State the Definition
What is a QHP?
Qualified Health Plan; insurance plans on Marketplace.
True or False? States will typically cover medically needy individuals even if not required to by federal law.
True - this is called an optional eligibility group, another common example are disabled people who are employed.
What is the difference between an HMO and PPO?
PPO: lower costs to consumer if in network, higher costs for out of network providers
What plan requires consumers to pay completely out of pocket for out of network services?
a.) HMO. b.) EPO. c.) FFS. d.) None of the above
b.) EPO (exclusive provider organization) is a managed care plan that only covers services that are in network.
Susan is a California resident and really wants to view her options for individual coverage. What is California's version of Medicaid?
MediCal
What does OEP stand for? What does it mean?
Open Enrollment Period. Time period consumers can enroll in individual coverage.
26 years old.
What is the difference between Medicare and Medicaid?
Medicare: federal coverage targeting 65+, disabled, people w/ ESRD; premium/benefits dependent on payroll taxes
Medicaid: state coverage targeting low-income, pregnant people, people with disabilities, etc.
What are the most common ways to obtain health insurance? (choose all correct answers)
Through a marketplace
Through one’s employer
Through a private insurance provider
The Onion Router (Tor)
Juan has back pain and asks you which plans will cover out-of-network care and pay for at least a portion of the health care costs. Which of the following types of health insurance plans should you tell him would give him access to those features?
PPO and POS plans
What is COBRA?
Continuation coverage that allows consumers to continue their employer sponsored insurance for a limited amount of time at a higher cost.
What is the disadvantage of finding health insurance outside the Marketplace?
consumers miss out on the programs in the Marketplace dedicated to lowering insurance costs.
What are the two military related health coverage plans?
TRICARE: one of 8 US uniformed services
VA Health Benefits: veterans
When do health insurance providers need to provide an SBC? (choose all that apply)
When a consumer enrolls in a health care plan
At the beginning of each plan year
Within one business day after a request for an SBC
Choices 1 and 2
Mary wants to know what the best plan is for her chronic pain as she often visits doctors and specialists. Her friend recommended she apply for a HDHP. Do you agree? Why or why not?
Absolutely do not agree if finances are her main concern. HDHPs will require her to pay high deductibles before she can get covered.
What is CHIP and who does it target?
program jointly funded by the federal and state governments providing health coverage to uninsured low-income children and, in some states, pregnant individuals in families with income too high to qualify for Medicaid but who can't afford private health insurance
What are the benefits of an FFS?
lets consumers choose their own providers, and the health insurance company reimburses providers (or you if you make a claim) for a portion of the total cost of each service that consumers use
What is the difference between HRAs and traditional health coverage?
optional: what does HRA stand for?
HRA: a group health plan funded solely by employer contributions that reimburses an employee’s medical care expenses up to a maximum dollar amount for a coverage period
Which of the following federal programs is incorrectly matched with the population it covers?
Medicaid: low-income families, pregnant women, people with certain disabilities
Medicare: people aged 65+, young people with disabilities, people with ESRD
CHIP: people age 30-65 who make too much to qualify for medicaid
TRICARE:Coverage for uniformed service members and their families
CHIP: covers minors and/or pregnant individuals
Joshua missed the open enrollment period to enroll in health insurance but he just moved to California. What do you suggest he do?
Moving is a qualifying event meaning he qualifies to apply for insurance during the Special Enrollment Period (SEP).
What are mandatory eligibility groups? Name the four groups.
demographics states are required to cover under federal law
Pregnant individuals at or below a certain household income level; Children and parents/caretaker relatives in households at certain income levels; People with disabilities; Certain low-income older adults
What are three actions individuals who have lost their job can take?
1.) COBRA
2.) Enroll in Marketplace insurance during SEP/find coverage outside Marketplace
3.) Medicai/CHIP eligibility
Why are HSAs and FSAs beneficial?
let a consumer pay for qualified out-of-pocket medical expenses on a pretax basis. The money that's contributed to an HSA or an FSA isn't subject to federal income tax at the time of deposit but must be used to pay for qualified medical expenses. HSA funds rollover.
What plan requires a referral from a primary doctor to see a specialist but also allows consumers to go to out of network providers? a.) PPO. b.) HMO. c.) EPO. d.) None of the above
d.) None of the above;
POS (point of service allows this) where consumers pay less to see in service providers but can visit out of network providers for a higher cost.
Jenny is undocumented but gave birth to her daughter in Utah. She desperately wants coverage for her daughter but is unsure how to go about it. What do you suggest?
CHIP is a great solution as it only depends on the child's citizenship status, not hers. BONUS points if you provide a solution for Jenny to receive coverage.