HMO = health care service plan; Knox-Keene Act of 1975; regulated by DMHC.

Subscriber pays; enrollees receive care.

Hospice is a basic health care service; dental is not.

Copays and deductibles are allowed if disclosed and within limits.

HMO: see the PCP first for a nonemergency specialist referral.

Capitation = fixed amount per enrollee per period, no matter how much care is used.

Hold harmless: the enrollee never owes what the plan owes the provider.

Emergency care until stabilization: no prior authorization.

Appointments: 48 hours urgent; 10 business days primary care; 15 business days specialist.

Grievance: resolve in 30 days; serious threat → written status in 3 days.

IMR = disputes over medical necessity, not contract exclusions.

PPO: no referral; out-of-network care covered at a higher cost.

Network providers accept the negotiated rate; non-network providers may balance bill.

Insurer PPO = alternative rates under §10133; regulated by CDI, not DMHC.

Network distance: primary care and hospitals 30 min/15 mi; specialists 60 min/30 mi.

EPO = network only, except emergencies.

HMO and EPO: no routine out-of-network coverage; PPO: yes, at higher cost.

Routine non-network visit in an EPO: the member pays it all.

In-network facility + non-network doctor = in-network cost sharing.

Out-of-network consent: only with out-of-network benefits, signed at least 24 hours ahead.

Terminated provider: a documented surgery within 180 days can be completed.

Insurer policy → CDI's IMR; HMO contract → DMHC's IMR.

HRA = employer money only; self-employed people cannot have one.

HSA: anyone may contribute, and the account is the individual's own.

A cash-out option makes every HRA distribution that year taxable.

HRA may pay premiums; a health FSA may not.

Small employer for Archer MSAs = 50 or fewer employees.

Limit: 65% of the deductible (self-only), 75% (family).

Employer OR employee contributes, never both in one year.

Non-medical withdrawal: 20% federal, 12.5% California; Medicare MSA: only Medicare deposits.

2026 self-only HDHP: deductible at least $1,700 AND out-of-pocket maximum no more than $8,500.

Medicare enrollment → HSA contribution limit becomes zero.

Dental, vision, disability and long-term care coverage do not spoil HSA eligibility.

No joint HSA; each spouse's catch-up goes into his or her own account.

Non-medical withdrawal before 65: income tax + 20% additional tax.

After 65, disability or death: no 20% tax, but still taxable income.

Medigap premiums are never HSA-eligible; Medicare's own premiums are, at 65+.

California does not exclude employer HSA contributions from income.

FSA = salary reduction, use it or lose it.

The full annual election is available from day one.

Grace period (up to 2½ months) OR carryover, never both.

No premiums from an FSA; only a limited-purpose FSA fits with an HSA.

Pediatric dental and vision = mandatory essential health benefits, to about age 19.

Adult dental and adult vision = optional coverages.

Covered California dental needs a health plan; adult vision is bought direct, year-round.

Grandfathered plans are exempt; no one may sell a non-compliant product as EHB compliant.

Premiums never count toward the out-of-pocket limit.

One family member's limit can't exceed the individual limit; out-of-network emergency care counts.

USPSTF A or B preventive services: $0 cost sharing.

Coordination of benefits caps the total at 100% of covered expenses.

Grace period: at least 30 days after notice; three months with advance premium tax credits.

Leaving the market: 180 days' notice and a five-year bar; one plan: 90 days.

After 24 months: no rescission for any reason.

Reconstructive surgery must be covered; cosmetic surgery need not be.

Experimental denial (serious condition): written notice of external review within 5 business days.

No preexisting condition exclusions and no lifetime or annual dollar caps in individual plans.

The intoxicants provision does not apply to health insurance.