Ohio · Accident & Health SampleInteractive Mind Map
Group Plan Benefits and Cost Sharing
A visual breakdown of Group Plan Benefits and Cost Sharing — one of the concepts you can count on seeing on the exam.
The TESTivity Interactive Mind Mapping Graphic we picked for the Ohio Health Insurance sample is Group Plan Benefits and Cost Sharing — and this is a concept you can count on seeing on your pre-licensing exam. Get the structure straight once and those questions turn into free points.
So explore it. Click through, see how the pieces relate, and let the layout do some of the remembering for you.
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The ACA defined ten categories that every compliant individual and small-group plan must cover.
Large group plans aren’t required to cover all ten — but if they cover an EHB category, they can’t put dollar limits on it.
1. Ambulatory (Outpatient) Services
Office visits, outpatient surgery, diagnostics.
2. Emergency Services
Emergency room and urgent care.
3. Hospitalization
Inpatient care, surgery, overnight stays.
4. Maternity & Newborn Care
Prenatal, labor, delivery, newborn care.
5. Mental Health & Substance Use
Treatment at parity with medical/surgical.
6. Prescription Drugs
Medications via a formulary.
7. Rehab & Habilitative Services
PT, OT, speech therapy, developmental services.
8. Laboratory Services
Blood tests, imaging, lab work.
9. Preventive & Wellness
USPSTF-recommended care at no cost sharing.
10. Pediatric Services
Including pediatric dental and vision.
How they test thisThe EHB mandate strictly binds individual and small-group ACA plans. Large group plans needn’t cover all ten — but any EHB category they DO cover cannot carry lifetime or annual dollar limits.
A cluster of federal laws forces specific protections into group plans — two named acts show up constantly.
Learn WHCRA (mastectomy reconstruction) and NMHPA (48/96-hour maternity stays) cold.
🌵 WHCRA
👶 NMHPA
Women’s Health & Cancer Rights Act
If a plan covers a mastectomy, it must also cover reconstruction, surgery on the other breast for symmetry, prostheses, and treatment of complications.
Newborns’ & Mothers’ Health Protection Act
Minimum hospital stay after childbirth: 48 hours (vaginal) / 96 hours (C-section). The plan can’t force an earlier discharge.
🚫
No Lifetime or Annual Dollar Limits
For EHBs a plan covers, dollar maximums (lifetime or per-year) are prohibited — small AND large groups.
🩸
Free Preventive Care
USPSTF Grade A & B services with no cost sharing in-network — no deductible, copay, or coinsurance.
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Summary of Benefits and Coverage (SBC)
A standardized plan summary — the group equivalent of an “outline of coverage.” Provided before enrollment and at renewal, enabling apples-to-apples comparison.
How they test thisPlan covers a mastectomy → WHCRA requires reconstruction, symmetry surgery, prostheses, and complication care (not “all cancer treatments”). Vaginal delivery → the plan can’t push discharge before 48 hours; C-section → 96 hours.
Group plans use the same cost-sharing tools as individual plans — plus one tax-favored standout: the HSA.
The exam’s favorite HSA fact is the triple tax advantage.
⚖️
Premium Split & OOP Maximum
The employer typically pays 70–80% of the employee premium; the employee pays the rest (more for dependents). ACA plans must include an out-of-pocket maximum — after it’s hit, the plan pays 100% in-network.
💰
HDHP + Health Savings Account (HSA)
The triple-tax-advantaged combo
An HSA pairs with a qualifying high-deductible health plan (higher deductible, lower premium). Its three tax breaks:
🧮 Triple tax advantage
1. Going in: contributions are tax-deductible (or pre-tax via payroll).
2. Growing: earnings grow tax-deferred.
3. Coming out: withdrawals for qualified medical expenses are tax-free.
✅ Two more facts
Portable — the account belongs to the employee, not the employer.
Rolls over year to year — no “use it or lose it” (unlike an FSA).
How they test thisHSA = deductible in, tax-deferred growth, tax-free out for medical expenses — and it requires a qualifying HDHP. Unlike a 401(k), qualified-medical withdrawals are never taxed.
Two end-of-coverage puzzles: how two plans split a bill, and how to keep coverage after the job ends.
The birthday rule and the conversion-vs-COBRA distinction are the tested pieces.
🤝
Coordination of Benefits (COB)
When someone has two group plans
Primary plan pays first, as if no other plan existed.
Secondary plan pays the remaining balance up to its limits — combined payment can’t exceed the total covered expense.
Birthday rule (children): the parent whose birthday falls earlier in the calendar year has the primary plan — month and day, not who’s older.
How they test thisMom’s birthday June 10, Dad’s February 22 → Dad’s plan is primary for the kids (Feb is earlier in the year). It’s never about who’s older or who enrolled the child first.
🔄 Conversion Privilege
📝 COBRA (preview)
What you get
An individual policy — often different, more limited benefits.
What you get
The same group plan continues unchanged.
Insurability
No evidence of insurability required.
Cost
Full unsubsidized group premium (up to 102%).
Governed by
State law; ~30–31 days to elect; individual (attained-age) rates.
Usually preferred
Keeps identical coverage — conversion is the fallback.
The common mistakeDon’t confuse them: conversion = a new individual policy (different benefits, higher individual-rate premium, no EOI). COBRA = the same group plan continued. COBRA is usually preferred when available.
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Top Exam Tips — Group Benefits & Cost Sharing
1. Ten EHBs are required for ACA individual and small-group plans; large groups needn’t cover all ten but can’t set dollar limits on the ones they do. 2. WHCRA: cover a mastectomy → must cover reconstruction, symmetry surgery, prostheses, complications. 3. NMHPA: minimum stay 48 hours (vaginal) / 96 hours (C-section). 4. HSA = triple tax advantage (deductible in, tax-deferred growth, tax-free out); requires an HDHP; portable; rolls over. 5. Birthday rule: the parent with the earlier calendar-year birthday has the primary plan for the kids. 6. Conversion = a new individual policy (no EOI, different benefits); COBRA = the same group plan continued.
Exam vocabulary
Key Terms to Know
Essential Health Benefits (EHBs)
Ten categories of services ACA-compliant individual and small-group plans must cover.
Summary of Benefits and Coverage (SBC)
A standardized plan summary required before enrollment and at renewal; enables plan comparison.
WHCRA
Women’s Health and Cancer Rights Act — requires mastectomy reconstruction (and symmetry, prostheses, complications) if a mastectomy is covered.
NMHPA
Newborns’ and Mothers’ Health Protection Act — minimum 48-hour (vaginal) or 96-hour (C-section) hospital stay after childbirth.
High-Deductible Health Plan (HDHP)
A higher-deductible, lower-premium plan that qualifies for HSA pairing.
Health Savings Account (HSA)
A triple-tax-advantaged account for medical expenses; requires an HDHP; portable; rolls over year to year.
Coordination of Benefits (COB)
Rules determining how two group plans split claim payment when someone has dual coverage.
Birthday Rule
For children with dual coverage, the parent with the earlier birthday in the calendar year has the primary plan.
Primary Plan (COB)
Pays first when there is dual coverage, as if no secondary plan existed.
Secondary Plan (COB)
Pays the remaining balance after the primary plan; combined payment can’t exceed the total covered expense.
Conversion Privilege
The right to convert group coverage to an individual policy without evidence of insurability; governed by state law.
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