Unit 13 Affordable Care Act

Question 1

What year was the ACA signed into law?

What year did the Supreme Court vote to uphold the law?

Answer 1

2010

2012

Question 2

ACA has also been referred to as the ____ and Affordable Care Act (PPACA).

Answer 2

Patient Protection

Question 3

Health insurance reforms that began in 2010:
1. No ____ or ____ dollar limits on essential health benefits
2. No recissions (cancellations), except for ____
3. Specific ____ services are covered free of charge to insured
4. Dependent coverage until a child’s ____th birthday
5. ____ must be covered for children under the age of 19

Answer 3

1. Lifetime or annual
2. Fraud
3. Preventive
4. 26th
5. Pre-existing conditions

Question 4

Health insurance reforms that began in 2014:
1. ____ must be covered for all eligible individuals (not just children)
2. ____ issue of health insurance policies
3. No discrimination based on ____ and ____ or due to pre-existing conditions
4. Community rating rules for ____
5. Health insurance exchanges or ____
6. Qualified health plans
7. Essential health benefits
8. Premium ____ and cost-sharing subsidy
9. The creation of ____

Answer 4

1. Pre-existing conditions
2. Guaranteed
3. Gender or health status
4. Premiums
5. Marketplaces
6. Tax credits
7. Navigators

Question 5

A ____ health policy is one that existed prior to the ACA. Costs cannot be increased and benefits may not be reduced on these policies. The plans are not required to comply with some of the consumer protections of the ACCA that apply to other health plans.

____ plans must comply with all rules and laws of the ACA.

Answer 5

Grandfathered Health Policy

Nongrandfathered Plans

Question 6

The following consumer protections apply to all plans (grandfathered and non-grandfathered)
1. ____ cannot be applied to essential health benefits
2. A policy cannot be ____ solely because of an honest mistake on an application
3. Dependent coverage must be extended to adult children until age ____.

Answer 6

1. Lifetime dollar limits
2. Canceled
3. 26

Question 7

Group plans and grandfathered plans are NOT required to:
1. Provide certain recommended ____ services for free
2. Offer new protections when an insured is ____ claims and coverage denials
3. Allow any choice of health care providers access to ____ care

Answer 7

1. Preventive
2. Appealing
3. Emergency

Question 8

Grandfathered individual health plans are NOT required to:
1. ____ annual dollar limits on essential health benefits (dollar limits can remain)
2. ____ pre-existing condition exclusions for children under 19 years old (pre-existing conditions can be excluded)

Answer 8

1. Phase out
2. Eliminate

Question 9

The Tax Cuts and Jobs Act of 2017 reduced the individual mandate penalty to $____ and ____% starting in 2019.

Answer 9

$0

0%

Question 10

Exemptions to the individual mandate may be granted for:
- Financial hardship
- ____
- ____
- Those without coverage for ____ months
- Undocumented immigrants
- Imprisoned individuals
- Those for whom the lowest cost plan option exceeds ____% of an individual’s income

Answer 10

Religious objections
American Indians
3 months
8%

Question 11

Health plans offered in the individual and small group markets must be qualified according to ACA standards. Qualified health plans (QHPs), Medicaid, state plans, and insurance policies in health insurance exchanges must cover the following essential benefits: (10)

Answer 11

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance abuse disorders
6. Prescription drugs
7. Rehabilitative services and devices
8. Lab services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Question 12

The ACA provides that emergency services are essential health benefits (EHBs). When an emergency occurs, no ____ may be demanded by insurers, whether the insured seeks help in-network or out-of-network. Out-of-network providers who provide emergency services must comply with normal cost-sharing requirements and may not impose admin requirements or coverage limits that are more restrictive than emergency services provided in-network.

Answer 12

Pre-authorization

Question 13

Every subscriber and dependent must designate a ____(PCP) who will serve as their source of medical care.

Answer 13

Primary care provider

Question 14

Individual and group plan carriers (unless they receive a waiver from the Secretary of the US Department of Health and Human Services) are prohibited from putting annual and lifetime dollar limits on ____.

*Grandfathered plans are allowed to have ANNUAL (not lifetime) dollar limits on these benefits.

Answer 14

Essential Health Benefits

Question 15

The ACA standardized the types of benefits and cost-sharing allowed in health plans offered through the ____ Marketplace into four levels of coverage. Each plan must cover the same minimum ESSENTIAL HEALTH BENEFITS. Individual and small group health plans categorize plans into one of four different metal tiers. The tiers represent the average portion of expected plan costs a plan will cover for an average population. The higher the amount of coverage, the higher the premiums.

Answer 15

Health Insurance Marketplace

Question 16

Name the tiers and corresponding percentages within the Health Insurance Marketplace: (4)

Answer 16

1. Bronze plan - 60%
2. Silver plan - 70%
3. Gold plan - 80%
4. Platinum plan - 90%

Question 17

____ means a limitation or exclusion of benefits based on a physical or mental condition that was present before the effective date of coverage.

Except for grandfathered ____ health insurance policies, health plans may no longer limit or exclude coverage for any individual (any age) by using pre-existing exclusions.

Answer 17

Pre-existing condition exclusion

Individual

Question 18

If grandparents are the legal gaurdian of children under 26, can the child be on their health plan?

Answer 18

Yes

Question 19

An unmarried child (of any age) who has physical or mental impairment and is financially dependent on the parents may stay on a parent’s health insurance past age 26 with proper ____.

Answer 19

Verification of Dependency

Question 20

____ Issue

This is a 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.

Subject to rules regarding ____ periods, network plans, and financial capacity.

Answer 20

Guaranteed Issue

Enrollment

Question 21

ACA requires states to have a health insurance exchange operated by either the state or federal government. Individuals, families, and small businesses can access, view, and sign up for health insurance plans using the federal government’s Health Insurance Marketplace using what web site?

Answer 21

www.healthcare.gov

Question 22

Individuals and families have an annual open enrollment each year. Special enrollment periods are available following certain QUALIFYING EVENTS:
1. ____
2. ____
3. ____
4. ____

Answer 22

1. Marriage
2. Birth or adoption of a child
3. Permanently moving to an area that offers different health plans
4. Loss of health coverage due to divorce, job loss, or loss of eligibility for coverage

Question 23

____(QHPs) are insurance plans sold on the health insurance exchange. QHPs provide essential health benefits, follow established limits on cost-sharing (like deductibles, co-payments, and out-of-pocket maximum amounts), and meet other requirements.

Answer 23

Qualified Health Plans

Question 24

The Small Business Health Options Program (SHOP) marketplace provides an online application where small employers can shop and compare a variety of health insurance plans. The employer must have ____ or fewer full-time employees.

Answer 24

50

Question 25

____(APTCs)

Answer 25

Advanced Premium Tax Credits

Question 26

To help defray the cost of health care purchased via the exchanges, the law offers subsidies that vary based on an individual or family’s household income. The subsidy could be in the form of APTCs that may be applied to lower the insured’s monthly premiums or cost-sharing reductions such as lower co-payment, coinsurance, and out-of-pocket limits. The cost-sharing reduction is only available through a health plan from the ____ metal tier plan category. When the insured applies through an exchange, their identity and income are verified and compared to federal ____ level income. The exchange calculates what subsidies are available (if any).

Answer 26

Silver

Poverty

Question 27

____ are funded by the federal government to help individuals determine their eligibility for public assistance programs using the health insurance exchange/marketplace website. They cannot legally provide advice to consumers about which health insurance plan to choose and are not permitted to sell insurance.

Answer 27

Navigators

Question 28

Marketplaces are required to have a ____ program available for consumers to assist with eligibility, enrollment, and coverage questions related to the ACA. Federally funded grants train these people to educate consumers and refer consumers to health insurance consumer assistance programs.

Answer 28

Navigators

Question 29

Are employers required to inform their employees about their right to affordable coverage and possible subsidies?

Answer 29

Yes

Question 30

A DOL notice entitled “New ____ Marketplace Coverage: Options and Your Health Coverage” should be distributed in the workplace.

Answer 30

Health Insurance

Question 31

Employer Mandate: Employers with 50 or more full-time employees must pay a $____ penalty per full-time employee if the employer does not offer health coverage and at least one full time employee receives a federal premium subsidy for coverage purchased through a health insurance exchange.

Answer 31

$2000

Question 32

Employer Mandate: Employers with 50 or more full-time employees that offer coverage but have at least one full-time employee receiving a premium subsidy will pay the lesser of $____ (indexed annually) for each employee receiving a premium subsidy, or $____ (indexed annually) for each full-time employee (excluding the first ____ employees).

Answer 32

$3000

$2000

30

Question 33

Small employers and small tax-exempt organizations can get tax credits to help offset the cost of the company’s health plan premium contribution. The maximum credit is ____% of premiums paid for small business employers and ____% of premiums paid for small tax-exempt employers.

Answer 33

50%

35%

Question 34

Health Care Tax Credit for Small Employers: To be eligible for the credit, a small employer must ____ on behalf of employees enrolled in a qualified health plan offered through the SHOP Marketplace or qualify for an exception to this requirement. The credit is available to eligible employers for ____ consecutive taxable years.

Answer 34

Pay premiums

Two

Question 35

Health Care Tax Credit for Small Employers: The credit is targeted to help employers with low and moderate-income workers afford to offer employees health insurance coverage. The eligibility formula is based on the number of full-time equivalent employees, not the total number of employees. Employers must have less than ____ FTE employees and cover at least ____% of the cost of employee-only (not family or dependent) health care coverage for each employee.

Answer 35

25 FTE employees

50%