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153 Cards in this Set

  • Front
  • Back
Premium conversion
is the most common component of a cafeteria plan.

allows employees to pay their cost of employer-sponsored health insurance premiums with pretax dollars through payroll deductions.
premium conversion and flexible spending arrangements
are company benefit programs that allow employees to use pretax dollars to pay certain out-of-pocket expenses.

are not health insurance plans.
Cafeteria plans
called 125 plans because they are defined in Section 125 of the Internal Revenue Service Code

are so called because employees can pick and choose from a menu of benefits custom designed by the employer.

The choices most-often offered are premium conversion and flexible spending arrangements.
Health care reimbursement system variations are caused by numerous factors including
cafeteria plans in place by health plans

underwriting conditions of employer groups

health care legislation (such as the Medicare Modernization Act).
Self-Insurance
A qualifying group of employers who insure themselves, instead of paying to transfer coverage to a profit-making insurance company
An individual self-insured
is an employer with sufficient significant assets to insure itself.
the premiums of self-insured employers
are paid to a pool from which losses are paid when incurred

are not paid to an insurance company
Mutual and indemnity insurance refers to
traditional profit-making, premium-based insurance companies where reimbursement or compensation for loss or personal injury is provided via a contract (pre-set policy with premiums).
In the 1960s, 1970s and even the 1980s, indemnity group health insurance plans
were quite common, until their premiums and annual increases became more than insureds could manage.
surged when large numbers of people began turning to managed care plans that offered lower premiums.
"Usual and customary charges" are usually used to reimburse for services in indemnity plans.
These "pre-set" charges are used to calculate payment of a majority percentage of the total bill, usually about 80%.
Managed care
is a system that controls the delivery and financing of health services to members who are enrolled in a specific type of health care plan.
The goals of managed health care are to ensure that:
 Providers deliver high-quality care in an environment that manages or controls costs
 The care delivered is medically necessary and appropriate for the patient’s condition
 Care is rendered by the most appropriate provider, and
 Care is rendered in the most appropriate, least-restrictive setting.
Managed care is a broad term that
describes the sector of health insurance in which health care providers are not independent businesses run by, for example, the private practitioner, but by administrative firms that manage the allocation of health care benefits.

defines an array of systems and processes meant to control increasing health care costs while coordinating quality health care services and products throughout a network of approved providers.

assume the risk of caring for the assigned individuals for a capitated, predetermined dollar amount.
Under a managed care system, the payer must
decide whether to give their beneficiaries a wide-open choice of providers or whether they wish to limit their choices.
More restrictive managed care plans
offer fewer choices of providers and greater restrictions on consumer behavior, but they yield lower costs.
Managed care can be thought of as a continuum of models. These models are generally classified as far left, least cost control but more provider selection to far right, more cost control but less provider selection:
indemnity insurance (far left)
service plans
preferred provider organizations (PPOs),
point-of-service health plans (POS),
and HMO plans HMO (far right)
indemnity insurance
offers less cost control but greater choice of provider
Under the traditional HMO model, “open-panel” HMO includes
the options of independent practice association (IPA) and direct-contract HMO.
Closed-panel HMO includes
the group model or the staff model, which offer more cost-control but less choice of provider.
As models move toward the managed care end of the continuum, certain features begin to appear, including
tighter elements of control over health care delivery; addition of new elements of control;
more direct interaction with providers;
increased overhead costs and complexity;
greater control of utilization;
net reduction in rate of rise of medical costs.
Newer models of managed care include Medical Home and Accountable Care Organizations (ACOs), under which
a coordinated, controlled, interdisciplinary team-approach to ongoing patient care is delivered that provides consistency of providers, shared documentation and records, and a number of other enhanced delivery services.
An HMO
Is an organization that provides health care for a geographic area and that accepts responsibility for delivering an agreed-upon set of health maintenance and treatment services to a voluntarily enrolled group.

collects a predetermined periodic payment paid in advance on behalf of each individual enrollee.

Services generally include inpatient and ambulatory care.

results in reduced out-of-pocket costs (ie, no deductible), no paperwork (ie, insurance forms), and only a small co-payment for each office visit to cover the paperwork
Benefits to members must be provided by HMO’s
providers in compliance with the HMO’s authorization procedures.
What are the most restrictive type of health plan because they give members the least choice in selecting a health care provider?
HMOs
HMOs fall into 3 categories:
open-access, open-panel and closed-panel. A fourth category, the true network model, is relatively uncommon.
Open-access HMOs
are more like PPOs than traditional HMOs

members may access any provider in the HMO without going through a primary care physician

members may access any provider in the HMO without going through a primary care physician
The HMO open-panel model allows
individual physicians to participate in HMO programs through independent practice associations, or IPAs.
In the closed-panel model, the HMO
contracts a group of physicians to become their network, called the Group Model.
The members of the medical group practice together share
the same premises and may share patients and revenues
a physician may decide to instead to join a staff-model HMO. In this model,
the HMO employs its own physicians.

The physician is actually a salaried employee of the HMO, works at the HMO building, and may not see non-HMO members.

The insured can only go to these specialists.
HMOs typically provide members with a
greater range of health benefits for the lowest out-of-pocket expenses.

generous health plan
Except in true emergencies, payment for services received from non-HMO providers is the
responsibility of the subscriber, not the HMO.
the IPA model is
the most common physician relationships with managed care plans

an association of physicians and other health care providers, including hospitals, contract with an HMO to provide services to enrollees, but they usually still see non-HMO patients and patients from other insurance companies
IPAs
give physicians the benefits of independence, multiple sources of patients, and other contracting agreements

reimburse physicians on a capitated or a fee-for-service basis
A discounted fee structure is usually on a fee-for-service (FFS) arrangement
When A managed care organization of health care delivery in which a third-party payer contracts with a group of medical care providers who furnish services at a lower than usual fee (usually about 10% to 20% below normal fees) in return for prompt payment and a certain volume of patients.
PPO
may reduce the total panel of providers to some degree

precertification is common

second opinion uncommon

benefits are reduced if a member seeks care from a provider who is not in the PPO network.

offer members "richer" benefits as financial incentives to use network providers

incentives may include lower deductibles, lower co-payments and higher reimbursements. For example, if a patient sees an in-network family physician for a routine visit, he or she may only have a small co-payment or deductible. If a patient sees a non-network family physician for a routine visit, he or she may have to pay for a considerable portion of the total bill.
The main difference between a PPO and an “indemnity” or “service” plan is
that failure to comply with these programs results in financial penalty to the provider, not to the subscriber

The provider may not bill the patient for any balance that the PPO does not pay, except for the normal deductible and co-insurance.

Although payment mechanisms to providers may fall along the lines mentioned under service plans, the discounts are generally greater
There are 2 broad approaches a PPO may take to establish a panel:
“any willing provider” acceptance versus criteria-based selection.
PPO-- “any willing provider”
any provider who wishes to participate in the organization and who agrees to the terms of the contract is offered a contract

this approach is more common.
PPO
uses objective criteria – such as credentials or practice pattern analysis – that a provider must meet before receiving a contract offer.
A PPO may reduce
the total panel of providers to some degree
Point-of-service plans combine
features of HMOs and traditional insurance plans
Point-of-service plans were developed because
of the conflict between cost control and total freedom of choice of providers.
POS system is sometimes referred to as an
"open-ended" HMO
POS (Point-of-Service Plan)
Is a health insurance program that offers two levels of coverage. The policy holder can select from a network of HMO providers and pay a small co-payment only, or can select a non-network provider, personally pay the bill in full, and subsequently receive a reduced reimbursement for payment of the service provided by the non-network provider. The patient is incentivized to use contracted providers through the fuller coverage offered for contracted care.

have become less common in recent years because their cost has not been favorable when compared with either PPOs or HMOs
In a POS
Members may choose which system to use at the point at which they obtain the service. By bringing the issue of cost differential directly to HMO members at the point at which they seek medical services, the members are more active participants in the process.
Refers to a method of payment under managed care for health services in which the health care provider is paid a fixed amount for each person over a specific amount of time, regardless of the actual number or nature of services/visits provided to each person.
Capitation
A pharmacy benefit manager
is an organization that manages pharmaceutical benefits for a MCO, other medical providers, or an employer.

contract with clients interested in optimizing the clinical and economic performance of their pharmacy benefit.

may include some or all of the following: benefit plan design, creation/administration of retail and mail-order pharmacy networks, claims processing and managed prescription drug care services such as drug utilization review, formulary management, generic dispensing, prior authorization and disease and health management.

offer personalized services involving counselors -- such as pharmacists, registered nurses, certified pharmacy technicians or case management specialists -- who work with the patient to achieve adherence with prescribed therapies.
Specialty pharmacies
have varying services which have generally come to include access to, and support for, most biologic pharmaceutical products (specialty drugs) for managed care patients
The drugs dispensed by specialty pharmacies include
most injectables, including those administered at home, and adjuvant therapies.

These products have high costs, are difficult to manage, and have reimbursement challenges.
Specialty Pharmacy Support services
for patients with specific diagnoses requiring biologic therapy treatment may include prior authorization and other utilization management services, data reporting, appeals processing, delivering medications and ancillary supplies (needles, syringes, alcohol swabs), and around-the-clock access to a health care professional for information and follow-up, as well as others.
specialty pharmacies coordinate
with manufacturers' external reimbursement programs and not-for-profit financial assistance foundations for patients needing those services. Home injection training support is coordinated when appropriate.

All of this helps to streamline the drug-distribution, delivery, and management processes which engage each patient in their own care.
Companies that provide only administrative services (ASO) are known as
TPAs
TPAs
These usually include self-funded employers and, in some cases, insurance companies.

assume the administrative responsibility (usually at a fixed negotiated rate) of handling all claims, including claims processing, answering claimant's questions, and acting as a liaison between the offices and officers of the payer and the health care provider groups.

may also contract to perform medical management services.
Medicare
Created in 1965 by amendments to the Social Security Act (SSA)

Is the hospital insurance, supplementary medical insurance system, and in some cases the outpatient drug insurance (Medicare Part D) for older Americans and the disabled.
The Centers for Medicare and Medicaid (CMS), formerly known as the Health Care Financing Administration (HCFA), administers
Medicare, which provides health insurance to persons age 65 and older, disabled persons, and persons with permanent kidney failure
SSDI beneficiaries qualify for Medicare:
after 25 months of receiving SSDI benefits (the general rule described previously)

at the first month of receiving SSDI benefits if the beneficiary has amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease); or after the third month when a beneficiary has end-stage renal disease (ESRD) or kidney failure; or in the month in which a beneficiary receives a kidney transplant.
Federal government assistance to the State Medicaid programs was administered by the
Social and Rehabilitation Service (SRS).
SSA and SRS were agencies in the
Department of Health, Education, and Welfare (HEW
In 1977, the Health Care Financing Administration was created under
HEW to effectively coordinate Medicare and Medicaid
In 1980, HEW was divided into
the Department of Education and the Department of Health and Human Services (HHS).
In 1945, Harry S. Truman was the first US President to propose
a prepaid health insurance plan
On November 19, 1945, President Truman outlined
a comprehensive, prepaid medical insurance plan for all people through the Social Security system
The comprehensive, prepaid medical insurance plan
was done in a special message to Congress.

This plan included doctors and hospitals, as well as nursing, laboratory, and dental services; it was dubbed "National Health Insurance."

Additionally, medical insurance benefits for needy people were to be financed from federal revenues.
it wasn't until 1965 that President Lyndon B. Johnson signed
H.R. 6675 (The Social Security Act of 1965; PL 89-97) to provide health insurance for the poor and the elderly.
President John F. Kennedy pressed legislators for health insurance for
the aged because A national survey found that only 56 percent of those 65 years of age or older had health insurance.
In Independence, Missouri, President Johnson signed
the Medicare and Medicaid Bill (Title XVIII and Title XIX of the Social Security Act) in 1965 in the presence of former President Truman, who then received the first Medicare card at the ceremony; Lady Bird Johnson, Vice-President Hubert Humphrey, and Mrs. Truman also were present.
In 1972, the Social Security Amendment expanded Medicare to provide
coverage to two additional high-risk groups: disabled persons receiving cash benefits for 24 months under the Social Security program, and persons suffering from end-stage renal disease.
Beginning in October 1983, Medicare was paid under a
DRG (Diagnosis Related Group) reimbursement schedule
In 1992, physicians under Medicare Part B began receiving payments
Based upon an RBRVS (Resource-Based Relative Value Scale) system

physicians were no longer reimbursed under the old "reasonable and customary charge" method, which had been the basis of reimbursement for physicians since the inception of Medicare in the 1960s.
Medicare has _____parts
four
Most of the aged population of the United States is enrolled in Medicare
Part A, also called Hospital Insurance, covers the expenses of hospitalization, skilled nursing facility care, and some hospice stays
Part B, or Supplementary Medical Insurance, pays for
services like
clinician visits
outpatient care
medical equipment and supplies
some preventive services
some drugs that are obtained by a physician and administered "incident to" a physician office visit.
Most vaccines
recipients of Medicare Part A
are automatically eligible for Medicare Part B, provided they can pay the monthly premiums established through insurance companies that provide Part B insurance.
People who choose to be covered by Part B
pay the monthly premiums established through insurance companies that provide Part B insurance.
Part C is the Medicare managed care option, in which
Medicare pays a capitated rate to an HMO, PPO, FFSP, or other managed care organization to provide the Medicare benefits.
Part C plans
used to be called Medicare+Choice plans, but now are known as "Medicare Advantage Plans.

funding level is higher than it was under the Medicare+Choice schema
the Medicare Modernization Act (MMA) provides for a
a phased-in chronic care case management plan and also includes chronic care case management as an element of quality improvement in the Medicare Advantage Plans.
Part C Medicare Advantage Plans offering a coordinated care plan must
collect, analyze, and report data measuring health outcomes and other quality indices.
Part C Medical Advantage established specialized MA plans (Special Needs Plans, or SNPs)
designed for those with special needs such as those that are institutionalized, entitled to medical assistance under Title XIX (Medicaid), or meet other requirements established by the Secretary of Health and Human Services (HHS).

provide all covered Medicare health benefits as well as more focused care to manage a disease or condition such as congestive heart failure, diabetes, or end-stage renal disease.

are conceptually linked to the Chronic Care Case Management initiative in the MMA and the requirement that all MA plans have ongoing quality improvement programs that include a chronic care improvement program.
Medicare also launched in 1983 the Prospective Payment System (PPS). The basis of PPS is
the DRG system developed by Yale University.

Total payments to a hospital under Medicare were split into prospective payment DRGs and reasonable cost payments.

All hospitals participating in Medicare programs were required to participate in PPS except for psychiatric hospitals, rehabilitation hospitals, children's hospitals, long-term care hospitals and hospitals in states with an approved waiver.l
Medicare Part D, was
instituted in January 2006.

a voluntary drug benefit instituted under the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 because few Medicare recipients had prescription drug coverage under Medicare
In the 1990s, Medicare initiated specifications for managed care contracts, whereby insurers were required to meet the following criteria when accepting Medicare enrollees:
Must offer all Medicare benefits
May provide additional benefits
HCFA approves premiums
Enrollment requirements
No health screenings allowed
Must have 5,000 commercial members
Beneficiaries are locked in for 30 days
Full financial risk borne by the managed care organization
On January 1, 1999, the Balanced Budget Act (BBA) of 1997 became effective and
significantly changed how providers were reimbursed for care and how consumers received their care

The primary intent of the new program, called Medicare Advantage, formerly known as Medicare+Choice, was to build upon the success of HMOs by providing additional options and encouraging further enrollment in plans separate from and different from traditional Medicare.
The BBA of 1997, as amended by the Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) of 1999, called for
the development and implementation of a prospective payment system (PPS) for Medicare home health services.

put into place the interim payment system (IPS) until the PPS could be implemented.

Note: Effective October 1, 2000, the home health PPS replaced the IPS for all home health agencies. The PPS proposed rule was published on October 28, 1999, with a 60-day public comment period. The final rule was published on July 3, 2000.
The Outcome and Assessment Information Set (OASIS) is
a group of data elements that form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI) and represent core items of a comprehensive assessment for an adult home care patient.
The OASIS is a key
key component of Medicare's partnership with the home care industry to foster and monitor improved home health care outcomes, and it is proposed to be an integral part of the revised Conditions of Participation for Medicare-certified home health agencies (HHAs).
Most data items in the OASIS were derived in the context of a
context of a CMS-funded national research program (co-funded by The Robert Wood Johnson Foundation) to develop a system of outcome measures for home health care.

This program, and the OASIS, have evolved over a ten-year developmental period.
OASIS core data items
were refined through several iterations of clinical and empirical research

have utility for outcome monitoring, clinical assessment, care planning, and other internal agency-level applications.

measures the changes in a patient's health status between two or more time points.

Note: Other items were added later by a work group of home care experts to augment the outcome data set with selected items deemed essential for patient assessment
The goal of OASIS
was not to produce a comprehensive assessment instrument, but to provide a set of data items necessary for measuring patient outcomes and essential for assessment — which HHAs in turn could augment as they judged necessary
OASIS data items encompass
sociodemographic, environmental, support system, health status, and functional status attributes of adult non-maternity patients, and selected attributes of health service utilization are included

should be part of a comprehensive patient assessment, but it is emphasized that the OASIS was not developed as a comprehensive assessment tool.
OASIS data have three important uses in the areas of patient assessment and care planning for individual adult patients:
agency-level case mix reports that contain aggregate statistics on various patient characteristics such as demographic, health, or functional status; health service utilization characteristics of the patient; and internal HHA performance improvement.
Oasis data
are collected at start of care, 60-day follow-ups, and discharge (and surrounding an inpatient facility stay).

All applications build on and implemented most efficiently and effectively when OASIS data items are thoroughly integrated into HHA clinical documentation.
Most of the OASIS items describe
patient health and functional status, which is useful in assessing the care needs of adult patients.

NOTE: HHAs will find it necessary to supplement the OASIS items in order to comprehensively assess the health status and care needs of their patients (for example, the OASIS does not include vital signs, which are typically included in patient assessments).
Two rules relating to HHAs were finalized by CMS.
The first rule revises the existing HHA Conditions of Participation by requiring that HHAs collect OASIS data.

The other expands those new Conditions of Participation by requiring HHAs to report OASIS to their state survey agency. HHAs are required to electronically transmit OASIS data to the standard state system, which has been installed by CMS. CMS has installed the additional software to accommodate this data transmission in each state.
The state is also responsible for preparing OASIS data for retrieval by a central repository to be established
by CMS
the goals for OASIS automation is
to fulfill the HHA provisions of the Balanced Budget Act (BBA) of 1997.

is to provide states with enhanced ability to direct on-site HHA inspection resources through the use of OASIS data.
The Medicare Modernization Act began because
"Full financial risk" borne by health plans over time became so significant that a mass exodus of health plans from Medicare occurred in the late 1990s and early 2000s
The BBA includes a Medicare requirement for
HHA prospective payment that depends on the data acquired by the OASIS system.

This provision of the BBA was effective for HHA's cost reporting periods starting October 1, 2000.
On December 8, 2003, President George W. Bush signed into law
the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003
the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003
is a landmark legislation providing seniors and people living with disabilities with a prescription drug benefit (the new Medicare Part D), more choices and better benefits under Medicare.

was the most significant improvement to senior health care in nearly 40 years.

was a new federal legislation enacted in 2006.

Had a number of sections provided herein which describe some of the changes that were instituted with this new legislation, including information describing the new medication coverage that applies to both Medicare and Medicaid populations.
two of the most important provisions of the Medicare Modernization Act (MMA)
new voluntary drug benefits

enhanced health plan choices in Medicare Advantage
As a result of these new Medicare Modernization Act (MMA) benefits beneficiaries
were and are able to get voluntary drug coverage and new support for their existing drug coverage through Medicare

can obtain access to preferred provider organizations (PPOs) through Medicare Part C
Regarding (PPOs) through Medicare Part C and Prescription Drug improvement:
were (PPO) the most popular health plan choices for non-Medicare beneficiaries

Regional (PPO) types were included in the new Medicare plan in addition to local Medicare Advantage programs.

In 2004, Prescription Discount Cards became available to Medicare recipients.

Enrollment for the new prescription drug plans began in 2005.
When the Medicare Modernization Act (MMA) was drafted, states saw the opportunity
to shift some benefit liability from Medicaid to Medicare (or from the state's budget to the federal budget).
Liability for prescription drugs for "dual eligibles" shifted to the
Medicare Part D program
Medicaid's program benefits are set by
Congress and are funded jointly by the federal government and the states

Note: Many states have run deficits in their Medicaid programs and have been looking for ways to reduce state Medicaid expenditures. When the Medicare Modernization Act (MMA) was drafted, states saw the opportunity to shift some benefit liability from Medicaid to Medicare (or from the state's budget to the federal budget). Liability for prescription drugs for "dual eligibles" shifted to the Medicare Part D program.
Vocational Rehabilitation (VR)
is a state system utilized to fund medical services and return-to-work training and education for individuals who otherwise have little or no medical and/or vocational coverage

is typically the last available resource for eligible candidates

Eligible candidates must demonstrate specific financial need and must be employable (with sufficient training and rehabilitation).

Environmental access, in both home and work settings, is often covered as part of the services provided to enable the individual to return to work
A Department of Veterans Affairs' Veterans Benefits Administration's Vocational Rehabilitation and Employment (VR&E) service
also exists for those with a service-connected disability.

is vested with delivering timely, effective vocational rehabilitation services to veterans

The purpose is to enable injured soldiers, sailors, airmen, and other veterans with disabilities for a seamless transition from military service to a successful rehabilitation and on to suitable employment after their military service
In catastrophic cases, the self-insured or traditional premium-based insurance company sets a threshold over which financial responsibility for health benefits will be borne by a stop-loss carrier. The stop-loss carrier is known as a reinsurance carrier. If a large loss happens, __________prevents the insurance company from going bankrupt.
Reinsurance


Reinsurance example: A company might have health care benefits of $1 million per covered life with a threshold set at $100,000 with a reinsurer insurance company. This means that there is coverage for clients for claims of $150,000 or $250,000, but the company only pays the first $100,000 out of its group coverage, and is reimbursed, dollar for dollar, by the stop-loss carrier for any costs over the threshold, up to $1 million.
Coordination of Wage Loss Benefits
When these benefits are applicable to the injured worker, wage loss payments under workers' compensation can be coordinated with SSDI (social security disability income) or Long Term Disability insurance.

it is the responsibility of the carrier to inform the injured worker about potential benefits under SSDI if the carrier suspects or confirms that the injured worker may be eligible.

the carrier cannot reduce or withhold wage loss benefits from the employee before the employee actually begins to receive SSDI payments.
Workers' compensation
is a no-fault, individually-governed state insurance system that addresses work related injuries

has been around since the enactment of the Workers' Compensation Act in 1911

law is intended to assure quick and efficient delivery of disability and medical benefits to an injured worker and to facilitate the worker's return to gainful employment whether or not the worker is at fault for the injury

pays for all reasonable and medically necessary care if an injury or developed occupational disease occurs because of conditions related to the job

Specific state laws determine the benefits to which the injured employee is entitled

Employers assume the cost of medical treatment and wage loss stemming from a worker's job-related injury whether the worker is part-time or full-time

NOTE: Employees are covered under workers' compensation immediately when they are hired
Workers' Compensation characteristics:
• State mandated guidelines
• No deductible or co-pay
• Wage loss benefit
• Physician of choice
• Specialist driven
• Unlimited medical coverage
• Heavy litigation
Managed Care characteristics:
• Company guidelines
• Deductible or co-pay
• No wage loss benefit
• Network arrangement
• Primary care driven
• Restricted coverage
• Moderate litigation
In some cases, claims denied under workers' compensation can result from
drug and/or alcohol abuse in the work place

NOTE:
Since many companies participate in a drug-free workplace which is approved by the state, this allows for workers' compensation claims to be denied if the employee is found to be using drugs/alcohol at the time the injury occurs.
Disability Case Manager
coordinates appropriate medical care for the injured worker, as well as arranges for timely return-to-work

Critical role is Ensuring and enhancing communication among the employer, the carrier, the primary care physician, specialty physicians, ancillary health care professionals, and the injured worker
Long-Term Care Insurance
provides one of the only options for supportive care available to the older population

Most private health insurance plans do not include long-term care coverage as a standard provision

For the younger population, it can be vitally important if a catastrophic injury occurs. The spinal cord injured patient's health insurance policy limits rehabilitation coverage and provides very limited or no custodial care benefit. Yet, the spinal cord injured patient may require lifelong assistance

Formerly, it provided only nursing home care, but today's expanded health care arena allows many services potentially covered under long-term care insurance. These may include: hospice, adult day care, sub-acute or skilled nursing facility (SNF), transitional living centers, home health care or custodial care.

Benefit triggers, which define the clinical conditions that must be present in order for the insured to receive benefits, respond to clinical deficiencies in two broad areas: activities of daily living; and cognitive impairment
Long-Term Care Insurance criteria
A contract will state how many activities of daily living (generally at least two) must be deficient and to what degree before the policy benefits take effect

Cognitive impairments are defined as deficiency in either short-term or long-term memory as to person, place or time, or deductive or abstract reasoning (judgment)

Some contracts also allow for medical necessity, which permits an insured to access benefits if he/she does not meet the activities of daily living or cognitive impairment standard. Under medical necessity, a physician or other health care professional (such as a case manager) can certify that the requested care is correct and appropriate to the insured's care.
Own Occ/Any Occ" Rule in Disability Insurance
is an important aspect of disability insurance

Disability management insurance payments can be based upon the client's own occupation ("own occ") or any comparable occupation ("any occ"), depending upon the plan's benefits

Some plans will only pay wage losses for the policyholder's own occupation for a specific period of time; thereafter, the wage loss payments can be based upon an "any occ" capitated rate

Example: a dentist is experiencing peripheral neuropathy. She is unable to perform the skills inherent to her profession. Under an "own occ" policy, the dentist would receive wage loss payments based upon her lost income. Under an "any occ" policy, the dentist may only receive a capitated payment for a "comparable" job, or may not receive wage loss at all, due to her ability to work in a completely different capacity
Disability insurance
is a form of health insurance that usually provides periodic payments to replace an insured's income when that person is unable to work due to an injury or illness

is "plan specific."
Short-term disability (STD) benefits
usually cover the individual during the time in which a disability exists, for a specified period not to exceed two years, or as otherwise specified in the policy
Long-term disability (LTD) insurance
can be issued to a group or individual to provide a reasonable replacement of a portion of income lost due to a serious or prolonged illness
Auto Liability
The medical coverage limits and wage loss replacement in auto insurance policies vary from state to state

In states where medical coverage is offered, the benefits are called personal injury protection (PIP). This can also be seen in rental car agreements.

The amount and intent of case management involvement also varies from policy to policy

EXAMPLE: In the case of Allstate Insurance Company v. Kane, the insurance company wished to involve itself in planning the rehabilitation program for its insured, who suffered permanent spastic paraplegia. The insurance company requested a court order for it to participate under Sections 404 and 405 of the No-Fault Law. The court held that these sections did not grant Allstate the right to participate in the administration of the rehabilitation process. Essentially, the insurance company in this case had no right to control the planning of the rehabilitation program, which was left to the treating medical professionals.
Social Services—Others
Women, Infants and Children (WIC); Family Medical Services (FMS); and Centers for Independent Living (CIL); are examples of various social service systems that exist from state-to-state, which operate under federal, state, and local funding provided through and within a fund-match system

These systems include clear requirements for the types of benefits and the required qualifications to receive the benefits

that are considered private can include the Muscular Dystrophy Association; the March of Dimes; the Paralyzed Veterans Association; the Easter Seals Foundation; the United Cerebral Palsy Association; the United Way; and Christmas in July.
Services covered under the basic TRICARE benefit
cannot be authorized under the TRICARE ECHO program

those services must be authorized under the TRICARE program option the beneficiary is using (TRICARE Prime, TRICARE Prime Remote, TRICARE Standard, TRICARE Extra
In addition to coverage received via the primary TRICARE plan, TRICARE ECHO benefits may include
• Medical and rehabilitative services
• Training to use assistive technology devices
• Special education
• Institutional care when a residential environment is required
• Transportation under certain circumstances
• Assistive services, such as those from a qualified interpreter or translator, for beneficiaries whose visual or hearing impairment qualifies them for ECHO benefits
• Durable equipment, including adaptation and maintenance
• In-home medical services through TRICARE ECHO Extended Home Health Care (EHHC)
• In-home respite care services (Note: Only one of the following respite care benefits may be used in a calendar month)
• ECHO Respite care -- 16 hours per month when receiving other authorized ECHO benefits
• EHHC Respite care -- up to 40 hours per week (eight hours per day, five days per week) if homebound
Another example of how TRICARE may interface with or replace existing legislation is the enactment of TRICARE's Extended Care Health Option (ECHO)
which went into effect September 1, 2005

replacing the existing TRICARE Program for Persons with Disabilities (PFPWD)

which provides financial assistance to active duty family members who have a qualifying condition as defined by law

which offers an integrated set of services and supplies that supplement the basic TRICARE program options
ECHO benefits are available with a qualifying condition to an active duty TRICARE eligible child or spouse of:
1. A member of one of the Uniformed Services of the United States, including members of the Reserve Component activated for a period of more than 30 days; or
2. Family members eligible for continued TRICARE medical benefits through the Transitional Assistance Management Program (TAMP); or
3. A former member of a Uniformed Service of the United States when the child or spouse is the victim of physical or emotional abuse.
The following are qualifying conditions under both PFPWD and ECHO:
• Moderate or severe mental retardation
• A serious physical disability
• An extraordinary physical or psychological condition of such complexity that the beneficiary is homebound
Over age 23 ECHO dependent eligibility
Recipients may retain their eligibility for ECHO services as long as the sponsor remains on active duty. Even children of sponsors who reach the usual TRICARE eligibility age limit (21, or age 23 if enrolled in college full-time) retain their eligibility for ECHO services, as long as the sponsor remains on active duty, the child is incapable of self-support because of a mental or physical incapacity that occurs prior to the loss of their eligibility, and the sponsor is responsible for more than one-half the child's support.
Medicare Part D and Tricare pharmacy
TRICARE pharmacy benefit is considered a secondary payer to the Medicare Part D prescription drug plan

When Part D went into effect by the Centers for Medicare and Medicaid Services (CMS) in January 2006, CMS began automatically enrolling some TRICARE beneficiaries in a Part D prescription drug plan

At that time the TRICARE Management Activity (TMA), the Defense Manpower Data Center (DMDC) and CMS jointly developed a customer-focused process for beneficiaries to resolve Medicare Part D and TRICARE coverage issues, to minimize any delays in obtaining medications.
65 YO TRICARE beneficiaries must enroll in
Medicare Part B to maintain their TRICARE eligibility
Medicaid (general)
provides medical assistance for certain individuals and families with limited resources

is a jointly-funded cooperative venture between the federal and state governments to assist states in the provision of adequate medical care to eligible needy persons

is the largest program providing medical and health-related services to America's poorest people
Medicaid was enacted
In 1965, under Title XIX of the Social Security Act
Medicaid
Within broad national guidelines which the federal government provides, each of the states:
• Establishes its own eligibility standards
• Determines the type, amount, duration and scope of services
• Sets the rate of payment for services
• Administers its own program
Medicaid (state policies)
policies for eligibility, services, and payment are complex and vary considerably, even among states of similar size or geographic proximity

eligibles in one state may not be eligible in another state, and the services provided by one state may differ considerably in amount, duration, or scope, from services provided in a similar or neighboring state

state legislatures may change Medicaid eligibility, services, and/or reimbursement during the year
Medicaid (who is covered)
does not provide health care services even for the very poor, unless they are in one of the designated groups

candidates low income is only one test for eligibility for those within these groups; their resources also are tested against threshold levels (as determined by each state within federal guidelines)

potential persons and families not previously covered by Medicaid may see new eligibility on a state-by-state basis with the introduction of health care reform's Health Insurance Marketplace in 2014
general category of mandatory Medicaid "categorically needy" eligibility groups for which federal matching funds may be provided:
• Individuals meeting the requirements for the Aid to Families with Dependent Children (AFDC) program
• Children under age 6 whose family income is at or below 133 percent of the federal poverty level (FPL), or children born after September 30, 1983, who are under age 19 and in families with incomes at or below the FPL
• Pregnant women whose family income is below 133 percent of the FPL (services to these women are limited to those related to pregnancy, complications of pregnancy, delivery, and postpartum care)
• Supplemental Security Income (SSI) recipients in most states (some states use more restrictive Medicaid eligibility requirements that pre-date SSI)
• Recipients of adoption or foster care assistance under Title IV of the Social Security Act
• Special protected groups (typically individuals who lose their cash assistance due to earnings from work or from increased Social Security benefits, but who may keep Medicaid for a period of time)
States also have the option of providing Medicaid coverage for other "categorically related" groups. These optional groups share characteristics of the mandatory groups (that is, they fall within defined categories), but the eligibility criteria are somewhat more liberally defined. The broadest optional groups for which states will receive federal matching funds for coverage under the Medicaid program may include the following:
• Infants up to age 1 and pregnant women not covered under the mandatory rules whose family income is no more than 133 percent of the FPL (the percentage amount is set by each state)
• Children under age 21 who meet the AFDC income and resources requirements
• Institutionalized individuals eligible under a "special income level" (the amount is set by each state -- up to 300 percent of the SSI federal benefit rate)
• Individuals who would be eligible if institutionalized, but who are receiving care under home and community-based services waivers individualized by each state
• Certain aged, blind, or disabled adults who have incomes above those requiring mandatory coverage, but below the FPL
• Recipients of state supplementary income payments
• Certain working and disabled persons with family income less than 250 percent of the FPL who would qualify for SSI if they did not work
• TB-infected persons who would be financially eligible for Medicaid at the SSI income level if they were within a Medicaid-covered category (however, coverage is limited to TB-related ambulatory services and TB drugs)
• Certain uninsured or low-income women who are screened for breast or cervical cancer through a program administered by The Centers for Disease Control and Prevention's The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law 106-354)
• "Optional targeted low-income children" included within the State Children's Health Insurance Program (SCHIP) established by the Balanced Budget Act (BBA) of 1997 (Public Law 105-33)
• "Medically needy" persons
To be eligible for Federal (Medicaid) funds, states are required to provide
Medicaid coverage for certain individuals who receive federally-assisted income-maintenance payments, as well as for related groups not receiving cash payments.
Title XIX of the Social Security Act allows considerable flexibility within the state's Medicaid plans. However, some federal requirements are mandatory if federal matching funds are to be received. A state's Medicaid program must offer medical assistance for certain basic services to most categorically needy populations. These services generally include the following:
• Inpatient hospital services
• Outpatient hospital services
• Prenatal care
• Vaccines for children
• Physician services
• Nursing facility services for persons aged 21 or older
• Family planning services and supplies
• Rural health clinic services
• Home health care for persons eligible for skilled-nursing services
• Laboratory and x-ray services
• Pediatric and family nurse practitioner services
• Nurse-midwife services
• Federally-qualified health center (FQHC) services, and ambulatory services of an FQHC that would be available in other settings
• Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21
States may also receive federal matching funds to provide certain optional services. Following are the most common of the thirty-four currently approved optional Medicaid services:
• Diagnostic services
• Clinic services
• Intermediate care facilities for the mentally retarded (ICFs/MR)
• Prescribed drugs and prosthetic devices
• Optometrist services and eyeglasses
• Nursing facility services for children under age 21
• Transportation services
• Rehabilitation and physical therapy services
• Home and community-based care to certain persons with chronic impairments
As with Medicare, substantive changes to Medicaid insurance were outlined under the Patient Protection and Affordable Care Act. As a result of the Act, specific changes to Medicaid beginning in 2010 included the following.
2010
• Cracking Down on Health Care Fraud, as outlined in the previous section on Medicare.
• Allowing States to Cover More People on Medicaid. States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents.
2011
• Improving Health Care Quality and Efficiency, as outlined in the previous section on Medicare.
• Increasing Access to Services at Home and in the Community. The new Community First Choice Option allows States to offer home and community based services to disabled individuals through Medicaid rather than institutional care in nursing homes.
2013
• Improving Preventive Health Coverage. To expand the number of Americans receiving preventive care, the law provides new funding to state Medicaid programs that choose to cover preventive services for patients at little or no cost.
• Increasing Medicaid Payments for Primary Care Doctors. As Medicaid programs and providers prepare to cover more patients in 2014, the Act requires states to pay primary care physicians no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services. The increase is fully funded by the federal government.
• Providing Additional Funding for the Children’s Health Insurance Program. Under the new law, states will receive two more years of funding to continue coverage for children not eligible for Medicaid.
2014
• Increasing Access to Medicaid. Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years.
states have begun implementing case management programs within their traditional Medicaid programs to address the needs of chronically ill patients, outside of the managed care because
According to the Agency for Healthcare Research and Quality (AHRQ), states have realized that some of their most costly enrollees are those with chronic illness, of which the majority of adult enrollees (nearly 60%) are often not cared for in managed care Medicaid programs, Medicaid fee-for-service (FFS) or primary care case management (PCCM) programs
more than 30 states have integrated case management programs due to the
CMS sending a letter to State Medicaid directors in February 2004 to encourage them to utilize case management opportunities in their fee-for-service (FFS) and primary care case management (PCCM) programs

NOTE: Evaluation of these case management programs could include determining whether the program goals are being met, identifying whether performance improvement is possible in this patient population, and determining whether similar effects can be achieved more efficiently than in this type of program.
Potential case management program outcomes anticipated by Medicaid program utilization include, but are not limited to:
improved quality of life;
improved health and functional status of patients with an increased ability to perform activities of daily living; better management of psychosocial effects of disease; improved indicators of high quality care delivery such as improved HEDIS scores (Healthcare Effectiveness Data and Information Set);
increased school or workplace attendance; increased treatment regimen adherence;
reduction in health complications of chronic diseases; increased use of evidence-based practice guidelines by providers;
reduced medical complications from chronic disease; reduced use of lab tests for acute episodes;
fewer emergency room visits and hospitalizations or re-admissions;
more effective treatment choices with fewer unscheduled office visits;
and shorter hospital stays.
In the MEDICAID medically needy (MN) option
A state may elect to provide MN eligibility to certain additional groups and may elect to provide certain additional services within its MN program.

persons would be eligible under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level set by their state.

may qualify immediately or may "spend down" by incurring medical expenses that reduce their income to or below their state's MN income level

Medicaid eligibility and benefit provisions for them do not have to be as extensive as for the categorically needy, and may be quite restrictive

Federal matching funds are available for these programs, however, if a state elects to have an MN program, there are federal requirements that certain groups and services must be included
In addition to their Medicaid programs, most states have additional
"state-only" programs to provide medical assistance for specified poor persons who do not qualify for Medicaid. Federal funds are not provided for state-only programs
In order to “bring an end to some of the worst abuses in the health care industry,” the Patient Protection and Affordable Care Act (commonly referred to as “Health Care Reform”) was signed into law by President Obama on March 23, 2010. The Act included a series of changes to be made over a period of 4 years. Some of the changes specific to Medicare include the following (part 1):
2010
• Offering Relief for 4 Million Seniors Who Hit the Medicare Prescription Drug “Donut Hole.” It was estimated that, in 2010, four million seniors would reach the gap in Medicare prescription drug coverage known as the “donut hole.” Under the provisions of the Act, each such senior would receive a $250 rebate, with checks mailed monthly throughout 2010 as seniors hit the coverage gap.
• Cracking Down on Health Care Fraud. In fiscal year 2009 alone, efforts to fight fraud returned more than $2.5 billion to the Medicare Trust Fund. The new law invested new resources and required new screening procedures for health care providers to boost these efforts and reduce fraud and waste in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
In order to “bring an end to some of the worst abuses in the health care industry,” the Patient Protection and Affordable Care Act (commonly referred to as “Health Care Reform”) was signed into law by President Obama on March 23, 2010. The Act included a series of changes to be made over a period of 4 years. Some of the changes specific to Medicare include the following (part 2):
2011
• Offering Prescription Drug Discounts. Seniors who reach the coverage gap will receive a 50% discount when buying Medicare Part D covered brand-name prescription drugs. Over the subsequent decade, seniors will receive additional savings on brand-name and generic drugs until the coverage gap is closed in 2020.
• Providing Free Preventive Care for Seniors. The law provided for certain free preventive services, such as annual wellness visits and personalized prevention plans for seniors on Medicare.
• Improving Health Care Quality and Efficiency. The law established a new Center for Medicare & Medicaid Innovation to begin testing new ways of delivering care to patients. The methods were expected to improve the quality of care and reduce the rate of growth in health care costs for Medicare, Medicaid, and CHIP.
• Improving Care for Seniors After They Leave the Hospital. The Community Care Transitions Program will help high-risk Medicare beneficiaries who are hospitalized avoid unnecessary readmissions by coordinating care and connecting patients to services in their communities.
• Introducing New Innovations to Bring Down Costs. The Independent Payment Advisory Board will begin operations to develop and submit proposals to Congress and the President aimed at extending the life of the Medicare Trust Fund. Under the Act, the Board will be expected to focus on ways to target waste in the system, and recommend ways to reduce costs, improve health outcomes for patients, and expand access to high-quality care.
• Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage. As of 2010, Medicare paid Medicare Advantage insurance companies over $1,000 more per person on average than was spent per person in Traditional Medicare. This resulted in increased premiums for all Medicare beneficiaries, including the 77% of beneficiaries who were not currently enrolled in a Medicare Advantage plan. The new law will level the playing field by gradually eliminating this discrepancy. People enrolled in a Medicare Advantage plan will still receive all guaranteed Medicare benefits, and the law will provide bonus payments to Medicare Advantage plans that provide high quality care.
In order to “bring an end to some of the worst abuses in the health care industry,” the Patient Protection and Affordable Care Act (commonly referred to as “Health Care Reform”) was signed into law by President Obama on March 23, 2010. The Act included a series of changes to be made over a period of 4 years. Some of the changes specific to Medicare include the following (part 3):
2012
• Linking Payment to Quality Outcomes. The law will establish a hospital Value-Based Purchasing program (VBP) in Traditional Medicare. This program will offer financial incentives to hospitals to improve the quality of care. Hospital performance would be required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients’ perception of care.
2013
• Expanding Authority to Bundle Payments. The law will establish a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care. Under payment “bundling,” hospitals, doctors, and providers will be paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team would be compensated with a “bundled” payment that provides incentives to deliver health care services more efficiently while maintaining or improving quality of care. The vision is that this change will align the incentives of those delivering care, and savings will be shared between providers and the Medicare program.
many of the changes to commercial insurance as a result of Health Care Reform will also be applied
to Medicare Advantage plans offered by these insurance companies.
Expenses that will not count towards the out-of-pocket (OOP) deductible in Medicare Part D include:
• State program assistance payments for non-formulary drugs
• Payments by third-party insurers, including retiree plans
• Payments for drugs not covered by Part D
• Payments for drugs covered under Parts A and B
Expenses that count towards the out-of-pocket (OOP) deductible in Medicare Part D include:
• State Prescription Assistance Programs (SPAP) Payments
• Previously established state programs to help Medicare beneficiaries pay for prescription drugs
• CMS anticipates funds that states used to pay for drugs will be shifted to assist with co-pays, but the states may eliminate the assistance altogether
• Payments by pharmaceutical industry philanthropy programs (such as those that might be obtained through http://www.rxassist.org) for drugs will be counted, but the value of the drugs provided free of charge will not count
• Federal subsidies for those who meet low income guidelines