Delaware health-insurance questions blend national medical-plan design with a layer of Delaware-specific continuation, conversion, and consumer-protection rules. This guide reviews the building blocks every health agent needs—plan types and cost-sharing—then makes the Delaware overlay the spine: the federal COBRA continuation rule, the conversion privilege, the Delaware Life and Health Insurance Guaranty Association, the external review right, and the policy provisions the Delaware Department of Insurance enforces.

The national base: types of medical plans

Most health questions begin with how a plan balances cost, choice, and network:

• Indemnity / fee-for-service — pays a share of covered charges with broad provider choice; now uncommon.
• HMO (Health Maintenance Organization) — lowest cost, network-only care through a primary care physician (PCP) with referrals to specialists; HMOs often pay providers by capitation (a fixed amount per member per period).
• PPO (Preferred Provider Organization) — a network with lower in-network cost but out-of-network access at a higher cost, usually without referrals.
• EPO (Exclusive Provider Organization) — network-only like an HMO but typically no PCP/referral requirement.
• POS (Point of Service) — a hybrid that lets the member choose network or out-of-network care at the time service is needed.

Universal cost-sharing terms apply across all designs: the premium (what you pay to have coverage), the deductible (paid before the plan shares), the copay (a flat per-visit charge), coinsurance (a percentage split after the deductible—e.g., 80/20, where the plan pays 80% and the insured 20%), and the out-of-pocket (OOP) maximum (the annual cap after which the plan pays 100% of covered, in-network care). A UCR (usual, customary, and reasonable) provision limits payment to the prevailing charge for a service in the area.

Coverage is sold group (the employer holds the master contract and employees get certificates) versus individual. Group plans may be contributory (employees pay part; a high percentage must enroll to limit adverse selection) or noncontributory (employer pays all). Coordination of benefits (COB) decides which plan is primary when someone has two plans.

Consumer accounts

• FSA (Flexible Spending Account) — lets an employee set aside pre-tax dollars for qualified medical expenses.
• HRA (Health Reimbursement Arrangement) — employer-funded; reimburses employees for eligible expenses up to a set amount.
• HSA (Health Savings Account) — must be paired with a qualified high-deductible health plan (HDHP) to allow tax-advantaged contributions.

The ACA floor (federal minimums)

The Affordable Care Act sets a national floor every Delaware plan must meet:

• Guaranteed issue — insurers cannot decline an applicant for health reasons.
• No health rating — premiums vary only by age, geography, tobacco use, and family size, not health status.
• Pre-existing conditions covered — no exclusions or waiting periods for prior conditions.
• Essential health benefits — ten required categories (e.g., hospitalization, maternity, prescriptions, mental health, preventive care).
• Dependents to age 26 — adult children may stay on a parent's plan.

Delaware builds on top of this floor; it does not subtract from it.

Delaware mandated benefits

Delaware requires insured (non-self-funded) health plans to include certain state-mandated benefits that often exceed the federal minimum. Treat these by category rather than memorizing dollar caps, which change: mental health/substance use (with parity), cancer screenings and childhood immunizations, maternity and newborn care, and diabetes supplies/education. Self-funded ERISA plans are generally exempt from state mandates—a common exam distinction.

Continuation: federal COBRA and Delaware continuation

• Federal COBRA applies to employers with 20 or more employees and allows a qualified individual who loses group coverage to continue the group plan for a limited period (generally up to 18 months, or 36 months for certain events) by paying the premium themselves.
• Delaware has its own group continuation provisions that can reach small employers below the federal COBRA threshold—verify the current eligibility, duration, and notice rules with the Department, as state continuation figures change.

The exam loves the size split: 20+ employees → federal COBRA; smaller employers may fall under Delaware's state continuation rule instead.

Conversion privilege

Separate from continuation, Delaware group health coverage generally carries a conversion privilege. When group coverage (or continuation) ends, the departing employee may convert to an individual policy without new evidence of insurability. Conversion coverage may offer narrower benefits, but it preserves access. On the exam, distinguish continuation (keeping the same group plan temporarily) from conversion (moving to an individual policy).

Medicaid, the marketplace, and guaranty protection

• Medicaid is a needs-based program jointly funded by the federal and state governments for those with limited income—distinct from Medicare. In Delaware it is administered through the state's health and social services agency (commonly the Department of Health and Social Services—verify), not the Department of Insurance.
• The ACA marketplace serves Delaware residents; verify the current state-based vs. federal platform status.
• The Delaware Life and Health Insurance Guaranty Association protects covered policyholders up to statutory limits if a member health insurer becomes insolvent.

Required policy provisions and consumer protections

The Delaware Department of Insurance (led by the elected Commissioner) enforces standard health-policy provisions and protections, including:

• Grace period — extra time to pay a late premium before the policy lapses.
• Free look — a window to return the policy for a full refund; verify the exact figure.
• Time limit on certain defenses / incontestability — after a set period the insurer generally cannot contest the policy for most misstatements.
• Prompt-payment — insurers must pay or deny clean claims within a set time or owe interest.
• External review — an insured may request an independent external review of an adverse determination (e.g., a denial as "not medically necessary").
• Replacement and privacy — disclosures are required when replacing a policy, and producers must safeguard protected health information.

Key Delaware numbers to memorize

Common exam traps

• Confusing COBRA and state continuation. Federal COBRA = 20+ employees; smaller employers may fall under Delaware continuation—verify the figures.
• Mixing up continuation and conversion. Continuation keeps the group plan temporarily; conversion moves to an individual policy with no new evidence of insurability.
• Sending Medicaid questions to the Department of Insurance. Medicaid is needs-based, joint federal/state, run by the state's human-services agency.
• Assuming the ACA floor can be undercut. Guaranteed issue, no health rating, and pre-existing coverage are federal minimums Delaware cannot reduce.
• Forgetting self-funded ERISA plans are usually exempt from state mandates.
• Pairing an HSA with the wrong plan. An HSA needs a qualified HDHP.
• Asserting exact mandate caps, free-look days, or continuation durations. Treat figures as statutory and verify.

Quick recap

Delaware medical-plan questions start with national design—HMO, PPO, EPO, POS, and indemnity—and the universal cost-sharing terms (premium, deductible, copay, coinsurance, OOP max, UCR), plus the ACA floor: guaranteed issue, no health rating, pre-existing coverage, essential health benefits, and dependents to age 26. The Delaware overlay is the spine: federal COBRA for 20+ employers (with state continuation possibly reaching smaller ones), a conversion privilege to individual coverage with no new underwriting, needs-based Medicaid, and the Delaware Life and Health Insurance Guaranty Association. Round it out with the provisions the elected Commissioner's Department enforces—grace period, free look, incontestability, prompt-pay, and external review—verify any specific number, and the Delaware health section becomes manageable.