Health insurance questions on the Pennsylvania exam blend national plan design with PA-specific mandates and continuation rights. This guide reviews the building blocks of medical plans—how HMOs, PPOs, and indemnity plans differ—then concentrates on the Pennsylvania rules you must know: Mini-COBRA continuation, conversion rights, and the state's mandated benefits and consumer protections.

National fundamentals (the quick review)

Medical plans differ mostly in how they balance cost, choice, and network:

• Indemnity (fee-for-service) – pays a share of covered charges with broad provider choice; the insured handles deductibles, coinsurance, and often files claims.
• HMO (Health Maintenance Organization) – lowest cost, network-only care, usually a primary care physician (PCP) and referrals to see specialists; emphasizes preventive care.
• PPO (Preferred Provider Organization) – a network of "preferred" providers with lower cost in-network and partial coverage out-of-network; usually no referral needed.
• POS (Point of Service) – a hybrid that uses a PCP/gatekeeper like an HMO but allows out-of-network care like a PPO.
• HDHP/HSA – a high-deductible plan paired with a tax-advantaged health savings account.

Common cost-sharing terms—premium, deductible, copay, coinsurance, and out-of-pocket maximum—apply across all of these. Pennsylvania regulates these plans through the Pennsylvania Insurance Department (and the Department of Health for HMO quality-of-care matters).

Pennsylvania continuation: Mini-COBRA

Federal COBRA applies to employers with 20 or more employees and allows continuation for 18 (sometimes 36) months. Pennsylvania fills the gap for small employers with Mini-COBRA (Act 2 of 2009):

• Who it covers: employees of small employers that normally have 2 to 19 employees.
• How long: up to 9 months of continuation, with no extensions under state law.
• Eligibility: the employee/dependent must have been continuously covered for the three months before the qualifying event and must not be eligible for Medicare or other group coverage.
• What continues: medical coverage only (stand-alone dental and vision are not required to continue).
• Cost: the participant pays the full premium (including the employer's former share) plus an administrative fee of up to 5%.
• Electing: the individual generally has about 30 days from notification to elect coverage; the employer is responsible for giving notice of Mini-COBRA rights.

Qualifying events mirror federal COBRA: termination (other than gross misconduct), reduction in hours, divorce, a dependent aging out, death of the covered employee, and similar events that cause loss of coverage.

Conversion rights

Separate from Mini-COBRA, many Pennsylvania group health contracts include a conversion privilege: when group coverage ends, an eligible person may convert to an individual policy without new evidence of insurability, typically by applying within a set window after group coverage terminates. Conversion policies may offer narrower benefits than the group plan, but they preserve access to coverage. On the exam, distinguish continuation (keeping the same group coverage temporarily) from conversion (moving to an individual policy).

Pennsylvania mandated benefits

Pennsylvania, like every state, requires insured health plans to include certain mandated benefits. The exact list changes over time and self-funded ERISA plans are generally exempt, so focus on the categories commonly tested rather than memorizing every dollar figure:

• Autism spectrum disorder treatment coverage (Pennsylvania's well-known Act 62 of 2008), subject to age and annual limits set by statute.
• Mammography and certain cancer screenings, and childhood immunizations.
• Maternity and newborn coverage, including a minimum hospital stay following childbirth consistent with federal standards.
• Mental health coverage consistent with applicable parity requirements.
• Diabetes education and supplies, and other condition-specific mandates added over time.

Because these mandates are periodically amended, treat any specific annual cap or age limit as the statutory figure of the time rather than a fixed number to assert on the exam.

Consumer protections and plan rules

• Internal and external review: Pennsylvania gives members the right to appeal denied claims and request independent external review of medical-necessity denials.
• Network adequacy and continuity of care: managed-care plans must maintain adequate provider networks and allow limited continuity of care when a provider leaves the network.
• Prompt payment / claims handling: insurers must process clean claims within required timeframes and may not engage in unfair claims practices.
• Guaranty protection: the PA Life & Health Insurance Guaranty Association backs covered health benefits if an admitted insurer becomes insolvent (caps apply; HMOs and self-funded plans are treated differently).
• Children's Health Insurance Program (CHIP): Pennsylvania operates a robust CHIP for children who don't qualify for Medical Assistance, a frequently referenced state program.

Key Pennsylvania numbers to memorize

Common exam traps

• Confusing COBRA and Mini-COBRA. Federal COBRA = 20+ employees, 18/36 months; PA Mini-COBRA = 2–19 employees, 9 months.
• Thinking Mini-COBRA continues dental and vision. It requires medical only.
• Mixing up continuation and conversion. Continuation keeps the group plan temporarily; conversion moves you to an individual policy.
• Assuming Mini-COBRA works alongside Medicare eligibility. Becoming eligible for Medicare generally ends Mini-COBRA eligibility.
• Asserting exact mandate caps. Autism and other mandate limits are set by statute and change—describe them qualitatively.
• Forgetting self-funded plans are usually exempt from state mandates under ERISA.

Quick recap

Pennsylvania medical-plan questions start with national plan design—indemnity, HMO, PPO, POS, and HDHP/HSA—and the universal cost-sharing terms. The state-specific spine is Mini-COBRA (Act 2 of 2009): small employers with 2–19 employees must offer up to 9 months of medical-only continuation to employees covered for at least 3 months, who pay the full premium plus up to a 5% fee and elect within about 30 days. Distinguish that from conversion to an individual policy with no new underwriting. Pennsylvania also imposes mandated benefits (such as the Act 62 autism mandate), guarantees appeal and external review rights, and backs admitted insurers through the Life & Health Guaranty Association. Keep the Mini-COBRA numbers crisp and you'll handle most PA health questions with confidence.