GA Navigator Training

Computers and navigating the Internet.

In order to combat the online enrollment issues of individuals who are unfamiliar with or uncomfortable using digital technology, Navigators and CACs must be adept at using:

Federal poverty level

In states that did NOT expand Medicaid, individuals may be eligible for marketplace subsidies if their household MAGI fall within a range of specified percentages of the:

Mandatory Categorically Needy

In which Medicaid eligibility group are the following individuals found: low-income families and qualified pregnant women and children?

Older people may be charged higher rates than younger people.

Older people could be charged no more than 3x the rate.

Short-Term, Limited Duration Insurance (STDI)

Originally intended and created to serve as temporary insurance for people who experienced a period without coverage while they were between plans.

Minimum Value

Plan that pays at least 60% of total costs of medical services for the standard population and it's benefits include substantial coverage of physician inpatient hospital services.

Medicare Part A (aka Hospital Insurance or HI)

Provides hospital insurance automatically @ age 65 (if FICA qualified) @ no fee but may have deductible & co-pay.

Cost-Sharing

Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism.

Copayments!

What is a fixed dollar amount an insured person must pay for a specific covered service at the time it is provided?

Out-of-pocket limit

What is the highest amount a person can pay during a policy period before the health plan begins paying 100% for covered essential health benefits?

$1,500,000

What is the maximum fine that may be imposed against a covered entity for all violations of HIPAA in the same calendar year?

Medical Loss Ratio (MLR)

What is the name of the ACA provision that requires all health plans to use a certain percentage of all premium dollars collected as payments on claims for health care costs?

Provide education, outreach, and assistance.

What is the primary purpose of navigators?

Advance premium tax credit

What permits an individual to apply a credit toward monthly health insurance premiums--up to a maximum amount?

Actuarial value

What term is used to define the percentage of total costs used by a qualified health plan to pay the cost of benefits? --EX: Insurance company pays 80%; Consumer pays 20%

Essential health benefits

What term is used to describe the 10 statutory benefits provided by a qualified health plan?

Health Maintenance Organization (HMO)

organization of medical provider who are employed or contracted by insurer to provide health care to members. PCP must be in-network and refer patient to specialist.

Preferred Provider Organization (PPO)

organization of medical providers that delivers medical treatment and services to enrollees based on fee schedule and guidelines for managed medical care. Able to seek services outside network.

Grandfathered Health Plan

plan issued or purchased on or before the date the ACA became law and is exempt from some of the ACA's provisions.

Networks

providers and facilities that contract with an insurer in a managed care plan.

CMS and the Center for Consumer Info and Insurance Oversight (CCIIO)

responsible for establishing and enforcing health insurance standards that promote fair and reasonable practice.

Recovery Audit Contractors (RACs)

working for CMS have permission to review payments under Medicaid and Medicare part C and D to correct improper Medicare payments.

Flexible Spending Account (FSA)

· Funded through voluntary salary reduction programs established by employers. · Both employer and employee must contribute; employee's contributions are made pre-tax. · ACA caps contributions at a specified dollar limit. · Funds forfeited if remains at end of year unlike HSA or MSA where funds rollover.

Archer Medical Savings Accounts (MSAs)

· Similar to an HSA except for different contribution limits, minimum annual deductibles, and maximum out-of-pocket limits.

Eligibility for small business tax credit, small employer must:

֎ Employ no more than a certain number of FTEs. ֎ Pay average annual wages of no more than a specified amount. ֎ Pay a uniform amount of premium, for employee-only coverage that reaches a minimum threshold.

Eligibility to purchase SHOP:

֎ Have primary place of business located in SHOP marketplace's service area. ֎ Have at least 1 common-law employee on payroll. ֎ Have no more than 50- full-time equivalent employees. ֎ Offer coverage to ALL full-time employees.

Medicare Part C (Medicare Advantage)

•Replaces and covers expenses found in Part A and B •Medicare private fee-for-service plans (PFFS) •Medicare managed care plans (HMOs and PPOs) •Medicare specialty plans

Larger employers

50+ employees

Medicaid

A collaborative undertaking of the federal and state government to finance health care for Americans who are unable to pay for it

Age 18 for both licenses

An individual must be at least what age before being licensed as a producer or navigator?

Open Enrollment Period (OEP)

Annual time during which anyone can enroll in a qualified health plan through a marketplace.

Special Enrollment Period (SEP)

Any time outside open enrollment and during which an individual is permitted to sign up for a QHP through a Marketplace.

Applicant's health insurance agent

As a navigator, you are NOT required to protect health information about a:

Small Business Tax Credit

Certain small business may receive a tax credit amount of their contributions to health insurance provided to employees.

Qualifying Life Event (QLE)

Changes in an individual's life that make him or her eligible for a special enrollment period. Examples include moving to a new state, certain changes in income, and changes in family size.

Essential Health Benefits

Comprehensive package of health care benefits and services required by ACA for all health plans for individual and small group market.

Anyone receiving compensation from a health insurer.

Conflict of interest provisions in the ACA do NOT allow which one of the following to become navigators?

managed care plans

Contract with health care providers and facilities to offer medical services and treatment at lower cost.

Summary of Benefits and Coverage (SBC)

Document that concisely details, in plain language, simple and consistent information about a health plan's benefits and its coverage of health services.

Certified Application Counselors (CAC)

Employees and volunteers working for organizations that have been designated by federal marketplace; however, state-based may choose to certify CACs directly rather than through designated organization.

Culturally sensitive

Ethnically diverse populations require specific and targeted outreach that is both language-appropriate and ___________ to the specific needs of these communities.

Affordable

Factor of an individual's eligibility for APTCs.

out-of-pocket limit

The most money that you would pay in a year for your healthcare.

Copayments

The out-of-pocket limit is required to include which one of the following?

Population served by Medicaid

*Children *Pregnant women *Disabled adults receiving SSI *Nondisabled adults who are parents or caretaker relatives with low incomes, medically needy, TB patients with low incomes, and women in need of breast and cervical cancer preventive and treatment

Grace Period

-A time period during which no finance charges will be added to your account -If premium on health insurance policy remains unpaid after due date, the policy will continue for a stated period of time. --Most marketplaces is 90-days if: ----Policyholder qualifies for advance payment of premium tax credit. ----At least 1 full month's premium has been paid during current benefit period.

Individual Coverage Health Reimbursement Arrangements (ICHRAs)

-Allows employees to choose their own qualified health plans on marketplace; group health plan is funded solely by employer. -----If considered affordable, employee not eligible for APTC; considered not affordable, employees are permitted to opt out of IRCHRA to purchase qualified health plan that's eligible for premium tax credits.

Circumstances that exempted individual from paying the shared responsibility payment (tax):

-Being uninsured for more than 2 months of calendar year. -Lowest priced health insurance available costs more than a certain % of individual annual household income. -------Posted annually by HHS. -Filing of federal income tax return not required because an individual annual income too low. -Membership in federal recognize Indian tribe or eligibility for services through Indian health care provider. -Membership in recognized health care sharing ministry. -Membership in a recognized religious sect that has conscientious and/or religious objections to insurance, including Social Security and Medicare. -Serving time in jail or prison and not being held while awaiting the disposition of charges. -Being present in U.S. unlawfully. -Being U.S. citizen living abroad or 1 of a certain type of non-citizen. -Qualification for hardship exemption.

Qualified Health Plan (QHP)

-Certified by the marketplace in which it is offered to provide the 10 essential health benefits. -A health insurance plan that has passed a federal certification process to be offered on a Marketplace.

Employer Mandate

-Imposes tax penalty on applicable large employers that don't offer Minimum Essential Coverage to at least a specified % of their full-time employers, including the employees' dependents. -Some large employers that do offer insurance to the required % of their full-time employees may still be subject to the tax penalty if the plans they offer aren't affordable or don't provide minimum value.

Advance Premium Tax Credit (APTC)

-Individual must meet certain requirements and only apply to health insurance purchased through Marketplace. -Individual chooses how much to apply to monthly insurance premium, up to max amount. -If individual doesn't file federal income tax return in a year where tax credit was paid on their behalf, marketplace will terminate individual's eligibility for financial assistance to help pay coverage.

Tobacco use

-Insurance can charge no more than 50% higher than another insurer if insurer has ____________ - Rates based on family composition must charge separate premium for each family member based on each individual's age and ________.

Insurance is guaranteed renewable unless:

-Nonpayment of premium. -Insured individual/plan sponsor commits a fraudulent act with respect to coverage or makes a material misrepresentation on the insurance application. -Group plan, contribution requirements aren't met. -Insured moves outside health plan's coverage area. -Health insurer/carrier withdraws health plan after providing 180 days' advance notice. -Health insurer/carrier withdraws all products; insurer may not sell health plans in that market for at least 5 years after last policy is non-renewed.

The Individual Manadate

-Originally required all Americans, unless specifically exempted under ACA, to maintain Minimum Essential Coverage (MEC) or owe a tax penalty- called shared responsibility payment, ---Tax penalty provision in ACA was repealed and reduced to $0 for tax year 2019 and declared unconstitutional in 12/2019.

Minimum Essential Coverage

-The Patient Protection and Affordable Care Act required all Americans who can afford to maintain ____________ ____________ ______________ starting in 2014 -CHIP, Part A/C, Medicaid, TRICARE, Any Marketplaces, Student health plans, etc.

Medicare Part B

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Employer- sponsored health insurance is considered affordable if...

...employee's share of the premium for employee-only coverage is no more than a specific % of employee's annual household income.

Conflict of interest standards established by federal government don't allow navigator entities, navigator, and assisters to:

1. Be an issuer of health insurance or stop loss insurance. 2. Be an association that lobbies on behalf of, or includes members of insurance industry. 3. Receive any type of compensation in any manner, from an issuer of health insurance or stop loss insurance in connection with enrollment of any person in any type of health.

Premium

Amount you pay monthly, quarterly, semiannually or annually to purchase different types of insurance

Eligible groups to receive low-cost health insurance coverage

1. Pregnant Women 2. Children 3. Parents and Caretaker Relatives 4. Adults 19-64 who aren't pregnant.

insurers may only rate health insurance using 4 criteria

Age Tobacco Use Family Composition Geographic Rating Area

30 or more hours per week

Full-time employees are defined by the ACA as those who work an average of:

Non-navigator Assistance Personnel (Assister)

Help public in a fashion similar to that of navigators, except their position is only help in state-based or state/federal partnership marketplaces.

As they do for "covered entities"

How do HIPAA regulations apply to the marketplace and navigator entities?

At least annually

How often does CMS require navigators in the federal and partnership marketplaces to complete continuing education and certification/recertification?

Most rules relating to pre-existing conditions were changed.

How will an applicant's COBRA benefits be affected by the ACA?

Health Insurance Marketplace(Marketplace)(Exchange)

Resource for individual, family, and small business to use to learn about health insurance options, to compare and choose between those options, and to enroll in health plans.

Federal Poverty Level (FPL)

Standard measurement of income used to determine individual eligibility for certain state and federal programs and benefits.

Gender

The ACA does not allow insurers to underwrite or rate health insurance based on which of the following factors?

Medicaid and CHIP

The ACA expanded which two government programs?

Nickname

The GLBA considers all the following to be personally identifiable information (PII), EXCEPT:

Fully-Insured Plan

The employer pays third party insurance carrier premiums that cover medical charges, administrative costs, sales commission, taxes and profits. All risk is borne by the third party provider.

Full-time Equivalent (FTE) Employee

Total number of hours of service for which wages were paid by the employer to employees during the taxable year and divided by 2080.

Premium Tax Credits for Individuals and Small Businesses

Under ACA, certain individual and small business are eligible for premium assistance in the form of tax credits if they enroll in health plans through a marketplace.

Consumer Assistance or Ombudsman Program

Under the ACA, CMS requires the states to provide state-specific health insurance consumer assistance OR which of the following programs?

Premium tax credit

Under the ACA, what are individuals and families eligible for if they have household incomes that represent a specific percentage of the Federal Poverty Level?

A vulnerable person

Under the ACA, which of the following terms BEST describes any individual whose ability to make fully informed health care decisions is diminished due to acute or chronic health conditions?

By August 31, every year

When must navigator's license be renewed?

In marketplace's business office

Which of the following is NOT a method for enrolling in a qualified health plan through the marketplace?

Administering an insurance exam

Which of the following is NOT an example of an insurance transaction?

They cannot solicit or sell insurance policies.

Which of the following is TRUE regarding navigators?

Insurance company

Which of the following organizations is NOT permitted to act as a navigator entity?

States may require additional training.

Which of the following statements BEST describes the training of navigators, assisters, and CACs in the state-based marketplaces?

Cost-sharing

Which of the following terms is used to describe funds paid by the insured for all the costs of health care other than the premium?

Managed care plans

Which type of health care plans seek to improve the quality of care while controlling costs?

Licensed agents and brokers

Who may sell qualified health plans through the marketplace?

Because of their specialized knowledge about health insurance

Why is the role of producers so important with respect to outreach and education in the health insurance exchanges?

Medicare—Part D Prescription Drug Coverage

a United States federal-government program to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.

Point of Service (POS)

a combination of a PPO and HMO plan using a contracted network of providers and PCP as Gate Keeper to control referrals. out-of-network services incur higher deductible. Able to seek out of network treatment if needed.

Medigap

a private insurance policy that pays the difference between the medical charge and the amount that Medicare pays

Deductible

a specified amount of money that the insured must pay before an insurance company will pay a claim

Health Savings Account (HSA)

a tax-free savings account—funded by employees, employer, or both—to spend on routine medical costs. Usually combined with a high-deductible policy to pay for catastrophic care

Coinsurance

a type of insurance in which the insured pays a share of the payment made against a claim.

Multiple Employer Trusts (METs)

allow employers with similar business characteristics to pool their employees into a single larger entity, enabling all participating business to pay lower premiums.

Pre-existing condition (job-based coverage)

any condition for which medical advice, treatment, care, or diagnosis was recommended/received within the 6 month period before enrollment in a health insurance plan.

Pre-existing condition

any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage.

Medical Loss Ratio (MLRs)

o Require 2 different methods to prove striving to keep costs of health insurance affordable: -----Rate Review Method -----80/20 Rule

High Deductible Health Plan (HDHP)

health plan that combines high deductible insurance and a funding option to pay for patients out of pocket expenses up to the deductible

Exclusive Provider Organization (EPO)

similar to POS because it's PPO plan that doesn't allow the use of OON providers without prior approval from EPO. May require pcp for routine health care without restricting in network specialist.

Benefit Year

the 12-month period for which health insurance benefits are calculated, not necessarily coinciding with the calendar year. Health insurance companies may update plan benefits and rates at the beginning of the benefit year.