Unit 13: Affordable Care Act Flashcards
ACA Reforms began in 2010:
- no lifetime dollar limits or annual dollar limits on essential health benefits (EHBs)
- no rescissions (cancellations), except for fraud
- specific preventive service are covered free of charge to insured
- dependent coverage until a child’s 26th birthday
- pre-existed conditions must be covered for children under the age of 19
ACA Reforms began in 2014:
- pre-existing conditions must be covered for all eligible individuals (not just children)
- guaranteed issue of health insurance policies
- no discrimination based on gender and health status, or due to pre-existing conditions
- community rating rules for premiums
- health insurance exchanges or marketplaces
- qualified health plans (QHP)
- essential health benefits (EHB)
- premium tax credits and cost-sharing subsidy
- creation of navigators
Grandfathered health policy
policy that existed prior to the ACA. Costs cannot be increased and benefits may not be reduced on these policies.
not required to comply with some of the consumer protections of the ACA that apply to other health plans
ALL plans require:
- lifetime dollar limits cannot be applied to essential health benefits
- a policy cannot be canceled solely because of an honest mistake on an application
- dependent coverage must be extended to adult children until age 26
Group plans and grandfathered plans are NOT required to:
- provide certain recommended preventive services for free
- offer new protections when an insured is appealing claims and coverage denials
- allow any choice of health care providers access to emergency care
Grandfathered INDIVIDUAL health plans are NOT required to:
- phase out annual dollar limits on essential health benefits (dollar limits can remain)
- eliminate pre-existing condition exclusions for children under 19 years old (pre-existing conditions can be excluded)
Excepted Benefits
(Minimum essential coverage does not include excepted benefits. Excepted benefits means benefits means benefits under one or more or any combination-of the following: )
- accident only or disability income insurance
- liability and supplemental liability insurance
- workers’ comp or similar insurance
- automobile medical payment insurance
- credit only insurance
- on-site medical clinics
Essential Health Benefits (EHBs)
(plans offered in the individual and small group markets must be qualified according to the ACA standards. Qualified health plans (QHPs), Medicaid state plans, and insurance policies in health exchange must cover the following benefits: )
-ambulatory patient services
-emergency services
-hospitalization
-maternity and newborn care
-mental health and substance use disorder services (must be treated with parity; deductibles, co-pays, and coinsurance must not differ from patients with physical conditions)
-prescription drugs
-rehabilitative services and devices
-laboratory services
preventive and wellness services and chronic disease management
-pediatric services, including oral and vision
Emergency Medical Services
no pre-auth required
in network or out of network
normal cost sharing requirements
Bronze Plan
60/40
Sliver Plan
70/30
Gold Plan
80/20
Platinum Plan
90/10
Metal Tiers
- four levels of coverage; each must cover minimum EHBs
- Tiers represent average portion of expected cost
- Percentages represent how much plan will pay
Coverage of Children
Up to, not including, age 26 UNLESS unmarried, financially dependent and have physical or mental impairments
can remain if:
- married
- not living with parents
- attending school
- not financially dependent
- eligible to enroll in employee’s plan
Guaranteed Issue
requirement that health plans permit you to enroll, regardless of health status, age, gender, or other factors that might predict the use of health services
must be offered to any individual or employer in the state
subject to rules
Qualifying Events
- marriage
- birth or adoption of child
- permanently moving to an area that offers different health plans
- loss of health coverage due to divorce, job loss, or loss of eligibility for coverage
Qualified Health Plans (QHP)
insurance plans sold ONLY on the health insurance exchange. _____ provide essential health benefits, follow established limits on cost sharing (deductibles, co-payments, and out-of-pocket maximums amounts) and other requirements
provide EHBs
only plan that provides tax credits and cost sharing
