Chapter
Appendix D. Administrative Actions to Delay Implementation of Specific ACA Provisions
Chapter 2 Health Insurance Exchanges under the Patient Protection a nd Affordable Care Act (ACA)
Establishment of ACA Exchanges
State-based Exchange (SBE)
Operational Structure of a SBE
Federally-Facilitated Exchange (FFE)
Eligibility and Enrollment
Eligibility for Enrollment in a QHP
Eligibility for Premium Tax Credits and Cost-Sharing Subsidies
Eligibility for Medicaid and CHIP
Eligibility for Enrollment in a BHP
Plan Management Responsibilities
Consumer Assistance and Accountability
Federal Responsibilities for Establishment and Administration of All Exchanges
Federal Financial Assistance
ACA Risk Mitigation Programs
Coverage Offered through the Exchanges
Coverage Levels and Benefits
Essential Health Benefits (EHB)
Cost-Sharing Requirements
Levels of Plan Generosity
Child-Only Qualified Health Plans
Consumer Operated and Oriented Plans
Stand-Alone Dental Benefits
Interaction with Other ACA Provisions
Reforms to Private Health Insurance Markets
Appendix. Risk Mitigation Programs
Chapter 3 Health Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA)
Part of a Tax-Filing Unit
Enrolled in an Individual Exchange
Household Income Is 100%-400% of Federal Poverty Level
Not Eligible for “Minimum Essential Coverage”
Exceptions to Minimum Essential Coverage Eligibility
Employer Contribution Toward Coverage in SHOP Exchanges
Potential Premium Contributions and Premium Credit Calculations
Illustrative Examples: If Premium Credits Were Available
Examples of Premium Credits for Self-Only and Family Coverage
Self-Only Coverage Examples
Reconciliation of Premium Credits
Chapter 4 Physician Supply and the Affordable Care Act
Size of the Physician Population
Measuring the Physician Population
Determining the Appropriate Size of the Physician Population
Determinants of the Size of the Physician Population
Expert Groups That Evaluate Physician Supply
ACA and the Size of the Physician Population
ACA Provisions Targeting the Number of Physicians Trained
ACA Provisions Targeting Physician Productivity
Composition of the Physician Population
Primary Care Supply and Factors Influencing Primary Care Supply75
ACA and the Composition of the Physician Population
ACA Provisions Targeting Primary Care Supply
Primary Care Content in Physician Training
Primary Care Physician Payment
Care Coordination by Primary Care Physicians
ACA Provisions Targeting Shortages in Specialties
Geographic Distribution of the Physician Population
Health Professional Shortage Areas and Medically Underserved Areas/Populations
Why Geographic Shortages May Exist
ACA and the Geographic Distribution of the Physician Population
ACA Provisions Targeting the NHSC125
ACA Provisions Targeting the Diversity of the Physician Workforce
ACA Provisions Targeting Rural Practice
ACA Provisions Amending HPSA and MUP Designation Criteria
ACA and Workforce Planning
Appendix. ACA Provisions That May Affect Physician Supply
Chapter 5 Patient Protection and Affordable Care Act: Annual Fee on Health Insurers
Annual Fee on Health Insurers
Insurers Subject to the ACA Fee
Benefits Covered by the Fee
Insurer Reporting Requirements
Penalties for Non-compliance
Impact of the Annual Premium Fee
Breakdown of the Premium Fee
Interaction of the ACA Tax and Other Provisions
Graduate Medical Education
Tax Treatment of Recovered Fees
Chapter 6 Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act (ACA): Issues for Congress
MLR Reporting Requirements under ACA
Minimum Standards Required
Components of the MLR Formula
Formula for Calculating the MLR
Medical Claims and Quality Improvement Expenditures
Definition of Medical Claims
Quality Improvement Expenditures
ICD-10 Implementation as Quality Improvement
Treatment of Fraud Reduction and Prevention Activities Relative to Quality Expenditures
Premiums and Taxes, Licensing and Regulatory Fees
Taxes, Licensing, and Regulatory Fees
Adjustments for Plan Size and Deductible
State Flexibility and Waivers
Medicare Advantage and Part D Drug Plans
Contract Level Calculation
Enrollment Ban and Contract Termination
Calculation of the Rebate
Who Is Eligible for a Rebate?
Form of Rebates to Current and Former Employees
Notification Requirements
High Deductible Health Plans
Appendix A. Rebates by State
Appendix C. Mini Med and Expatriate Plans
Appendix D. Medicare Credibility Adjustments
The Affordable Care Act: Developments and Considerations
( Health Care Issues, Costs and Access )
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