Health questions on the Virginia exam start with national plan design and the federal Affordable Care Act (ACA) floor, then layer on Virginia's own continuation, conversion, and consumer-protection rules. This guide reviews how medical plans are built—HMO, PPO, EPO, POS, and indemnity—and the cost-sharing terms that apply to all of them, then makes the Virginia overlay the spine: state mandates, small-employer continuation, conversion, Cardinal Care Medicaid, and Virginia's own ACA marketplace. Virginia regulates these plans through the Virginia Bureau of Insurance, a division of the State Corporation Commission (SCC).

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; the insured handles deductibles and coinsurance and may file claims. Largely historical now.
• HMO (Health Maintenance Organization) — lowest cost, network-only care, usually a primary care physician (PCP) and referrals to specialists; emphasizes prepaid, 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.
• EPO (Exclusive Provider Organization) — network-only like an HMO but typically without a PCP/referral requirement.
• POS (Point of Service) — a hybrid that uses a PCP/gatekeeper like an HMO but allows out-of-network care like a PPO.

Universal cost-sharing terms apply across all of these: premium, deductible, copay, coinsurance, and out-of-pocket maximum. Coverage also splits into group (employer-sponsored, usually cheaper, often guaranteed issue to eligible employees) versus individual (purchased directly or through the marketplace).

The ACA floor

Federal law sets the minimum every insured major-medical plan must meet:

• Guaranteed issue — insurers cannot decline an applicant for health reasons.
• No health-based rating — premiums vary only by allowed factors (such as age, geography, tobacco use, family size), not health status.
• Pre-existing conditions covered — no exclusions or waiting periods for prior conditions.
• Essential health benefits (EHBs) — a defined set of core categories (such as hospitalization, prescription drugs, maternity, mental health) must be covered.
• Dependents to age 26 — adult children may stay on a parent's plan.

Self-funded ERISA plans are generally exempt from state mandates, so Virginia's add-ons below apply mainly to fully insured plans.

Virginia continuation: small-employer "mini-COBRA"

Federal COBRA applies to employers with 20 or more employees and allows continuation generally up to 18 (sometimes 36) months. Virginia fills the gap for smaller groups below that threshold with its own state continuation ("mini-COBRA"):

• Who it covers: employees and dependents of fully insured small employers under the federal 20-employee COBRA threshold.
• How long: a limited continuation period—commonly cited as up to 12 months—but treat the exact length as a statutory figure to verify, since it has changed over time.
• Cost: the participant generally pays the full premium (plus any allowed administrative charge).
• Electing: the individual must elect within the notice window set by the policy/statute and continue paying premiums on time.

On the exam, anchor on the split: 20+ employees → federal COBRA; smaller groups → Virginia state continuation. Hedge the precise duration rather than asserting a fixed number.

Conversion privilege

Separate from continuation, many Virginia 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. Conversion policies may offer narrower benefits than the group plan but preserve access to coverage. Distinguish continuation (keeping the same group plan temporarily) from conversion (moving to an individual policy).

Virginia mandated benefits

Like every state, Virginia requires fully insured plans to include certain mandated benefits. The list changes over time, so focus on the categories commonly tested rather than memorizing dollar figures or caps:

• Mental health and substance use coverage consistent with parity requirements.
• Maternity and newborn care, including a minimum hospital stay after childbirth.
• Mammography and certain cancer screenings, and childhood immunizations.
• Diabetes education and supplies, and other condition-specific mandates added over time.

Treat any specific cap or age limit as the statutory figure of the time, not a fixed exam number.

Virginia Medicaid (Cardinal Care) and the marketplace

• Cardinal Care is Virginia's unified Medicaid program (the rebranding of the former FAMIS/Medicaid structure). Virginia expanded Medicaid under the ACA, extending eligibility to many low-income adults—a frequently referenced state development.
• Virginia's Insurance Marketplace is the state's own state-based ACA exchange. Virginia recently moved off the federal HealthCare.gov platform to run its own marketplace (generally for plan years beginning around 2024—verify the exact start year). For the exam, know that Virginia operates a state-based exchange, not the federal one.

Provisions and timelines

• Grace period — a window (commonly 31 days for many health/group policies) to pay an overdue premium before lapse; verify the exact figure for the policy type.
• Free look — health policies generally allow the buyer to return the policy for a refund; commonly cited as about 10 days for individual health (longer for senior products—see the senior guide).
• Incontestability — after the policy has been in force for the statutory period (commonly 2 years), the insurer generally cannot contest it for misstatements except for fraud or nonpayment.
• Prompt payment of claims — insurers must pay clean claims within required timeframes or owe interest; this is enforced by the Bureau of Insurance.

Key Virginia numbers to memorize

Common exam traps

• Confusing COBRA and Virginia state continuation. Federal COBRA = 20+ employees; Virginia's continuation covers smaller groups, for a shorter (verify) period.
• Asserting an exact continuation length. It has changed—hedge ("commonly ~12 months; verify").
• Mixing up continuation and conversion. Continuation keeps the group plan; conversion moves to an individual policy with no new underwriting.
• Saying Virginia uses HealthCare.gov. Virginia now runs its own state-based exchange, Virginia's Insurance Marketplace.
• Forgetting Virginia expanded Medicaid (now Cardinal Care).
• Asserting exact mandate caps. Mandate limits are set by statute and change—describe them qualitatively.
• Forgetting self-funded ERISA plans are usually exempt from state mandates and continuation rules.

Quick recap

Virginia medical-plan questions begin with national design—indemnity, HMO, PPO, EPO, POS—the universal cost-sharing terms, and the ACA floor (guaranteed issue, no health rating, pre-existing covered, EHBs, dependents to 26). The Virginia overlay is the spine: state "mini-COBRA" continuation for groups under the 20-employee federal threshold (length commonly ~12 months—verify), the conversion privilege to an individual policy without new underwriting, and a set of mandated benefits on fully insured plans. Virginia expanded Medicaid under Cardinal Care and now runs its own state-based ACA exchange, Virginia's Insurance Marketplace, after moving off the federal platform. Keep the standard timelines in mind—grace, ~10-day free look, 2-year incontestability, prompt-pay—all enforced by the Bureau of Insurance under the SCC, and most VA health questions become reliable points.