Indiana health-insurance questions blend national medical-plan design with a layer of Indiana-specific provision, continuation, and consumer-protection rules. This guide reviews the building blocks every health agent needs—plan types and cost-sharing—then makes the Indiana overlay the spine: the policy provisions the Indiana Department of Insurance enforces, group continuation and conversion, the ACA floor, and Medicaid through the state's program.

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, often limited to usual, customary, and reasonable (UCR) amounts; now uncommon.
• HMO (Health Maintenance Organization) — lowest cost, network-only care through a primary care physician (PCP) "gatekeeper" with referrals to specialists.
• PPO (Preferred Provider Organization) — a network with lower in-network cost but out-of-network access, usually without referrals.
• EPO (Exclusive Provider Organization) — network-only like an HMO but typically no PCP/referral requirement.
• POS (Point of Service) — a hybrid using a PCP gatekeeper like an HMO while allowing out-of-network care like a PPO.

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), and the out-of-pocket (OOP) maximum / stop-loss (the annual cap after which the plan pays 100% of covered, in-network care). Capitation pays a network provider a fixed amount per member per period, while in-network providers accept negotiated, discounted fees. Coverage is sold group (employer-sponsored, lower cost, limited or no individual underwriting) versus individual (bought directly, now guaranteed issue under federal law).

The ACA floor (federal minimums)

The Affordable Care Act sets a national floor every Indiana 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.

Indiana builds on top of this floor; it does not subtract from it. Self-funded ERISA plans are generally exempt from state mandates—a common exam distinction.

Required policy provisions Indiana enforces

The Indiana Department of Insurance enforces standardized health-policy provisions drawn from the NAIC uniform provisions. Know them by name:

• Entire contract — the policy plus the attached application is the whole agreement.
• Grace period — extra time to pay a late premium before the policy lapses (length varies by payment mode).
• Reinstatement — if the insurer accepts a late premium without requiring an application, coverage is reinstated automatically.
• Notice of claim / proof of loss — the insured must notify the insurer and submit written proof within stated time limits.
• Time limit on certain defenses — Indiana's version of incontestability: after the policy has been in force a set period, the insurer generally cannot contest it for misstatements (except fraud).
• Free look — a window to return an individual health policy after delivery for a full refund; the exact number of days is set by statute (verify).
• Grievance and appeal — insurers must let insureds challenge a claim denial.
• Renewability — policies are classified as noncancellable, guaranteed renewable, conditionally renewable, or cancellable/optionally renewable; guaranteed renewable means the insurer must renew but may change premiums by class.

Group health: continuation and conversion

• Master policy / certificates. In a group plan the master policy is issued to the employer, and members receive certificates of coverage.
• Federal COBRA applies to employers with 20 or more employees and allows continuation generally up to 18 months (or 36 months for certain events such as divorce, death, or a dependent aging out). The participant pays the full premium plus a small administrative charge.
• Indiana state continuation fills the gap for smaller employers below the federal COBRA threshold, letting a qualified person keep group coverage for a limited period (verify the size threshold and duration—they are statutory and change).
• Conversion privilege. Separate from continuation, group coverage generally carries a conversion privilege: when group coverage ends, the insured may convert to an individual policy without new evidence of insurability. On the exam, distinguish continuation (keeping the same group plan temporarily) from conversion (moving to an individual policy).

Indiana mandated benefits and Medicaid

• Like every state, Indiana requires insured (non-self-funded) plans to include certain state-mandated benefits. Treat these by category rather than memorizing dollar caps, which change.
• Medicaid in Indiana is the income- and asset-based public program (distinct from Medicare). Indiana has historically operated coverage through programs such as the Healthy Indiana Plan (HIP)—verify current program names and operation. The Department of Insurance regulates insurers; Medicaid is run by the state's family/social-services agency, not the IDOI.
• The ACA marketplace in Indiana has generally relied on the federal HealthCare.gov platform—verify the current operational status.

Key Indiana numbers to memorize

Common exam traps

• Confusing COBRA and state continuation. Federal COBRA = 20+ employees; Indiana state continuation reaches smaller employers.
• 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 run by the state's social-services agency, not the IDOI.
• Assuming the ACA floor can be undercut. Guaranteed issue, no health rating, and pre-existing coverage are federal minimums Indiana cannot reduce.
• Confusing coinsurance with copay. Coinsurance is a percentage after the deductible; a copay is a flat per-visit charge.
• Forgetting self-funded ERISA plans are usually exempt from state mandates.

Quick recap

Indiana 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/stop-loss), plus the ACA floor: guaranteed issue, no health rating, pre-existing coverage, essential health benefits, and dependents to age 26. The Indiana overlay is the spine: the required policy provisions the Department of Insurance enforces (entire contract, grace period, reinstatement, notice/proof of loss, time limit on defenses, free look, grievance/appeal, and renewability classes), group continuation and conversion rights, and Medicaid through the state's program rather than the IDOI. Verify any specific number, and the Indiana health section becomes manageable.