule explicitly stacks them. The response charging the $250 deductible again wrongly assumes the deductible reapplies (the prompt said it was met). The response charging the member 100% of the $500 ignores the plan's coverage entirely. And the response paying only the $30 copay no matter what the schedule says assumes copay-only without checking the plan's design.

HMO organizational models under the federal HMO Act and California Knox-Keene Act include: (1) STAFF model — physicians are W-2 employees of the HMO working in HMO-owned facilities and seeing only HMO members; (2) GROUP model — the HMO contracts with one multi-specialty medical group, which may or may not see outside patients; (3) NETWORK model — the HMO contracts with multiple groups; (4) IPA (Independent Practice Association) model — the HMO contracts with an IPA whose individual physicians remain in private practice and see other patients. Contracting with multiple independent physician practices whose doctors keep seeing non-HMO patients therefore describes the IPA model, not the staff model. Letting each member choose any community physician with fee-for-service reimbursement describes traditional indemnity, not an HMO at all. Federal Medicare ownership is fabricated; HMOs are private (Medicare Advantage HMOs are private plans contracting with CMS, but the HMOs themselves are not federally owned). Staff-model HMOs are the most tightly integrated form.

A Point-of-Service (POS) plan is a managed-care hybrid that gives the member a choice 'at the point of service.' In-network with a primary-care-physician referral, the member receives HMO-level benefits with low cost-sharing. Out-of-network or without a referral, the member can still get covered care, but at PPO-like cost levels (a higher deductible, higher coinsurance, and balance-billing risk) — that two-tier structure is the correct distinction from a pure HMO. The description of a plan with no provider network paying a fixed percentage of usual and customary charges to any licensed provider is wrong; POS plans have networks and gatekeepers. The description that never requires a referral and reimburses out-of-network providers at 100% of billed charges is wrong; the very point of the structure is to make out-of-network MORE expensive, not free. And limiting the plan to emergency and urgent care with routine services bought through a separate indemnity rider is fabricated. The defining feature is the two-tier benefit structure tied to whether the member uses the HMO core or steps outside it.

Under IRC §223 and annual IRS revenue procedures, an HSA-eligible HDHP must satisfy TWO numerical tests, set separately for self-only and family coverage and adjusted annually for inflation: first, the annual deductible must be at LEAST the IRS minimum (for 2026, in the rough range of $1,700 self-only / $3,400 family — candidates should rely on current Rev. Proc.); and second, the maximum out-of-pocket limit for in-network care must NOT EXCEED the IRS ceiling (in the rough range of $8,500 self-only / $17,000 family for 2026). Preventive services may be covered before the deductible without disqualifying the plan, which is why the statement describing both tests with separate self-only and family figures is the accurate one. The single fixed $1,000 deductible minimum applying to both coverage tiers with no out-of-pocket cap fabricates a flat deductible and removes the ceiling. The claim that only family coverage can be paired with an HSA is wrong; both self-only and family HDHPs qualify. And the assertion that the thresholds have gone unadjusted for 20 years because IRC §223 fixed them in the statute is wrong; the plan-qualification figures are inflation-adjusted yearly by revenue procedure.

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medigap plans that cover the Medicare Part B deductible (Plan F and Plan C) cannot be SOLD to people who become NEWLY eligible for Medicare on or after January 1, 2020. Beneficiaries who were already eligible before that date may keep or buy Plan F or Plan C, but newly eligibles must choose another standardized plan. Plan G is now the most comprehensive available to newly eligibles; it pays everything Plan F pays except the Part B deductible, with Plan N as the other common alternative. California Insurance Code §10192 et seq. mirrors federal Medigap standardization and adds California-specific protections (e.g., the birthday rule under §10192.11). Saying Plan F remains available to every newly eligible beneficiary and must be offered on request overstates Plan F's availability. Saying Plan G provides exactly the same benefits as Plan F including full payment of the Part B deductible is wrong; Plan G expressly excludes the Part B deductible. And restricting Plan G to under-65 beneficiaries who qualify through end-stage renal disease is fabricated.

The federal Medigap Open Enrollment Period under 42 U.S.C. §1395ss is a ONE-TIME 6-month window that begins on the first day of the month in which the beneficiary is both age 65 or older AND enrolled in Medicare Part B. During this window, insurers must issue ANY Medigap plan they offer in the state on a guaranteed-issue basis, without medical underwriting and without surcharges for pre-existing conditions (subject to limited HIPAA-style lookback rules). After this window closes, future Medigap purchases are generally subject to medical underwriting unless a federal or state guaranteed-issue 'trigger' applies (e.g., loss of employer coverage). California layers a state-specific Birthday Rule under §10192.11 allowing annual same-or-lesser-benefit switches without underwriting. Options A, D, and B fabricate other windows.

The elimination period is a waiting period, measured from the start of a covered disability, that must pass before the insured begins receiving benefit payments; it functions like a time deductible and a longer elimination period lowers the premium. The maximum time benefits are paid is the benefit period, a different concept. The insurer's ability to cancel relates to renewability provisions. The time to return the policy for a refund is the free-look period. Only the elimination period delays the start of benefits.

Coinsurance is the sharing of covered expenses on a percentage basis (for example, the insurer pays 80% and the insured pays 20%) after the deductible has been satisfied. A flat dollar amount per visit is a copayment, not coinsurance. The amount the insured pays before the plan pays is the deductible. The most the plan will ever pay is a maximum benefit limit. Coinsurance specifically refers to the proportional cost split, and it stops once the insured reaches the out-of-pocket maximum (stop-loss).

Morbidity measures the frequency and severity of illness, injury, and disability within a defined population, and health insurers use morbidity tables to price coverage. Mortality, by contrast, measures the rate of death and is used mainly for life insurance pricing. Morbidity is not an interest or investment measure, nor is it a marketing or commission figure. Understanding the morbidity-versus-mortality distinction is fundamental: health insurance risk is about getting sick or disabled, while life insurance risk is about dying.

HMOs emphasize managed care: members generally must use in-network providers and often select a primary care physician (a gatekeeper) who coordinates care and referrals to specialists, in exchange for lower costs. A PPO offers more flexibility, allowing out-of-network care at a higher cost, so identical cost sharing in and out of network is not accurate for either an HMO or a PPO. Pure fee-for-service reimbursement with no network describes a traditional indemnity plan. HMOs actually stress preventive care, so saying they cover no routine physicals or screenings is wrong.

The stop-loss (out-of-pocket maximum) provision caps the insured's annual cost sharing; once the insured has paid that amount in deductibles and coinsurance, the plan pays 100% of additional covered expenses for the remainder of the year, protecting the insured from catastrophic costs. It does not stop the plan's payments, nor shift all remaining costs to the insured, which are the opposite of its purpose. Reaching the stop-loss does not cancel the policy. The provision exists specifically to limit the insured's financial exposure.

Health insurance divides into medical expense coverage, which pays for care such as hospital, physician, and surgical services, and disability income coverage, which replaces part of the income lost when the insured cannot work. Life insurance and annuities are separate product lines. Property and casualty is a different branch of insurance entirely. Fixed and variable describe how certain life and annuity products are invested, not health insurance categories. Recognizing these two purposes, paying medical bills versus replacing income, frames all health coverage.

Basic medical expense plans historically paid 'first dollar' benefits, meaning they began paying with little or no deductible, but they had relatively low benefit limits for specific services. Major medical, by contrast, provides broad, high-limit protection after a deductible and coinsurance, and is meant to handle large or catastrophic costs. So basic coverage is characterized by low limits and first-dollar payment, not high limits or a large deductible. The two are often combined so basic pays first and major medical covers the excess.

A calendar-year (or annual) deductible must be met once during each year; once the insured's covered costs reach that amount, the plan pays its share for the rest of the year, and the deductible resets the following year. A deductible applied to each separate illness is a per-cause deductible. It is not a one-time lifetime deductible, and it does not reset monthly. The calendar-year structure is the most common deductible design in medical expense plans.

A family deductible sets an aggregate limit so that once a specified number of family members (commonly two or three) have each satisfied the individual deductible, the family deductible is considered met and no further deductibles apply for the year. It does not require every member to meet a full deductible with no cap, does not change coinsurance, and does not remove the out-of-pocket maximum. The provision protects larger families from stacking up multiple full deductibles.

Coordination of benefits applies when a person is covered by more than one group plan; it establishes which plan pays first (primary) and which pays second (secondary) so that the total reimbursement does not exceed 100 percent of the actual covered expenses. It does not bar filing claims, block preventive care, or stop the insurer from paying. COB exists to prevent duplicate payment and the profit motive that could arise from being over-reimbursed by multiple plans.

Disability income benefits are capped at a portion of income (often around 60 percent) because disability benefits are generally received income-tax-free when the individual paid the premiums, so replacing too much income could leave the insured better off not working, creating a moral hazard. The limit is not about advertising costs, Medicare, or property insurance. Keeping the benefit below full pay maintains the insured's motivation to recover and return to work.

A presumptive disability provision automatically deems the insured totally disabled, and pays full benefits without the usual proof, upon certain severe losses such as loss of sight, hearing, speech, or the loss of use of two limbs, even if the insured could technically still work. Missing one day of work, a minor illness like a cold, or changing jobs do not qualify. The provision recognizes that these catastrophic losses are so serious that disability is presumed as a matter of course.

A recurrent disability provision states that if the insured recovers and then suffers the same disability again within a short specified time (often six months), it is treated as a continuation of the original disability, so a new elimination period does not have to be served. It has nothing to do with premium calculation, the free-look period, or a death benefit. The provision protects an insured from having to satisfy a fresh waiting period when the same condition quickly returns.

A residual disability benefit applies when the insured can work but, due to the ongoing effects of the disability, earns less than before; the benefit is generally paid in proportion to the percentage of income lost. It is not for total permanent disability (which pays full benefits), not for full recovery with no lost income, and not for voluntary retirement. The residual benefit bridges the gap between total disability and full recovery by covering a partial loss of earnings.

HSAs offer a rare triple tax advantage: contributions are deductible or made pre-tax, the account grows tax-free, and withdrawals for qualified medical expenses are tax-free. Contributions are not taxable when made, the balance does carry over year to year, and funds are not forfeited at year-end. This favorable treatment, combined with the balance being the owner's to keep, makes the HSA a powerful savings tool alongside a high-deductible plan.

HSA balances roll over indefinitely and belong to the account owner, who keeps them even when changing employers or health plans, so the account can grow over many years. An FSA, by contrast, is generally subject to a use-it-or-lose-it rule. HSA funds do not revert to the employer and are not taxed at a flat penalty rate simply for remaining in the account. Portability and rollover are key advantages of the HSA over the FSA.

A UCR charge is the amount an insurer considers reasonable for a given service, determined by the usual fee the provider charges, the customary fees of similar providers in the same area, and what is reasonable for the situation; the plan bases reimbursement on this figure, and the insured may owe amounts a provider bills above it. UCR is not the deductible, premium, or copay. UCR limits how much a plan will recognize for out-of-network or fee-for-service charges.

Preauthorization (precertification) requires that the plan review and approve certain non-emergency services, such as a planned hospital stay or a costly procedure, before they are provided, both to confirm medical necessity and to ensure the service will be covered. It is not a requirement to pay the full bill first, to wait a year, or to file a police report. Managed care plans use preauthorization to control costs and steer care to appropriate settings.

Under capitation, the HMO pays the physician a set amount for each enrolled member per month (per capita), whether or not that member seeks care, which shifts some financial risk to the provider and encourages efficient, preventive care. It is the opposite of fee-for-service, which pays per service. It is not a claim-triggered or year-end-only payment. Capitation is a hallmark of the HMO managed care model.

As a gatekeeper, the primary care physician manages the member's overall care and must generally provide a referral before the member sees a specialist, which helps the HMO control costs and avoid unnecessary services. The gatekeeper does not collect premiums, own the HMO, or set the deductible. The gatekeeper model is a defining feature of traditional HMOs and a key difference from PPOs, which usually let members self-refer to specialists.

A POS plan combines HMO and PPO characteristics: members typically choose a primary care physician and use the network for the lowest cost, but they may also go outside the network at the point of service by paying more. It is not a pure indemnity plan, not identical to an HMO (it allows out-of-network use), and it does provide some out-of-network coverage. The 'point of service' name reflects that the member decides in or out of network each time care is needed.

The waiver of premium feature in a disability income policy relieves the insured of paying premiums once they have been disabled for a specified period (often 90 days), and coverage continues without payment while the disability lasts. It does not eliminate the elimination period, double the benefit, or add a death benefit. The feature protects the policy from lapsing at the very time the disabled insured may struggle to pay premiums.

A guaranteed renewable policy requires the insurer to renew the coverage (usually to a stated age) and forbids singling out an individual for a rate increase or nonrenewal; premiums can be changed only for an entire class of similar policyholders. The insurer cannot cancel at renewal, cannot raise one person's premium for their own claims, and cannot refuse renewal because health declined. This provision sits between the stronger noncancelable and weaker conditionally renewable forms.

A conditionally renewable policy lets the insurer refuse renewal only for reasons spelled out in the contract (such as the insured reaching a certain age or leaving employment), but it may not decline renewal simply because the insured's health has deteriorated. It is not renewable-or-cancelable at the insurer's whim, is not guaranteed under all circumstances, and has no twenty-year rule. This form gives the insurer more control than guaranteed renewable but still protects against nonrenewal for health reasons.

An optionally renewable policy reserves for the insurer the option, at renewal (policy anniversaries or premium due dates), to either decline renewal or adjust the premium, giving the insurer substantial discretion. It does not lock in premiums, does not guarantee renewal, and generally does not permit cancellation in the middle of a paid term (renewability decisions occur at the renewal points). Optionally renewable is a weaker guarantee for the insured than guaranteed renewable.

Workers compensation is a separate, employer-provided coverage that pays for work-related injuries and illnesses, including medical care and a portion of lost wages, which is why private disability income policies are often written as nonoccupational. A nonoccupational policy specifically excludes on-the-job losses. Major medical is general health coverage, not the primary payer for work injuries, and Medicare is a federal program for seniors and certain disabled persons, not the on-the-job payer. Coordinating with workers compensation is an important design point for disability coverage.

A hospital indemnity policy pays a predetermined flat amount (for example, a set dollar figure per day of confinement) whenever the insured is hospitalized, no matter what the actual bill is, and the insured may use the cash for any purpose. It does not reimburse the exact bill (that is a medical expense plan), is not limited to surgery, and does provide a hospital benefit. Because it is a limited, fixed-benefit product, it supplements rather than replaces comprehensive medical coverage.

An accident-only policy provides benefits solely for losses caused by accidental injury, such as emergency treatment, hospitalization, or disability resulting from an accident, and it does not cover illness. It is not comprehensive coverage for both sickness and injury, is not limited to checkups, and is not long-term care. Because it excludes sickness, an accident-only policy is a narrow, lower-cost product that should be presented as a supplement, not a substitute for major medical coverage.

A specified or dread disease policy pays benefits only if the insured is diagnosed with a particular disease named in the contract, most commonly cancer, and pays nothing for other conditions. It is not general coverage for any illness, not an accident policy, and not dental coverage. Because its benefits are limited to one disease, it is a supplemental product, and producers must be careful not to let a consumer treat it as comprehensive health insurance.

AD&D coverage pays the full principal sum if the insured dies as a result of a covered accident, and pays a capital sum, a stated percentage of the principal, for the accidental loss of, or loss of use of, limbs or eyesight (for example, half the principal for the loss of one hand). It does not pay for illness, provide retirement income, or fund long-term care. AD&D is limited strictly to accidental death and dismemberment, so it is inexpensive but narrow.

Dental plans typically classify services as preventive (cleanings and exams, often covered at or near 100 percent), basic (fillings and simple extractions), and major (crowns, bridges, and dentures), frequently applying deductibles and an annual dollar maximum. Inpatient and outpatient, accident and sickness, and skilled and custodial are classifications used in other kinds of coverage, not dental. Knowing the preventive-basic-major structure helps explain why dental plans emphasize low-cost preventive care.

The future increase option lets the insured raise the benefit as earnings rise, without proving insurability again. It does not reduce coverage, address occupation taxes, or waive the elimination period.

Accident-only coverage pays for injuries but excludes sickness, so an illness like pneumonia or cancer is not covered. Falls, car-accident injuries, and dismemberment are accidents and are covered.

A dread disease policy is a limited plan paying only when a named condition, like cancer or heart attack, is diagnosed. It does not cover all illnesses, accidents generally, or long-term care.

These describe the levels of long-term care, from skilled medical care down to non-medical custodial help. They are not surgeries, Medicare parts, or annuity options.

Custodial care is non-medical assistance with daily living activities and is what most long-term care recipients require. Skilled care under a doctor's order and surgery are different, higher levels of care.

An HMO delivers prepaid, managed care through its network with an emphasis on prevention and low member cost-sharing. Fee-for-service reimbursement and no network describe indemnity plans.

A PPO still covers out-of-network care but at a higher cost to the insured, preserving flexibility. It neither denies out-of-network care nor charges the same as in-network.

A POS plan combines HMO gatekeeping for the lowest cost with the option to go out-of-network at higher cost, deciding at the point of service. It is not the same as indemnity coverage.

HSA contributions require enrollment in a qualified high-deductible health plan and no disqualifying coverage. Low-deductible HMOs, Medicare, and dental plans do not qualify a person to fund an HSA.