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Flashcards in Health Care Regulation Deck (28)
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"Other employee benefit plans" are called welfare plans, and these plans are established and maintained to provide:

Health benefits
Disability Benefits
Death benefits
Prepaid legal services
Vacation benefits
Day care centers
Scholarship funds
Apprenticeship and training


What are the four minimum health standards regulated by ERISA

1. Provide plan information
2. Fiduciary responsibility
3. Establishing a grievance and appeal process
4. Allow participants right to sue


What major amendments to ERISA predated ACA

Women's Health and Cancer Rights Act
Michelle's law


What events entitle an individual to COBRA

Termination of employment
Child's loss of dependent status


Describe some disadvantages of COBRA

Employers may require individuals who elect continuation coverage to pay the full cost of the coverage, plus 2% admin charge.

Lasts for limited amount of time


Which type of employers must offer COBRA

All group health plans maintained by private sector employers (20 employees) or state and local governments. Does not apply to federal government or churches/church related organizations


Which common benefits are not subject to COBRA

Life insurance and disability benefits


In what ways does HIPPA offer protection to workers and their families?

1. Provide additional opportunities to enroll in group health plan coverage when they lose other health coverage, get married or add new dependent

2. Prohibits discrimination in enrollment and in premiums charged to employees and dependents based on any health factors

3. Preserves the states' role in regulating health insurance


What are two special enrollment rights under HIPPA

Loss of eligibility for other coverage
Marriage, birth, adoption, or placement for adoption

*Must request enrollment within 30 days of event


HIPAA nondiscrimination rules stipulate that employees and their family members cannot be denied eligibility or benefits based on certain _______ ______.

Health factors


ACA prohibits plans from imposing preexisting condition exclusions for plan years beginning on or after ______________

January 1, 2014


What were the major policy objectives of the ACA

1. Improve quality and lower health care costs for individuals and government programs

2. Provide new consumer protections

3. Expand access to health care


What was the National Federation of Independent Business v. Sebelius Supreme Court Decision

Upheld the Medicaid expansion but precluded the federal government from withholding all Medicaid federal funding if states failed to accept and comply with ACA Medicaid expansion requirements. 19 states not currently expanding Medicaid


Summarize which categories of benefits are deemed essential health benefits

Ambulatory patient services
Emergency services
Mental Health
Prescription drugs
Rehabilitative services
Lab services
Preventative and wellness
Pediatric, oral and vision


Under ACA, generally, group health plans are prohibited from offering coverage that establishes any lifetime or ________ ________ on the dollar value of essential health benefits

Annual limits


How does ACA strive to make health insurance more affordable?

Provides tax credits to people with income between 100% and 400% of the poverty line


What is the shared responsibility mandate, or "the employer mandate"

Requires applicable large employers to offer health coverage to their full-time employees or pay a penalty.

Must offer minimum essential coverage that is affordable and provides minimum value


A full time employee is, for a calendar month, an employee employed on average at least ___ hours or service per week, or ___ hours of service per month.



Employers with 50 or fewer employees can purchase health insurance coverage for their employees through _______

SHOP Marketplace
(Small business health options program)


Under what circumstances can plans lose their grandfathered status?

1. Elimination of all or substantially all benefits to diagnose or treat a particular condition

2. Increase in a percentage cost-sharing requirement

3. Increase in deductible

4. Increase in co-payment

5. Decrease in an employers contribution by more than 5 percentage points

6. Imposition of annual limits on the dollar value of all benefits


Which provisions apply to grandfathered health plans

Prohibition on:
Preexisting conditions
Excessive waiting period
Lifetime/restricted annual limits

Extension of dependent coverage
Summary of benefits and coverage and uniform glossary
Coverage of preventative services
Internal claims and appeals
Patient protections


For most cases, eligible employees are entitled to up to ___ weeks of leave in a 12-month period



Under which circumstances are eligible employees able to take FMLA leave

Birth of a child

Placement with the employee of a child for adoption

To care for the employees spouse, child, or parent who have serious health condition

Serious health condition for the employee

Military member on covered active duty


What aspect of Americans with Disabilities Act is a major concern to employer sponsored health plans?

Wellness programs


USERRA establishes _____ years as the cumulative length of time that an individual may be absent from work for military duty.



Are employers permitted to offer retiree health benefits that vary depending on whether the retiree is eligible for Medicare?



Describe the Medicare Secondary Payer rules for when Medicare coverage is available alongside other health insurance through a group plan

1. 65 or older, covered by an employer group health plan through current employment or spouse's current employment and employer has FEWER than 20 employees: Medicare pay primary, group health plan pays secondary

2. 65 or older, covered by an employer group health plan through current employment or spouse's current employment and employer has MORE than 20 employees: Group health plan pays primary, Medicare secondary

3. Individual is aged 65 or older, self employed and covered by an employer group health plan through current employment or spouse's current employment and employer has 20 or more employees: Group health plan pays primary, Medicare secondary

4. Individual is disabled, is covered by a group health plan through his or her own current employment and the employer has 100 or more employees: Group health plan pays primary, Medicare secondary


Medicare remains the primary payer for individuals aged 65 or over who are also covered under an employer __________ plan.