Center for Medicare and Medicaid Innovation
Posted on May 13, 2010 |
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Background
The Centers for Medicare and Medicaid Services (CMS) is the agency within the U.S. Department of Health and Human Services (HHS) that administers the Medicare, Medicaid, and CHIP programs. While HHS historically has undertaken far-reaching demonstrations, Congress never has vested the Department with explicit authority and direction to undertake wide-ranging testing of different Medicare service delivery and payment structures, including approaches that focus on the intersection between Medicare and Medicaid and the beneficiaries they serve both separately and jointly. Of particular importance are the 9 million individuals who are dually eligible for coverage (dual eligibles). These beneficiaries, who include some of the nation’s most vulnerable elderly and disabled populations, are poorer and sicker than the general Medicare population and account for some $250 billion in 2009 in combined Medicare and Medicaid spending.[1] Over the years this population has been a focus of attention, but the federal and state governments have undertaken no systematic effort to strengthen the quality of care it receives or achieve greater program integration.
CMS historically has relied on several research and demonstration authorities: §1115(a) of the Social Security Act (which authorizes the HHS Secretary to undertake demonstrations related to Medicaid program design and administration);[2] and other provisions of the Social Security Act which permit demonstrations related to payment, delivery systems, and benefits and coverage.[3]
Changes Made by the Health Reform Law
P.L. 111- 148, § 3021
The health reform law:
- Adds a new §1115A to the Social Security Act, establishing a Center for Medicare and Medicaid Innovation (CMI) and empowering and directing the CMI to “test innovative payment and service delivery models to reduce program expenditures under the applicable titles [Medicare and Medicaid] while preserving or enhancing the quality of care furnished to individuals under such titles.”[4]
- Instructs the HHS Secretary, in selecting payment and service delivery models, to “give preference to models that also improve the coordination, quality and efficiency” of care for Medicare beneficiaries, Medicaid beneficiaries, and dual eligibles.[5] The law also allows the Secretary to test models within geographic areas.
- Requires the CMI to test certain payment and service delivery models during Phase I, using selection criteria specified in the legislation. The selection criteria specified in the law require that the Secretary determine that there is “evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures” and specify a focus on models that are expected to “reduce program costs . . . .while preserving or enhancing the quality of care. . . .”[6]
- Establishes a Phase I testing of models, specifying that during this phase, consideration be given to models that include a process for updating care plans, are patient-centered, provide for in-person contact with patients, use health information technology, use a team-based approach to care delivery, and involve the exchange of information between providers and suppliers.[7]
- Specifies that Phase I selected models should improve the quality of care without increasing spending, reduce spending without reducing quality, or improve the quality of care and reduce spending.
- Specifies 20 “Phase I testing” candidate model “opportunities:”[8]
- Promoting “broad payment and practice reform in primary care, including patient- centered medical home models for high-need Medicare and Medicaid beneficiaries, medical homes that address women’s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive or salary based payment.”
- Contracting directly with provider groups to promote innovative care delivery such as through “risk-based comprehensive payment” or salary-based payment.[9]
- Using geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of Medicare and Medicaid beneficiaries with multiple chronic conditions and either an inability to perform 2 or more activities of daily living or cognitive impairment, including dementia.
- Promoting care coordination between providers of services “and suppliers” that “transition health care providers away from fee-for-service based reimbursement and toward salary-based payment.”
- Supporting care coordination for “chronically-ill applicable individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology.”
- Varying payment to physicians who order advanced diagnostic imaging services according to “adherence to appropriateness criteria for the ordering of such services, as determined in consultation with physician specialty groups and other relevant stakeholders.”
- Using medication therapy management services.
- Establishing community-based health teams to support “small-practice medical homes” by assisting the primary care practitioner in chronic care management, including patient self-management activities.
- Assisting Medicare and Medicaid beneficiaries in “making informed health care choices” by paying providers for using “patient decision support tools” that meet PHS Act standards and that “improve applicable individual and caregiver understanding of medical treatment options.”
- Allowing states to “test and evaluate fully integrating care for dual eligible individuals” including the “management and oversight of all funds” under Medicare and Medicaid.
- Allowing states to “test and evaluate” systems of “all-payer” payment reform for the medical care of residents of the state, including dual-eligible individuals.
- Aligning “nationally recognized, evidenced based guidelines of cancer care with payment incentives” under Medicare in the area of treatment planning and follow-up care planning, including the “identification of gaps in applicable quality measures.”
- Improving “post-acute” care through “continuing care” hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or skilled nursing care during an inpatient stay and for 30 days immediately following discharge.
- Funding home health providers who offer “chronic care management services . . . in connection with interdisciplinary teams.”
- Promoting “improved quality and reduced cost” by “developing a collaborative of high-quality, low cost health care institutions” responsible for “developing . . . implementing, documenting, and disseminating best practices” in order to demonstrate “further improvements in quality and efficiency” and “providing and care methods.
- Facilitating inpatient care, including intensive care, through the use of “electronic monitoring by specialists, including intensivists and critical care specialists, based at health care systems.”
- Promoting greater efficiencies and access to outpatient care (such as outpatient physical therapy services) through “models that do not require a physician or other health professional to refer the service or be involved in establishing the plan of care. . . when such service is furnished by a health professional who has the authority to furnish the service under existing state law.”
- Establishing “comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities that, through their structure, operations, and joint activity, deliver a full spectrum of integrated and comprehensive health care services” to Medicare and Medicaid beneficiaries “while also incorporating innovative methods for the clinical training of future health care professionals.”
- Utilizing tele-health services “in particular in entities located in medically underserved areas and facilities of the Indian Health Service (whether operated by the HIS or by a tribe or tribal organization” in treating behavioral health issues and stroke and to improve the capacity of non-medical providers and non-specialized medial providers to provide health services for patients with chronic, complex conditions.
- Utilizing a diverse network a diverse provider, supplier, and service network to “improve care coordination of Medicare beneficiaries with 2 or more chronic conditions and a history of hospitalization through interventions developed under the Medicare Coordinated Care Demonstration Project developed special demonstration authority under the Balanced Budget Act of 1997.
- Sets forth additional factors that CMI “may consider” in selecting models, specifically, whether the model:[10]
- “includes a regular process for monitoring and updating patient care plans” in a “manner that is consistent with the needs and preferences of” Medicare and Medicaid beneficiaries.
- “places” Medicare and Medicaid beneficiaries’ “family members and other informal caregivers” at the “center of the care team.”
- provides for “in-person contact” with the patient.
- “utilizes technology such as electronic health records and patient-based remote monitoring systems, to coordinate care over time and across settings.”
- “relies on a team-based approach to interventions, such as comprehensive care assessments, care planning, and self management coaching.”
- allows providers and suppliers to share information with patients, caregivers and other service providers “on a real-time basis.”
- demonstrates “effective linkages with other public sector or private sector payers.”
- Specifies that the Secretary “shall not require” as a condition for testing a Phase I model that the design of such model ensure that such model is budget neutral “initially.”[11]
- Provides that the Secretary “shall terminate or modify the design and implementation of a model unless the Secretary determines (and the Chief Actuary [of CMS] certifies), after testing has begun, that the model is expected to (i) improve the quality of care (as determined by the Administrator) without increasing spending; (ii) reduce spending under the applicable title without reducing the quality of care; or (iii) improve the quality of care and reduce spending.” Termination may occur any time after testing has begun and before completion of the testing.
- Provides for “evaluation” of each Phase 1 model tested, which must include an analysis of the quality of care “including the measurement of patient-level outcomes and patient centeredness criteria determined appropriate by the Secretary” and “changes in spending under” Medicare and Medicaid. The Secretary must make evaluation information “available to the public” and “may” establish requirements for states and other entities participating in the testing of models to collect and report information that the Secretary determines is necessary to monitor and evaluate such models.”
- Provides for a Phase II expansion of models “taking into account the evaluation” requirements of the law. Under Phase II, the Secretary may, through rulemaking and “to the extent determined appropriate by the Secretary” expand (including implementation on a nationwide basis) the duration and scope of a model that is being tested under Phase I” or a Medicare Coordinated Care demonstration.[12] The expansion may occur only if (1) the secretary determines that the expansion is expected to reduce spending without reducing the quality of care or improve the quality of patent care without increasing spending and (2) the Chief Actuary for CMS certifies that the expansion would reduce or would not result in any increase in net program spending under Medicare and Medicaid and (3) the Secretary determines that the expansion would “not deny or limit the coverage or provision of benefits” to Medicare or Medicaid beneficiaries.
- Gives the Secretary the power to waive “such requirements of titles XI [quality, fraud]and XVIII [Medicare] and of §§1902(a)(1), 1902(a)(13), and 1903(m)(2)(A)(iii) as may be necessary to . . . test models.”[13]
- Prohibits both administrative and judicial review under Medicare of “selection of models, the selection of organizations, sites or participants to test these models, the elements, parameters, scope and duration of such models for testing or dissemination, determinations regarding budget neutrality, the termination or modification of the design and implementation of a model, and determinations about the expansion of the duration and scope of a model, including that a model is not expected to meet the criteria for expansion.”[14]
- Specifies that in developing and testing these models, all requirements under Title XI (administrative requirements) and Title XVIII (Medicare) may be waived. The law also specifies that under Title XIX (Medicaid), HHS may waive requirements related to “statewideness” (i.e., the statewide application of Medicaid eligibility and coverage standards),[15] requirements related to the use of a public process to set payment rates,[16] and actuarial soundness requirements.[17]
- Extends the demonstration authority of §1115A to the Children’s Health Insurance Program [CHIP].
- Requires the Secretary to report to Congress biannually beginning in 2012. Each report must describe the models tested including the individuals participating, payments made for services under models chosen for testing, and the results of evaluations and recommendations for further legislative reforms to “facilitate the development and expansion of successful payment models.”
- Amends Medicaid to add as a state plan amendment requirement “implementation of the payment models specified . . . for implementation on a statewide basis unless the state demonstrates to the satisfaction of the Secretary that implementation would not be administratively feasible or appropriate to the health care delivery system of the state.”
- Extends the term specified for the Medicare Coordinated Care Demonstration Project to go beyond the 5-year term initially provided.
Implementation
Agency and Timeline
The Centers for Medicare and Medicaid Services is responsible for developing the CMI and overseeing the testing of innovative payment and delivery models. The law requires that the CMI be operational by January 1, 2011.
Process
The Secretary has authority to implement the CMI through regulation or through policies, guidance, and grant-making authority.
Key Implementation Issues
- Prioritization of models: Given the large number of “opportunities,” the requirement that any model whose testing is not terminated or modified be evaluated, and the relatively modest evaluation budget in relation to the total number of possible test model opportunities, how will possible opportunities be prioritized? What process and approaches might CMI use to generate multiple types of testable models given the agency’s overall budget? By what process will potential models be prioritized and what will the criteria for prioritization be?
- Scope and duration: In light of the fact that the testing of models must be sufficiently robust to be evaluated, how many models within each potential category of testable opportunities must be implemented in order to permit the development of meaningful and reliable evidence? How long must the testing period run before a model potential is a candidate for bringing to national scale?
- Demonstration authority: Will the Secretary permit models that combine the demonstration authority established under §1115A with the demonstration authority that exists under §1115(a) and other demonstration authorities? In view of the fact that models cannot, if brought to scale, result in the diminution of benefits and coverage, will model testing allow alterations in benefits and coverage?
- Terms and definitions: How will the Secretary define the numerous terms and definitions found in the models, such as “patient centered,” “patient based remote monitoring” and the like?
- Budget neutrality: How will budget neutrality be defined by the Secretary and the Chief Actuary in order to assure long-term savings or avoidance of additional spending without limiting the ability to spend higher than expected in the short term?
- Other demonstrations: How will the CMI demonstrations align with other CMS demonstrations related to accountable care organizations and medical homes?
- Beneficiary matters: The models assume extensive beneficiary participation; will participation be voluntary or mandatory, and what patient safeguards and participation incentives will be established for each tested model, particularly in the case of beneficiaries with serious and chronic health conditions?
- Involvement of states: How will states be involved in the prioritization of models, the development of testable models, and the evaluation of models and their scaling up? Will states be permitted to independently regulate certain types of service delivery models (e.g., through the imposition of licensure requirements on models that involve the assumption of financial risk or limits on the extent to which medical practice laws might be altered or beneficiary protections revised?) Will the federal government take a more preemptive approach to the models, that is, viewing the models as empowering the federal government to supersede limitations that otherwise might constrain the reach of the model under state law?
Recent Agency Action
No action has been taken as of this writing.
Authorized Funding Levels
The law provides $5 million for the “design, implementation, and evaluation of models” and $10 billion for CMI activities from 2011 to 2019.[18]
[1] Center for Health Care Strategies, Options for Integrating Care for Dual Eligible Beneficiaries, http://www.chcs.org/usr_doc/Options_for_Integrating_Care_for_Duals.pdf (Accessed May 3, 2010).
[2] 42 U.S.C. §1315(a).
[3] SSA §402(a) as amended by SSA §222(b); 42 U.S.C. section 1396b-1.
[4] 111-148 § 3021(a)adding SSA §1115A(1).
[5] Id. at § 3021(a), adding SSA §1115A(a)(1) and (4)(A)(i)-(iii).
[6] Id. at § 3021(a), adding SSA §1115A(b)(1) and (2).
[7] Id. at § 3201(a), adding new §1115A(b)(2)(C) into the Social Security Act.
[8] Id. at § 3021(a), adding SSA §1115A(b)(2)(B), describing 20 separate models.
[9] Id. at § 3021(a), adding SSA §1115A(b)(2)(B)(ii).
[10] Id. at § 3021(a), adding SSA §1115A(b)(2)(C).
[11] Id. at § 3021(a), adding SSA §1115A(b)(3).
[12] Id. at § 3021(a), adding SSA §1115A(c).
[13] Id. at § 3021(a) adding §1115A(d)(1).
[14] Id. at § 3021(a) adding §1115A(d)(2).
[15] Id. at § 3021(a), adding new § 1115A(d) into the Social Security Act, which authorizes the Secretary to waive requirements of § 1902(a)(1) of the Social Security Act.
[16] Id. at § 3021(a), adding new § 1115A(d) into the Social Security Act, which authorizes the Secretary to waive requirements of § 1902(a)(13) of the Social Security Act.
[17] Id. at § 3021(a), adding new § 1115A(d) into the Social Security Act, which authorizes the Secretary to waive requirements of § 1903(m)(2)(A)(iii) of the Social Security Act.
[18] Id. at § 3021(a), adding new 1115A(f) into the Social Security Act.
Office of the National Coordinator for Health Information Technology –
Health Information Technology for Economic and Clinical Health Act – Part of American Recovery and Reinvestment Act, the act imposes more stringent regulatory requirements under the security and privacy rules of HIPAA, increases civil penalties for a violation of HIPAA, provides funding for hospitals and physicians for the adoption of health information technology, and requires notification to patients of a security breach.
Culturally and linguistically appropriate and competent services – A federal standard designed to assure better access and quality of care in order to eliminate ethnic and racial disparities in health care.
Substance Abuse and Mental Health Services Administration– The federal agency within the United States Department of Health and Human Services charged with improving the quality and availability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses.
Exchange-participating health benefits plan contracts – Contracts signed between the administrator of an exchange and health insurers that govern products sold in an exchange.
Health Insurance Portability and Accountability Act – A federal law that regulates health information privacy, health insurance portability and non-discrimination and health insurance simplification and whose provisions have been broadly expanded by the Patient Protection and Affordable Care Act.
Mental health and substance abuse disorder parity – A federal law barring discriminatory limits on mental health and substance abuse disorder coverage by insurers and employer-sponsored benefit plans. The Patient Protection and Affordable Care Act extends parity standards to health insurance products sold through state health insurance exchanges.
National Strategy to Improve Health Care Quality – A national strategy spanning federal and state health programs, health care providers, and public and private health insurers whose aim is to prioritize areas for national health care quality improvement and coordinate across payers and programs to make more rapid change possible. The National Strategy is required under the Patient Protection and Affordable Care Act.
Interagency working group on health care quality – A working group established as part of a national strategy to improve health care quality. The group will identify national priorities for quality improvement as determined by certain criteria and coordinate efforts across federal and state agencies and programs as well as the private sector to achieve quality improvement.
Medicaid and CHIP Payment and Access Commission – A congressional advisory committee established by the Patient Protection and Affordable Care Act responsible for advising Congress on methods to improve the performance of the Medicaid and CHIP programs, including eligibility, enrollment and retention, coverage and quality, interactions between Medicare and Medicaid, and other matters.
Health Resources and Services Administration – A federal agency within the Department of Health and Human Services (HHS) that administers a range of federal health care access, health professions education programs, including community health centers, the National Health Service Corps, health professions training programs, the 340 B prescription drug program, and the Maternal and Child Health Block Grant Program. HRSA also administers the organ transplant program.
Prevention and Public Health Investment Fund – A trust fund established under the Patient Protection and Affordable Care Act to provide sustained funding for federal public health and prevention programs.
Center for Medicare and Medicaid Innovation – A unit within the Centers for Medicare and Medicaid Services that under the health reform law is responsible for overseeing demonstrations and pilot programs aimed at increasing the efficiency and quality of Medicare, Medicaid, and CHIP.
Centers for Disease Control and Prevention – The CDC is a federal agency within the Department of Health and Human Services charged with disease prevention, education, and public health activities.
Agency for Health Care Research and Quality – The federal agency within the United States Department of Health and Human Services that has lead responsibility for efforts to improve the quality of health care and the promotion of health services research.
Exchange-participating health benefit plans – Health insurance plans offered to individuals and small employers through health insurance exchanges. Companies offering plans in the exchange must meet federal and applicable state requirements.
Centers for Medicare and Medicaid Services – The federal agency within the United States Department of Health and Human Services that administers Medicare, Medicaid, CHIP, and innovations in federal insurance programs. CMS also oversees state demonstration programs under §1115 of the Social Security Act as well as other demonstration and pilot programs involving Medicare, Medicaid, and the Children’s health Insurance Program (CHIP)
Emergency Medical Treatment and Labor Act – A federal law that obligates all Medicare-participating hospitals with emergency departments to furnish an “appropriate” screening, stabilization care, or a medically appropriate transfer. ETMALA obligations are triggered for individuals who come to an emergency department and on whose behalf a request for screening is made. EMTALA duties are not limited to uninsured or medically indigent persons.
Comptroller General of the United States – See Government Accountability Office.
Subrogation of health insurance benefits – The practice by which an insurer pays an individual health insurance claim then seeks to recoup losses from a responsible third party, such as another health insurer or a recovery in a medical liability or personal injury action. Individuals who sue for medical malpractice and recover may be required to repay their insurers for the cost of covered medical care.
Employee Retirement Income Security Act – A law passed by Congress in 1974, which establishes federal standards governing both pension plans and employer-sponsored “health and welfare benefit plans,” offered by private employers. Church plans are exempt, as are public employee health benefit plans. The health reform law establishes additional federal standards for ERISA-governed health benefit plans.
Department of Health and Human Services – The federal cabinet-level agency that administers federal health, welfare, and human services programs and activities. HHS has lead agency responsibility for significant aspects of the Patient Protection and Affordable Care Act and is home to the Centers for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the National Institutes of Health, the HHS Inspector General, the HHS Office for Civil Rights, the HHS Office of Minority Health, the Substance Abuse and Mental Health Services Administration, the Indian Health Service, and other federal agencies that oversee the Patient Protection and Affordable Care Act.
Health information privacy and security – Standards and procedures to ensure that personal health information is not compromised or disclosed in processing health care transactions.
Multiple Employer Welfare Arrangements– An employee health or welfare benefit plan that is marketed to two or more employers and is subject to ERISA regulation as well as applicable state law.
Federal Employee Health Benefits Plan – The health benefit plan that covers federal civilian employees and their dependents.
Children’s Health Insurance Program– A program established in 1997 and reauthorized in 2009, which is administered by states and funded through a combination of federal and state payments. CHIP allows states to provide health insurance (known as child health assistance) to uninsured “targeted” low-income children. States also may provide coverage to targeted low-income pregnant women. State CHIP programs can establish state CHIP plans as separately administered programs, Medicaid expansions, or a combination of the two. Unlike Medicaid, the CHIP program caps federal funds available to states and must periodically be reauthorized.
Discrimination based on health status – Insurer practices that deny coverage either prior to or following enrollment. Discrimination at the point of enrollment can encompass the total denial of enrollment or the imposition of waiting periods or pre-existing condition exclusions following enrollment. Post enrollment discrimination can involve the use of flat limits on treatment (expressed either on a dollar or quantitative basis) that are aimed at limiting coverage for costlier conditions. For example, a child born with cerebral palsy might be denied coverage entirely; alternatively an insurer might impose waiting periods, exclusions on coverage, or limits on the amount of coverage available for certain treatments (e.g., only $10,000 annually for physical therapy or only 20 physical therapy sessions annually, or a total exclusion of physical therapy for conditions related to birth injuries). .
Interstate health insurance compacts – An agreement among multiple states to permit the sale of multiple-state licensed insurance products across state lines.
National Health Workforce Commission – A special commission to advise Congress, the President, the states, and localities on health workforce needs and measure the unmet need for care.
Medicare Payment Advisory Commission – An independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.
Graduate medical education payments – Payments made under Medicare or other health care financing authorities to support the cost of medical residency training.
Small business employer health plan – A plan offered by an employer with fewer than 100 full-time employees.
Comparative effectiveness research– A specific type of health services research that compares different approaches to treating medical conditions in order to determine which methods are most likely to produce the best outcomes.
Indian Health Care Improvement Act – A federal law that provides for the establishment and support of health care services to American Indians, Native Hawaiians, and Alaska Natives. The Indian Health Care Improvement Act is overseen by the Indian Health Service.
Government Performance Results Act– A federal law enacted in 1993 designed to prevent waste and fraud in federal programs, which, as a result of amendments in the Patient Protection and Affordable Care Act, is strengthened in terms of federal enforcement and violations for penalties.
Federally Qualified Health Center – A federally funded community health center, as well as a health center that meets all federal requirements applicable to the federal community health centers program (location, scope of services, use of a sliding fee scale, and community board governance) but that does not actually receive a federal grant. Because of their location and high level of treatment of the uninsured, FQHCs receive special payment rates from Medicare, Medicaid. and CHIP and are eligible for special supplemental payments from exchange-participating health insurance plans. See also Community health centers.
Home and community-based services – Health care services offered in the home and community to individuals with serious and chronic physical, mental, or developmental conditions that require ongoing care. Home and community based services are designed to promote community residence and to avoid unnecessary institutional care.
Essential health benefits package – See Essential health benefits.
State health insurance exchanges – State-based marketplaces for the sale and purchase of health insurance established in federal law and operated in accordance with federal requirements. Health insurers that sell products in the exchanges to small employers and individuals will be required to meet federal standards of coverage, fair practices, and plan administration.
Government Accountability Office– A special arm of Congress that oversees the integrity and accountability of federal programs and expenditures and that is headed by the Comptroller General of the United States.
Disproportionate share hospital – A hospital whose patients are disproportionately low-income as measured by federal standards under the Medicare and Medicaid programs. DSH hospitals receive additional payments to offset the greater severity of illness present among low-income patients.
Health insurance market reforms – Reforms contained in the Patient Protection and Affordable Care Act that are designed to stop certain types of exclusionary or discriminatory activities by insurers. Conduct specifically targeted by market reforms encompasses the use of preexisting condition exclusions, discrimination based on health status, fair health insurance premiums whose rates vary by family size, rating area, age and tobacco use, guaranteed availability and renewability of coverage, non-discrimination against health care provider participation, and the use of excessive waiting periods.
Modified adjusted gross income–The calculation of income and assets used to determine eligibility for federal programs including Medicaid, and premium and cost sharing assistance for tax credits provided to low and moderate income individuals under the health reform law. In determining income, states must disregard or reduce countable income by 5 percent for the income pathway.
Discrimination in health care – Differences in patient treatment by health care providers based on race, gender, age, ability to pay for care, disability, language, or severity of illness. Under federal civil rights laws, discrimination may be intentional or de facto.
Public health investment fund – A trust fund established in health reform legislation designed to ensure a consistent funding stream for federal public health, prevention, and wellness activities.
National Health Service Corps – A program authorized under the Public Health Service Act that provides grants and loan repayment assistance to medical and health professionals in exchange for a specified term of service in an urban or rural location identified as having a shortage of health professionals.
National Institutes of Health – A federal agency within the Department of Health and Human Services that has lead responsibility for biomedical, clinical, and translational research.
Accountable care organization – A group of health care providers that have entered into a formal arrangement to assume collective responsibility for the care of a specific group of patients and that receive financial incentives to improve the quality and efficiency of health care. .
Health coverage participation – The requirement under the Patient Protection and Affordable Care Act that most individuals not eligible for public insurance programs purchase private health insurance coverage.
Health information technology – Technology that allows the comprehensive management of health information and enables its exchange among health professionals, consumers, health care providers, health care payers, and public health agencies.
Employer sponsored insurance– A health benefit plan offered by an employer to employees and dependents. Health insurance coverage is optional for employers. Employers may opt to purchase an insurance policy for their employees, offer coverage on a self-insured basis, or a combination of the two.
Nurse-managed health centers – Clinics managed by nurses supported by federal grants authorized under the Patient Protection and Affordable Care Act.
Exchange-eligible individual – An individual who is permitted to obtain coverage through a state health insurance exchange.
Food and Drug Administration – The federal agency within the United States Department of Health and Human Services responsible for protecting and promoting public health through the regulation and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), veterinary products, and cosmetics.
Supplemental Security Income– A Federal income supplement program funded by general tax revenues to help aged, blind, and disabled people, who have little or no income.
Guaranteed issue and renewal – A rule that bars insurers from denying enrollment or dropping coverage for reasons other than fraud or non-payment of health insurance premiums. Guaranteed issue and renewal are commonly associated with the Patient Protection and Affordable Care Act’s broad prohibition against discrimination on the basis of health status.
Administrative transactions – The exchange of health care information between health plans and providers to determine eligibility, coverage, and payment for health services.
Flexible Spending Accounts – See Cafeteria plans.
Primary care professionals – Health care professionals who specialize in a primary care practice field such as family medicine, pediatrics, obstetrics and gynecology, adult medicine, nurse practice, and other types of practice designated as primary health care. State Medicaid programs will be required to pay for primary health care at 100 percent of the Medicare payment rate (which typically is significantly higher) beginning in 2014. For two years, the federal government will contribute 100 percent of the cost of primary care payments.
Graduate medical education – See Graduate medical education payments.
Minimum essential coverage – The minimum insurance package that fulfills the requirement of the mandate that all individuals carry insurance.
School-based health clinic – A clinic that is located in or in connection with a school and that receives funding under a new grant program authorized in the Patient Protection and Affordable Care Act.
Exchange-eligible employer – An employer that is permitted to obtain coverage for its employees through a state health insurance exchange.
Health insurance ombudsman – A grant program authorized under health reform legislation to assist in health insurance enrollment, eligibility for premium assistance eligibility determinations, consumer education on rights and responsibilities, and assistance in dispute resolution between plan beneficiaries and health insurers.
Individual responsibility – The requirement that all individuals obtain health insurance or pay a penalty. This is also referred to as the “individual mandate.”
Small business tax credit – A tax credit for small employers to help offset the cost of health insurance coverage provided to their employees. Eligible small businesses consist of those with 25 or fewer employees whose employees’ average annual wages do not exceed specified limits.
Office of Minority Health – OMH was established in 1986 by the U.S. Department of Health and Human Services (HHS). It advises the Secretary and the Office of Public Health and Science (OPHS) on public health program activities affecting American Indians and Alaska Natives, Asian Americans, Blacks/African Americans, Hispanics/Latinos, Native Hawaiians, and other Pacific Islanders.
Excessive waiting periods – The period of time before coverage begins for a new enrollee. The Patient Protection and Affordable Care Act limits waiting periods to no more than 90 days.
Hawaii Prepaid Health Act – Hawaii’s state law, enacted in 1974 (and later exempted from ERISA’s bar against state laws that regulate employee benefit plans) that requires employers to provide health insurance coverage to employees who work more than twenty hours per week.
Grandfathered health plan– See Grandfathered plan.
Health care related taxes – Taxes imposed on the health care industry under the Patient Protection and Affordable Care Act on health insurance plans, prescription drugs, and medical devices.
Essential health benefits – The minimum level of coverage that must be offered by qualified health plans operating in state health insurance exchanges. Essential benefits are defined in relation to the classes of services and benefits covered, the level of financial protection against deductibles, and cost-sharing protection they provide.
State innovation waivers – Special waivers given by the Secretary of the United States Department of Health and Human Services that would allow a state to replace the exchange system with an alternative approach to coverage. The Secretary is authorized to waive provisions of the Patient Protection and Affordable Care Act related to qualified health plans, consumer choices cost-sharing protections, and individual and small employer tax credits. Waivers of the law’s provisions related to exchanges can be combined with Medicare and Medicaid waivers so as to permit states to create entirely alternative forms of health insurance coverage, such as a single payer plan.
Insurance premium rating – The process by which health insurers determine what rates will be charged for health insurance premiums, taking into consideration age, health status, gender, industry, certain personal health care practices (such as use of tobacco), geography, and other factors.
Federal Trade Commission – An independent federal agency charged with protecting consumers from anticompetitive practices in the health care industry and other types of conduct that violates federal laws related to competition.
Information transparency – Provisions of the Patient Protection and Affordable Care Act that promote clearness and fairness in health insurance information including coverage, rights and responsibilities, and patient and consumer protections. The law mandates that information on health plan terms and conditions and payment policies be spelled out in plain language consumers can understand.
Community health centers – Non-profit clinics established under the Public Health Service Act and that provide or arrange for a broad range of primary health care services. Health centers must meet a series of federal criteria related to the scope of care they furnish, the prospective adjustment of charges in accordance with the ability to pay, location in or service to medically underserved communities and populations, and governance by a community board, 51% of whom must be patients of the clinic. See also, Federally Qualified Health Centers.
Coordination of benefits – The process of reconciling health care that is covered by more than one form of health insurance. For example, if a child is insured through both parents, one insurer is generally considered the primary policy, and the secondary policy reimburses for services not covered under the primary policy.
Health insurance issuers – Entities that sell health insurance products to employer-sponsored health plans, individuals in exchanges, and the open market.
Electronic Health Record - An evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems.
Diagnosis related group – A system of patient care classification based on diagnosis, which is used to establish payment rates to hospitals. Certain further adjustments are made to the payment based on patient age, geographic location and severity of illness.
Retiree health benefits – Health benefits provided by an employer to its retirees.
Therapeutic foster care – Services provided to special-needs children in foster care by families and group care providers that have received special training as well as ongoing support and supervision including regular contact with case managers or care coordinators.
Public health workforce – A term used to define a range of health professionals in public and private practice who provide public health services such as disease diagnosis, primary care, and public education.
Performance measurement – A set of recommendations, requirements, or data used to determine whether plans, providers, or programs meet or exceed a specified standard of care.
Presumptive eligibility – A state option under Medicaid which permits certain health care providers to presume that a patient is eligible for Medicaid and allow Medicaid reimbursement for services for a limited time until an official eligibility determination is made by the state.
Employer responsibility– A requirement that certain employers assist in the cost of coverage for workers and their dependents, either through the provision of a health plan or through contribution toward coverage via a payment on the individual’s behalf to a state health insurance exchange. This is also referred to as an “employer mandate.”
Pre-existing condition – A health condition that exists for a set time prior to enrollment into a health plan, regardless of whether the condition has been formally diagnosed. The Patient Protection and Affordable Care Act prohibits insurers and employer-sponsored health plans from denying or limiting coverage to individuals with pre-existing health conditions.
Value-based purchasing – An approach to health care purchasing employed by consumers and health care payers that considers and rewards health care value as part of paying for care. Health care value is typically associated with quality (as measured by objective benchmarks), provision of useful comparative information about performance, and efficiency as measured by objective standards.
Participating provider - An entity comprised of providers of services and suppliers, including a hospital, a physician group, a skilled nursing facility, and a home health agency, who are otherwise participating in Medicare.
Advanced care planning – A process in which a patient and physician discuss treatment options and develop a treatment or care plan. This is helpful for patients who choose to make their preferences known to family members and providers in case they are incapacitated, as well as for those with a terminal illness.
Acute episodes of care – A period of time related to a major health event that requires medical intervention. An episode of care may include tests performed prior to surgery, a surgical procedure, and post-operative treatment or follow-up care.
Bundled payment system - Under a bundled-payment system, providers are not reimbursed for each discrete service, interaction, or procedure. Instead, a single payment is made for each episode of care for a single patient, which is divided appropriately amongst the providers involved in his or her care.
Department of Defense– The federal cabinet-level agency that administers health care programs for active military and their dependents. Coverage is furnished through a publicly funded and privately administered health program called TriCare. The DOD also administers federal military health care facilities.
Basic health programs – An option under the Patient Protection and Affordable Care Act that permits a state to establish and oversee a health insurance program for low-income persons who are ineligible for Medicaid and whose family incomes do not exceed twice the federal poverty level. States electing this option would cover the low-income population directly, rather than through a health insurance exchange. States would receive direct federal assistance for the cost of establishing and administering such programs equal to the premium support available were low-income individuals to enroll into an exchange-qualified health plan.
Qualified health plan – Health insurance plans that meet minimum federal insurance-market rules including offering a standard set of services, benefits, and other requirements as determined by health exchanges.
Indian Health Service – The federal agency within the United States Department of Health and Human Services that oversees health care programs and services for American Indians, Native Hawaiians, and Alaska Natives.
Federal Poverty Level – Income criteria that are adjusted by family size and are published by HHS that are used to determine eligibility for income-related programs, such as Medicaid and the CHIP. Although guidelines are usually updated and published in March of each year, Congress has prohibited HHS from updating the 2009 guidelines until after March 1, 2010. As of date of posting, HHS has not updated the guidelines. Current guidelines are available online at:
http://aspe.hhs.gov/POVERTY/09extensionfedreg.shtml.
Medical underwriting – The practice of assessing the medical condition of individuals prior to insurance enrollment in order to identify existing physical or mental health conditions that may affect eligibility for enrollment or the level of coverage following enrollment. The Patient Protection and Affordable Care Act limits medical underwriting both prior to and following enrollment in order to eliminate discrimination based on health status. Medical underwriting may result in the total exclusion from a plan (i.e., the denial of availability) or restrictions on coverage for individuals once they are enrolled.
Nursing Home Compare – A website sponsored by the Department of Health and Human Services designed to provide nursing home quality information to consumers.
Rights of conscience – Federal or state laws that prohibit discrimination against health care professionals, entities, or health insurers that refuse to furnish or cover certain types of treatments because of religious or personal beliefs.
Cadillac health plan – A term used to describe health coverage available through employee health benefit plans where the value of the coverage exceeds a stated annual dollar threshold. See also Excise tax.
Preventive services – Procedures and treatments whose purpose is to avoid disease or to identify disease or conditions before they become acute and symptomatic. Immunization, screening programs for breast, cervical, or prostate cancer, and “well-child” or “well-adult” checkups are examples of preventive services.
Department of Labor – The federal cabinet-level agency responsible for administration and enforcement of the Employee Retirement Income Security Act (ERISA), a federal law that sets requirements for private employer-sponsored health benefit plans, both those that are self-insured as well as plans that are fully insured.
Creditable coverage– A term that encompasses public and private health insurance as well as coverage under certain other arrangements such as the Indian Health Service. The term is defined in §2701(c) of the Public Health Service Act.
Patient protections – Certain laws establishing protections for patients, such as the right to health information, choice of provider, access to care, the right to file a grievance, or the right to appeal a denied health benefit claim.
Ready Reserve Corps – A special group of health care professionals within the Commissioned Corps of the United States Public Health Service, whose establishment is authorized by the Patient Protection and Affordable Care Act in order to carry out specific duties in the event of a public health emergency.
Premium tax credits – Refundable tax credits, paid in advance, that are used for the purchase of health insurance through a state health insurance exchange. Individuals with family incomes greater than 133 percent of the federal poverty level but below 400 percent of the federal poverty level will be eligible for premium credits beginning in 2014.
Affordable coverage – A term used in the health reform law to designate both the types of coverage arrangements available to individuals and the level of family income that is considered available to pay health insurance premiums. The term is used to describe an individual who lacks access to coverage below 8 percent of household income for the purposes of being eligible for a free choice voucher and below 9.8 percent of income for purposes of allowing the purchase of a catastrophic health insurance plan. Medicaid, employer-sponsored coverage, coverage secured through state health insurance exchanges, and the Children’s Health Insurance Program (CHIP),all are considered forms of coverage. The health reform law also directs the HHS Secretary to conduct a study of affordable coverage.
Eligible individual – A term used in the health reform law to describe an individual who meets the eligibility criteria for a program or service authorized under federal law. Program or benefit criteria vary based on the program.
Medicare donut hole– The uncovered portion of a Medicare beneficiaries’ Part D prescription drug benefit plan that leaves them financially obligated for the cost of covered prescription drugs once a certain level of expenditures is reached during an enrollment year. The Patient Protection and Affordable Care Act gradually eliminates the donut hole.
Patent exclusivity– The period of time during which a prescription drug or biological product can be marketed and sold only by the manufacturer holding the patent and cannot be generically copied.
Benchmark coverage –Benefit plans defined under Section 1937 of the Social Security Act that states may use in lieu of Medicaid mandatory and optional benefits, for newly eligible Medicaid beneficiaries, who gain eligibility as a result of the provisions of the health reform law.
Medicare Advantage – Private health insurance plans and HMOs that participate in Medicare and into which Medicare beneficiaries may elect to enroll.
Price transparency – The ability on the part of consumers and patients to see the actual price of health care charges, as well as accurate information about health insurance charges, in order to promote knowledgeable health care purchasing decisions.
Grandfathered plan – A health benefit plan or health insurance policy in effect as of the date of enactment of the Patient Protection and Affordable Care Act. The term is not defined in the law; the Departments of Health and Human Services, Labor, and Treasury are expected to provide additional clarification regarding the conditions under which grandfathering protections are available as well as what constitutes a “plan” that may be subject to grandfathering limitations.
Dependent coverage – Health insurance coverage of a spouse, child, or domestic partner of an insured individual.
Health disparities – Measurable differences in health and health care that are associated with race, ethnicity, income, language, place of residence, and other factor unrelated to the need for or ability to benefit from health care.
Inspector General – The office within the Department of Health and Human Services (HHS) that is charged with protecting the financial integrity of programs administered by the Department, protecting the health and welfare of program beneficiaries and reporting problems to the secretary of HHS and Congress along with recommendations for correcting identified problems.
Wellness programs – Special services and benefits offered by employers to employees in addition to coverage under health benefit plans. First authorized in HIPAA, wellness programs offer participation “incentives,” such as premium or cost-sharing discounts, as a means of encouraging employees to lose weight, quit smoking, follow health-maintenance regimens, and generally adopt more healthy lifestyles.
Individual market – The health insurance market for individuals who purchase health insurance directly rather than through an employer-sponsored or other group health plan. This is also known as the “non-group market.”
Program Integrity – A special program of the federal government to detect and stop health care fraud and abuse.
Health care homes – Primary health care providers that furnish or arrange for comprehensive primary health care, use health information technology, and meet federal and state standards of quality and efficiency. Health care home demonstrations are authorized under the Patient Protection and Affordable Care Act.
Employer mandate – See Employer responsibility.
Non-group market– Also known as the individual market, the health insurance market for individuals who purchase coverage directly rather than through an employer-sponsored or group health plan.
Current coverage – A health insurance policy in effect before the effective date of the Patient Protection and Affordable Health Care Act. Current coverage is “grandfathered” under the law. Certain new requirements, such as a prohibition on excessive waiting periods, limits on lifetime coverage, prohibitions against rescissions, and extension of dependent coverage, would apply to grandfathered plans.
Fraud and abuse – Practices by health insurers or health care providers that violate a range of federal and state civil and criminal laws such as the filing of false claims, payment or receipt of bribes and kickbacks, racketeering, self-referrals and other forms of prohibited self-dealing, and violation of laws requiring good faith and fair dealing.
Actuarial value– A mathematical calculation used to determine the monetary value of benefits.
Episode of care– A concept that focuses on a health condition from its inception through treatment as a means of measuring both the quality of care received and the efficiency of the care provided. For example, an episode of care in the context of a stroke would include a specified period of time preceding the stroke, the acute hospitalization episode, and aftercare aimed at helping an individual recover from the stroke and its effects. Episodes of care are the unit by which bundled payment arrangements will be designed and the quality of care measured.
Risk adjustment – A tool for evaluating the relative risk of enrollees within each insurance plan and providing for a financial transfer from plans with low-risk to plans with higher-risk enrollees.
Plan disclosure – A requirement in the Patient Protection and Affordable Care Act to provide consumers with information on the terms and conditions of health insurance policies and the relationships between insurers, providers, pharmacy benefit managers, and other third-party benefit providers.
Bundled payment - A single payment for all health care services related to a specific course of treatment or condition over a period of time.
High-risk pools – A method provided under the Patient Protection and Affordable Care Act for insuring individuals with pre-existing conditions who have been uninsured for six months. High-risk pools will be operated by states during the period prior to the implementation of health insurance exchanges as a means of providing coverage availability to individuals who otherwise cannot secure coverage in the individual market. The subsidies that are available to exchange participants in 2014 will not begin earlier for high-risk pool participants.
Small employers – Employers that on an average business day employ 100 employees or fewer.
Large employers – Employer groups that, on average, of a certain number of full-time employees. The definition of large employer varies based on the provision of law. For determining participation in insurance markets, a large employer has 101 or more employees. For determining whether a large employer may be subject to a fine if the employer fails to provide coverage, a large employer has 50 or more employees.
Lifetime limits – An aggregate upper limit on the amount of benefits that an insurer will pay over the lifetime of a policy.
Newly eligible – Effective January 1, 2014, states will be required to provide Medicaid coverage to individuals ages 19-65 with incomes under 133 percent of FPL, who were not eligible for Medicaid based on the state’s eligibility criteria as of December 1, 2009.
SHOP exchanges – Exchange programs run for small businesses.
Fair marketing – A term that encompasses a range of reforms aimed at assuring accuracy and completeness in the information provided by an insurer or health benefit plan, fairness in the premium charged, and reasonable and fair practices in coverage.
Cafeteria plan – A benefit plan sponsored by an employer under which employees may set aside pre-tax wages to be used for various expenses, including medical expenses not otherwise covered by their health insurance, such as copayments and deductibles, or uncovered medical costs, such as dental care. The special accounts that hold these pre-tax wages to be spent on health care are known as Flexible Spending Accounts (FSAs). Health reform legislation limits employee contributions to FSAs to $2,500 annually (indexed for inflation) and reverses previous policy by prohibiting their use for over-the-counter medications.
Affordability – See Affordable coverage.
CO-OP Program – A special program established under the Patient Protection and Affordable Care Act that allows for the development of qualified non-profit health plans selling essential health benefit plans through state exchanges.
Early retiree – Early retirees are defined under the Patient Protection and Affordable Care Act as individuals aged 55 and over who are not yet eligible for Medicare.
Elder Justice Act – Provisions included the health reform law to authorize services and supports aimed at protecting elderly persons from the knowing infliction of physical or psychological harm.
Whistleblower – An individual (typically a current or former employee) who discloses information not readily obtainable and in connection with potential fraud and abuse.
Antitrust law – A body of federal laws whose purpose is to promote market competition and to prevent anticompetitive, monopolistic, and collusive conduct. Health insurers are exempt from certain aspects of antitrust law, but not others. Antitrust laws also cover health care providers.
Annual limits – Limits imposed by insurers or employer sponsored health benefit plans on the amount of covered treatment or services that will be considered covered during a single plan year. Limits may be expressed in dollar or quantitative terms (e.g., no more than $1000 annually; no more than 30 treatments annually). The health reform law addresses dollar limits but not quantitative treatment limits.
Medical home – Health care entities that offer and arrange for comprehensive health care, meet performance, quality, and efficiency standards, use health information technology, and meet other requirements that may be established by public and private health insurers.
Urban Indian – Special programs administered by the Indian Health Service (IHS) and by tribal governments that serve American Indians, Native Hawaiians, and Alaska Natives who reside in urban areas.
Cost-sharing – A requirement that insured patients pay a portion of their medical costs, either as a deductible, or a flat dollar copayment, or as coinsurance (i.e., a percentage of the total paid claim for a covered benefit or service).
Gainsharing– Allowing health care providers that meet standards of quality and efficiency to share in savings realized by insurers for reduced use of unnecessary care.
Reinsurance – Risk protection offered to insurers or self-insured employer-sponsored health benefit plans in order to protect them from unpredictably high cost exposure. Reinsurance begins at an “attachment” point and is designed to cover losses after the losses incurred by an insurer or self-insured plan reach this threshold.
Territories – Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
Coinsurance – Cost-sharing for covered health insurance benefits and services, expressed as a percentage of the approved payment amount for the benefit or service (e.g., 20 percent of the payable amount).
Young adult – Individuals ages 22-26 who, under the Patient Protection and Affordable Care Act, can remain covered under their parents’ employer-sponsored or individually purchased health benefit plans.
Grievances – A complaint against an insurer or health plan other than one involving the denial of covered benefits. An example of a grievance would be inappropriate behavior by a network provider or too few pharmacies that are members of a network.
Deductible– The amount patients must pay out of pocket before coverage begins.
Telehealth – Electronic information and telecommunications technologies that support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.
Preemption – A legal concept, grounded in the United States Constitution’s Supremacy Clause, which specifies the displacement of state laws by federal laws with which state laws are found to conflict.
Rescission – The cancellation or refusal to renew a health insurance policy following issuance, typically after the filing of medical claims. A policy may be rescinded in cases in which an individual made material misrepresentations of health status at the time of enrollment. Insurers have been found liable for rescinding policies simply because medical claims were filed and in the absence of any fraud on the part of the enrollee.
Excise tax – A tax on health insurance and health benefit plans whose annual dollar value exceeds a specified limit, as well as on the sale of certain health care items and services such as medical devices and equipment. See also Cadillac health plan.
Copayments– Cost-sharing for covered health insurance benefits, expressed as a flat dollar payment (e.g., $5.00 for a prescription drug).
CLASS Act – A federal program of voluntary long-term care insurance.
Exclusion – The denial of coverage on the basis that the requested item or service is not covered under the terms of the plan. An exclusion differs from a medical necessity denial because treatment is not covered regardless of the medical facts of a particular case. An example would be a request for a prescription drug not on a plan’s drug formulary or exclusion of particular types of surgery (e.g., bariatric surgery).
Medicare – The federal health insurance program for individuals ages 65 and older, as well as persons with end-stage renal disease and certain persons with disabilities. Medicare covers beneficiaries for hospital, post-hospital extended care, and home health care, as well as a range of medical care services and benefits. Medicare enrollment is compulsory for all individuals covered by the Social Security Act. At their option, Medicare beneficiaries can buy “Part D” outpatient prescription drug coverage. Beneficiaries can elect to enroll either in “traditional” Medicare (which allows patients to receive care from any participating physician, hospital or health care supplier) or through Medicare Advantage plans, most of which restrict patients to specific network providers while typically offering additional benefits and coverage. The Patient Protection and Affordable Care Act expands Medicare coverage for preventive services and additional levels of prescription drug coverage while also introducing reforms to improve health care quality and efficiency.
Medicaid – A federal program enacted in 1965 that is funded by the federal and state governments and administered by the states that provides health insurance coverage to certain low-income populations. The Patient Protection and Affordable Care Act expands Medicaid to cover all low-income individuals with family incomes below 133 percent of the federal poverty level. Medicaid is a major source of health insurance coverage for “dual enrollees” who are elderly and disabled Medicare beneficiaries who are low-income or medically impoverished and who qualify for both Medicare and Medicaid.
Bundling – A health insurance payment arrangement under which which providers are paid a set amount for the treatment they furnish for a particular condition or for an “episode of care.” In contrast to fee-for-service payments, which can encourage a high volume of treatment, “bundling” is thought to incentivize more cost-effective care.
Premium – The recurring charge paid by individuals or employer-sponsored groups for the purchase of health insurance.
Appeals – The process by which health insurance beneficiaries can dispute a denial, reduction, or delay in covered treatments and services.
Rating – The practice by insurers of charging different premium amounts to different individuals or groups based on the characteristics of the individual or group as well as other considerations such as location.
SAMHSA – See Substance Abuse and Mental Health Services Administration.
MACPAC – See Medicaid and CHIP Payment and Access Commission.
EMTALA – See Emergency Medical Treatment and Labor Act.
MedPAC – See Medicare Payment Advisory Commission.
HITECH – See Health Information Technology for Economic and Clinical Health Act.
Parity – See Mental health and substance abuse disorder parity.
ERISA – See the Employee Retirement Income Security Act.
FEHBP – See Federal Employee Health Benefits Plan.
HIPAA – See Health Insurance Portability and Accountability Act.
COBRA – The nickname for a law, enacted as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), that allows individuals to continue to purchase employee health benefits for a period of 18 to 36 months following a “qualifying event” such as unemployment, death of a wage earner, divorce, or termination of minor dependent coverage.
MEWAs – See Multiple Employer Welfare Arrangements.
FQHC – See Federally Qualified Health Center.
AHRQ – See Agency for Health Care Research and Quality.
HRSA – See Health Resources and Services Administration.
GPRA – See Government Performance Results Act.
Pool – A group of individuals whose premiums are used to pay the covered medical costs of its members. Insurance companies may charge higher premiums to a pool whose members are older or less healthy in order to cover the risk that its members will submit more medical claims.
CHIP – See Children’s Health Insurance Program.
SSI– See Supplemental Security Income.
VBP – See Value-based purchasing.
ACO – See Accountable care organization.
CMS – See Center for Medicare and Medicaid Services.
EHR - See Electronic Health Record.
DSH – See Disproportionate share hospital.
GAO – See Government Accountability Office.
FTC – See Federal Trade Commission.
ESI – See Employer sponsored insurance.
FDA – See Food and Drug Administration.
DRG – See Diagnosis related group.
DOL – See Department of Labor.
NIH – See National Institutes of Health.
OIG – See Inspector general.
CDC – See Centers for Disease Control and Prevention.
CER – See Comparative Effectiveness Research.
DOD– See Department of Defense.
HIT – See Health information technology.
OMH – See Office of Minority Health.
[...] specifically about how CMS should begin thinking about defining priorities for its newly forming Center for Medicare and Medicaid Innovation. (CMI). This entity was established as a result of the Affordable Care Act (the new healthcare [...]
[...] writes this post about the provision in the national health care reform act that created the Center for Medicare and Medicaid Innovation (CMI). This agency has $10 billion to “research, develop, test and expand innovative payment and [...]
[...] will be conducted by a nacient branch of the Department of Health and Human Services called the Center for Medicare and Medicaid Innovation (CMI). It goes without saying that many of the pilots proposed could have grave consequences [...]
[...] been thinking a great deal about the newly formed Center for Medicare and Medicaid Innovation. (CMI). This entity was established as a result of the Affordable Care Act (the new healthcare [...]
[...] been thinking a great deal about the newly formed Center for Medicare and Medicaid Innovation. (CMI). This entity was established as a result of the Affordable Care Act (the new healthcare [...]
[...] will be conducted by a nacient branch of the Department of Health and Human Services called the Center for Medicare and Medicaid Innovation (CMI). It goes without saying that many of the pilots proposed could have grave consequences [...]
I have developed a problem solving method that can be used for medical diagnosis. I envision a body of professionals who are able to keep up with the latest literature who would maintain a diagnostic service to which physicians can subscribe. If the courts accept following the advice of this service as a defense in medical malpractice cases, this may cut down on the number of unnecessary procedures taken to defend against medical malpractice and possibly reduce the costs of malpractice insurance. If physicians were to provide feedback on how they used this advice in specific cases and the outcomes, it could contribute to developing Evidence Based Medicine.
The method is based on using knowledge in the form of cause-and-effect statements and propositional logic to find explanations for behaviors that occur within the domain of the knowledge base.
I am looking for someone with whom I can discuss this who might be able to bring it to the attention of those who could see that the technique is evaluated and according to that evaluation be implemented.
Donald V Steward can be contacted at steward@problematics.com .
Go to problematics/readings.asp and click on The Explainer – P.doc and look particularly at section 2.2 Using the Explainer to Reduce Medical Costs
[...] you know there is going to be a Center for Medicare and Medicaid Innovation? The authority comes from the new health reform law. And it appears to give the Health and Human [...]