MODULE 3 Flashcards
WHAT IS A QUALIFIED HEALTH PLAN?
HEALTH INSURANCE PLAN THAT HAS PASSED A MARKETPLACE CERTIFICATION PROCESS
WHAT IS MEC?
MINIMUM ESSENTIAL COVERAGE - TYPE OF COVERAGE AN INDIVIDUAL MUST HAVE TO MEET THE INDIVIDUAL RESPONSIBILITY UNDER ACA.
WHAT ARE INSURANCE AFFORDABILITY PROGRAMS?
ACA PROVISIONS THAT LOWER THE AMOUNT THAT SOME ELIGIBLE CONSUMERS PAY FOR PREMIUMS AND / OR CO-PAYMENTS / COINSURANCE
WHAT ARE THE PREMIUM TAX CREDIT AND COST-SHARING REDUCTIONS CALLED UNDER THE ACA?
INSURANCE AFFORDABILITY PROGRAMS
WHAT ARE THE TWO WAYS FOR INDIVIDUALS TO BUY HEALTH INSURANCE?
- HEALTH INSURANCE MARKET
2. FEDERAL MARKETPLACE
WHO OVERSEES THE FEDERAL MARKETPLACE?
THE FEDERAL DEPARTMENT OF HEALTH AND HUMAN SERVICES
WHAT DOES S.H.O.P. STAND FOR?
SMALL BUSINESS HEALTH OPTIONS PROGRAM
WHAT IS DONE ON THE FEDERAL MARKETPLACE WEBSITE?
- ASSESS ELIGIBILITY FOR MEDICAID, PTC’S, CSR’S, AND INDIVIDUAL MANDATE EXEMPTIONS
- MANAGE ELIGIBILITY APPEALS
- FACILITATE ENROLLMENT IN QHP’S
- ENSURES APPROPRIATE PTC AND CSR PYMTS MADE TO HEALTH INS PLANS
- COLLECTS & PUBLISHES QUALITY DATA ON HEALTH PLANS
- OPERATES CONSUMER ASSISTANCE CALL CENTER
- IN 2015.. COLLECTS PREMIUMS FOR SMALL BUSINESSES
WHO CAN USE THE MARKETPLACE?
INDIVIDUAL US CITIZENS, NATIONALS AND LEGAL RESIDENTS OF THE US WHO ARE RESIDENTS OF INDIANA AND NOT INCARCERATED.
CAN INDIVIDUALS PURCHASE INSURANCE ANYWHERE BESIDES THE FEDERAL MARKETPLACE?
YES. PLANS STILL MUST BE REGULATED BY THE IDOI; CANNOT USE PTC OR CSR. WILL NEED TO GO THROUGH AN AGENT OR BROKER OR SHOP DIRECTLY THROUGH INSURANCE COMPANIES
WHAT EMPLOYERS ARE ELIGIBLE FOR S.H.O.P.?
2014-2015 - <100 EMPLOYEES
CAN EMPLOYERS USE OBTAIN COVERAGE ANOTHER WAY?
YES. THROUGH BROKERS
HOW CAN AN EMPLOYER QUALIFY FOR A TAX CREDIT?
MUST HAVE LESS THAN 25 EMPLOYEES
WHAT BENEFITS FOR BUSINESS OWNERS WILL BE ADDED TO S.H.O.P. IN 2015?
- ABILITY TO CHOOSE A PLAN LEVEL OR SPECIFIC PLAN FOR EMPLOYEES.
- ABILITY TO CHOOSE A REFERENCE PLAN TO SET EMPLOYER CONTRIBUTIONS.
WHAT IS AN EHB?
ESSENTIAL HEALTH BENEFIT - 10 TYPES OF HEALTH COVERAGE THAT IS REQUIRED TO BE PART OF A QUALIFIED HEALTH PLAN.
WHAT TYPE OF HEALTH PLANS ARE EXEMPT FROM THE AV REQUIREMENTS THAT APPLY TO OTHER NON-GRANDFATHERED INDIVIDUAL AND GROUP INSURANCE PLANS?
CATASTROPHIC PLANS
WHAT ARE THE ELIGIBILITY CRITERIA FOR PURCHASING A CATASTROPHIC PLAN?
INDIVIDUAL UNDER 30
OR
INDIVIDUAL RECEIVED EXEMPTION FROM REQUIREMENT TO MAINTAIN MEC
WHAT CHARACTERIZES A CATASTROPHIC PLAN?
DEDUCTIBLE IS CLOSE TO THE OUT OF POCKET MAXIMUMS
SOLD ON AND OFF FEDERAL MARKETPLACE
QUALIFIES AS MEC
NOT ELIGIBLE FOR PTC OR CSR
WHAT ARE THE COMMON QUALITIES OF ALL HEALTH PLANS SOLD ON THE FEDERAL MARKETPLACE?
ALL PROVIDE MEC ALL COVER EHB'S ALL MEET AV STANDARDS ALL MEET PROVIDER NETWORK STANDARDS NONE CAN CONSIDER THE HEALTH STATUS OF THE APPLICANT FOR THE PURPOSES OF PLAN ELIGIBILITY OR PLAN COST.
WHO IS ELIGIBLE FOR PTC?
CITIZEN, NATIONAL, LEGAL U.S. RESIDENT, NON-INCARCERATED
AND
HOUSEHOLD INCOME 100%-400% OF FPL
AND
NO OTHER MEC IS AVAILABLE
OR
AVAILABLE MEC HAS PREMIUM OF 9.5% OF HOUSEHOLD INCOME OR DOES NOT PROVIDE 60% AV
WHAT IS THE PURPOSE OF THE PTC?
TO REDUCE PREMIUM COSTS FOR INDIVIDUALS - CAN BE PAID DIRECTLY TO INS COMPANIES OR CAN BE CLAIMED LATER WHEN TAXES ARE FILED.
HOW DO YOU APPLY FOR THE PTC?
AT THE FEDERAL MARKETPLACE
CAN YOU OBTAIN THE PTC IF YOU PURCHASE HEALTH INS THROUGH AN AGENT OR BROKER?
NO
HOW MUCH IS THE PTC?
IT EQUALS THE COST OF THE MARKETPLACE’S SILVER PLAN THAT WOULD COVER THE APPLICANT AND THEIR DEPENDENTS
WHAT ARE THE THREE OPTIONS FOR USING THE PTC?
FULL ADVANCED PAYMENT
PARTIAL ADVANCED PAYMENT
CLAIM ON TAXES
WHAT IS THE CALCULATION FOR THE PTC?
ANNUAL PREMIUM OF THE MARKETPLACE SILVER PLAN COVERING THE APPLICANT AND THEIR DEPENDENTS
MINUS
CONSUMER’S ANNUAL REQUIRED CONTRIBUTION (BASED ON FPL%)
EQUALS
CONSUMER’S PTC
ACCORDING TO THE 2013 FPL, WHAT IS THE INCOME RANGE THAT COULD BENEFIT FROM THE PTC?
$11,490-$45,460 ANNUAL HOUSEHOLD INCOME
WHAT HAPPENS IF THE CONSUMER CHOOSES A BRONZE PLAN IN THE MARKETPLACE AND APPLIES FOR THE PTC?
IT WILL LOWER THE CONSUMER’S PREMIUM CONTRIBUTION
WHAT HAPPENS IF THE CONSUMER CHOOSES A GOLD PLAN IN THE MARKETPLACE AND APPLIES FOR THE PTC?
CONSUMER WILL NEED TO MAKE UP THE COST DIFFERENCE. THE PREMIUMS WILL BE INCREASED
WHO IS ELIGIBLE FOR CSR?
1. MEETS ALL REQUIREMENTS FOR PTC AND 2. HOUSEHOLD INCOME IS 100%-250% OF FPL AND 3. CONSUMER ENROLLS IN SILVER (70%-AV) ON FEDERAL MARKETPLACE
WHAT IS THE PURPOSE OF THE CSR?
IT INCREASES THE AV OF HEALTH COVERAGE PLANS FOR LOW-INCOME CONSUMERS & REDUCES THE OUT OF POCKET COSTS FOR CONSUMERS
CAN YOU GET CSR AND PTC OR JUST ONE?
CSR IS IN ADDITION TO PTC
IS THERE A SEPARATE APPLICATION FOR CSR?
NO.
WHAT SITUATIONS WOULD ALLOW AN INDIVIDUAL TO HAVE A SPECIAL ENROLLMENT EVENT FOR ACA COVERAGE?
LOSS OF MEC GAIN OR LOSE DEPENDENT CHANGE IN MARITAL STATUS BIRTH ADOPTION FOSTER CARE PLACEMENT CONSUMER OR DEPENDENT GAINS CITIZEN, NATIONAL, OR LAWFUL PRESENCE STATUS
IF AN ERROR IS MADE AT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES, FAILING TO ENROLL A CONSUMER IN A QHP, WOULD A SPECIAL ENROLLMENT BE ALLOWED?
YES
IF A QHP SIGNIFICANTLY VIOLATES ITS CONTRACT WITH THE CONSUMER, COULD A SPECIAL ENROLLMENT BE ALLOWED?
YES
WHAT HAPPENS IF YOU GAIN OR LOSE ELIGIBILITY FOR PTC AND CSR?
SPECIAL ENROLLMENT CIRCUMSTANCE
WHAT HAPPENS IF A CONSUMER MOVES TO ANOTHER STATE OR INTO INDIANA?
ALLOWED TO HAVE A SPECIAL ENROLLMENT CIRCUMSTANCE
HOW OFTEN CAN AMERICAN OR ALASKAN INDIANS ENROLL OR CHANGE QHP’S?
ONE TIME PER MONTH
WHEN DOES COVERAGE BECOME ACTIVE FOR A CONSUMER WHEN ENROLLING IN A QHP?
IF PURCHASED BEFORE (EX.) JUNE 15TH, WILL BE EFFECTIVE ON JULY 1ST
IF PURCHASED AFTER (EX.) JUNE 16TH, WILL BE EFFECTIVE ON AUGUST 1ST
IF A CONSUMER WANTS TO RE-ENROLL IN THE SAME QHP FOR A SECOND YEAR, WHAT SHOULD THEY DO?
NOTHING
WHAT IF A CONSUMER WANTS TO CHANGE TO A DIFFERENT QHP DURING AN OPEN ENROLLMENT PERIOD?
RESPOND TO NOTICE OF ELIGIBILITY AT THE END OF A YEAR OF COVERAGE.
