How health plans are structured and funded: fully insured versus self-funded, plan types, and what coverage includes.
Plans & Coverage Topics
Prescription Drugs
Pharmacy benefits, formularies, PBMs, and drug costs.
Provider Networks
In- vs out-of-network care and balance billing.
Claims & Appeals
EOBs, coordination of benefits, denials, and appeals.
Preventive Care
Services covered at no cost under the ACA.
HMOs
Health Maintenance Organization plans.
PPOs
Preferred Provider Organization plans.
EPOs
Exclusive Provider Organization plans.
POS Plans
Point-of-Service plans.
Self-Funding
How self-funded plans work and when they fit.
Cost-Sharing
Deductibles, copays, coinsurance, and out-of-pocket maximums.
Metal Tiers
Bronze, Silver, Gold, and Platinum coverage levels.
Prior Authorization
When a plan must approve care before it pays.
Telehealth
Virtual care and its coverage rules.
Mental Health Parity
Equal coverage for mental health and substance-use care.
Continuity of Care
Keeping your provider at in-network rates when they leave the network mid-treatment.
Essential Health Benefits
The ten categories of care ACA plans must cover, including maternity and newborn care.
State Mandates
State coverage requirements that go beyond federal rules, such as fertility and IVF.