CH 13 - Affordable Care Act Questions and Answers 2023

CH 13 - Affordable Care Act Questions and Answers 2023 Affordable Care Act (ACA) -also known as PPACA, Obamacare, and Health Care Reform -signed in 2010 with some reforms -additional reforms began in Jan 2014 health care law includes reforms to the affordability, quality & availability of health insurance and regulations for public and private health insurance companies -see page 272 with details on plan grandfathered and non-grandfathered plans -grandfathered - existed before ACA -non-grandfathered - existed after ACA therefore, must comply with all rules and laws of the ACA Grandfathered - costs cannot be increased, benefits may not be reduced on these policies; also not required to comply with some of the consumer protections of the ACA that apply to other health plans both plans: -lifetime $ limits cant be applied to essential health benefits -policy can not be canceled solely bc of honest mistake on app -dependent coverage must be extended to age 26 group plans & grandfathered plans NOT required to: -provide certain recommended preventative services for FREE -offer new protections when insured is appealing claims -allow any choice of health care providers access to emergency care -grandfathered individual health plans NOT required to: -phase out annual $ limits on essential health benefits -eliminate pre-existing conditions for children under 19 (these can be included) individual mandate -us citizens and legal residents are REQUIRED to have minimum qualifying health care coverage -there is a tax penalty if they do not have coverage (with some exemptions - financial hardship, religious objections, american indians, can be w/o coverage for less than 3 months, undocumented immigrants, incarcerated individuals, lowest cost plan exceeds 8% of an individuals income, and those not over tax filing threshold) Minimum Essential Coverage coverage from any of the following: -govt. sponsored programs -employer-sponsored plans -plans in individual market -grandfathered health plans -other coverage minimum essential coverage doesnt include excepted benefits: ex: wc, accident only, disability income, long term care, dental, vision, etc. essential health benefits (EHB's) -health plans must be qualified to fit ACA standards -QHP's, medicaid state plans and insurance on health exchange must also meet these requirements qualified health plans must cover or offer the following essential health benefits: -ambulatory patient services -emergency services -hospitalization -maternity and newborn care -mental health & substance disorder services -prescription drugs -rehab services -lab services -preventative wellness services and chronic disease management -pediatric services - oral and vision care emergency medical services -provided under essential health benefit (EHB) thanks to aca -no pre-authorization required -in-network or out-of-network -normal cost-sharing requirements primary care provider designation -every insured and dependent must have a PCP (primary care provider) Prohibition on Lifetime and Annual Limits -on all EHB's (except for grandfathered plans) limits are allowed on non-EHB's -grandfathered plans are exempt from this Metal Tiers of ACA 4 levels of coverage - each must cover minimum EHB's tiers represent average portion of expected costs percentages represent how much plan will pay 1. bronze - insurance covers 60% 2. silver - insurance covers 70% 3. gold - insurance covers 80% 4. platinum - insurance covers 90% premium goes up the higher plan you have free preventative care take care of yourself now to prevent costly, future chronic conditions pre-existing conditions health plans can no longer exclude pre-existing conditions (except grandfathered plans)*** aka they must cover pre-existing plans Coverage of Children to Age 26 -up to, not including, age 26 -children can remain on if: married not living with parents attending school not financially dependent eligible to enroll in employer's plan -past age 26 if unmarried, financially dependent AND have physical or mental impairment *** eligibility person may be eligible for health insurance plans through medicaid, health insurance exchanges, group insurance or individual coverage ..... depends on: income employment status if you have coverage through employer guaranteed issue must be offered to any individual or employer in the state subject to rules Health Benefit Exchange/ Marketplace ACA requires states to have a health insurance exchange that individuals, families, small businesses can access, view and sign up for health insurance via: Health Insurance Marketplace -open enrollment each year; special enrollment periods for qualifying life events such as - marriage, birth, adoption, permanently moving to an area where diff. health plans are offered, loss of health coverage due to job, divorce, etc. -required -operated by state and federal govt. -annual open enrollment and special enrollment depending on qualifying life events Qualified Health Plan (QHP) QHP's are insurance plans sold on the health insurance exchange -provide EHB - essential health benefits -ONLY available ON the exchange -ONLY plan that provides tax credits and limits on cost-sharing (deductibles, co=pays, oo pocket max) SHOP (Small Business Health Options Program) -online application where small employers can shop & compare a variety of health plans -50 or less full-time employees subsidies to help with cost of health care purchased via exchanges, the law offers subsidies that vary based on individual or family's household income -a sum of money given by the federal govt. -advanced premium tax credits (APTC) - ;pwer the insured's monthly pemiums or cost sharing reductions such as lower co pay, coinsurance or out of pocket limits -cost-sharing (only available in silver tier)