Unit 13: Affordable Care Act

Question 1

ACA Reforms began in 2010:

Answer 1

-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

Question 2

ACA Reforms began in 2014:

Answer 2

-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

Question 3

Grandfathered health policy

Answer 3

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)

Question 4

Excepted Benefits

Answer 4

(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

Question 5

Essential Health Benefits (EHBs)

Answer 5

(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

Question 6

Emergency Medical Services

Answer 6

no pre-auth required
in network or out of network
normal cost sharing requirements

Question 7

Bronze Plan

Answer 7

60/40

Question 8

Sliver Plan

Answer 8

70/30

Question 9

Gold Plan

Answer 9

80/20

Question 10

Platinum Plan

Answer 10

90/10

Question 11

Metal Tiers

Answer 11

-four levels of coverage; each must cover minimum EHBs
-Tiers represent average portion of expected cost
-Percentages represent how much plan will pay

Question 12

Coverage of Children

Answer 12

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

Question 13

Guaranteed Issue

Answer 13

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

Question 14

Qualifying Events

Answer 14

-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

Question 15

Qualified Health Plans (QHP)

Answer 15

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

Question 16

Small Business Health Options Program (SHOP)

Answer 16

marketplace provides an online application where small employers can shop and compare a variety of health insurance plans.

MUST have 50 or fewer full-time employees

Question 17

Subsidies

Answer 17

gOvErNmEnT

-a sum of money given by the federal government
-advanced premium tax credits (APTC)
-cost-sharing (only available to silver tier)

Question 18

Employer Mandate - Employer Shared Responsibility

Answer 18

50 or more full time employees (FTE) must pay a $2000 penalty per FTE if the employer does not offer health coverage and at least one FTE receives a federal premium subsidy for coverage purchase through a health insurance exchange

50 or more FTE that offer coverage but have at least one FTE receiving a premium subsidy will pay the lesser of $3000 (annually) for each FTE receiving a premium subsidy or $2000 (annually) for each FTE excluding the first 30 employees

Employers with less than 50 FTE are exempt from penalties

Question 19

Names for ACA

Answer 19

Obamacare

Health Care Reform

Patient Protection and Affordable Care Act (PPACA)

Question 20

Excepted Benefit

Answer 20

-Accident Only Insurance
-Disability Income Insurance
-Workers’ Compensation