Affordable Care Act Flashcards
Subsidy to buy health insurance
- Because of the Affordable Care Act, many people who buy their own health insurance can get financial assistance that lowers your costs. This assistance is called a subsidy.
Subsidies - 2 types
- the Advanced Premium Tax Credit (APTC); and
- Cost Sharing Reduction
The Advanced Premium Tax Credit (APTC)
- Goes toward the insured’s monthly insurance premium;
- Can apply it to our bronze, silver, gold and platinum plans.
The Advanced Premium Tax Credit (APTC) -
Eligibility
- Household income is 100 to 400 percent above the Federal Poverty Level. Most people in this range will be eligible, but not everyone.
- Employer doesn’t offer health insurance that costs < 9.5% of an individual’s income and pays at least 60% of covered benefits.
- Not eligible for health insurance through a government program like Medicaid or Medicare.
- Married and file a joint return.
- Not claimed as a dependent by another person.
Note: If at the end of the year you’ve taken more premium tax credit in advance than you’re due based on your final income, you’ll have to pay back the excess when you file your federal tax return. If you’ve taken less than you qualify for, you’ll get the difference back.
(*calculated by California Health Benefit Exchange (Covered California) and paid by the Exchange to insurers)
Essential Health Benefits
Beginning January 1, 2014, the exchange allowed any qualified plans meeting the minimum standards established by the exchange to be offered in the exchange.
All plans must include the following:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative services and devices
- Laboratory services
- Preventative and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Ambulatory care
- Also called outpatient care
- medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services.
- This care can include advanced medical technology and procedures even when provided outside of hospitals.
Open Enrollment Period (OEP)
- the annual period when people can enroll in a health insurance plan.
- Year 2021: begins on November 1, 2020 and continues until January 31, 2021.
- But there’s a special enrollment period, through August 31, for uninsured residents, and additional enrollment opportunities for people who lose their jobs or are affected by California’s wildfires.
Special Enrollment Period (SEP)
- a period outside of open enrollment in which you can get coverage due to qualifying life events.
- This exception allows you to apply for health insurance if you’ve had certain qualifying life events, such as:
- Losing your job
- Moving to a new state
- Getting married or divorced
- Becoming a widow or widower
- Aging off your parent’s plan
- Having a new baby
Medical Loss Ratio (MLR)
- Under the Affordable Care Act, the Medical Loss Ratio (MLR) limits the portion of premium dollars health insurers may spend on administration, marketing, and profits.
- Under health care reform, health insurers must publicly report the portion of premium dollars spent on health care and quality improvement and other activities in each state they operate.
- Insurers failing the MLR test in a calendar year for all plans in a given market segment (individual or group) must refund excess premiums to consumers enrolled in plans in that market segment
MLR for Individual & Group Plans
- The MLR for individual plans is 80%
- The MLR for group plans is 85%
- % spent on healthcare
Cost Sharing Reduction (CSR)
- a discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance.
- In the Health Insurance Marketplace, cost-sharing reductions are often called “extra savings’
