Healthcare Programs & Coverage Options Flashcards

Which metal tier plan on the Marketplace typically has the lowest monthly premium but highest out-of-pocket costs when care is received?

Answer: Bronze

Bronze plans have the lowest premiums but highest out-of-pocket costs, covering roughly 60% of average costs.

A family's income is 210% of the Federal Poverty Level. Which cost-sharing reduction (CSR) tier applies if they enroll in a Silver plan?

Answer: 73% actuarial value tier

Incomes between 200–250% FPL qualify for the 73% AV CSR tier on Silver plans.

CHIP (Children's Health Insurance Program) primarily covers which population?

Answer: Uninsured children in families who earn too much for Medicaid but too little to afford private coverage

CHIP targets uninsured children in families whose income exceeds Medicaid limits but who cannot afford private insurance.

What is the income threshold (as a percentage of FPL) below which adults in Medicaid expansion states generally qualify for Medicaid under the ACA?

Answer: 133% (effectively 138% with the 5% income disregard)

ACA expansion covers adults up to 133% FPL, and with the mandatory 5% income disregard, the effective limit is 138% FPL.

Which Marketplace plan network type generally requires members to choose a primary care physician and get referrals to see specialists?

Answer: HMO

HMO (Health Maintenance Organization) plans require a PCP selection and referrals for specialist visits.

A consumer wants to keep seeing an out-of-network specialist. Which plan type should a CAC recommend to allow out-of-network coverage?

Answer: PPO

PPO plans cover both in-network and out-of-network providers, though out-of-network costs are higher.

Which federal program provides health coverage to people age 65 and older, as well as certain younger people with disabilities?

Answer: Medicare

Medicare is the federal health insurance program for people 65+ and qualifying individuals under 65 with disabilities or end-stage renal disease.