Affordable Care Act (ACA) Flashcards
(13 cards)
How does the ACA address access?
- Prohibits discrimination based on preexisting conditions.
- Section 1557 prohibits other discrimination
- Guaranteed issue
- Individual mandate
- Can stay on parents’ health insurance until turn 26
- Employer Mandate
- Small business tax credits
Health Insurance Marketplace:
A place where consumers can go, browse through the range of available insurance options, and choose the insurance plan that best suits themselves and their families.
ACA and Affordability examples:
- Modified community rated premiums:
-Can only consider geographic location, age, and tobacco use - Small Business Tax Credits
- Premium Assistance Tax Credits (subsidies) for those earning 100-400% of poverty level & buying marketplace policy
- Cost-sharing reduction limits for Marketplace plans:
-Maximum out-of-pocket limit
-Specific actuarial value:
–(% of of an average person’s health costs that a plan will pay for covered benefits… in other words, % of coverage)
- No lifetime or annual limits
- No cost-sharing for preventive care
Internal Review/Appeal:
Filed by the consumer to ask the health plan to reconsider its denial of services, payment of a claim, or application of coverage. Completed by health plans themselves.
External Review:
Conducted by third parties, as opposed to internal appeals which are conducted by the health plan themselves.
What kind of health plan must include both internal and external review?
Group health plans
Consumer Protections Examples:
- Medical Loss Ratios
- Insurers must justify unreasonable premium increases
Medical loss ratios:
MLR: ratio of amounts that the insurer spent on clinical services and for activities that improve health care quality to adjusted premium revenue.
Insurers must:
1. Spend 85% of premium revenues on health services or
- On quality promoting services or
- Pay enrollees rebates
ACA guidance on Corporate Wellness Programs (CWPs):
- Yearly opportunity to qualify
- Restrictions on size of reward (30% of cost)
- Reasonable alternatives must exist & be disclosed
- Can’t be a subterfuge (deception) for discrimination
ACA Disclosure Requirements
HHS developed standards for disclosure of a Summary of Benefits and Coverage (SBC).
-These standards preempt state laws that allow plans to provide less information.
ACA Waiver Requirements (Section 1331 specifically)
-States have waivers for particular provisions
Section 1331 allows states to establish a basic health care program under which the state can offer one or more standard health care plans that cover essential benefits to individuals who have:
- Household incomes between 133% and 200% FPL
- Are not elligible for Medicaid or affordable employment-related coverage
- Are under age 65.
Individuals elligible for the program must not be required to pay a premium higher than the premium for the benchmark plan in the Marketplace after application of premium tax credits and cost-sharing reductions.
ACA Waiver Requirements (Section 1332 specifically)
Section 1332 enables states to apply for a waiver to modify key provisions of the ACA and create a new coverage system that better suits the local context and preferences, while still fulfilling the goals of the ACA.
States may apply to HHS for waiver of certain ACA requirements:
- Marketplaces
- Qualified health plans
- Premium affordability credits
- Cost-sharing reduction payments
- Small employer tax credits
- Individual and employer mandates
ERISSA:
A state cannot deem “self-funded plan” as insurance (state law does not rule self funded plans)
