Affordable Care Act Basics

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26 Terms

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Qualified individuals of ACA

  • Get affordable health coverage regardless of any pre-existing conditions.

  • Access health coverage through the Marketplace in their state.

  • Keep existing health coverage for young adults under a parent's plan.

  • Obtain certain preventive services without cost sharing.

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Features of the ACA require most health insurance companies and the plans they offer to:

  • Provide a standardized Summary of Benefits and Coverage (SBC) so consumers can easily understand their coverage and compare it to other available options;

  • Not exclude coverage for consumers based on pre-existing conditions;

  • Refrain from terminating coverage after they have already agreed to cover consumers (unless an exception applies);

  • Offer a core comprehensive set of benefits, known as essential health benefits (EHB), when offering coverage to individual consumers and small employers; and

  • Prohibit annual and lifetime dollar limits on coverage of EHB.

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Marketplaces for individuals and families

  • Collect and verify eligibility information from consumers and their families.

  • Consumers may qualify for:

    • Advance Premium Tax Credit (APTC)

    • Cost-Sharing Reductions (CSRs)

    • Medicaid and CHIP

  • Verify all consumer information, including immigration status.

  • Consumers can apply:

    • During the Open Enrollment Period (OEP)

    • During a Special Enrollment Period (SEP)

    • For Medicaid and CHIP at any time

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SHOP Marketplaces

  • Collect eligibility information from small employers.

  • APTC and CSRs not available for SHOP plans.

  • Some small employers may qualify for small business health care tax credits.

  • Do not verify citizenship or immigration status (employers are responsible for legal work status).

  • Employers can purchase coverage at any time of the year.

  • Coverage can be obtained by working with:

    • A QHP issuer

    • SHOP-registered agent or broker

    • SHOP Marketplace directly

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Qualified Health Plan (QHP)

Under the ACA, a health insurance plan that's certified by a Marketplace is called a QHP. A QHP:  

  • Provides EHB, including recommended preventive services that are covered with no additional out-of-pocket costs;

  • Follows established limits on cost sharing (e.g., deductibles, copayments, coinsurance, and out-of-pocket maximum amounts);

  • Must be certified by each Marketplace in which it is sold; and

  • Meets other requirements.

can enroll in QHPs during the annual OEP or during an applicable SEP.

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Open Enrollment Period

starts on November 1 and ends January 15

Coverage will begin on January 1 for consumers who enroll by December 15. For consumers who enroll between December 16 and January 15, coverage will begin on February 1.

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Special Enrollment Period

Consumers who experience certain life events, like getting married or having a child, may qualify for an SEP to enroll in or change QHPs outside of the OEP.

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Qualified Health Plan (QHP) Eligibility

  • Be U.S. citizens, U.S. nationals, or lawfully present non-citizens and reasonably expect to maintain this status for the entire time they plan to have coverage;

  • Not be incarcerated (unless pending the disposition of charges);

  • Live in the U.S. and live in a state served by the Marketplace where they're applying.

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Essential Health Benefits (EHBs)

These requirements apply to:

  • Qualified Health Plans (QHPs) in the individual and small group markets sold through the Marketplaces.

  • Non-grandfathered individual and small group market insurance plans sold outside the Marketplaces.

  • Medicaid plans for individuals who became eligible under Medicaid expansion in participating states.

    Routine adult dental coverage isn't considered an essential health benefit, and most QHPs don't offer it; however, consumers may be able to purchase stand-alone dental plans in the Marketplace.

    The Marketplace must ensure that plans that offer pediatric dental care either as part of QHP coverage or through stand-alone dental plans; however, consumers aren't required to buy dental insurance for their dependent children.

<p>These requirements apply to:</p><ul><li><p class="">Qualified Health Plans (QHPs) in the individual and small group markets sold through the Marketplaces.</p></li><li><p class="">Non-grandfathered individual and small group market insurance plans sold outside the Marketplaces.</p></li><li><p class="">Medicaid plans for individuals who became eligible under Medicaid expansion in participating states.</p><p><span>Routine adult dental coverage isn't considered an essential health benefit, and most QHPs don't offer it; however, consumers may be able to purchase stand-alone dental plans in the Marketplace.</span></p><p><span>The Marketplace must ensure that plans that offer pediatric dental care either as part of QHP coverage or through stand-alone dental plans; however, consumers aren't required to buy dental insurance for their dependent children.</span></p><p></p></li></ul><p></p>
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Categories of QHPs

  • Bronze: cover 60%

  • Silver: cover 70%

  • Gold: cover 80%

  • Platinum: cover 90%

  • Catastrophic:

    under age 30.

    Available to consumers age 30 or older only if they qualify for a hardship or affordability exemption (e.g., natural disaster, financial hardship).

    For Plan Year 2025, an affordability exemption applies if the cost of minimum essential coverage exceeds 7.28% of annual household income

    protect against very high medical costs.

    Covers preventive services at no cost sharing.

    Covers at least three primary care visits per year before the deductible is met.

    low premiums, higher cost-sharing, NO APTC (Advance Premium Tax Credit) and CSRs (Cost-Sharing Reductions)

Health insurance companies that sell QHPs in a Marketplace must offer at least one Silver and one Gold plan.

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Minimal Essential Coverage (MEC)

Most private health insurance plans are considered MEC. Taxpayers are required by law to have MEC or qualify for a health coverage exemption.

Starting in tax year 2019, consumers who do not maintain Minimum Essential Coverage (MEC) or do not qualify for a health coverage exemption do not have to pay an individual shared responsibility payment, because the Tax Cuts and Jobs Act reduced the penalty to $0 at the federal level.

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MEC Coverage Qualification

Coverage Type

Does it qualify as MEC?

Any Marketplace medical plan or any individual health insurance plan you already have (other than certain excepted benefits)

Yes

Most individual health plans bought outside the Marketplaces, including grandfathered plans (not all plans sold outside the Marketplaces qualify as MEC)

Yes

Employer-sponsored coverage, including retiree plans and Consolidated Omnibus Reconciliation Act (COBRA) continuation coverage

Yes

Medicare Part A

Yes

Medicare Part C (also known as Medicare Advantage)

Yes

Full benefit Medicaid coverage

Yes

Medicaid coverage of family planning services only

No

Medicaid coverage of emergency services only

No

Most Children's Health Insurance Program (CHIP) coverage, including CHIP buy-in programs that provide identical coverage to the state's Title XXI CHIP program

Yes

Coverage under a parent’s plan (that qualifies as MEC)

Yes

Health coverage for Peace Corps volunteers

Yes

Certain types of veterans’ health coverage through the Veterans Affairs (VA)

Yes

Most TRICARE plans

Yes

Department of Defense Non-appropriated Fund Health Benefits Program

Yes

Refugee Medical Assistance

Yes

Coverage only for vision care or dental care

No

Workers' compensation

No

Coverage only for a specific disease or condition

No

Medical discount plans, or plans that offer only discounts on medical services

No

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employer shared responsibility payment

For employers with 50 or more full-time and full-time-equivalent (FTE) employees who don't offer MEC

may still have to pay a fee if their offer of coverage:

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Premium Tax Credits (PTC)

annual household income falls between 100 percent and 400 percent of the federal poverty level (FPL)

only available to consumers who enroll in QHPs through a Marketplace. Eligible consumers can use all, some, or none of their PTC in advance to lower their monthly premiums— advance payments of premium tax credits (APTC).

PTCs may also be available to lawfully present individuals with household incomes below 100 percent FPL if they aren't eligible for Medicaid because of immigration status

  • If consumers use more APTC than the PTC they're determined eligible for, they may be required to repay the difference when they file their federal income tax returns.

  • If consumers use less APTC than the premium tax credit they're determined eligible for, they may receive the difference as a refund

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Cost-sharing Reductions

onsumers who qualify for income-based CSRs and enroll in a Silver plan through a Marketplace

eligibility:

  • Have a household income under 250 percent of the FPL;

  • Be eligible to receive APTC;

  • Enroll in a Silver plan through a Marketplace

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FFM Privacy Requirements for Assisters

Create a marketplace account

Complete the eligibility process and apply for coverage

Enroll in a qualified health plan (QHP)

Assess options for lowering costs of coverage

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Standards of use and disclosure of PII

  • Verify policies and procedures

  • Provide consumers with the Privacy Notice Statement

  • Display Privacy Notice Statement on public website

  • Obtain consumers’ consent before discussing or accessing PII

  • Tell consumers the “what, why, how, and with whom” about their PII

  • Collect only necessary information, and get consent for additional use

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Privacy

consumer’s right to control how their personal information is used or disclosed.

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Security

systems and physical safeguards in place to protect a consumer’s personal information.

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Confidentiality

Respecting your limitations when accessing or disclosing a consumer’s information. You should abide by relevant laws and safeguard consumers’ personal privacy and proprietary information.

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Breach

privacy incident that poses a risk of harm to applicable individuals. The determination of whether a Centers for Medicare & Medicaid Services (CMS) privacy incident rises to the level of a breach is made exclusively by the CMS Breach Analysis Team (BAT)

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Information security

protection of information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction to provide confidentiality, integrity, and availability.

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Fraud

happens when an individual or an entity (for example, a business) deliberately omits or mis-states important information for personal benefit.

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Reporting Process: Victim of Fraud

For example:

  • Refer consumers with complaints against agents or brokers to their state Department of Insurance or other state agency that regulates these entities.

  • Direct consumers who believe their SSN or PII has been stolen to contact the Federal Trade Commission (FTC) by calling 1-877-382-4357 (1-877-FTC-HELP) or visiting the FTC website.

You can also:

  • Direct consumers to contact the Social Security Administration (SSA) if they need help getting a new SSN.

  • Help consumers avoid unsolicited offers by encouraging them to register their home and cell phone numbers with the National Do Not Call Registry online or by phone at 1-888-382-1222.

  • Inform consumers they should review their EOB from their insurance company to check if they were billed for services or equipment they didn't receive.  

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Reporting Process: Consumer as Frauds

  1. Office of Inspector General:

  • Online: HHS OIG Fraud Hotline

  • Phone: 1-800-HHS-TIPS (1-800-447-8477);
    TTY 1-800-377-4950

  • Mail: HHS OIG

ATTN: OIG HOTLINE OPERATIONS

P.O. Box 23489

Washington, DC 20026

  1. Contact to report agent/broker fraud.

    Contact your state DOI.

  2. Federal Trade Commission:

    Online: Secure Complaint Form

    Phone: 1-877-ID-THEFT (1-877-438-4338);
    TTY 1-866-653-4261

  3. Marketplace call center: Phone: 1-800-318-2596; TTY: 1-855-889-4325 (all languages available)

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