The national Medical Plans guide covers plan design: indemnity versus managed care, HMOs, PPOs, POS plans, deductibles, coinsurance, out-of-pocket maximums, and the ACA framework. This guide adds what Alaska layers on top: the coverage mandates in AS 21.42, the managed-care protections in AS 21.07 and the HMO law (AS 21.86), prompt payment, external review, and a few marketing rules. Expect Alaska questions to ask for a specific age, day count, or percentage, so the numbers below matter.

Quick refresher on plan types

• HMO: care through network providers, usually coordinated by a primary care physician who authorizes specialist referrals. Alaska HMOs are organized under AS 21.86.
• PPO: network discounts, with out-of-network care allowed at a higher cost and usually no referral requirement.
• POS: an HMO-PPO hybrid where the member chooses in or out of network at the time of service.
• Cost sharing: deductible first, then coinsurance (in an 80/20 plan the plan pays 80%), with copays for some services and an out-of-pocket maximum after which the plan pays 100% of covered charges.

Alaska managed-care protections

• Non-network option. A health care insurer (other than an HMO) that covers services only through a provider network must also offer a non-network option at initial enrollment. That option may carry higher cost sharing or premium (AS 21.07.030(a)).
• Choice of primary care provider. If a plan requires a designated primary care provider, the covered person may choose any available participating primary care provider, including a pediatrician (AS 21.07.030(d)).
• No retroactive denial of preauthorization. A preauthorization for a covered procedure based on medical necessity may not be retroactively denied unless it was based on materially incomplete or inaccurate information from the provider (AS 21.07.020).
• Chiropractic access in HMOs. An HMO enrollee may use a licensed chiropractor of the enrollee's choosing without prior approval from the HMO, a gatekeeper, or the primary care physician (AS 21.86.075).
• Provider nondiscrimination. A group health policy covering services on an expense-incurred basis may not unfairly discriminate against listed licensed providers, such as chiropractors, for covered services within the scope of their license (AS 21.36.090(d)).
• No forced provider. A health policy generally may not require that services be provided by a particular hospital or person, except for HMOs (AS 21.54.020).

Coverage mandates and required offers

A mandate requires the coverage to be included. An offer requirement means the insurer must make the coverage available and the buyer may decline it. The dental, vision, and hearing rule is an offer.

Prompt payment of claims

Alaska repealed the standard "time of payment of claims" provision for health policies. Its prompt-pay statute governs instead (AS 21.36.495):

• A health care insurer must pay or deny a clean claim within 30 calendar days after it (or its TPA) receives the claim.
• If the claim is not clean, the insurer must tell the covered person or assigned provider within those 30 days what is wrong or what information it needs. If it doesn't, the claim is presumed clean.
• After requesting specific information, the insurer must pay within 15 calendar days after receiving that information or within 30 days after receiving the claim (AS 21.36.495(d)).
• Late payments accrue interest at 15% a year.

Grievances and external review

• When an insurer issues a final adverse determination based on medical necessity, the covered person may request external review by independent health care professionals. The request is submitted to the Director of the Division of Insurance (3 AAC 28.952).
• If the insurer has not decided an internal grievance within 30 days of filing (absent an agreed delay), the internal process is treated as exhausted and the person may go to external review (3 AAC 28.956).

Marketing and pricing rules

• Unfair discrimination: health premiums, benefits, and terms may not unfairly discriminate between individuals of the same class and essentially the same hazard (AS 21.36.090(b)).
• Wellness programs: rewards under a qualifying wellness program are not illegal rebates if, among other conditions, total rewards do not exceed 20% of the cost of coverage (AS 21.36.110).
• Health discount plans are not insurance and must say so in bold, prominent type. A buyer may cancel within 30 days of purchase for a full refund, less a nominal processing fee (AS 21.36.505).

Federal rules tested alongside

• ACA premium tax credits (Section 1401) apply only to plans bought through the marketplace. Alaska residents use the federally facilitated marketplace at HealthCare.gov.
• Cost-sharing reductions (Section 1402) apply only to silver marketplace plans.
• Non-grandfathered plans cover recommended preventive services without cost sharing in network (PHS Act 2713).
• Individual and small group plans cover the ten essential health benefit categories, including pediatric oral and vision care (ACA 1302).
• Mental health parity means mental health and substance use benefits may not have more restrictive financial requirements than medical and surgical benefits.

Common exam traps

• Newborns are covered from birth; the 31-day window is only for notice and any added premium.
• An adopted child is covered from placement, not from the final adoption decree.
• The mammogram schedule is 35-39 baseline, 40-49 every two years, 50+ yearly.
• Autism coverage runs to under 21, not 18 or 26.
• A network-only insurer that is not an HMO must offer a non-network option.
• Clean claims are paid or denied in 30 calendar days, and late claims accrue 15% interest.
• External review requests go to the Director, not to the insurer.
• Dental, vision, and hearing coverage must be offered, not included.