Study Guide for the final, part 7 Flashcards
ACA compliance requirements
Coverage for young adults under 26 on their parents’ plans
Coverage for pre-existing conditions
Coverage for preventive services without cost sharing
Imposing a fee on insurers for selling plans through the exchanges
No dollar limits on benefits
Limits on out of pocket costs for deductibles and copayments/coinsurance
Required minimum medical lost ratios (MLR)
What are the conditions of the ACA individual mandate?
All legal residents must have “minimum essential coverage” or pay a penalty tax
Plans must include the essential health benefits in 10 categories
What are the exemptions to the ACA individual mandate?
Unaffordability
Religious opposition to insurance
Being a member of a recognized Indian tribe
Exempt from filing income taxes
A coverage gap < 3 mos
Plans purchased at the health insurance marketplace
Problems with the ACA individual mandate
The penalty tax is not strong enough
Qualifications for the subsidies is based solely on income
How many tiers are there of marketplace plans?
4
What are marketplace premiums, cost, and cost sharing based on?
Actuarial value
To whom are marketplace premium subsidies available?
100-400% of the federal poverty level via tax credits
What are the mandated essential health benefits under the ACA?
Ambulatory pt svcs
Emergency svcs
Hospitalization
Maternity and newborn care
Mental health and substance use disorder svcs, including behavioral health tx
Prescription drugs
Rehabilitative and habilitative svcs and devices
Laboratory svcs
Preventive and wellness svcs and chronic dz mgmt
Pediatric svcs, including oral and vision care
What are the three groups of Medicare beneficiaries?
65 yrs and older
Disabled entitled to social security
Those with end stage renal dz
What are the parts of Medicare?
A
B
C
D
What is Medicare part A?
Hospital insurance
When are no premiums required for Medicare part A?
If a person or spouse has worked and earned 40 credits
Medicare part A benefits
90 days of inpatient hospital care per benefit period
Lifetime care of 190 days in a psych hospital
Up to 100 days of care in a Medicare-certified SNF subsequent to inpt hsopitalization
Home health care through a Medicare-certified agency
Hospice care
What is Medicare part B generally?
Supplemental medical insurance
Covers various outpt svcs
Means-testing and Medicare part B
Started in 2007
A higher income threshold triggers Income Relative Monthly Adjustment Amount (IRMAA)
Results in higher premium
What is Medicare part C?
Medicare advantage
Aspects of Medicare part C
Pay additional premiums
Additional benefits
No need for Medigap
Lower out of pocket costs
What is Medicare part D?
Prescription drug coverage
What can enrollees choose between for Medicare part D?
Stand-alone plans for prescriptions only
Part C (all svcs through managed care)
Payment in Medicare part D
Requires payment of a deductible
Three levels of out-of-pocket costs after deductible in Medicare part D
Basic level
Coverage gap (doughnut hole)
Catastrophic level
Aspects of Medicare out of pocket costs
Relatively high deductibles, copayments, and premiums
No eyeglasses, dental, long-term care coverage
No limit on out of pocket expenses in the original Medicare program
-Exception: a half of the Medicare Advantage plans have cost sharing limits
-A typical beneficiary spends about 20% of income on out of pocket costs
Who does Medicaid finance?
Indigent as determined by each state (means tested)
Who are dual eligible beneficiaries?
Eligible for both Medicare and Medicaid
Full duals for Medicare and Medicaid
Qualified for all benefits under both Medicare and Medicaid
Partial duals for Medicare and Medicaid
Some of the costs paid by Medicaid
