Unit 13: Affordable Care Act

Question 1

What is the ACA also known as?

Answer 1

•patient protection & affordable care act (PPACA)
•Obamacare
•health care reform

•signed in 2010 with some reforms
•additional reforms began January 2014

Question 2

What are some ACA health insurance reforms that began in 2010?

Answer 2

•no lifetime dollar limits or annual dollar limits on essential health benefits (EHBs)
•no rescissions (cancellations), except for fraud
•specific preventive services are covered free of charge to insured
•dependent coverage until a child’s 26th birthday
•pre-existing conditions must be covered for children under age 19

Question 3

What are some ACA health insurance reforms that began in January 2014?

Answer 3

•pre-existing conditions must be covered for all eligible individuals (not just children)
•guaranteed issue of health insurance policies
•no discrimination based on gender & health status, or due to pre-existing conditions
•community rating rules for premiums
•health insurance exchanges or marketplaces
•qualified health plans (QHPs)
•essential health benefits (EHBs)
•premium tax credits & cost-sharing subsidy
•the creation of navigators

Question 4

What is a grandfathered health policy?

Answer 4

•existed before ACA
•costs cannot be increased & benefits may not be reduced
•not required to comply with some of the consumer protections of the ACA that apply to other health plans

Question 5

What is a nongrandfathered plan?

Answer 5

•existed after ACA
•must comply with all rules & laws of the ACA

Question 6

What are some consumer protections that apply to all plans (grandfathered & nongrandfathered)?

Answer 6

•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

Question 7

Group plans & grandfathered plans are NOT required to:

Answer 7

•provide certain recommended preventive services for free
•offer new protections when an insured is appealing claims & coverage denials
•allow any choice of health care providers access to emergency care

Question 8

Grandfathered individual health plans are NOT required to:

Answer 8

•phase our 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 9

What is the individual mandate?

Answer 9

•US citizens & legal residents are required to have qualifying health care coverage (minimum essential coverage)
•insurance provided by employers satisfied this
•starting in 2019, there is no monetary penalty if an individual does not comply
•exemptions may be granted for financial hardship, religious objectives, American Indians, those without coverage for less than 3 months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual’s income, & those with incomes below the tax-filing threshold

Question 10

What is minimum essential coverage?

Answer 10

Coverage from any of the following:
•government-sponsored programs (ex. Medicare, Medicaid, CHIP, TRICARE, COBRA)
•employer-sponsored plans (small or large group market)
•plans in the individual market
•grandfathered health plans
•other coverage (ex. State health benefits risk pool)

**does NOT include excepted benefits

Question 11

What are excepted benefits?

Answer 11

**NOT included in minimum essential coverage

Benefits under 1 or a combination of the following:
•accident only or disability income insurance
•liability & supplemental liability insurance
•workers’ comp or similar insurance
•automobile medical payment insurance
•credit-only insurance
•on-site medical clinics
•other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits
•the following, if provided in a separate policy:
-limited scope dental or vision benefits
-long-term care insurance
-coverage only for a specified disease or illness
-hospital indemnity or other fixed indemnity insurance
-Medicare supplements

Question 12

What are essential health benefits (EHBs)?

Answer 12

•health plans must be qualified to fit ACA standards
•qualified health plans (QHPs), Medicaid state plans, & insurance on the health exchange must meet requirements

•ambulatory patient services
•emergency services
•hospitalization
•maternity & newborn care
•mental health & substance use disorder services
—>must be treated with parity; deductibles, co-pays, & coinsurance must not differ from patients with physical conditions
•prescription drugs
•rehabilitative services & devices
•laboratory services
•preventive & wellness services & chronic disease management
•pediatric services, including oral & vision care

Question 13

Emergency medical services

Answer 13

•no pre-authorization required
•in-network or out-of-network
•normal cost-sharing requirements
•an EHB

•when an emergency occurs, no pre-authorization 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 & may not impost administrative requirements or coverage limits that are more restrictive than emergency services provided in-network

Question 14

What is the primary care provider designation?

Answer 14

•every subscriber & dependent must designate a participating primary care provider (PCP) who will serve as his usual source of medical care

Question 15

What is the prohibition on lifetime & annual limits?

Answer 15

Individual & group plan carriers are prohibited from putting annual & lifetime dollar limits on EHBs.

•plans are allowed to place annual dollar limits & lifetime dollar limits on health care services that are NOT EHBs
•grandfathered individual health plans are allowed to have annual dollar limits on EHBs

Question 16

What are the metal tiers (categories)?

Answer 16

•4 levels of coverage; each must cover minimum EHBs
•fires represent average portion of expected voters
•% represent how much the plan will pay
•the higher the amount of coverage—>the higher the premium will be for the insured

•bronze plan-60%
•silver plan-70%
•gold plan-80%
•platinum plan-90%

Question 17

What is free preventive care?

Answer 17

•take care of yourself now to prevent costly, future, chronic conditions
•ACA focuses on prevention & primary care to help people stay healthy & manager chronic medical conditions before they become more complex & costly to treat

Question 18

Pre-existing conditions

Answer 18

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

Question 19

Coverage of children to age 26

Answer 19

•group health plans & health insurance issuers offering group or individual health insurance coverage that provide dependent coverage to children of the insured must make coverage available for adult children up to age 26

•children can remain if:
-married
-not living with parents
-attending school
-not financially dependent
-eligible to enroll in employer’s plan
•past age 26 if unmarried, financially dependent, & have physical or mental impairment

Question 20

A person may be eligible for health insurance coverage through Medicaid, health insurance exchanges, group insurance, or individual coverage, depending on:

Answer 20

•income
•employment status
•if the individual has coverage though their employer

*individual tax credits & cost-sharing subsidies are only available through the health insurance exchange plans

Question 21

What is guaranteed issue?

Answer 21

•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
•a health insurance issuer that offers health coverage in the individual, small group, or large group market must offer to any individual or employer in the state all products that are approved for ale in the applicable market, & must accept any individual or employer that applies for any of those products—>subject to rules regarding enrollment periods, network plans, & insurer financial capacity

Question 22

Health insurance marketplace

Answer 22

•required
•operated by state or federal government
•annual open enrollment & special enrollment depending on qualifying events

Question 23

What are qualified health plans (QHPs)?

Answer 23

•insurance plans only available on the health insurance exchange
•provide EHBs
•follow established limits on cost-sharing (like deductibles, co-pays, & out-of-pocket maximum amounts) & meet other requirements
•only plans that provide premium tax credits & cost-sharing reductions for eligible individuals

Question 24

What is the small business health options program (SHOP)?

Answer 24

•SHOP marketplace provides an online application where small employers can shop & compare a variety of health insurance plans
•employers must have 50 or fewer full-time employees

Question 25

What are subsidies?

Answer 25

•sum of money given by the federal government •offered to help defray the cost of health care purchased via the exchanges •vary based on an individual or family’s household income •could be in the form of advanced premium tax credits (APTCs) that may be applied to lower the insured’s monthly premiums or cost-sharing reductions such as lower co-pay, coinsurance, & out-of-pocket limits •cost-sharing reduction is only available in silver tier plans •when the insured applies through an exchange, their identity & income is verified & compared to federal poverty level incomes •exchange calculates what subsidies are available, if any

Question 26

What are navigators?

Answer 26

•funded by government through federal grants •cannot sell insurance or provide advice •help determine eligibility for public assistance •funded by the federal government to help individuals determine their eligibility for public assistance programs using the health insurance exchange/marketplace website •marketplaces required to have a navigator program available for consumers to assist with eligibility, enrollment, & coverage questions related to the ACA •federally funded grants train navigators to educate consumers & refer consumers to health insurance consumer assistance programs

Question 27

What are the employer notification responsibilities?

Answer 27

•employers are required to inform employees about their rights to affordable coverage & possible subsidies •access to coverage can be either via plans offered through employment or through the health exchange individually •a dept of labor notice titled “new health insurance marketplace coverage: options & your health coverage” should be distributed in the workplace

Question 28

What is the employer mandate-employer shared responsibility?

Answer 28

•for employers with 50 or more full-time employees (FTEs) •penalty if not followed •exempt if less than 50 FTEs •employers with 50+ FTEs must pay a $2,000 penalty per FTE if the employer does not offer health coverage & at least 1 FTE receives a federal premium subsidy for coverage purchased through a health insurance exchange •employers with 50+ FTEs that offer coverage but have at least 1 FTE receiving a premium subsidy will pay the lesser of $3,000 (indexed annually) for each employee receiving a premium subsidy, or $2,000 (indexed annually) for each FTE (excluding the first 30 employees) •employers with less than 50 FTEs are exempt from the above penalties^^

Question 29

What is the health care tax credit for small employers?

Answer 29

•to be eligible for the credit, a small employer must pay premiums on behalf of employees •maximum credit -50% of premiums paid for small business employers -35% of premiums paid for small tax-exempt employers -eligible for 2 years •small employers & small tax-exempt organizations can get tax credits to help offset the cost of the company’s health plan premium contribution •maximum credit is 50% of premiums paid for small business employers & 35% of premiums paid for small tax-exempt employers •to be eligible for the credit, a small employer must pay premiums on behalf of employees enrolled in a qualified health plan offered through the SHOP marketplace or qualify for an exception to this requirement •this credit is available to eligible employers for 2 consecutive tax years •credit is targeted to help employers with low & moderate income workers afford to offer employees health insurance coverage •eligibility formal is based on the number of FTEs, NOT the total number of employees •employers must have less than 25 FTEs & cover at least 50% of the cost of employee-only (NOT family or dependent) health care coverage for each employee