Affordable Care Act Flashcards
(ACA) Affordable Care Act
aka Patient Protection and ACA (PPACA), Obamacare, or Health Care Reform
2010 Health Reforms
no lifetime dollar limits/annual dollar limits on essential health benefits - no rescissions (cancellations), except for fraud - specific preventative services are covered free of charge to insured - dependent coverage until a child’s 26th birthday - preexisting conditions must be covered for children under age 19.
2014 Health Reforms
preexisting conditions must be covered for all eligible individuals (not just children) - guaranteed issue of health insurance policies - no discrim based on gender, health status, or preexisting conditions - community rating rules for premiums - health insurance exchanges or marketplaces - qualified health plans (QHPs) - essential health benefits (EHBs) premium tax credits and cost sharing subsidy - the creation of navigators
Grandfathered Health Policy
existed prior to ACA. costs cannot be increased and benefits may not be reduced on these policies. - policy is not required to comply with some of the consumer protections of the ACA that apply to ther health plans.
Nongrandfathered Plans
must comply with all rules and laws of the ACA
Individual Mandate
US citizens and legal residents are required to have qualifying health care coverage (minimun essential coverage)
Minimum Essential Coverage
Gvnt Sponsored Programs, Employer Sponsored plans, individuals plans, grandfathered health plans, other coverage)
Essential Health Benefits (EHBs)
Ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services. prescription drugs. rehab serivces and devices. Lab services. Preventative and wellness services, chronic disease management, pediatric services (including oral and vision care)
Emergency Medical Services
No pre-auth required. In-network/Out-of-network. Normal cost-sharing requirements
Pre-existing Condition
a limitation or exclusion of benefits based on a physical or mental condition that was present before the effective date of coverage (health plans can no longer exclude)
Guaranteed Issue
a requirement that health plans permit you to enroll, regardless of health status, age, gender, or other factors that might predict the use of health services.
Health Plan Exchange/Marketplaces
Required. Operated by state or federal government. Annual open enrollment and special enrollment depending on qualifiying events
Qualified Health Plans (QHPs)
sold on the health insurance exchange; provide essential health benefits, follow established limits on cost-sharing (like deductibles, copayments, and OOP max amounts, and meet other requirements (only plan that provides tax credits and cost sharing)
Small Business Health Options (SHOP)
provides an online application where small employers can shop and compare a variety of health insurance plans (employer must have 50 or fewer full-time employees)
Subsidies
A sum of money given by the federal government (premium tax credits (APTCs) that may be applied to lower the insured’s monthly premiums or cost-sharing reductions such as lower copayment, coinsurance, and OOP limits.
