Malcolm Rivera
In the context of minimum wage for healthcare workers, a qualified health plan refers to an insurance plan that meets the requirements of the Affordable Care Act (ACA) or Obamacare. It must be certified by the Health Insurance Marketplace, provide essential health benefits, follow established limits on cost-sharing, and meet other ACA requirements. This includes covering pre-existing conditions, following cost-sharing limits, and covering the ACA's ten essential health benefits without imposing dollar limits on annual or lifetime benefits. These plans are designed to ensure that employers offer affordable and valuable health insurance to their full-time employees, with specific provisions for healthcare workers in certain facilities. The ACA's employer mandate, which applies to employers with 50 or more full-time employees, stipulates that employers must provide affordable coverage that pays at least 60% of the cost of covered services. This mandate is particularly relevant for healthcare workers, as recent legislation has increased the minimum wage for those employed by certain healthcare facilities.
| Characteristics | Values |
|---|---|
| Certified by | Health Insurance Marketplace® |
| Provides | Essential health benefits |
| Follows | Established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts) |
| Meets | Requirements under the Affordable Care Act (ACA) |
| Meets | Certification requirements of the state's health insurance exchange/Marketplace |
| Rules | Licensed in the state where coverage is provided |
| Rules | Covers pre-existing conditions |
| Rules | Follows cost-sharing limits |
| Rules | Covers the ACA's ten essential health benefits with no dollar limits on annual or lifetime benefits |
| Certified by | Federal or state-run health insurance marketplace/exchange |
| Annual certification | |
| Availability | Available off-exchange, directly from the health insurance company |
| Only qualify for ACA's premium tax credits if you buy a QHP policy through federal or state health insurance Marketplace | |
| Only available to those without employer-provided coverage and who don't meet eligibility requirements for Medicare or Medicaid | |
| All individual/family and small group major medical health plans with effective dates of 2014 or later are required to be fully compliant with the ACA | |
| Covers essential health benefits and pre-existing conditions | |
| No annual or lifetime benefit caps |
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What You'll Learn
A qualified health plan is specific to Obamacare/the Affordable Care Act (ACA)
A qualified health plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA), also known as Obamacare. These plans are designed for people who do not have employer-provided coverage and do not meet the eligibility requirements for Medicare or Medicaid.
To be considered a QHP, a plan must be certified by the Health Insurance Marketplace® and meet specific requirements, including providing essential health benefits, following established limits on cost-sharing (such as deductibles, copayments, and out-of-pocket maximums), and covering pre-existing conditions. Additionally, QHPs must not place dollar limits on annual or lifetime benefits, ensuring comprehensive coverage for individuals and families.
The categorization of individual and small group plans by metal levels, such as Bronze or Gold, helps consumers compare policies based on their actuarial value. While all QHPs must cover essential health benefits, the level of coverage varies, with higher metal level policies typically providing more comprehensive coverage.
It is important to note that QHPs are subject to annual certification by federal or state-run health insurance marketplaces/exchanges. This certification process ensures that the plans remain compliant with the ACA's requirements and provide consumers with the necessary protections and benefits.
The ACA also includes an employer mandate, which requires employers with 50 or more full-time employees to offer affordable, minimum value health insurance to at least 95% of their full-time employees and their children up to the age of 26. This mandate ensures that employees have access to quality health coverage, with the cost not exceeding a certain percentage of their household income.
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The plan must be certified by the Health Insurance Marketplace
A qualified health plan (QHP) is a health insurance plan that meets the requirements of Obamacare, also known as the Affordable Care Act (ACA), and is certified by the federal or state-run Health Insurance Marketplace. The Health Insurance Marketplace is a government-run service that allows individuals to shop for and enrol in health insurance plans. It was created as part of the ACA to make it easier for people to compare and purchase health insurance.
The Marketplace offers a variety of plans, including bronze, silver, gold, and platinum, which vary in terms of premiums, out-of-pocket costs, and the percentage of medical expenses covered. All plans sold on the Marketplace, regardless of their level, are considered QHPs. These plans must meet certain requirements, such as being licensed in the state where coverage is provided, covering pre-existing conditions, following established limits on cost-sharing (such as deductibles, copayments, and out-of-pocket maximums), and providing essential health benefits without annual or lifetime dollar limits.
The certification process for QHPs occurs annually before the Marketplace's enrolment period. This process ensures that the plans meet the established standards and protect consumers' rights. While some insurers offer their certified QHPs both on and off the Marketplace, purchasing a plan through the Marketplace is the only way to qualify for the ACA's premium tax credits and cost-sharing reductions.
It is important to note that QHPs are distinct from other types of health insurance plans, such as employer-provided coverage or Medicare. Individuals with Medicare, for example, are not eligible to purchase a QHP, as there is no coordination of benefits between the two. QHPs are specifically designed for those without employer-provided coverage and who do not meet the eligibility requirements for Medicare or Medicaid.
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It must provide essential health benefits
A qualified health plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA), also known as Obamacare. One of the critical criteria for a plan to be considered a QHP is that it must provide essential health benefits.
The ACA's ten essential health benefits are comprehensive and include coverage for pre-existing conditions, with no dollar limits on annual or lifetime benefits. This means that a QHP must cover essential health services without imposing maximum coverage limits. For example, a QHP cannot limit the number of doctor's visits or the total amount reimbursed for a specific medical condition.
The essential health benefits encompass a broad range of services, ensuring that individuals have access to the care they need. These services include hospitalization, emergency care, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, laboratory services, preventive and wellness services, chronic disease management, and pediatric services, including oral and vision care for children.
By mandating essential health benefits, the ACA ensures that QHPs provide meaningful coverage for individuals and families. This requirement helps protect individuals from incurring significant financial burdens due to unexpected or extensive medical needs. It also promotes access to necessary healthcare services, contributing to improved health outcomes for those with qualified health plans.
It is important to note that while all QHPs must cover essential health benefits, the specific level of coverage may vary. Different metal levels categorize QHPs, with lower metal levels, such as Bronze, covering a smaller percentage of average healthcare costs compared to higher metal levels like Gold. Nonetheless, regardless of the metal level, all QHPs are required to provide essential health benefits as a fundamental component of their coverage.
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The plan must follow established limits on cost-sharing
A qualified health plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA) and is certified by the federal or state-run health insurance marketplace/exchange. One of the requirements for a plan to be considered a QHP is that it follows established limits on cost-sharing. This means that the plan must have limits on the amount of money that the insured person has to pay out of their own pocket for deductibles, copayments, and out-of-pocket maximum amounts.
The specific rules around cost-sharing limits vary depending on the state where the coverage is provided. For example, some states may have higher or lower deductibles, copayments, or out-of-pocket maximums that providers must follow. Additionally, there may be different rules for specific groups, such as low-income individuals or families.
Cost-sharing limits are important because they protect consumers from excessive out-of-pocket expenses. Without these limits, some individuals might be unable to afford necessary medical care. By setting maximum out-of-pocket costs, QHPs ensure that people can access the healthcare they need without facing financial hardship.
It is important to note that while following established limits on cost-sharing is a requirement for a plan to be considered a QHP, there are also other requirements that must be met. These include being licensed in the state where coverage is provided, covering pre-existing conditions, and covering the ACA's essential health benefits.
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It must be licensed in the state where coverage is provided
A qualified health plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA), also known as Obamacare. One of the requirements for a plan to be considered a QHP is that it must be licensed in the state where coverage is provided. This means that the insurance company offering the plan must be authorised to sell insurance in that state.
The state licensing requirement ensures that insurance providers comply with state-specific regulations and consumer protection laws. Each state has its own insurance department or division that oversees the insurance industry within its jurisdiction. These departments are responsible for regulating insurance rates, handling consumer complaints, and enforcing insurance laws to protect consumers. By requiring QHPs to be licensed in the state where they provide coverage, consumers can have confidence that their health insurance plan meets the state's standards and that they have recourse if any issues arise.
The process of obtaining a license to sell insurance varies by state, but typically involves a thorough review of the insurance company's financial stability, business practices, and compliance with state regulations. Insurance companies must submit detailed applications, provide financial statements, and demonstrate their ability to meet the state's standards for providing fair and equitable insurance products. This rigorous process helps ensure that only reputable and financially sound insurance companies are authorised to sell health insurance plans within the state.
State licensing also allows insurance providers to tailor their plans to meet the specific needs and requirements of the state's population. Each state has unique demographics, healthcare challenges, and provider networks. By obtaining a license to operate in a specific state, insurance companies can design their QHPs to align with the state's healthcare infrastructure and ensure that enrollees have access to a comprehensive network of healthcare providers and services.
It's important to note that while state licensing is a crucial aspect of QHPs, it is just one component of the overall certification process. QHPs must also meet other requirements, such as covering pre-existing conditions, following established limits on cost-sharing (deductibles, copayments, and out-of-pocket maximums), and providing essential health benefits without imposing dollar limits on annual or lifetime benefits. These comprehensive standards ensure that QHPs offer individuals and families comprehensive and affordable health insurance options.
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Frequently asked questions
A qualified health plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA) or Obamacare. QHPs are also certified by the federal or state-run health insurance marketplace/exchange.
QHPs must be licensed in the state where coverage is provided, cover pre-existing conditions, follow cost-sharing limits, and cover the ACA’s ten essential health benefits with no dollar limits on annual or lifetime benefits.
If your employer offers insurance, it must meet the standard of minimum coverage and be considered “affordable” to be a qualified health plan. This means that it must pay at least 60% of the total cost of medical services and include substantial coverage of physician and inpatient hospital services.
If you don't have employer-provided insurance, you can purchase a QHP through the federal or state health insurance Marketplace. You can also qualify for ACA's premium tax credits and/or cost-sharing reductions if you buy a QHP policy through the Marketplace.
