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Key Concepts

The Affordable Care Act brings into play many new concepts. Here we sort out some of the key points of contention and supporting concepts.

Accountable Care Organization (ACO)

Actuarial Value

Acute vs. chronic condition

Advanceable Tax Credit

Basic health plan

Block grant

Bundling, or bundled payment

Catastrophic coverage

Churn

Comparative effectiveness research/Patient-Centered Outcomes Research

Consumer Assistance Program Grants

Consumer-Driven (or Consumer-Directed) Health Plan

Consumer Operated and Oriented Plans

Cost sharing

Cost sharing subsidy (or cost sharing reduction)

Data hub

Donut Hole

Dual eligibles

Essential health benefits

Federally facilitated exchanges

Grandfathered health plans

Guaranteed Issue

Hardship exemptions

Health Insurance Exchanges/Marketplaces

HealthCare.gov

High-risk pools

Hospital value-based purchasing

Individual mandate

Individual mandate: Exemptions

Job loss and coverage in 2014 and later

Medicaid "bump" payment

Medicaid premium assistance

Multi-State Plan

Off-exchange enrollment

Premium support

Presumptive eligibility

Primary care

Private insurance exchanges

Rate review

Section 1115 waivers

Social Determinants of Health

Special enrollment period

Tax credits for small businesses

Value-based purchasing

Wellness programs

Women’s Preventive Health Care

Accountable Care Organization (ACO)

There is no single agreed-upon definition for an ACO; models are evolving, and even Medicare has introduced variants. (i.e. Pioneers, Medicare Shared Savings Programs.) But, basically, an ACO is an organization that links (physically or virtually) physicians, hospitals and other providers, and provides more coordinated and integrated care. An ACO is supposed to emphasize primary care, use evidence-based medicine, electronic medical records and a team approach that promotes better communication between health care providers, and between the providers and the patient. The organization is, as the name states, supposed to be accountable for the cost and the quality of care - and the quality criteria must be measurable and transparent.

In Medicare, an ACO that saves money (compared to what "normal" non-ACO care for a similar patient population would have cost) gets to split the savings with Medicare. But other ACOs may get a capitated (per patient) or global payment from a private insurer, or perhaps from a large employer contracting with the ACO to care for the workers and dependents. A variety of financial arrangements can exist between the hospitals and the doctors (staff, or various kinds of contractual arrangements). Interestingly, the initial expectation was the hospitals would form most of the ACOs but in fact many are led by physician groups.

ACOs do have some traits in common with the HMOs of the 1990s in the sense that they are supposed to "manage" care. But there are important differences - notably the emphasis on quality and outcomes, not just shaving costs. In Medicare, Quality measurement pertains to Caregiver Experience, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population. In addition, in the current,early Medicare models, patients are free to choose their own doctor, see specialists without a "gatekeeper" referral, or go outside the ACO network altogether.

Actuarial Value

Actuarial value is a confusing term, but a deceptively simple idea. Think of it as the amount of the health expenses that the insurer would pay – that's the actuarial value. (The policy-holder or beneficiary would pay the rest through deductibles, copays, etc.) The term applies to covered benefits – not to health services that aren't part of the health plan. And it doesn't guarantee that the health plan would pay that proportion of costs of every individual; the concept applies to a covered population. In the health exchanges in 2014, the different plans – "Gold," "Silver" etc. – would cover the same essential benefits but have different actuarial values.

Acute vs. chronic condition

An acute condition is severe – and sudden. It can range from a broken arm to a heart attack.

A chronic condition usually develops more gradually – but it can cause an acute episode. Asthma, for instance, is a chronic condition but a severe asthma attack is an acute episode. Cardiovascular disease is chronic – a heart attack or stroke is acute.

The National Center for Health Statistics defines a chronic disease as lasting three months or more – and they usually last much longer. They can be managed but not all of them can be cured.

Chronic diseases generally cannot be prevented by vaccines or cured by medication, nor do they just disappear. Older Americans often live with several chronic diseases. Common ones include arthritis, cancer, diabetes and cardiovascular conditions such a hypertension or congestive heart failure.

The CDC says four behaviors are heavy contributors to chronic disease: lack of physical activity, poor nutrition, tobacco use and excessive alcohol consumption.

Advanceable Tax Credit 

Lower- and middle-income people who are getting subsidies to help them pay for their insurance in the new health exchanges in 2014 and beyond aren’t getting a check. They are actually getting a tax credit – or rather, an advanceable tax credit, which means they get it up front, when their health insurance premium is due. They don’t have to wait to file their tax return the next year. (A tax credit isn’t the same as a tax deduction. It’s more valuable because it slices off the amount of taxes owed, rather than reducing the income on which taxes are owed)

These credits are only available in the exchanges, not for policies purchased outside the exchange, even if the off-exchange policy meets ACA standards. The credit is paid directly to the insurer on behalf of the eligible individual, which is much simpler for the consumer. However, with all the ongoing problems with the ‘back end' of the exchanges, it can be problematic for the health plans. In addition, for people who are eligible on the basis of their income for additional cost-sharing reduction (such as reduced co-pays), it takes place at the point of service. In other words, individuals don't have to pay and then try to get reimbursed. They will get the medical service, and CMS works it out with insurers. (See Cost sharing subsidy.)

Basic health plan

When the health insurance exchanges open in 2014, people up to 133 percent of poverty will be eligible for Medicaid, and others may qualify for subsidies on a sliding scale to help them purchase coverage. But for one group – those just above Medicaid eligibility but still quite poor, the 133 to 200 percent of poverty group – states have another option. Instead of having them in the exchange, they can create a “Basic Health Plan” which would be outside the state exchanges but would fulfill the essential benefit requirements and have low cost-sharing. The federal government will give states 95 percent of what it would have paid to subsidize them in the exchange. NOTE: HHS has delayed the Basic Health Plan until 2015, although it has said it will work with states that already operate, or want to introduce, similar programs.

Bundling, or bundled payment

Most health care payments now are based on “fee for service” — the patient, insurance company, Medicaid or Medicare is billed for each test, each physician interaction, each procedure. Bundling would be a fee for all services related to a specific treatment or condition over a period of time. Some bundle payments apply to treatment only in the hospital. Others apply to an episode that can bridge inpatient and outpatient. The idea is that it’s going to promote better quality of care and better care coordination at a lower cost – but the jury is still out.

Private insurers are testing bundling in a variety of ways and, in 2013, Medicare began testing it with participating organizations. There are four models – various mix of inpatient only, inpatient and rehab, hospital only and hospital and doctors.  They are working on bundled payment systems for 48 different conditions, from acute episodes like heart attacks to chronic diseases like diabetes.

Block grant

A lump sum usually given to a state or local government for a specific purpose. There can be some requirements attached to the grant, but in Medicaid debate which has cropped up repeatedly in Congress, the basic idea championed by the Republicans is to give the money to the states with few strings attached. That would give the governors great flexibility in who to cover, and what benefits to offer, changing the very nature of the Medicaid entitlement. Jointly funded by the state and federal governments and largely administered by the states, Medicaid was established in 1965. It provides health care for certain low-income and disabled people. It also covers long term care, such as nursing homes, for low-income elderly.

The Republican block grant proposals that have been offered over the years generally would mean federal spending would be predictable - and lower than it would otherwise be. (The federal government, on average, pays 57 cents of each Medicaid dollar, higher in poor states, lower in wealthier ones. It’s paying 100 percent of Medicaid expansion for three years, and then phases down to 90 percent.) Block grant advocates argue that if freed of the federal bureaucracy, governors could come up with more creative and innovative and efficient ways of covering people in need. But critics, including most congressional Democrats, say the grants would grow so slowly that they would not be able to keep up with the needs - and that states would either have to pick up the tab, or slash already low provider payments - or cut benefits or beneficiaries. The Congressional Budget Office has said that that state-level innovation would not be able to make up for the huge loss of federal income.

After the Supreme Court ACA Medicaid expansion optional in 2012, many states tried negotiating with HHS to get more flexibility in their Medicaid program, though stopping short of a block grant. Some states – Arkansas being the best known example – have won some flexibility but the feds have rejected proposals that undermine core elements and practices of Medicaid.

Catastrophic coverage

This kind of health plan traditionally has covered only big, serious expenses. Some also could have annual or lifetime limits to how much they covered even then. The new catastrophic option in the ACA health insurance markets does include additional coverage and consumer protections. It covers three primary care visits a year, and certain recommended preventive services. Then the beneficiary pays bills out of pocket. In the event of a serious illness or accident, the beneficiary must meet the deductible, which is usually high. But out-of-pocket annual expenses are limited to $6,350 for an individual and $12,700 for a qualified health plan. People who qualify for federal subsidies on the exchange – tax credits toward paying for insurance – can’t use them for a catastrophic policy.

Churn

This term refers to what happens when people’s income – and their eligibility for various health programs – changes. It’s especially common among lower-income people. In the context of the health law, it means that people could bounce back and forth from Medicaid eligibility to the subsidized exchange plans. A 2012 report from the Robert Wood Johnson Foundation estimated nearly 30 million people would experience it.  It can create confusion, potential gaps in coverage and, potentially, disruptive changes if people have to change doctors and clinics repeatedly (particularly in the absence of interoperable electronic medical records). Minimizing churn is one of the arguments made by states that want to put the Medicaid expansion population in private health plans in the exchanges: It may create more continuity of coverage and care.

Comparative effectiveness research/Patient-Centered Outcomes Research

The 2010 health law expanded federally funded comparative effectiveness research and set up a new federal organization to shape the research. A lot of the research will focus on comparing different drugs, therapies or treatments and figuring out which ones are more effective than alternatives. The institute is not a part of the government; it is an independent, non-profit, non-governmental organization. By law, it will not make cost-benefit analysis (although insurers, health plans, physician, researchers and patients can all use the data to make their own more informed decisions.)

The mission of PCORI is broader than that, however. The center is not just looking at drugs and procedures but at what works and doesn’t in the health care system itself, including how to improve health care for patients with multiple chronic conditions, health IT and deploying the health care workforce. It is also addressing health care communication, how to disseminate information, shared decisionmaking, and disparities.

Consumer assistance program grants

Under the health reform law, about $30 million was made available in grants to states to help people understand what their insurance is supposed to provide, or protect them from abuses or bad practices. States and territories have developed a variety of approaches.

Consumer Driven (or Consumer Directed) Health Plan

This refers to a high-deductible health plan that is paired with a tax-preferred health savings account. People (or their employers) put pre-tax dollars into the special account, which is then available for health expenses. The high-deductible insurance plan means the beneficiary will have to pay a large deductible before the health plan kicks in. The money in the health savings account could be available. Advocates say it will make consumers smarter and more cost-conscious consumers of health services; critics say it leaves people at risk of unaffordable health bills and discourages preventive care, particularly for lower-income groups.

Consumer Operated and Oriented Plans

Once it became clear that the “public option” wasn’t going to make it into the health law, co-ops emerged as an alternative. These nonprofit plans, with public boards, were supposed to provide some competition to the largely private commercial plans expected to dominate the exchanges. Congress allocated $6 billion for loans to start them up—but cut the funds in 2011 and again in the fiscal cliff deal at the end of 2012. So only about two dozen co-ops were funded, and no more loans are forthcoming.

Advocates had expected them to provide competition to the for-profits and help constrain costs – and see the decision to cut them as a sop to the insurance industry. But some analysts had questioned how easy it would be to start health plans from scratch and create provider networks in some parts of the country.

And while much of the focus has been on rural areas – the Freelancers Union is expanding them through New York, New Jersey and Oregon.

Cost sharing

These are the costs that the patient, not the insurer, has to pay. This includes the deductible, the copay (and any additional charges if the doctor, hospital, or other provider is out of network). The deductible is what the patient starts to pay before the plan kicks in – i.e., if there’s a $1,000 deductible, and the doctor’s bill is $200, that will go toward the deductible. (Preventive care or other specified services in the health plan are covered and don’t count toward the deductible.) But it’s a one-time fee – it’s a deductible for the patient’s entire year, not for each medical service. The copay, which tends to be something like $25 per office visit (sometimes more for specialists) is each visit – each time a patient gets care, they pay it. Sometimes there is co-insurance: instead of a flat fee copay, there is a percentage, say 20 percent of the charge. This is often the payment arrangement for out-of-network care – a flat copay for the in-network provider, a percentage for out-of-network care. The structure of these payments varies from plan to plan and some services (again, certain preventive care) have no copay. The term "cost-sharing" usually doesn’t encompass the premiums, certain out-of-network costs or the cost of any service that the health plan doesn’t cover.

Cost sharing subsidy (or cost sharing reduction)

It’s widely known that the ACA includes subsidies in the form of tax credits to help people under 400 percent of poverty pay for their insurance premiums in the new exchanges. But there’s a second set of subsidies that bring down cost-sharing for individuals or families under 250 percent of poverty. That brings down total out of pocket costs and reduces deductibles, copayments etc. These subsidies are only available for people purchasing silver-tier plans on the exchanges, and they are on a sliding scale, phased out at 250 percent of FPL. A silver plan would normally cover about 70 percent of health costs, but these subsidies could bring it as high as 94 percent for the lowest income brackets on the exchange.

Data hub (also see HealthCare.gov)

The data hub was the part of the online health care exchange/marketplace that experts worried about the most, and ironically, it was one of the parts of HealthCare.gov that didn’t melt down in the fall of 2013. The hub is very complicated, drawing data from the Department of Health and Human Services, Social Security, the Department of Homeland Security, the Internal Revenue Service and the U.S. Treasury. All these departments had their own privacy systems, so the hub has to be able to interact securely with all of them. The hub isn’t a database – it doesn’t keep all that information. It sort of darts in and out of the various agencies, getting the information that it needs but not storing it in the federal exchange apparatus.

Donut Hole

The 2003 Medicare prescription drug law included a gap in coverage that became known as the “donut hole.” People got help paying for their drugs up to a certain point. Then had to pay themselves, while continuing to pay monthly premiums - until they hit another higher “catastrophic” cost level, when the plan started paying for medications again.

The law phases the “donut hole” out over a decade, filling it in 2020. CMS estimated that four years after the passage of the ACA (March 2014) 7.9 million people with Medicare had saved more than $9.9 billion on prescription drugs, or an average of $1,265 per beneficiary. During 2014, seniors who hit the coverage gap will pay 47.5 percent of the plan's cost for covered brand-name prescription drugs.

Dual eligibles

"Dual eligibles" are people who are covered by both Medicare and Medicaid. They are sicker, and poorer than the population as a whole. And they use a disproportionate amount of health care. Many require long-term care, in a nursing home or other setting.

The health reform legislation created a special office within CMS to address their needs, and the cost. This includes developing new ways of providing care coordination, addressing some of the perverse incentives that contribute to fragmentation , poor care and cost-shifting. It also helps states identify and overcome barriers to more efficient and more seamless care. The new office also works closely with  Medicare and Medicaid Innovation Center.

Read more: ‘Dual eligibles’ pingpong between programs, getting stuck along the way

Essential health benefits

The health reform law requires that all health plans, inside and outside of the state-based insurance exchanges, offer a comprehensive set of benefits starting in 2014.

The law defines essential health benefits to "include at least the following general categories and the items and services covered within the categories:"

  • ambulatory patient services

  • emergency services

  • hospitalization

  • maternity and newborn care

  • mental health and substance use disorder services, including behavioral health treatment

  • prescription drugs

  • rehabilitative and habilitative services and devices

  • laboratory services

  • preventive and wellness services and chronic disease management

  • pediatric services, including oral and vision care.

The federal department of Health and Human Services will define, and can review and update, the basic benefits but it will draw on outside advice including from the independent Institute of Medicine, which often provides scientific advice to the government.

Federally facilitated exchanges

The Affordable Care Act, as written, anticipated that states would run their own new health insurance marketplaces called exchanges. But more than half the states decided not to establish exchanges, meaning the federal government is running them and in most cases will do so indefinitely. These federally facilitated exchanges are still state-based in the sense that people across the country will not shop in one big national insurance pool. Each state has its own, with the federal government doing much of the work in creating and running them in these states. However, state officials still play a significant role in regulating the insurers who participate. The state exchanges are accessed through the federal portal HealthCare.gov.

Consumers may not detect much difference between state and federal exchanges – they are able to purchase similar insurance plans and federal subsidies are available on a sliding scale. For more details on the federal exchange, see this issue brief from Health Affairs and RWJF.

Grandfathered health plans

Partly because of the political promise to allow people to “keep your health care if you like it,” some health plans that existed when the health law was signed on March 23, 2010 are “grandfathered.” That means they don’t have to offer all certain consumer protections that other plans now have to include under the new law. But if the health plan makes significant changes – changes that reduce benefits or boost the costs for health care services – it loses its “grandfathered” status and must comply with all provisions from that point on. Increases in premiums don’t strip a plan of its grandfathered status

Some of the consumer protections in the law – such as coverage for young adults – apply to all plans, grandfathered or not.  For instance, plans can’t retroactively cancel coverage (rescissions)  and they can’t impose lifetime limits on health benefits. The rules are slightly different for the individual market and the employer-related group market. For more information, see this document from HHS' Center for Consumer Information and Insurance Oversight (PDF).

Guaranteed Issue

This means that a health insurer must cover someone even if they have a "pre-existing condition" or a high-risk medical history,. However, states that have tested this requirement without other regulations (including an individual mandate) have found that insurance premiums rise. And without consumer protections and health reform policies, guaranteed "issue" doesn't mean guaranteed "affordability." An insurance company has to offer a policy – but it can underwrite, or charge a lot more to someone likely to run up health costs. The Affordable Care Act introduces guaranteed issue (and guaranteed renewal for existing coverage0 as of Jan. 1, 2014. That's when the new state-based insurance exchanges are to open, and that's also when the individual mandate goes into effect and coverage subsidies become available. Guaranteed issue has been the law for children (under age 19) since six months after the national health law passed.

Hardship exemptions

In addition to the basic affordability exemptions to the individual mandate, people can also be exempt because of specific hardships. (and exempt people may qualify for catastrophic coverage) Examples of hardship exemptions include: Being homeless or facing eviction/ foreclosure or having had serious property damage because of fire flood or other disaster; having had your utilities shut off; being a victim of domestic violence; in bankruptcy; having had medical expenses you couldn’t pay in the last two years (including arising from family caregiving). People who would be eligible for expanded Medicaid – but  can’t get it because their state didn’t expand – are also exempt.

On Dec. 19, 2013, the administration clarified that people whose insurance had been canceled could get a hardship exemption. The letter from HHS Secretary Kathleen Sebelius is here and  more information from HHS is here.

Health Insurance Exchanges/Marketplaces

The health insurance exchanges (the Obama administration prefers to call them “marketplaces”) were established by the Affordable Care Act. They were supposed to be run by the states, with a federal exchange serving as a backup or transitional bridge to state exchanges. As it turned out, roughly two-thirds of the states opted for a federal exchange (or a variant known as a partnership.) The federal exchange is now likely to be a permanent and large fixture – not a transitional entity. Conservative states largely opted out of state exchanges on ideological grounds; some other states, particularly smaller ones, found creating a state exchange too technically daunting, costly, or impractical. A handful of states (such as Oregon) whose own exchanges failed in 2014 are turning over all or part of the exchange to the feds in 2015. The exchanges began enrolling people in late 2013 and began coverage on Jan. 1, 2014. Enrollment for 2015 runs for three months beginning Nov. 15, 2014.

The exchanges are supposed to create a more organized, regulated, and competitive market for buying health insurance. They offer a choice of different health plans (with some states having more competitive markets than others), certifying plans that participate and providing information to help consumers better understand their options.

The exchanges primarily serve individuals buying insurance on their own. The small business or SHOP exchanges, which can serve small businesses with up to 100 employees, have gotten off to a slower start. (States can choose to include larger employers in the future.)

HealthCare.gov (also see data hub)

This is the notorious consumer portal to the health exchanges, particularly the 36 exchanges that are being run all or in part by the federal government in states that cannot or would not run the exchanges by themselves in 2014. Its debut was an epic mess – and it remains to be seen how fast or how well it can be repaired.

The website isn’t simply an e-commerce tool selling insurance. It does that – but it also must do more than confirm identities, display plan options and take a credit card. Its “data hub” must link sensitive information from multiple federal agencies – the IRS, the INS and others – to both verify eligibility and calculate premium subsidies for those people who are eligible. When everything works right, it is supposed to figure out whether someone goes into the exchange or Medicaid – or whether different family members go into different kinds of coverage – Mom into exchange, kid into Children’s Health Insurance Program for instance. AND when all that’s done – it has to send the enrollment information securely and accurately to the health plans. When subsidies are available, the government pays directly to the insurer – and the covered person or family pays the balance.

States running their own exchanges STILL have to interact with the federal exchange – specifically the hub – as do insurers or e-brokers selling exchange plans directly to consumers. They rely on the data hub to verify eligibility, subsidies etc.

High-risk pools

The Affordable Care Act created Pre-Existing Condition Insurance Plans (PCIP) as a temporary way to offer coverage to high-risk, hard-to-insure people until the new state exchanges, consumer protections and subsidies are available in 2014. To qualify, they have to have been uninsured for at least six months because of pre-existing conditions (such as diabetes, asthma, cancer and HIV/AIDS). Many experts and advocates predicted the pools would be flooded with the uninsured, and that it would burn through the $5 billion available well before 2014. Instead, enrollment in most states has been a trickle – only about 41,000 people as of October 2011. Costs are high, and some analysts have suggested that people who really value health coverage find some way of cobbling together some kind of solution. Some are already in state high-risk pools, which pre-date the federal law and which have different eligibility rules. The new pools can be administered by the state (23 states and D.C. have chosen to do so), or the federal government (the remaining 27).

Individual mandate

The “individual mandate” is one of the most contentious aspects of the 2010 health reform law, and questions about its constitutionality form the basis of most of the lawsuits challenging the legislation.

The mandate, which goes into effect in 2014, requires that people have "minimum essential health insurance coverage" or pay a penalty. This can mean purchasing insurance (with or without a government subsidy), or getting it on the job, or through a public program like Medicaid or Medicaid.

There are a few exceptions, for people who truly do not have access to affordable coverage (defined in the law as being more than 8 percent of the person’s household income). Some very poor people won’t be subject to the mandate, as well as those who have religious objections to insurance.

The penalties are low, starting at no more than either $285 per family or 1 percent of family income in 2014 and rising to $2,085 or 2.5 percent of family income in 2016. That’s much less than the cost of insurance, and some health policy experts question whether it will have much impact on purchasing behavior.

The mandate is not a politically popular feature of the law. But if backers of the mandate say that if insurers are going to be obligated to take everyone, including those with pre-existing conditions, they have to be able to spread the risk, the cost, over a larger population that encompasses both the well and the not-so-well.

Individual mandate: Exemptions

Not all Americans will have to have insurance when the individual mandate kicks in Jan 1, 2014. HHS recently finalized the exceptions to that rule (PDF).

Here are highlights of who is exempt:

  • People for whom coverage is unaffordable as defined in the law/regulations, including people whose income is below the tax filing threshold

  • People who have a coverage gap of three months or less are not considered uncovered for the purposes of the mandate.

  • People who have qualifying hardship circumstances according to HHA – including anyone who qualifies for Medicaid expansion but lives in a state that isn’t expanding

  • Members of certain religious groups

  • People who fall in the so-called “family glitch” in which the employee’s coverage is affordable but the family plan through that employer is not.

  • People eligible for care through an Indian health care provider

  • Undocumented immigrants

  • Incarcerated individuals

Job loss and coverage in 2014 and later

If you have coverage on your job and you lose or leave your job, (or if you are covered through a spouse or partner who loses the job) there will be more options once the full-coverage provisions of the Affordable Care Act kick in Jan 1, 2014:

In some cases there is another employer-sponsored option (i.e. getting on a spouse/partner’s plan).

COBRA (Consolidated Omnibus Budget Reconciliation Act) will continue to exist as an option even after 2014. That means if you lose your job, you can continue your employer-sponsored coverage – but you pay the whole thing, without the employer subsidy, plus a surcharge. There will be people who make this choice (for various reasons they may not want to change plans or doctors at that time, or the exchange options are not more affordable for them). It’s also time-limited – usually 18 months. But most people will have other options.

The exchanges or marketplaces: Normally there will be “open-enrollment periods” – six months the first year, shorter in subsequent years. But in the case of a job change, you can buy a plan through the exchange at any time. Some people will qualify for tax credits or for Medicaid or the Children’s Health Insurance Program (CHIP).

There still will be health plans outside the exchanges, but government subsidies will not be available for them.

Medicaid "bump" payment

Medicaid is a notoriously low payer – and many doctors won’t take Medicaid patients. Yet the Affordable Care Act relies on Medicaid for much of the coverage expansion. In order to encourage physicians to take more low-income patients, the authors of the ACA decided they needed to “bump up” payment at least for 2013-14. Medicaid has to pay primary care physicians and a limited number of primary care subspecialties the same rates as Medicare, for those two years. The federal government was supposed to pay the whole cost, about $11.9 million, and not split it with the states. Implementation was slow, partly because of delays in federal rule-making, partly because at the state end. In early 2014 some physician groups began pushing for the “bump” to be extended into future years . The verdict is still out on whether the higher pay actually persuaded more physicians to take Medicaid.

Medicaid premium assistance

You’ve heard a lot about how the GOP wants “premium support” for Medicare – an idea that got put on the sidelines by the 2012 election. But some states are promoting a related – but not identical – idea for Medicaid, particularly for those who become eligible for Medicaid under the health care law in 2014. (Sometimes states have used premium assistance to make employer-sponsored coverage more affordable for low-wage workers.)   It’s quite literally that the eligible person will get financial assistance to pay the premium. But in the Medicare debate, part of the fight was over whether the premium support would be enough over time – whether the money (often called a voucher) would keep up with the rising cost of Medicare. In Medicaid and the Children’s Health Insurance Program, benefits are spelled out more explicitly in the law. The support has to be enough to pay for a plan that covers the necessary benefits, or there has to be a “wraparound” benefit to supplement the health plan to make sure the beneficiary is getting everything he or she is entitled to under the law. A number of states are exploring how to use premium assistance in Medicaid expansion. That will be subject to a lot of negotiation with HHS about what kind of benefits this low income population will get, and at what cost – to the government and themselves.

Multi-State Plan

The government in late November released a proposed rule to implement the Affordable Care Act’s Multi-State Plan Program.  And if you don’t remember what a multi-state plan is – think back to the fight over the passage of the health law in 2009-10  and the endless acrimony over the “public option.” The public option fell by the wayside, and the multi-state plan emerged as a weaker substitute. Basically the government – the Office of Personnel Management, to be specific – will contract with two of these high-quality plans to offer coverage in state insurance exchanges, whether the exchange is run by the state or the feds. They’ll start in about 30 states, but be in all 50 within four years. At least one of the plans has to be a nonprofit. The idea is to add more consumer options and competition into the exchanges – because some states don’t have a lot of insurance carriers active in the small group or individual markets. But OPM (which also administers the Federal Employees Health Plan) has to be careful as it fleshes out the details with these plans that they don’t overwhelm the local carriers and destabilize the playing field.

Off-exchange enrollment

Several million people are still being covered in the individual market outside of the exchange. Most of these plans meet the new ACA rules, and more will over time as plans lose their grandfathered status, or are no longer offered. (States have the option of allowing plans that were to have been cancelled to remain on the market for up to three more years.) Subsidies are only available on the exchanges, so the off-exchange population tends to be higher income. They are not included in the federal exchange enrollment reports but both on and off the exchange enrollees count in an insurers’ risk pool. Because they probably skew younger and healthier, they may keep the markets and premiums more stable.

Premium support

Proposal to give people a voucher or coupon to help pay for health insurance. At the moment, it's most often used in the context of Medicare. There are several variants of premium support. Some would make it an alternative to traditional Medicare, some would make it a substitute for traditional Medicare. (The House-passed budget would make it a substitute, with the voucher unlikely to keep up with the rising health care costs) Premium support lets the federal government cap its Medicare spending, but the costs could get shifted to individuals

Premium support is in the news now because House Budget chairman Paul Ryan (R-WI) wants to turn Medicare into a "premium support" program. It's not a totally new idea - House Republicans, including former Speaker Newt Gingrich and former House Ways and Means chairman Bill Thomas, had somewhat similar ideas that began circulating in the mid-1990s. But the Ryan idea is starker - or bolder, depending on your perspective.

Basically premium support is like a coupon or voucher. Instead of having a federal Medicare program pay your doctors and hospitals, etc. - drawing on tax revenue and the premiums beneficiaries pay - people on Medicare would get a voucher. (Ryan shuns the word "voucher" He prefers the word "subsidy"). The voucher would go up in value each year - but not as fast as health care costs rise. Critics say this means that the federal government will save money but the elderly and the disabled will pay more and more each year. Ryan says it will mean cost savings; his critics say it means cost-shifting to a relatively poor slice of the population that can't bear the cost. Plans accepting those vouchers and covering Medicare-age people would have to operate in a health insurance exchange of some type, and meet some requirements and government regulations under Ryan's plan. Details would have to be hashed out by Congress.

For more information, see this tip sheet.

Presumptive eligibility

Under traditional Medicaid, states could allow health care providers to “presume” that a patient is eligible for Medicaid. The provider could get reimbursed until eligibility was determined by the state. The ACA expands presumptive eligibility in Medicaid. If it appears hospital patients fit the Medicaid income requirements, the hospital will be able to get reimbursed and the patient can also get follow-up care. Eventually, the goal is to have data systems good enough to determine eligibility almost instantly. In the meantime, this will help hospitals get paid, and patients will be connected with coverage.

Primary care

This term is used all the time in health policy, but it's worth taking a look at precisely what it means. An oft-cited definition was put forth by the Institute of Medicine back in 1996. "The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." Of course, in today's system, with fragmented care, harried primary care practiioners, specialization and subspecialization – not to mention access problems, particularly for the uninsured, underinsured, and people in underserved rural and inner city areas – there is quite a gap between the classic definition and the patient experience.

The health reform law contains a few programs designed to encourage more primary care; In 2010, the federal government invested $250 million from the health law's Prevention and Public Health Fund into professional training for primary care. The goal is to encourage more medical students to make a career out of primary care; now only about one in four have that goal, and some medical groups forecasts that it will keep dropping. But good primary care – whether given by physicians or by physicians working with nurse practitioners and physician assistants – is going to be necessary to carry through on some of the elements of the health legislation, including more stress on prevention, "population health," avoiding unnecessary care, improving coordination and restraining costs. Primary care will be the fulcrum for some of the new delivery systems including medical homes, and accountable care.

Primary care encompasses general and family practitioners, internists, pediatricians and geriatricians. (Some consider OB-GYNs part of the primary care workforce, as many women use them as their main health care provider, but they aren't usually counted in primary care stats).

Primary versus specialist is one big divide in health care, but another way of thinking about it may be "cognitive" versus "proceduralist." Primary care is a "cognitivie" practice – as are certain specialties. Proceduralists do more – and get paid more in the fee-for-service system. An example: a neurologist may be largely "cognitive" but the neurosurgeon is a "proceduralist."

Private insurance exchanges

There’s a growing interest among large employers in “private insurance exchanges,” which are distinct from the state-based ones created by the Affordable Care Act for individuals and small businesses. These exchanges, run by benefits/human resources companies, allow employers to shift from a defined benefit model to  defined contribution – they give workers a set amount or contribution toward health coverage. The employee would use that cash plus his/her own payment to choose from a number of options on the private exchanges. Once the employer mandate goes into effect in 2015, the coverage would have to meet ACA standards of coverage and affordability. (The tax treatment of the payments would be the same as traditional employer-sponsored coverage.) Aon Hewitt, Mercer and Towers Watson are all players in the emerging private exchange market.

So far these exchanges are very small, but there’s growing interest in the human resources and employee benefits fields. Backers of the idea say costs will be more predictable for employers, consumers will have more health plan choices, and the larger market will restrain costs by encouraging insurance competition.

Rate review

Back during the debate about the health reform  legislation, there was a great deal of discussion about how “bending the curve” of health care spending could bring down –or at least slow the growth of – health care costs. Less attention was focused on the power that state or federal government has to limit big premium increases. 

The state powers vary widely; Rhode Island, for instance, in August 2011 used its power to reject several proposed premium hikes. But, as of December 2010, fewer than half the states had such powers. Other states can demand and publicize information – and the publicity can exert pressure on the health plan to tamp down the proposed increase, as has sometimes happened in California. The federal law gave the states or Washington more power to have independent review of proposed rate increases that exceed 10 percent,  but not to directly approve or reject them. Legislation has been introduced, but not enacted,  that would expand rate regulation powers of the federal government as a fallback if the states lack such authority.

The Affordable Care Act did set new “medical loss ratio” rules that require health plans to spend more money on actual care, not administration, marketing and profit.

Related: Why insurers care about the medical-loss ratio

Section 1115 waivers

Critics of Medicaid often call it a “one-size fits all” program; in fact it varies widely state by state. Waivers add another layer of state variation (and can serve as incubators for ideas that may work in other states).  There are several kinds of waivers, but the ones that the governors are often talking about when they talk about Medicaid reform or coverage expansion are the Section 1115 waivers.  They allow HHS to approve assorted experiments. They are typically five year programs (often renewable for three more years) and they must be budget-neutral – i.e. they can’t add costs.  According to HHS, the three main purposes are

  • Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible

  • Providing services not typically covered by Medicaid

  • Using innovative service delivery systems that improve care, increase efficiency, and reduce costs.

For a list of current waivers, see this CMS website.

Social Determinants of Health

This refers to all the factors other than ”health care” and “medicine” per se that affect our health – our social environment; our physical environment; the neighborhoods in which we live, work, and play in; our access to recreation, our educational level, our income and socio-economic status and discrimination based on racial and ethnic factors.

Tax credits for small business

Individuals can get subsidies in the ACA exchanges, whereas businesses in the SHOP exchange generally cannot. However, employers with fewer than 25 employees whose average annual earnings are $50,000 are an exception. They can get a tax credit to help pay for coverage. Through 2013, it was up to 35 percent of the employer costs. In 2014, it rose to a 50 percent credit for two years.

Value-based purchasing (or Hospital value-based purchasing)

The Hospital Value-Based Purchasing program was created by the health law, but it builds on earlier initiatives that rewarded doctors and hospitals that reported on quality. Starting in October 2012, Medicare will pay hospitals partly based on how well they perform on specific quality measures, not just for the amount of services they provide. Measurements include how well hospitals follow best clinical practices. CMS plans on expanding the value-based initiative to nursing homes, home health agencies and ambulatory surgical centers.

Special enrollment period

People can sign up for health insurance outside the standard open enrollment season when they have a “qualifying life event,” such as a birth, marriage or divorce, job change, or a move to a new state. This is true in both the private sector and the new health exchanges. For 2015, special enrollment would take place after the regular signup season ends on Feb. 15, 2015.

In addition, the Department of Health and Human Services has the power to create other special enrollment periods, as they did in April 2014, when they accommodated some people who had problems up for the federal exchange by the March 31 deadline.

There is no enrollment season or deadline for Medicaid or CHIP application. People can apply at any time if they are eligible.

Wellness programs

The heath care law contains incentives for people to participate in programs intended to improve health and fitness, through the workplace or, less often, directly through the insurers. People can get discounts on their health premiums. The programs are typically directed at things like smokinge cessation, diabetes management, weight loss and preventive health screenings.

“Participatory wellness programs,” are what they sound like – they are based on participation, not on the person’s health status before and after. “Health-contingent wellness programs” measure outcomes such as lowering cholesterol or quitting smoking. Those have been more controversial but under the final HHS rules, the measurements are supposed to account for people’s medical condition – some people cannot achieve certain goals as easily as other, healthier, people.

Women’s Preventive Health Care

Few provisions of the Affordable Health Care law have generated as much controversy as the requirement, effective Aug. 1 2012, that health plans cover contraceptives as not charge. But that provision is part of a larger set of preventive health services for women that will become available to what HHS estimates is about 47 million women. The eight new prevention-related services are:

  • Well-women visits.

  • Gestational diabetes screening for pregnant women.

  • Domestic  violence screening and counseling.

  • FDA-approved contraceptive methods, and contraceptive education and counseling.

  • Breastfeeding support, supplies, and counseling.

  • HPV DNA testing, for women 30 or older.

  • STD counseling for sexually-active women.

  • HIV screening and counseling for sexually-active women.

These are in addition to the general preventive care provisions in the law for services like cholesterol screenings and flu shots. They were developed based on recommendations from the Institute of Medicine.

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