Affordable Care Act (ACA) Flashcards
What are the 2 most important years for
The Affordable Care Act (ACA)
3 Parts
The Affordable Care Act (ACA)
2010 - The ACA was signed into law by President Obama
2014 - Additional reforms were put in place (January)
Other Names:
* Obamacare
* Heath Care Reform
* Patient Protection and Affordable Care Act (PPACA)
What are the Differences?:
Grandfathered vs. Non-Grandfathered
4 Parts / 1 Part
The Affordable Care Act (ACA)
Grandfathered Policies
* Existed prior to the ACA
* Costs cannot be increased
* Benefits may not be reduced
* Not required to comply with some of the consumer protections
Non-Grandfathered Policies
* Must comply with all rules and laws of the ACA
What are the 3 Consumer Protections that apply to Grandfathered and Non-Grandfathered Policies?
The Affordable Care Act (ACA)
- Lifetime dollar limits cannot be applied to “Essential Health Benefits”
- A policy cannot be canceled due of an honest mistake on the application
- Dependent coverage must be extended to adult children until age 26
What are some Consumer Protections that Group Policies/Grandfathered Policies are not required to follow?
Group - 3 Parts / Grandfathered - 5 Parts
The Affordable Care Act (ACA)
Not Required to…
Group Plans & Grandfathered Plans:
1. Provide certain (recommended) preventive services for free
2. Offer new protections if an insured is appealing Claims/Coverage denials
3. Allow any choice of Health Care Providers access to emergency care
Grandfathered Plans (only):
1. Phase out annual dollar limits on “Essential Health Benefits”
(annual dollar limits can remain)
2. Eliminate pre-existing condition exclusions for children under 19 years old (pre-existing conditions can be excluded)
Definition:
Individual Mandate
2 Parts
The Affordable Care Act (ACA)
U.S. Citizens and Legal Residents are required to have qualifying health care coverage (“Minimum Essential Coverage”)
Anyone not following this mandate must pay a tax penalty
(Some exemptions may apply)
In 2019, the The Tax Cuts and Jobs Act of 2017 (TCJA) reduced the penalty to $0/0% - there is no monetary penalty for not complying with the mandate
Definition:
Minimum Essential Coverage
5 Parts
The Affordable Care Act (ACA)
Must have coverage from…
* Government-Sponsored Programs
(Medicare, Medicaid, CHIP, TRICARE, COBRA)
- Employer-Sponsored Plans
(Small or Large Group Market) - Individual Market Plan
- Grandfathered Health Plans
- Other (State Health Benefits)
Exemption Examples:
Individual Mandate
8 Parts
The Affordable Care Act (ACA)
- Financial Hardship
- Religious Objections
- American Indians
- Those without coverage for less than three months
- Undocumented Immigrants
- Incarcerated/Imprisoned Individuals
- If the lowest cost plan option exceeds 8% of an individual’s income
- Individuals whose incomes is below the tax-filing threshold
Definition:
Essential Health Benefits
(EHBs)
5 Sub-Parts
The Affordable Care Act (ACA)
The below plans must be qualified to fit ACA standards
1. Individual Plans
2. Small Group Market Health Plans
3. Qualified Health Plans (QHPs)
4. Medicaid State Plans
5. Insurance on the Health Exchange
Prohibited Features:
Essential Health Benefits
(EHBs)
3 Parts
The Affordable Care Act (ACA)
- Lifetime Limits
- Annual limits
(except for grandfathered individual health plans)
Lifetime/Annual Limits are allowed on** non-EHBs**
Key Points:
Emergency Medical Services
3 Parts
The Affordable Care Act (ACA)
- No pre-authorization required
- In-network or out-of-network
- Normal cost-sharing requirements
Requirements for a:
Primary Care Provider
The Affordable Care Act (ACA)
A Primary Care Provider (PCP) is required for Subscribers/Dependents of:
* Health Maintenance Organization (HMO)
* Point of Service (POS)
Definition:
Metal Tiers
3 Parts / 4 Tier Names/Percentages
The Affordable Care Act (ACA)
4 levels of coverage - each must cover minimum EHBs
The Tier Percentages represent how much plan will cover
Tiers:
* Bronze - 60%
* Silver - 70%
* Gold - 80%
* Platinum - 90%
Key Points:
Preventive Care
2 Parts
The Affordable Care Act (ACA)
- Preventive Care is FREE
- The ACA focuses on Prevention and Primary Care
“Take care of yourself now to prevent costly (future) chronic conditions”
Key Points:
Pre-Existing Conditions
2 Sub-Parts
The Affordable Care Act (ACA)
Health Care Plan cannot limit or exclude coverage for an individual based on a condition that was present before the effective date of coverage
* Any Age
* Any Condition (Physical or Mental)
(except for grandfathered plans)
Key Points:
Dependent Coverage
3 Parts / 5 Sub-Parts / 3 Sub-Parts
The Affordable Care Act (ACA)
Optional Coverage for dependents up to (not including) age 26
Until Age 26 (even if they are):
(Only 1)
* Married
* Not living with Parents
* Attending School
* Not Finanically Dependent
* Eligible to enroll in Employer’s Plan
Age 26 (and older):
(Must have all 3)
* Unmarried
* Financially Dependent
* Have Physical or Mental Impairment
Definition:
Guaranteed Issue
2 Parts
The Affordable Care Act (ACA)
Health Plans must allow enrollment, regardless of:
* Health Status
* Age
* Gender
* Other
Must be offered to any individual or employer in their state
(Subject to rules)
Definition:
Health Benefit Exchanges/Marketplaces
3 Parts / 4 Sub-Parts
The Affordable Care Act (ACA)
Operated by State or Federal Government
Open (Annual) Enrollment
Special Enrollment (for Qualifying Events):
* Marriage
* Birth/Adoption
* Permanent Move (to a new area)
* Loss of Coverage (Divorce, Job Loss, Eligibility Change, etc)
Definition:
Qualified Health Plans
(QHP)
5 Parts
The Affordable Care Act (ACA)
- Only sold on the Health Insurance Exchange
- Provide “Essential Health Benefits” (EHBs)
- Follow established limits on Cost-Sharing
(Deductibles, Co-Pays, Out-of-Pocket Max, etc.) - Meet other ACA requirements
Only plan that provides Tax Credits and Cost-Sharing
Key Points:
Small Business Health Options Program
(SHOP)
2 Parts
The Affordable Care Act (ACA)
- Online application to compare health plans
- 50 (or less) full-time employees
Definition:
Subsidies
2 Parts / 2 Sub-Parts
The Affordable Care Act (ACA)
Money given by the Federal Government to help cover healthcare costs
(based on an Individual/Family’s household income)
Typically offered as:
1. Advanced Premium Tax Credits (APTC)
(Applied to Premium to lower the monthly payment)
- Cost-Sharing (Silver Tier only)
(Lowers: Co-Pays, Coinsurance, and Out-of-Pocket Limits)
Definition:
Navigators
2 Sub-Parts
The Affordable Care Act (ACA)
Help individuals determine their eligibility for Public Assistance Programs
- Funded by the Government through Federal Grants
- Cannot sell insurance or provide advice
Definition:
Employer Mandate/Responsibilities
3 Parts
The Affordable Care Act (ACA)
Employer Responsibilities
* Required to let employees know their rights to affordable coverage
Employer Mandate (50+ Employees)
* Employer must pay penalty if they don’t offer Health Coverage and (at least) 1 employee receives a Federal subsidy
* Penalty - $2,000 (per full-time employee)
Employer Mandate (less than 50 Employees)
* Exempt from rule
Definition:
Small Employer Tax Credit
Credit % / Eligibility Timeframe
The Affordable Care Act (ACA)
Maximum Credit
* Small Businesses Employers - 50% of Premiums Paid
* Small Tax-Exempt Employers - 35% of Premiums Paid
The credit is available for 2 (consecutive) taxable years
The Affordable Care Act (ACA)
