GBA 1 Module 11 with Complete
Solutions Graded A+
Explain the ACA preexisting provisions. - Answer-ACA prevents insurance companies
from denying coverage due to a preexisting
condition. It initially applied only to children; today insurance companies are
prohibited from refusing to sell coverage or renew policies because of an individual's
preexisting conditions. Also, in the individual and small group market, the law
eliminates the ability of insurance companies to charge higher rates due to gender or
health status.
Summarize which categories of benefits are deemed essential health benefits
(EHBs) under ACA. - Answer-(a) Ambulatory patient services (outpatient care provided
without being admitted
to a hospital)
(b) Emergency services
(c) Hospitalization (like surgery and overnight stays)
(d) Pregnancy, maternity and newborn care (both before and after birth)
(e) Mental health and substance use disorder services, including behavioral health
treatment (this includes counseling and psychotherapy)
(f) Prescription drugs
(g) Rehabilitative and habilitative services and devices (services and devices to help
people with injuries, disabilities or chronic conditions gain or recover mental
and physical skills)
(h) Laboratory services
(i) Preventive and wellness services and chronic disease management
(j) Pediatric services, including oral and vision care (but adult dental and vision
coverage aren't essential health benefits).
Under ACA, can plans place lifetime or annual limits on the dollar value of
essential benefits? - Answer-Under ACA, generally, group health plans are prohibited
from offering coverage that
establishes any lifetime or annual limits on the dollar value of essential health
benefits. While self-insured plans of any size and large plans are not required to offer
essential health benefits (EHBs), if they do, they are prohibited from imposing these
types of limits. Most of these plans do cover a majority of the ten EHBs. Thus, this
provision applies to all group health plans regardless of grandfathered status.
, How does ACA strive to make health insurance more affordable? - Answer-ACA strives
to make health insurance more affordable by providing tax credits to
people with income between 100% and 400% of the poverty line who are not eligible
for other affordable coverage. (In 2016, 400% of the poverty line is about $47,520 for
an individual or $97,200 for a family of four.) The tax credit is advanceable, so it can
lower premium payments each month, rather than making the individual wait for
tax time. It's also refundable, so even moderate-income families can receive the full
benefit of the credit.
Define the ACA mandate known as shared responsibility for employers. - Answer-The
shared responsibility mandate is sometimes referred to as "the employer
mandate" or "the play-or-pay provision." The law amended the tax revenue code by
adding Internal Revenue Code (IRC) Section 4980H requiring employers—referred
to as applicable large employers (ALEs)—to offer health coverage to their full-time
employees or pay a penalty.
To be an ALE for a particular
calendar year, an employer must have had an average of at least 50 full-time
employees (including full-time-equivalent employees) during the preceding calendar
year.
Describe the penalties an ALE employer faces if it fails to provide affordable and
minimum value benefits? - Answer-An ALE member will owe the first type of employer
shared responsibility payment if
it does not offer minimum essential coverage to at least 95% of its full-time
employees (and their dependents) and at least one full-time employee receives the
premium tax credit for purchasing coverage through the Health Insurance
Marketplace.
may owe the second type of
employer shared responsibility payment for each full-time employee who receives
the premium tax credit for purchasing coverage through the Marketplace. In general,
a full-time employee could receive the premium tax credit if: (1) the minimum
essential coverage the employer offers to the employee is not affordable, (2) the
minimum essential coverage the employer offers to the employee does not provide
minimum value or (3) the employee is not one of at least 95% of full-time employees
offered minimum essential coverage.
In general, a full-time employee is one employed on average at least how many
hours? - Answer-a full-time
employee is, for a calendar month, an employee employed on average at least 30
hours of service per week, or 130 hours of service per month.
Explain the role of the Health Insurance Marketplace established by ACA. - Answer-
ACA established the Health Insurance Marketplace—so called ACA exchanges—to
allow private insurance companies to offer "qualified health plans" for purchase by
Solutions Graded A+
Explain the ACA preexisting provisions. - Answer-ACA prevents insurance companies
from denying coverage due to a preexisting
condition. It initially applied only to children; today insurance companies are
prohibited from refusing to sell coverage or renew policies because of an individual's
preexisting conditions. Also, in the individual and small group market, the law
eliminates the ability of insurance companies to charge higher rates due to gender or
health status.
Summarize which categories of benefits are deemed essential health benefits
(EHBs) under ACA. - Answer-(a) Ambulatory patient services (outpatient care provided
without being admitted
to a hospital)
(b) Emergency services
(c) Hospitalization (like surgery and overnight stays)
(d) Pregnancy, maternity and newborn care (both before and after birth)
(e) Mental health and substance use disorder services, including behavioral health
treatment (this includes counseling and psychotherapy)
(f) Prescription drugs
(g) Rehabilitative and habilitative services and devices (services and devices to help
people with injuries, disabilities or chronic conditions gain or recover mental
and physical skills)
(h) Laboratory services
(i) Preventive and wellness services and chronic disease management
(j) Pediatric services, including oral and vision care (but adult dental and vision
coverage aren't essential health benefits).
Under ACA, can plans place lifetime or annual limits on the dollar value of
essential benefits? - Answer-Under ACA, generally, group health plans are prohibited
from offering coverage that
establishes any lifetime or annual limits on the dollar value of essential health
benefits. While self-insured plans of any size and large plans are not required to offer
essential health benefits (EHBs), if they do, they are prohibited from imposing these
types of limits. Most of these plans do cover a majority of the ten EHBs. Thus, this
provision applies to all group health plans regardless of grandfathered status.
, How does ACA strive to make health insurance more affordable? - Answer-ACA strives
to make health insurance more affordable by providing tax credits to
people with income between 100% and 400% of the poverty line who are not eligible
for other affordable coverage. (In 2016, 400% of the poverty line is about $47,520 for
an individual or $97,200 for a family of four.) The tax credit is advanceable, so it can
lower premium payments each month, rather than making the individual wait for
tax time. It's also refundable, so even moderate-income families can receive the full
benefit of the credit.
Define the ACA mandate known as shared responsibility for employers. - Answer-The
shared responsibility mandate is sometimes referred to as "the employer
mandate" or "the play-or-pay provision." The law amended the tax revenue code by
adding Internal Revenue Code (IRC) Section 4980H requiring employers—referred
to as applicable large employers (ALEs)—to offer health coverage to their full-time
employees or pay a penalty.
To be an ALE for a particular
calendar year, an employer must have had an average of at least 50 full-time
employees (including full-time-equivalent employees) during the preceding calendar
year.
Describe the penalties an ALE employer faces if it fails to provide affordable and
minimum value benefits? - Answer-An ALE member will owe the first type of employer
shared responsibility payment if
it does not offer minimum essential coverage to at least 95% of its full-time
employees (and their dependents) and at least one full-time employee receives the
premium tax credit for purchasing coverage through the Health Insurance
Marketplace.
may owe the second type of
employer shared responsibility payment for each full-time employee who receives
the premium tax credit for purchasing coverage through the Marketplace. In general,
a full-time employee could receive the premium tax credit if: (1) the minimum
essential coverage the employer offers to the employee is not affordable, (2) the
minimum essential coverage the employer offers to the employee does not provide
minimum value or (3) the employee is not one of at least 95% of full-time employees
offered minimum essential coverage.
In general, a full-time employee is one employed on average at least how many
hours? - Answer-a full-time
employee is, for a calendar month, an employee employed on average at least 30
hours of service per week, or 130 hours of service per month.
Explain the role of the Health Insurance Marketplace established by ACA. - Answer-
ACA established the Health Insurance Marketplace—so called ACA exchanges—to
allow private insurance companies to offer "qualified health plans" for purchase by
