PUBH 6012 Exam 2 Questions and Answers |Complete Solutions Graded A+ |100% Correct
Catastrophic Plan Type of HDHP available through the marketplaces for people under 30 (or
people who have a hardship or affordability exemption). Very high deductible, low premiums,
some limited benefits available before meeting deductible (preventive services and three
primary care visits per year); can't use subsidies
Short-Term Health Insurance Just stopgap, limited benefits (excludes preexisting conditions,
might not cover Rx), not minimum essential coverage for purposes of ACA
•Can't deny coverage for preexisting conditions
•Only allowed to vary premiums based on age, geographic area, tobacco use, and number of
family members
•No lifetime limits and can't rescind coverage
•Young adults can stay on parents' plan up to age 26
•Waiting period for coverage limited to 90 days New rules for insurers following ACA
Subsidies Financial support from the government for individuals between 133% and 400%
federal poverty limit (FPL)
- Only if employer doesn't offer or employee's share for coverage exceeds 9.5% of income
- Additional subsidies to cover cost sharing under 250% FPL
- For small businesses (under 50 employees)
Medical Loss Ratio (MLR) ACA requires health insurance issuers to spend a certain
percentage of their premium income on medical care and health care quality improvement,
leaving the rest for administration, marketing, and profit; •Plans must provide an annual rebate
to consumers (enrollees) if they do not meet these requirements
80% MLR % for individual and small group markets
85% MLR % for large group market (does not apply to self-insured plans)
,10 Benefits All Insurance Must At Least Cover
•Ambulatory patient services (outpatient care)
•Emergency services
•Hospitalization
•Maternity and newborn care
•Mental health and substance use disorder services, including behavioral health treatment
•Prescription drugs
•Rehabilitative and habilitating services and devices
•Laboratory services
•Preventive and wellness services and chronic disease management
•Pediatric services 10 Essential Health Benefits
Minimum Value - Health plan is designed to pay at least 60% of the total cost of medical
services for a standard population.
- Health Plan benefits include substantial coverage of physician and inpatient hospital services
Affordability A job-based health plan covering only the employee that costs 9.5% (adjusted
annually - 9.12% for 2023) or less of the employee's household income. If a job-based plan is
"affordable" and meets the "minimum value" standard, you're not eligible for a premium tax
credit if you buy a Marketplace insurance plan instead
Screenings for cancer, mental health, STDs, vaccinations, full range of FDA-approved
contraceptives for women (not abortions or vasectomies)
- Some religious employers are exempt from birth control coverage requirement Preventive
Services Covered with NO Cost Sharing:
State Health Insurance Exchanges - States can choose to operate an insurance marketplace
but if state opts out, federal government must create one for state residents
, - Minimum set of benefits: determined mostly by states
- Limits out-of-pocket costs (for everyone and lower for low-income people) by setting an out-
of-pocket maximum for in-network essential health benefits
- No public plan
- No abortion coverage with public money in exchange plans (may offer if paid separately with
private money, or state may prohibit coverage altogether
1.Bronze: insurance pays 60%, individual pays 40%
2.Silver: 70/30
3.Gold: 80/20
4.Platinum: 90/10 Four levels of cost sharing based on value:
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
Catastrophic Plan Type of HDHP available through the marketplaces for people under 30 (or
people who have a hardship or affordability exemption). Very high deductible, low premiums,
some limited benefits available before meeting deductible (preventive services and three
primary care visits per year); can't use subsidies
Short-Term Health Insurance Just stopgap, limited benefits (excludes preexisting conditions,
might not cover Rx), not minimum essential coverage for purposes of ACA
•Can't deny coverage for preexisting conditions
•Only allowed to vary premiums based on age, geographic area, tobacco use, and number of
family members
•No lifetime limits and can't rescind coverage
•Young adults can stay on parents' plan up to age 26
•Waiting period for coverage limited to 90 days New rules for insurers following ACA
Subsidies Financial support from the government for individuals between 133% and 400%
federal poverty limit (FPL)
- Only if employer doesn't offer or employee's share for coverage exceeds 9.5% of income
- Additional subsidies to cover cost sharing under 250% FPL
- For small businesses (under 50 employees)
Medical Loss Ratio (MLR) ACA requires health insurance issuers to spend a certain
percentage of their premium income on medical care and health care quality improvement,
leaving the rest for administration, marketing, and profit; •Plans must provide an annual rebate
to consumers (enrollees) if they do not meet these requirements
80% MLR % for individual and small group markets
85% MLR % for large group market (does not apply to self-insured plans)
,10 Benefits All Insurance Must At Least Cover
•Ambulatory patient services (outpatient care)
•Emergency services
•Hospitalization
•Maternity and newborn care
•Mental health and substance use disorder services, including behavioral health treatment
•Prescription drugs
•Rehabilitative and habilitating services and devices
•Laboratory services
•Preventive and wellness services and chronic disease management
•Pediatric services 10 Essential Health Benefits
Minimum Value - Health plan is designed to pay at least 60% of the total cost of medical
services for a standard population.
- Health Plan benefits include substantial coverage of physician and inpatient hospital services
Affordability A job-based health plan covering only the employee that costs 9.5% (adjusted
annually - 9.12% for 2023) or less of the employee's household income. If a job-based plan is
"affordable" and meets the "minimum value" standard, you're not eligible for a premium tax
credit if you buy a Marketplace insurance plan instead
Screenings for cancer, mental health, STDs, vaccinations, full range of FDA-approved
contraceptives for women (not abortions or vasectomies)
- Some religious employers are exempt from birth control coverage requirement Preventive
Services Covered with NO Cost Sharing:
State Health Insurance Exchanges - States can choose to operate an insurance marketplace
but if state opts out, federal government must create one for state residents
, - Minimum set of benefits: determined mostly by states
- Limits out-of-pocket costs (for everyone and lower for low-income people) by setting an out-
of-pocket maximum for in-network essential health benefits
- No public plan
- No abortion coverage with public money in exchange plans (may offer if paid separately with
private money, or state may prohibit coverage altogether
1.Bronze: insurance pays 60%, individual pays 40%
2.Silver: 70/30
3.Gold: 80/20
4.Platinum: 90/10 Four levels of cost sharing based on value:
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
