Health Care Regulation Flashcards
Module 11
“Other employee benefit plans” are called welfare plans, and these plans are established and maintained to provide:
Health benefits Disability Benefits Death benefits Prepaid legal services Vacation benefits Day care centers Scholarship funds Apprenticeship and training
What are the four minimum health standards regulated by ERISA
- Provide plan information
- Fiduciary responsibility
- Establishing a grievance and appeal process
- Allow participants right to sue
What major amendments to ERISA predated ACA
COBRA HIPAA MHPAEA NMHPA Women's Health and Cancer Rights Act Michelle's law
What events entitle an individual to COBRA
Death Termination of employment Divorce Medicare Child's loss of dependent status
Describe some disadvantages of COBRA
Employers may require individuals who elect continuation coverage to pay the full cost of the coverage, plus 2% admin charge.
Lasts for limited amount of time
Which type of employers must offer COBRA
All group health plans maintained by private sector employers (20 employees) or state and local governments. Does not apply to federal government or churches/church related organizations
Which common benefits are not subject to COBRA
Life insurance and disability benefits
In what ways does HIPPA offer protection to workers and their families?
- Provide additional opportunities to enroll in group health plan coverage when they lose other health coverage, get married or add new dependent
- Prohibits discrimination in enrollment and in premiums charged to employees and dependents based on any health factors
- Preserves the states’ role in regulating health insurance
What are two special enrollment rights under HIPPA
Loss of eligibility for other coverage
Marriage, birth, adoption, or placement for adoption
*Must request enrollment within 30 days of event
HIPAA nondiscrimination rules stipulate that employees and their family members cannot be denied eligibility or benefits based on certain _______ ______.
Health factors
ACA prohibits plans from imposing preexisting condition exclusions for plan years beginning on or after ______________
January 1, 2014
What were the major policy objectives of the ACA
- Improve quality and lower health care costs for individuals and government programs
- Provide new consumer protections
- Expand access to health care
What was the National Federation of Independent Business v. Sebelius Supreme Court Decision
Upheld the Medicaid expansion but precluded the federal government from withholding all Medicaid federal funding if states failed to accept and comply with ACA Medicaid expansion requirements. 19 states not currently expanding Medicaid
Summarize which categories of benefits are deemed essential health benefits
Ambulatory patient services Emergency services Pregnancy Hospitalization Mental Health Prescription drugs Rehabilitative services Lab services Preventative and wellness Pediatric, oral and vision
Under ACA, generally, group health plans are prohibited from offering coverage that establishes any lifetime or ________ ________ on the dollar value of essential health benefits
Annual limits
How does ACA strive to make health insurance more affordable?
Provides tax credits to people with income between 100% and 400% of the poverty line
What is the shared responsibility mandate, or “the employer mandate”
Requires applicable large employers to offer health coverage to their full-time employees or pay a penalty.
Must offer minimum essential coverage that is affordable and provides minimum value
A full time employee is, for a calendar month, an employee employed on average at least ___ hours or service per week, or ___ hours of service per month.
30
130
Employers with 50 or fewer employees can purchase health insurance coverage for their employees through _______
SHOP Marketplace
Small business health options program
Under what circumstances can plans lose their grandfathered status?
- Elimination of all or substantially all benefits to diagnose or treat a particular condition
- Increase in a percentage cost-sharing requirement
- Increase in deductible
- Increase in co-payment
- Decrease in an employers contribution by more than 5 percentage points
- Imposition of annual limits on the dollar value of all benefits
Which provisions apply to grandfathered health plans
Prohibition on:
Preexisting conditions
Excessive waiting period
Lifetime/restricted annual limits
Extension of dependent coverage Summary of benefits and coverage and uniform glossary Coverage of preventative services Internal claims and appeals Patient protections
For most cases, eligible employees are entitled to up to ___ weeks of leave in a 12-month period
12
Under which circumstances are eligible employees able to take FMLA leave
Birth of a child
Placement with the employee of a child for adoption
To care for the employees spouse, child, or parent who have serious health condition
Serious health condition for the employee
Military member on covered active duty
What aspect of Americans with Disabilities Act is a major concern to employer sponsored health plans?
Wellness programs
USERRA establishes _____ years as the cumulative length of time that an individual may be absent from work for military duty.
5
Are employers permitted to offer retiree health benefits that vary depending on whether the retiree is eligible for Medicare?
Yes
Describe the Medicare Secondary Payer rules for when Medicare coverage is available alongside other health insurance through a group plan
- 65 or older, covered by an employer group health plan through current employment or spouse’s current employment and employer has FEWER than 20 employees: Medicare pay primary, group health plan pays secondary
- 65 or older, covered by an employer group health plan through current employment or spouse’s current employment and employer has MORE than 20 employees: Group health plan pays primary, Medicare secondary
- Individual is aged 65 or older, self employed and covered by an employer group health plan through current employment or spouse’s current employment and employer has 20 or more employees: Group health plan pays primary, Medicare secondary
- Individual is disabled, is covered by a group health plan through his or her own current employment and the employer has 100 or more employees: Group health plan pays primary, Medicare secondary
Medicare remains the primary payer for individuals aged 65 or over who are also covered under an employer __________ plan.
retirement
