PUBH 6012 Exam 2 Questions and Answers |Complete Solutions Graded A+ |100% Correct
Premium Tax Credits (Subsidies) - Marketplace enrollees are eligible for premium subsidy if
income between 100%-400%
- 100-133% FPL: those not eligible for Medicaid
- 133-400% FPL: available on a sliding-scale basis
- Over 400% FPL and below 100% FPL: no subsidy
- Tax credit amount varies based on the cost of a plan in the exchange and the amount by which
the premium exceeds a certain percentage of an individual's income
- Can be applied to any metal level plan
Cost-Sharing Reduction Subsidies - Some marketplace enrollees are eligible for limits on out-
of-pocket spending, in addition to premium tax credits.
- ACA makes cost-sharing subsidies available for those with incomes below 250% FPL for out-of-
pocket costs (such as deductibles, co-pays, and coinsurance).
- One must select a silver plan for the CSR to be applied
- Costs continue to rise, discouraging people from signing up and prompting drop outs
- Market conditions and prices vary significantly and change year to year
- Limited provider network
- Providers may refuse to participate in MP plans
- Very expensive for higher income people Challenges with Marketplace Plans
American Rescue Plan •For 2021 and 2022: people up to 150% FPL can now get silver plans
for zero premium with vastly reduced deductibles; additional subsidies up to 400% FPL
•New open enrollment period until 5/15/21 for people using Healthcare.Gov and some state
exchanges
•Additional provisions for uninsured people and relief from repayment of excess subsidies
•These changes were going to expire at the end of 2022, but Congress passed the Inflation
Reduction Act in mid-2022 that extended them through 2025
,Tax, spend, regulate interstate commerce Primary federal powers (3)
- Is ACA (especially the individual mandate) a legitimate exercise of federal power?
- Does it infringe on individual and state rights in violation of the Tenth Amendment? Main
constitutionality of health reform
NFIB v. Sebelius In 2012, the Supreme Court ruled that the federal government had the
authority to require that individuals purchase health insurance because Congress had the
authority to levy taxes. (p. 692)
Consequences of Supreme Court Decision (Congress cannot require states to expand Medicaid
for everyone up to 133% FPL) - We now have two Medicaid structures in the U.S.: expansion
(income-based, ACA rules) and non-expansion (categorical eligibility, pre-ACA rules)
- This created the coverage gap because subsidies for Marketplace coverage are not available
under 100% FPL
- This holding is a new limit on federal power. It raises questions about how the federal
government can manage other federal programs that similarly provide incentives for states to
participate
- Continual efforts by Republicans to overturn ACA
- Congress passed a law (Tax Cut and Jobs Act) that changed the tax penalty amount to zero
- There was no injury from the individual mandate provision in the absence of a penalty, so the
lawsuit was dismissed Threats to ACA
- Require health insurance for all (penalty fine if you don't get health insurance)
- Subsidiary system for low-income, but don't qualify for Medicare/Medicaid
- Insurance companies have to treat preexisting conditions (no exclusions of people)
- Employers with larger companies have to offer insurance to employees Basics of the ACA
, Access, Quality, Affordable, Better, Improved population health Major Goals of the ACA
Medicaid Expansion States allowed, but not required, to expand to cover low-income
uninsured adults between 18 and 64
Children's Health Insurance Program (CHIP) Existing nationwide coverage for low-income
children who cannot qualify for Medicaid
Creation of Health Insurance Marketplace Get rid of health insurance through work, sells
new Qualified Health Plans (QHPs) and provides federal subsidies to help pay QHP premium
and OOPs
Medicaid expansion, CHIP, Creation of Health Insurance Marketplace 3 pathways to
affordable care
- How many people in your family/plan?
- Age?
- Specific location in state?
- Do you use tobacco? 4 Questions a State can Ask when Getting Insurance
QHP Rules - NO exclusions for preexisting conditions
- Rates determined by the 4 questions
- Rate increases must be filed with HHS
- Require coverage for EHBs
- No annual or lifetime limits or caps on coverage
- Annual OOPs limit
- Adult routine dental and eye exams
Premium Tax Credits (Subsidies) - Marketplace enrollees are eligible for premium subsidy if
income between 100%-400%
- 100-133% FPL: those not eligible for Medicaid
- 133-400% FPL: available on a sliding-scale basis
- Over 400% FPL and below 100% FPL: no subsidy
- Tax credit amount varies based on the cost of a plan in the exchange and the amount by which
the premium exceeds a certain percentage of an individual's income
- Can be applied to any metal level plan
Cost-Sharing Reduction Subsidies - Some marketplace enrollees are eligible for limits on out-
of-pocket spending, in addition to premium tax credits.
- ACA makes cost-sharing subsidies available for those with incomes below 250% FPL for out-of-
pocket costs (such as deductibles, co-pays, and coinsurance).
- One must select a silver plan for the CSR to be applied
- Costs continue to rise, discouraging people from signing up and prompting drop outs
- Market conditions and prices vary significantly and change year to year
- Limited provider network
- Providers may refuse to participate in MP plans
- Very expensive for higher income people Challenges with Marketplace Plans
American Rescue Plan •For 2021 and 2022: people up to 150% FPL can now get silver plans
for zero premium with vastly reduced deductibles; additional subsidies up to 400% FPL
•New open enrollment period until 5/15/21 for people using Healthcare.Gov and some state
exchanges
•Additional provisions for uninsured people and relief from repayment of excess subsidies
•These changes were going to expire at the end of 2022, but Congress passed the Inflation
Reduction Act in mid-2022 that extended them through 2025
,Tax, spend, regulate interstate commerce Primary federal powers (3)
- Is ACA (especially the individual mandate) a legitimate exercise of federal power?
- Does it infringe on individual and state rights in violation of the Tenth Amendment? Main
constitutionality of health reform
NFIB v. Sebelius In 2012, the Supreme Court ruled that the federal government had the
authority to require that individuals purchase health insurance because Congress had the
authority to levy taxes. (p. 692)
Consequences of Supreme Court Decision (Congress cannot require states to expand Medicaid
for everyone up to 133% FPL) - We now have two Medicaid structures in the U.S.: expansion
(income-based, ACA rules) and non-expansion (categorical eligibility, pre-ACA rules)
- This created the coverage gap because subsidies for Marketplace coverage are not available
under 100% FPL
- This holding is a new limit on federal power. It raises questions about how the federal
government can manage other federal programs that similarly provide incentives for states to
participate
- Continual efforts by Republicans to overturn ACA
- Congress passed a law (Tax Cut and Jobs Act) that changed the tax penalty amount to zero
- There was no injury from the individual mandate provision in the absence of a penalty, so the
lawsuit was dismissed Threats to ACA
- Require health insurance for all (penalty fine if you don't get health insurance)
- Subsidiary system for low-income, but don't qualify for Medicare/Medicaid
- Insurance companies have to treat preexisting conditions (no exclusions of people)
- Employers with larger companies have to offer insurance to employees Basics of the ACA
, Access, Quality, Affordable, Better, Improved population health Major Goals of the ACA
Medicaid Expansion States allowed, but not required, to expand to cover low-income
uninsured adults between 18 and 64
Children's Health Insurance Program (CHIP) Existing nationwide coverage for low-income
children who cannot qualify for Medicaid
Creation of Health Insurance Marketplace Get rid of health insurance through work, sells
new Qualified Health Plans (QHPs) and provides federal subsidies to help pay QHP premium
and OOPs
Medicaid expansion, CHIP, Creation of Health Insurance Marketplace 3 pathways to
affordable care
- How many people in your family/plan?
- Age?
- Specific location in state?
- Do you use tobacco? 4 Questions a State can Ask when Getting Insurance
QHP Rules - NO exclusions for preexisting conditions
- Rates determined by the 4 questions
- Rate increases must be filed with HHS
- Require coverage for EHBs
- No annual or lifetime limits or caps on coverage
- Annual OOPs limit
- Adult routine dental and eye exams
