Study Guide for the final, part 7

Question 1

ACA compliance requirements

Answer 1

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)

Question 2

What are the conditions of the ACA individual mandate?

Answer 2

All legal residents must have “minimum essential coverage” or pay a penalty tax
Plans must include the essential health benefits in 10 categories

Question 3

What are the exemptions to the ACA individual mandate?

Answer 3

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

Question 4

Problems with the ACA individual mandate

Answer 4

The penalty tax is not strong enough
Qualifications for the subsidies is based solely on income

Question 5

How many tiers are there of marketplace plans?

Answer 5

4

Question 6

What are marketplace premiums, cost, and cost sharing based on?

Answer 6

Actuarial value

Question 7

To whom are marketplace premium subsidies available?

Answer 7

100-400% of the federal poverty level via tax credits

Question 8

What are the mandated essential health benefits under the ACA?

Answer 8

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

Question 9

What are the three groups of Medicare beneficiaries?

Answer 9

65 yrs and older
Disabled entitled to social security
Those with end stage renal dz

Question 10

What are the parts of Medicare?

Answer 10

A
B
C
D

Question 11

What is Medicare part A?

Answer 11

Hospital insurance

Question 12

When are no premiums required for Medicare part A?

Answer 12

If a person or spouse has worked and earned 40 credits

Question 13

Medicare part A benefits

Answer 13

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

Question 14

What is Medicare part B generally?

Answer 14

Supplemental medical insurance
Covers various outpt svcs

Question 15

Means-testing and Medicare part B

Answer 15

Started in 2007
A higher income threshold triggers Income Relative Monthly Adjustment Amount (IRMAA)
Results in higher premium

Question 16

What is Medicare part C?

Answer 16

Medicare advantage

Question 17

Aspects of Medicare part C

Answer 17

Pay additional premiums
Additional benefits
No need for Medigap
Lower out of pocket costs

Question 18

What is Medicare part D?

Answer 18

Prescription drug coverage

Question 19

What can enrollees choose between for Medicare part D?

Answer 19

Stand-alone plans for prescriptions only
Part C (all svcs through managed care)

Question 20

Payment in Medicare part D

Answer 20

Requires payment of a deductible

Question 21

Three levels of out-of-pocket costs after deductible in Medicare part D

Answer 21

Basic level
Coverage gap (doughnut hole)
Catastrophic level

Question 22

Aspects of Medicare out of pocket costs

Answer 22

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

Question 23

Who does Medicaid finance?

Answer 23

Indigent as determined by each state (means tested)

Question 24

Who are dual eligible beneficiaries?

Answer 24

Eligible for both Medicare and Medicaid

Question 25

Full duals for Medicare and Medicaid

Answer 25

Qualified for all benefits under both Medicare and Medicaid

Question 26

Partial duals for Medicare and Medicaid

Answer 26

Some of the costs paid by Medicaid