Definitions
What is SHOP?
Small Business Health Options Program (SHOP) - for small employers who want to provide health and/or dental insurance to their employees
What are the 4 (or 5) health plan categories?
Bronze
Consumer pays 40% on avg
Silver
Consumer pays 30% on avg
Gold
Consumer pays 20% on avg
Platinum
Consumer pays 10% on avg
Be U.S. citizens, U.S. nationals, or lawfully present non-citizens and be reasonably expected to be so for the entire time they plan to have coverage.
Not be incarcerated (unless pending the disposition of charges).
Live in the U.S. and live in a state served by the Marketplace where they’re applying.
Name the Essential Health Benefits (100/each)
Ambulatory patient services (e.g., doctor and clinic visits)
Emergency services (e.g., ambulance, first aid, and rescue squad)
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices (e.g., therapy sessions, wheelchairs, oxygen)
Laboratory services
Preventive and wellness services and chronic disease management (e.g., blood pressure screening, immunizations)
Pediatric services, including dental and vision care
What are key protections for qualified individuals under ACA?
Get affordable health coverage regardless of any pre-existing conditions they have
Access health coverage through the Marketplace in their state
Keep existing health coverage for young adults under a parent's health plan
Obtain certain preventive services included in their health coverage without cost sharing
A health insurance plan that meets the Affordable Care Act's (ACA) requirements for health coverage. MEC plans typically offer basic coverage, such as preventive care, wellness-related tests, and common treatments. They are often more affordable than premium health plans.
What is MAGI and what is it used for?
-Adjusted gross income of a family (monthly)
-used to determine eligibility for tax credits/savings for Marketplace insurance, CHIP, and Medicaid
What counts as a small employer?
Employed 1 to 50 (100 in some states) full-time and full-time-equivalent (FTE) employees, on average, on business days during the preceding calendar year, and
Employs at least one employee on the first day of the plan year.
What are the benefits of a catastrophic health plan?
protect consumers from very high medical costs by only providing coverage when they need a lot of care
They do cover certain preventive services with no cost sharing and also cover at least three primary care visits per year before the deductible is met.
Catastrophic plans have lower premiums than the other health plan categories, but consumers are responsible for higher cost sharing amounts.
Generally, consumers must have a household income between what percent and what percent of the FPL to be eligible for APTC?
Consumers must generally have a household income between 100 percent and 400 percent of the FPL to be eligible for APTC
What is a QHP?
Qualified Health Plan that is sold in the marketplace.
What is the difference between assessment and determination?
Assessment is initially screening by FFM, but sent over to state for final approval.
Determination is FFM decides.
consumers' projected annual household income falls between 100 percent and 400 percent of the federal poverty level (FPL)
PTCs are only available to consumers who enroll in QHPs through a Marketplace.
What are requirements of a QHP?
Provides EHB, including certain recommended preventive services that are covered with no additional out-of-pocket cost to the consumer,
Follows established limits on cost sharing (e.g., deductibles, copayments, coinsurance, and out-of-pocket maximum amounts) and meets other requirements,
Must be certified by each Marketplace in which it is sold
List the four parts of Medicare.
What is APTC?
Advanced Premium Tax Credit: tax credit to lower monthly payments
available to individual market consumers under age 30 or consumers age 30 or older who qualify for a hardship or affordability exemption
Can PTC's be used for people with problems with their immigration status?
PTCs may also be available to lawfully present individuals with incomes below 100 percent of the FPL if they aren't eligible for Medicaid because of their immigration status.
How can a PTC be used for an APTC?
Eligible consumers can use all, some, or none of their PTC in advance to lower their monthly premiums—these are called APTCs.
What is the eligibility of a CSR?
Have a household income between 100 percent and 250 percent of the FPL;
Be eligible to receive the PTC; and
Enroll in a Silver plan through a Marketplace.
What is OEP, SEP, and IEP?
Open Enrollment Period: 11/1 - 1/15 and for anyone wanting a QHP in marketplace
Special Enrollment Period: special circumstance that gives you access to marketplace
Initial Enrollment Period: first seven months someone is eligible for Medicare
a standard of minimum coverage that applies to employer-sponsored health plans.
What is the eligibility for an APTC?
Be a non-incarcerated U.S. citizen, U.S. national, or legal U.S. resident.
between 100 percent and 400 percent of the FPL*.
Have no other minimum essential coverage (MEC) and not be considered eligible for MEC, including employer-sponsored coverage that is affordable** (a premium less than 9.12 percent of household income for 2023) and meets the minimum value standard***.
File a federal income tax return for the benefit year the consumer enrolled in a QHP and reconcile prior APTC.
File a joint tax return, if married, unless the consumer is a victim of domestic abuse or spousal abandonment.
Not be claimed as a dependent on another taxpayer’s federal income tax return.
What are the benefits of a CSR?
They will generally have a lower deductible.
They will generally have lower copayments or coinsurance.
They will generally have a lower "out-of-pocket maximum."
George is 30 years old, single, has no dependents, and works at a local coffee shop. George currently makes $26,000 a year, which is between 150 percent and 200 percent of the FPL. Based on his income only, which programs will George likely be eligible for when he submits his application through a Marketplace?
-premium tax credit (100-400% FPL)
-CSRs (100-250% FPL + silver plan enrollment)