ACA Certification Questions and Answers Graded A

ACA Certification Questions and Answers Graded A Young Adult Coverage Under the Affordable Care Act, health plans that cover children must make coverage available to children up to age 26. Young adults can join or remain on a parent's plan even if they are: Married (coverage does not extend to married child's spouse) Not living with a parent Not attending school Not financially dependent on a parent Eligible to enroll in their employer's plan (starting in 2014) Guaranteed Issue The Affordable Care Act requires health insurance issuers to offer all of their individual market and group market plans to any applicant in the state. It also requires health insurance issuers to accept any individual who applies for those policies, as long as the applicant agrees to the terms and conditions of the policy, including the payment of premiums. This provision is called "guaranteed issue." Guaranteed Renewability Additionally, the Affordable Care Act requires health insurance issuers to offer to renew or continue in force coverage at the option of the policyholder. This is called "guaranteed renewability." Pre-existing Conditions Effective for all health plans with plan years beginning on or after January 1, 2014, the Affordable Care Act prohibits health insurance issuers from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. For persons under age 19, this provision became effective for policy years beginning on or after September 23, 2010. Generally, a pre-existing condition is any health condition or illness that was present before the coverage effective date, regardless of whether medical advice or treatment was actually received or recommended. Clinical Trials The Affordable Care Act prohibits health insurance issuers from: Precluding participation of qualified individuals in an approved clinical trial Denying, limiting, or placing additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in an approved clinical trial Discriminating against qualified individuals on the basis of their participation in an approved clinical trial Medical Loss Ratio Is a basic financial measurement that shows how much of the premium dollars a health insurance issuer spends on health care expenses, as opposed to profits or administrative costs. As of 2012, a health insurance issuer that does not spend enough of its premium dollars on health care services must provide rebates to insured individuals or policyholders. Two Types of Martketplaces (exchanges) The Individual Marketplaces for individual consumers and their families such as Kate, the self-employed interior decorator The SHOP Marketplaces for small business owners such as Tony, the owner of the small Italian restaurant Functions of Marketplace Certifying health plans to participate in a Marketplace as QHPs Determining individuals' eligibility for enrollment in a QHP Determining individuals' eligibility for premium tax credits and cost-sharing reductions Determining or assessing individuals' eligibility for enrollment in Medicaid and/or the Children's Health Insurance Program (CHIP) Facilitating individuals' enrollment in a QHP Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing compliance with certification requirements Facilitating employers' applications and employee enrollments in coverage through SHOP Some states will establish their own Marketplaces; however, if a state does not choose to establish its own Marketplace, HHS will establish a Federally-facilitated Marketplace. Qualified Health Plan Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits, or EHB Benefit design standards, including non-discrimination requirements and limits on cost-sharing Network adequacy standards Essential Health Benefits Reflect appropriate balance among the 10 EHB categories Do not discriminate based on age, disability or expected length of life Take into account the health care needs of diverse segments of the population 10 EHB Categories Ambulatory patient services(dr. visits) Mental health and substance abuse, including behavioral health Rehabilitative and habilative services and devices Laboratory services