Reforms & Mandates
Health plans must meet ACA standards to provide EHBs. Name 5 of the 10 Essential Health Benefits
Ambulatory care:
Emergency medicine:
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services:
Prescription drugs
Physical medicine and rehabilitation:
Laboratory services
Free preventive care
Pediatric care
Penalty for not offering health coverage to 50+ full-time employees:
A. Individual Mandate
B. Employer Responsibility
C. Eligibility
D. Employer Penalty
Employer Penalty
Required provider for insured and dependents
A. Primary Care Provider
B. Participating Provider
C. Managed Care Plans
D. Insurance Provider
Primary Care Provider
Navigators
Individuals who are NOT eligible to purchase health insurance through an individual exchange include:
- illegal aliens
-those who are incarerate
Health plans are no longer allowed to exclude coverage for:
Pre-existing condition
Government-funded individuals assisting with public assistance eligibility:
A. Certified Application Counselors
B. Navigators
C. Subsidies
Navigators
Restriction on EHBs with exceptions for grandfathered plans
A. Pre existing conditions
B. Qualified Health Plans (QHP)
C. Prohibition On Lifetime/annual Limit
Prohibition On Lifetime/annual Limit
compare health insurance plans online
select a plan
apply for subsidies for which they are eligible
receive verification of enrollment in a plan
1. must be enrolled in a QHP through an individual exchange
2. household income must be between 100% and 400% of the FPL
3. individual must not have access to affordable, adeguate coverage through an employer or govt program such as Medicaid, Medicare or Tricare
4. person must not be incarcerated or illegal alien
FOUR considerations for individuals eligible for advance premium tax credits :
Children can remain on their parents' plan up to age
26
Small businesses with __________ employees can use the SHOP platform to compare health plans.
50 or fewer full-time employees c
Four coverage levels based on expected costs
Metal Tiers
Health insurance exchanges are also know as health insurance ____
marketplaces
-children (family income below 133% of FPL)
-parents and caretaker relatives (take care of children under 18)
-pregnant women (family income at or below 133% of FPL)
-elderly, disabled, and blind (who receive SSI)
-low-income adults (133% FPL)
Categories of individuals that may be eligible for Medicaid:
Open enrollment and special enrollment periods are available based on
qualifying events
What is Guaranteed Issue
Insurance must be offered to any individual or employer in the state, subject to specific rules. A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors
Cost-free care to prevent future chronic conditions
Free Preventive Care
As an example, a bronze plan will cover 60% of healthcare costs, and plan members will be responsible for the remaining ___%
40
Name 6 healthcare options:
1. Health Maintenance Organizations (HMO)
2. Preferred Provider Organizations (PPO)
3. Point of Service (POS) plans
4. Exclusive Provider Organizations (EPO)
5. High Deductible Health Plans (HDHPs)
6. Health Savings Account (HSA) / Health
Lifetime/annual limits are prohibited on Essential Health Benefits (EHBs) except for
grandfathered plans.
There are ______ levels of metal tiers, each required to cover minimum EHBs. Tiers represent the average portion of expected costs. Name the tiers.
Four: Bronze, Silver, Gold, and Platinum.
No pre-authorization needed for in/out-of-network care
Emergency Medical Services
5 things that exchanges must do to meet requirements of ACA:
1. handle the needs of 2 distinct marketplace (individuals and small businesses_
2. provide assistance to purchasers
3. facilitate applications for the premium tax credits and cost-sharing subsidies offered under the ACA
4. provide individuals with access to other health benefit programs through a "no wrong door" policy
5. certify that health plans meet benefit standards
provide EHBs
follow established limits on cost-sharing
meet all other minimum standards of the ACA
To be certified as a Qualified Health Plan, the plan must meet the requirements: