Lecture 4 (ACA) Flashcards
What was the main reason the Affordable Care Act (ACA) was created and how was it mandated for states?
Reduce the cost of insurance coverage for qualifying people
Mandated- federal government runs state based “marketplace”
Which ACA mandate was overturned in 2018?
Individual mandate penalty (This meant that the person would have had to pay a penalty if they did not have health insurance )
What is the marketplace and its purpose?
A service that helps people shop for and enroll in affordable health insurance
The federal government operates the Marketplace for most states
Some states run their own Marketplaces
The Health Insurance Marketplace (akak “Marketplace” or “exchange”)
Provides health plan shopping and enrollment services through websites, call centers and in-person help
Small businesses can use the Small Business Health Options Program (SHOP) Marketplace to provide health insurance for employees
Income and household info. Determine which plans you qualify for
Premium tax credits & other savings that make insurance more affordable
Coverage through the Medicaid and Children’s Health Insurance Program (CHIP) in your state
How many titles are there under the ACA and what is the overall purpose for each one?
There are 10 Different Titles
Title 1: Quality Affordable Health Care for All Americans
All Americans must have coverage
Prohibits denying coverage based on pre-existing conditions
Cannot drop people if they get sick
Extends dependent coverage to age 26
Requires full coverage of preventive care & immunization
Creates individual insurance exchange
Tax subsidies for individuals up to 400% federal poverty level (FPL)
However, the Supreme Court (2 years after the ACA was passed allowed states to alter/stretch the federal low income threshold, thus increasing the gap of low income individuals acquiring affordable insurance
Established individual and employee mandates and penalties
Title 2: The Role of Public Programs
Extends Medicare and preserves CHIP & the exchanges
Simplifies enrollment for families
Reduces prescription drug costs
Expands Medicaid to 138% of the federal poverty level
Title 3: Improving Quality and Efficiency of Health Care
Provides incentives for accountable care organizations (ACO)
To provide accountability for quality healthcare
Closes donut hole!
Provide access to services in underserved areas
Title 4: Prevention & Improving Public Health
Increases access and availability to services
Reduce incidences of preventable diseases in US
Relies on small businesses and state and local gov. to be innovative and provide access/available services to community and workplace
Title 5: Health Care workplace
Modifies federal loans-student programs to provide scholarship payments and bonuses to certain healthcare workers
Provide scholarship and loan repayment programs has increased access to a wide range of providers (doctors, nurses, dentists, MH care providers etc.) to underserved communities
Title 6: Transparency and Program Integrity
Creates screens for providers and suppliers to decrease fraud in health care
Creates patient center outcomes institute (PCOI)
Helps families find right nursing homes for oves one and ensure improved quality service in choice of nursing home
Title 7: Improving Access to innovate medical technologies
Streamlines process of FDA licensing for products
Ends anti-competitive behavior for drug companies
Extends drugs discounts to hospitals and communities that service low-income patients
Title 8: Community Living Assistance and Services and Support
Provides Americans with new option to finance long-term services and care in the event of disability
Flexible benefit in wide-range communities
Title 9: Revenue provisions
Makes healthcare more affordable for families and small business owners by providing largest middle class tax cuts in US history
Increases taxes in people who earn high wages
Title 10: Reauthorization of the Indian HealthCare Improvement Act
Reauthorizes ICHIA (provides health services to American Indians and Alaskan Natives)
Modernizes and improves healthcare services for designated population
List the key provisions on healthcare coverage by the ACA
Healthcare Exchanges (to buy policies to private insurances and purchase coverage in marketplace)
Individual
Small Business Health Option Program (SHOP)
Small business (<100 employees)
Self-employed
Essential benefit packages for individual and small groups (bronze, silver, gold, platinum)
Minimal Essential Coverage
Ambulatory patient services, ER, hospitalization, maternity & new-born, mental health and substance abuse services, medications, rehabilitation (PT/OT. Psych etc.), labs, prevention & wellness & chronic disease management, and peds services (dental & vision)
Consumer-operated and oriented plan (CO-OP)
Healthcare Exchanges: Four Categories & Catastrophic Category
Bronze Plan (minimum creditable coverage, provides essential health benefits – covers 60% of health care costs)
Silver Plan (Essential Benefits – covers 70%)
Gold Plan (Essential Benefits – covers 80%)
Platinum (Essential Benefits – covers 90%)
Catastrophic (up to age 30 & exempt from mandate b/c cannot afford health insurance – only available in individual market [cheapest])
Premiums
Vary by state
Cannot vary by pre-existing conditions
Can vary by age, smoking status
Subsidies
Individual - meet additional requirements
Determined by sliding scale (FPL)
Can only be used in exchange
Premium subsidy
Helps people pay for premiums
Cost-sharing
Helps poorer families pay for out pocket such as deductible and copays
Small business subsidies - encourage employers w/ up to 25 low wage employees to purchase employers w/ up to 25 low wage employees to purchase insurance for their workers in exchange
Describe the ACA mandates for healthcare coverage provided by employer/companies of different sizes (i.e., small vs. large)
Companies with 1-50 employees are not mandated to provide insurance to employees
SHOP: health insurance for small business
Large Companies 50+
Fees for not offering coverage that satisfies minimum essential coverage
Large Companies with 200+ employees
Automatically enroll employees into health insurance plans
What is the Accountable Care Organization and how are they rewarded by the federal government for better quality care?
ACOs
Networks of physicians, hospitals, skilled nursing, pharmacies, and specialists that take both clinical and financial care of patients
Breakdown silos and coordinate care
Focus on quality care and reduce duplication
Lower costs
Decrease unnecessary treatment
Still keep people healthy by reducing ER visits and hospitalization
They are rewarded via
Electronic Health Records
National quality improvement strategy
Physician quality reporting system
Transform the Physician Quality Reporting System (PQRS)
Value-Based Purchasing
Patient-Centered Outcomes Research Institute (PCORI)
What is open enrollment under ACA and what are the exceptions for that?
open enrollment (for 2020: 11/1/2019-12/15/2019)
cannot enroll in health plans till next open enrollment unless circumstances change outside enrollment (60 day opportunity)
– loss of eligibility for other coverage- loss of job
– gaining a dependent
– loss of coverage due to divorce or legal separation
– loss of dependent status
– moving to another state
– exhaustion of COBRA (law that mandates that insurance program gives employee who lost/left that job the ability to continue health insurance coverage w/ that job until they find different options)
– losing eligibility of Medicaid
– change in immigration status
cannot change plans (bronze, silver etc.) until next enrollment
can drop COBRA & enroll in Marketplace plan during enrollment period - but cannot drop COBRA & trigger special enrollment (if outside period)
should buy coverage in state you live in (absolutely essential)
American Indians & Alaska Natives (can enroll in coverage throughout the year)
