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MODULE 1 Flashcards

1
Q

WHAT IS THE FEDERAL POVERTY LEVEL?

A

FEDERAL GOV’T ESTIMATES AMT INDIVIDUAL OR FAMILY NEEDS TO COVER BASIC LIVING EXPENSES.

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2
Q

WHAT IS THE FEDERAL MARKETPLACE?

A

FEDERAL WEBSITE WHERE CONSUMERS SHOP FOR & PURCHASE HEALTH COVERAGE & APPLY FOR COST ASSISTANCE.

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3
Q

HOW MANY EMPLOYEES ARE IN A LARGE EMPLOYER? SMALL EMPLOYER?

A

50+

2-50

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4
Q

WHEN WILL THE PENALTY FOR EMPLOYERS WHO DO NOT OFFER SUFFICIENT HEALTH INSURANCE GO INTO EFFECT?

A

2015

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5
Q

WHAT IS THE INDIVIDUAL MANDATE?

A

TAX PENALTY FOR INDIVIDUAL THAT DOES NOT HAVE SUFFICIENT HEALTH COVERAGE.

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6
Q

WHAT IS AN ENROLLEE?

A

A GROUP OF PEOPLE WHO PAY INTO A FUND

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7
Q

WHAT IS AN INSURER?

A

A HEALTH INSURANCE CO THAT MANAGES THE FUND THAT ENROLLEES PAY INTO.

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8
Q

WHAT IS THE MONEY PAID BY THE ENROLLEE INTO A FUND CALLED?

A

PREMIUM

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9
Q

WHAT IS A COPAYMENT?

A

A FLAT FEE THAT MUST BE PAID BEFORE SEEING A PROVIDER.

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10
Q

WHAT IS COINSURANCE?

A

A PERCENTAGE OF THE COST FOR CARE THAT IS THE PATIENT’S RESPONSIBILITY.

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11
Q

WHAT IS THE DEDUCTIBLE?

A

AN AMOUNT THAT MUST BE PAID BEFORE ANY OF THE MEDICAL COSTS WILL BE PAID BY THE INSURANCE CO.

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12
Q

UNDER THE ACA, WHAT WILL THE OOP MAXIMUM FOR AN INDIVIDUAL AND FOR A FAMILY?

A

$6350

$12,700

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13
Q

WHERE CAN THE COST SHARING POLICIES BE FOUND IN AN INSURANCE POLICY?

A

IN THE SUMMARY OF BENEFITS & COVERAGE

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14
Q

WHAT ARE TWO OF THE FEATURES OF THE ACA?

A
  1. TARGETS UNINSURED INDIVIDUALS

2. ADDS CONSUMER CONSIDERATIONS

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15
Q

HOW DOES THE ACA HELP UNINSURED INDIVIDUALS?

A
  1. SUBSIDIZES COVERAGE FOR LOW INCOMES
  2. NO MORE PRE-EXISTING CONDITIONS
  3. INSTITUTES PENALTIES FOR INDIVIDUALS W/O HEALTH INSURANCE AND IN 2015 FOR EMPLOYERS WHO DO NOT OFFER HEALTH INSURANCE COVERAGE.
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16
Q

HOW DOES THE ACA ADD CONSUMER CONSIDERATIONS?

A
  1. REVIEWS INSURANCE RATE INCREASES
  2. REQUIRES INS CO TO SPEND CERTAIN % OF PREMIUMS ON DIRECT CARE
  3. MAKES INS POLICIES GUARANTEED AVAILABLE & RENEWABLE.
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17
Q

WHAT ARE THE 3 OPTIONS FOR STATES IN THE ACA?

A

STATE-BASED MARKETPLACE, PARTNERSHIP MARKETPLACE, FEDERAL MARKETPLACE

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18
Q

WHICH OF THE 3 OPTIONS FOR CARRYING OUT THE ACA FOR STATES DID INDIANA CHOOSE?

A

FEDERAL MARKETPLACE

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19
Q

WHAT DOES IT MEAN FOR INDIANA TO HAVE A FEDERAL MARKETPLACE?

A

FED GOV’T WILL SET GUIDELINES, SET UP & RUN MARKETPLACE. INDIANA WILL OBSERVE THE GUIDELINES.

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20
Q

WHAT IS MEC?

A

MINIMUM ESSENTIAL COVERAGE

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21
Q

UNDER THE ACA, WHO MUST BE COVERED BY INS?

A

ALL INDIVIDUALS & THEIR DEPENDENTS

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22
Q

IF AN INDIVIDUAL DOES NOT HAVE MEC, WHAT WILL HAPPEN?

A

IN 2014, THERE IS A PENALTY OF $95 PER ADULT & $48 PER CHILD WITH A MAX OF $285. THE INDIVIDUAL CAN ALSO APPLY FOR AN EXEMPTION.

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23
Q

WHAT IS THE MAXIMUM PENALTY EQUIVALENT TO?

A

THE NATIONAL AVERAGE PREMIUM FOR THE BRONZE QUALIFIED HEALTH PLAN TO COVER THE INDIVIDUAL.

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24
Q

WHAT ARE THE PENALTIES FOR 2015 IF COVERAGE IS NOT IN PLACE?

A

ADULT - $325; CHILD - $163; MAX $975

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25
Q

WHAT TYPES OF COVERAGE ARE ON THE FEDERALLY APPROVED MEC PLANS

A 
MEDICARE
MOST MEDICAID
CSHCS
VA
PEACE CORPS COVERAGE
EMPLOYER HEALTH PLANS
INDIVIDUAL MARKET HEALTH COVERAGE
GRANDFATHERED HEALTH PLANS
SELF-FUNDED STUDENT COVERAGE
REFUGEE MEDICAL ASSISTANCE
MEDICARE ADVANTAGE
STATE HIGH RISK POOL COVERAGE
OTHERS THAT APPLY TO BE MEC
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26
Q

WHAT MEDICAID PLANS ARE NOT CONSIDERED MEC?

A

FAMILY PLANNING
PREGNANCY COVERAGE
EMERGENCY MEDICAID

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27
Q

WHAT IS THE AFFORDABILITY EXEMPTION?

A

IF EMPLOYER SPONSORED COVERAGE IS UNAFFORDABLE BECAUSE IT IS MORE THAN 8% OF HOUSEHOLD INCOME

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28
Q

WHAT IS THE PREMIUM TAX CREDIT?

A

WHEN CONTRIBUTION FOR EMPLOYER SPONSORED INSURANCE IS MORE THAN 9.5%.

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29
Q

WHERE DO YOU SEND AN EXEMPTION APPLICATION?

A

FEDERAL MARKETPLACE OR THE IRS

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30
Q

WHAT ARE SOME OF THE REASONS THAT AN EXEMPTION WOULD BE APPROVED?

A

INDIAN TRIBE, LOW INCOME, HEALTHCARE SHARING MINISTRY, IN PRISON, SHORT GAP IN COVERAGE.

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31
Q

IN 2015, WHEN WILL AN EMPLOYER BE PENALIZED?

A

IF THE EMPLOYER HAS AT LEAST 50 FULL TIME EMPLOYEES, AND AT LEAST ONE OF THEM RECEIVES THE PREMIUM TAX CREDIT.

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32
Q

HOW DOES AN INDIVIDUAL QUALIFY FOR THE PREMIUM TAX CREDIT?

A
  1. BETWEEN 100%-400% OF FEDERAL POVERTY LEVEL
    AND
    EMPLOYER COVERAGE NOT AVAILABLE
    OR
    EMPLOYER COVERAGE DOES NOT COVER AT LEAST 60% OF HEALTH CARE COSTS
    OR
    SINGLE COVERAGE IS MORE THAN 9.5% OF HOUSEHOLD INCOME
33
Q

IN 2015, WHAT PENALTY WILL AN EMPLOYER PAY WHEN ASSESSED?

A
  1. IF OFFERING COVERAGE TO AT LEAST 95% OF FTE, $3000 PER EMPLOYEE OR THE PENALTY FOR EMPLOYERS NOT OFFERING COVERAGE.
  2. IF NOT OFFERING COVERAGE TO AT LEAST 95% OF FTE, PAY $2000 FOR EVERY FTE AFTER THE FIRST 30 EMPLOYEES.
34
Q

WHAT IS THE MLR?

A

MEDICAL LOSS RATIO - A RATIO THAT HELPS DETERMINE IF THE INSURANCE COMPANY IS SPENDING PREMIUMS ON DIRECT CARE.

35
Q

WHAT “RATING” RULES ARE ELIMINATED BY ACA?

A

AGE, LOCATION, SMOKING STATUS, HEALTH HISTORY, HEALTH STATUS CANNOT BE USED TO DETERMINE RATING

36
Q

HOW DO PRE-EXISTING CONDITIONS AFFECT COVERAGE?

A

CANNOT BE DENIED FOR PRE-EXISTING CONDITIONS.

37
Q

UNTIL WHAT AGE CAN A DEPENDENT BE KEPT ON PARENT’S INSURANCE?

38
Q

WHAT EXPANSIONS IN COVERAGE WILL BE REQUIRED UNDER ACA?

A

PREVENTATIVE SERVICES

39
Q

WHAT ARE THE LIFETIME AND ANNUAL MAXIMUMS FOR INSURED UNDER ACA?

40
Q

WHAT IS AV?

A

ACTUARIAL VALUE - AVERAGE PERCENT OF PLAN COSTS THE INSURER EXPECTS TO PAY FOR ALL ENROLLEES IN THAT PLAN

41
Q

WHAT IS MV?

A

MINIMUM VALUE - APPROVED PLANS MUST OFFER A PLAN THAT HAS AN AV OF AT LEAST 60%

42
Q

WHAT ARE THE MLR PERCENTAGE REQUIREMENTS FOR EMPLOYERS & INDIVIDUALS?

A

LARGE GROUP - 85%
SMALL GROUP - 80%
INDIVIDUALS - 80%

43
Q

WHAT HAPPENS IF THE INSURANCE CO DOES NOT MEET MLR REQUIREMENTS?

A

INDIVIDUALS & SMALL BUSINESSES RECEIVE A REFUND

44
Q

WHAT ARE THE 3 FACTORS ALLOWED FOR INSURANCE COMPANIES TO DETERMINE PREMIUMS?

A

AGE - 3 TO 1 RATIO
TOBACCO - 1.5 TO 1 RATIO
GEOGRAPHIC AREA

45
Q

WHAT ARE SOME THINGS THAT INSURERS ARE NOT ALLOWED TO USE TO DETERMINE PREMIUMS?

A

GENDER

HEALTH STATUS

46
Q

WHAT ARE THE EHB’S AND WHAT DO THEY INCLUDE?

A

ESSENTIAL HEALTH BENEFITS

  1. AMBULATORY SVCS
  2. ER SVCS
  3. HOSPITALIZATION
  4. MATERNITY & NEWBORN CARE
  5. MENTAL HEALTH / SUBSTANCE ABUSE
  6. RX COVERAGE
  7. REHAB SERVICES & DEVICES
  8. LAB SVCS
  9. PREVENTATIVE SVCS
  10. PEDIATRIC SVCS W/ DENTAL
47
Q

FOR A BRONZE PLAN, WHAT ARE THE TARGET COSTS COVERED BY THE HEALTH PLAN AND THE TARGET COSTS COVERED BY ENROLLEES?

48
Q

FOR A SILVER PLAN, WHAT ARE THE TARGET COSTS COVERED BY THE HEALTH PLAN AND THE TARGET COSTS COVERED BY ENROLLEES?

49
Q

FOR A GOLD PLAN, WHAT ARE THE TARGET COSTS COVERED BY THE HEALTH PLAN AND THE TARGET COSTS COVERED BY ENROLLEES?

50
Q

FOR A PLATINUM PLAN, WHAT ARE THE TARGET COSTS COVERED BY THE HEALTH PLAN AND THE TARGET COSTS COVERED BY ENROLLEES?

51
Q

WHO IS ELIGIBLE FOR PTC’S?

A

CITIZEN, LEGAL RESIDENT, NON-INCARCERATED, INDIANA RESIDENT
100-400% FPL
NO OTHER MEC OR AVAILABLE MEC W/ PREMIUM MORE THAN 9.5% OF HOUSEHOLD INCOME OR MEC DOESN’T HAVE 60% AV

52
Q

WHO IS ELIGIBLE FOR COST SHARING REDUCTIONS (CSR) ?

A

ELIGIBLE FOR PTC
100-250% FPL
ENROLLED IN SILVER PLAN

53
Q

HOW DOES GOVERNOR PENCE WANT TO EXPAND HEALTH COVERAGE IN INDIANA?

54
Q

WHAT TWO WAYS CAN INDIVIDUALS BUY HEALTH INSURANCE?

A

COMMERCIAL HEALTH INSURANCE MARKET

FEDERAL MARKETPLACE

55
Q

WHO OVERSEES THE COMMERCIAL HEALTH INSURANCE MARKET?

A

IDOI -INDIANA DEPT OF INSURANCE

56
Q

WHO ADMINISTERS THE FEDERAL MARKETPLACE?

A

DEPARTMENT OF HEALTH & HUMAN SERVICES

57
Q

WHERE DO SMALL GROUPS GO TO OBTAIN HEALTH INSURANCE?

A

SMALL BUSINESS HEALTH OPTIONS PROGRAM

SHOP

58
Q

WHAT IS THE FEDERAL MARKETPLACE MANDATED TO DO?

A
  1. ASSESSES ELIGIBILITY FOR MEDICAID, PTC, CSR’S, INDIVIDUAL MANDATE EXEMPTIONS
  2. MANAGES ELIGIBILITY APPEALS
  3. FACILITATES ENROLLMENT IN QHP’S
  4. ENSURES APPROPRIATE PTC & CSR PYMTS TO INSURANCE PLANS
  5. COLLECTS & PUBLISHES QUALITY DATA
  6. OPERATES CONSUMER ASSISTANCE CALL CENTER
  7. IN 2015, COLLECTS PREMIUMS FOR SMALL BUSINESSES
59
Q

WHO CAN USE SHOP?

A

2014-2015 - EMPLOYERS < 50 EMPLOYEES

2016 - EMPLOYERS <100 EMPLOYEES

60
Q

WHEN CAN AN EMPLOYER RECEIVE A TAX CREDIT?

A

WHEN THEY HAVE LESS THAN 25 EMPLOYEES

61
Q

WHEN IS THE INITIAL ENROLLMENT PERIOD FOR ACA?

A

10/1/13-3/31/14

62
Q

WHEN WILL ANNUAL OPEN ENROLLMENT HAPPEN?

A

10/15-12/7 EACH YEAR

63
Q

ARE THERE EXCEPTIONS TO OPEN ENROLLMENT PERIOD?

A

YES! JOB CHANGES, FAMILY SIZE, ETC.

64
Q

WHEN IS SHOP ENROLLMENT?

A

IT IS ROLLING AND DOES NOT CONFORM TO STANDARD OPEN ENROLLMENT PERIODS

65
Q

WHAT ARE THE 3 FUNCTIONS OF A NAVIGATOR?

A
  1. ASSIST INDIVIDUALS IN FILLING OUT APPLICATIONS IN THE FEDERAL MARKETPLACE
  2. PROVIDE GENERAL INFORMATION TO INDIVIDUALS REGARDING PLAN SELECTION
  3. DIRECT QUESTIONS FROM INDIVIDUALS ABOUT ACA TO THE FEDERAL MARKETPLACE
66
Q

WHAT IS ELIGIBILITY FOR INDIVIDUALS BASED ON?

A

MAGI-MODIFIED ADJUSTED GROSS INCOME

67
Q

WHAT IS MAGI?

A

AGI FROM FEDERAL TAXES
PLUS FOREIGN EARNED INCOME
PLUS TAX EXEMPT INTEREST
PLUS TAX-EXEMPT TITLE II SOC SEC BENEFITS

68
Q

WHAT ARE EXCEPTIONS TO USING MAGI FOR ELIGIBILITY?

A

NO TAXES FILED

TAX INFO DOESN’T REFLECT CURRENT SITUATION

69
Q

HOW IS MEDICAID FUNDED?

A

STATE & FEDERAL GOVERNMENT

70
Q

WHAT 3 CHANGES WILL BE MADE TO ELIGIBILITY FOR MEDICAID?

A

THE WAY PEOPLE IN THE HOUSEHOLD ARE COUNTED
INCOME
ASSETS

71
Q

WHO WILL NOT USE MAGI FOR MEDICAID ELIGIBILITY?

A

AGED, BLIND, DISABLED

CURRENTLY ELIGIBLE - WILL USE MAGI FOR REDETERMINATION

72
Q

HOW CAN SOMEONE UP TO AGE 26 QUALIFY FOR MEDICAID?

A

FORMER FOSTER CHILD

ACTIVE MEDICAID WHEN AGED OUT OF SYSTEM

73
Q

WHAT IS PRESUMPTIVE ELIGIBILITY?

A

SHORT TERM COVERAGE WHILE MEDICAID APP IS PENDING FOR LOW INCOME POPULATIONS

74
Q

WHEN IS PE CURRENTLY USED?

A

FOR PREGNANT MOMS

75
Q

WHO WILL BE ELIGIBLE FOR PE AS OF 1/1/14?

A 
HOSPITALS WHO ARE "QUALIFIED PROVIDERS" WILL DETERMINE PE FOR
CHILDREN UNDER 19
LOW INCOME PARENTS/CARETAKERS
FAMILY PLANNING ELIGIBILITY
FORMER FOSTER CARE CHILDREN UP TO 26
76
Q

WHAT GROUPS OF PEOPLE WILL BE ABLE TO ASSIST HOOSIERS WITH INSURANCE ISSUES?

A 
INDIANA NAVIGATORS
APPLICATION ORGANIZATIONS
AUTHORIZED REPRESENTATIVES
INSURANCE AGENTS/BROKERS
FEDERAL NAVIGATORS
CERTIFIED APPLICATION COUNSELORS
77
Q

WHAT TYPES OF APPLICATIONS MUST A CONSUMER ASSISTANT BE CERTIFIED TO ASSIST WITH?

A

FEDERAL MARKETPLACE

INDIANA HEALTH COVERAGE PROGRAMS

78
Q

WHAT IS AN APPLICATION ORGANIZATION? (AO)

A

ORGANIZATION W/ EMPLOYEES OR VOLUNTEERS ASSISTING CONSUMERS W/ APPLICATIONS ON THE FEDERAL MARKETPLACE, INDIANA HEALTH COVERAGE PROGRAMS

ACA (4 decks)

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