Health Care Regulation

Question 1

“Other employee benefit plans” are called welfare plans, and these plans are established and maintained to provide:

Answer 1

Health benefits
Disability Benefits 
Death benefits
Prepaid legal services
Vacation benefits
Day care centers
Scholarship funds
Apprenticeship and training

Question 2

What are the four minimum health standards regulated by ERISA

Answer 2

1. Provide plan information
2. Fiduciary responsibility
3. Establishing a grievance and appeal process
4. Allow participants right to sue

Question 3

What major amendments to ERISA predated ACA

Answer 3

COBRA
HIPAA
MHPAEA
NMHPA
Women's Health and Cancer Rights Act
Michelle's law

Question 4

What events entitle an individual to COBRA

Answer 4

Death
Termination of employment
Divorce
Medicare
Child's loss of dependent status

Question 5

Describe some disadvantages of COBRA

Answer 5

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

Question 6

Which type of employers must offer COBRA

Answer 6

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

Question 7

Which common benefits are not subject to COBRA

Answer 7

Life insurance and disability benefits

Question 8

In what ways does HIPPA offer protection to workers and their families?

Answer 8

1. Provide additional opportunities to enroll in group health plan coverage when they lose other health coverage, get married or add new dependent
2. Prohibits discrimination in enrollment and in premiums charged to employees and dependents based on any health factors
3. Preserves the states’ role in regulating health insurance

Question 9

What are two special enrollment rights under HIPPA

Answer 9

Loss of eligibility for other coverage
Marriage, birth, adoption, or placement for adoption

*Must request enrollment within 30 days of event

Question 10

HIPAA nondiscrimination rules stipulate that employees and their family members cannot be denied eligibility or benefits based on certain _______ ______.

Answer 10

Health factors

Question 11

ACA prohibits plans from imposing preexisting condition exclusions for plan years beginning on or after ______________

Answer 11

January 1, 2014

Question 12

What were the major policy objectives of the ACA

Answer 12

1. Improve quality and lower health care costs for individuals and government programs
2. Provide new consumer protections
3. Expand access to health care

Question 13

What was the National Federation of Independent Business v. Sebelius Supreme Court Decision

Answer 13

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

Question 14

Summarize which categories of benefits are deemed essential health benefits

Answer 14

Ambulatory patient services
Emergency services
Pregnancy
Hospitalization
Mental Health
Prescription drugs
Rehabilitative services
Lab services
Preventative and wellness
Pediatric, oral and vision

Question 15

Under ACA, generally, group health plans are prohibited from offering coverage that establishes any lifetime or ________ ________ on the dollar value of essential health benefits

Answer 15

Annual limits

Question 16

How does ACA strive to make health insurance more affordable?

Answer 16

Provides tax credits to people with income between 100% and 400% of the poverty line

Question 17

What is the shared responsibility mandate, or “the employer mandate”

Answer 17

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

Question 18

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.

Answer 18

30

130

Question 19

Employers with 50 or fewer employees can purchase health insurance coverage for their employees through _______

Answer 19

SHOP Marketplace

Small business health options program

Question 20

Under what circumstances can plans lose their grandfathered status?

Answer 20

1. Elimination of all or substantially all benefits to diagnose or treat a particular condition
2. Increase in a percentage cost-sharing requirement
3. Increase in deductible
4. Increase in co-payment
5. Decrease in an employers contribution by more than 5 percentage points
6. Imposition of annual limits on the dollar value of all benefits

Question 21

Which provisions apply to grandfathered health plans

Answer 21

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

Question 22

For most cases, eligible employees are entitled to up to ___ weeks of leave in a 12-month period

Answer 22

12

Question 23

Under which circumstances are eligible employees able to take FMLA leave

Answer 23

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

Question 24

What aspect of Americans with Disabilities Act is a major concern to employer sponsored health plans?

Answer 24

Wellness programs

Question 25

USERRA establishes _____ years as the cumulative length of time that an individual may be absent from work for military duty.

Answer 25

5

Question 26

Are employers permitted to offer retiree health benefits that vary depending on whether the retiree is eligible for Medicare?

Answer 26

Yes

Question 27

Describe the Medicare Secondary Payer rules for when Medicare coverage is available alongside other health insurance through a group plan

Answer 27

1. 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
2. 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
3. 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
4. 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

Question 28

Medicare remains the primary payer for individuals aged 65 or over who are also covered under an employer __________ plan.

Answer 28

retirement