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48 Cards in this Set
- Front
- Back
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The Patient Protection and Affordable Care Act was signed into law by
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President Obama on March 23, 2010.
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Affordable Care Act
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outlined a series of changes to US health insurance, to be implemented over a period of 4 years.
prohibited insurance companies from denying coverage for children because of a pre-existing condition; putting lifetime or annual limits on care; canceling a policy without proving fraud; or denying claims without undergoing an appeal process. also enabled consumers to receive cost-free preventive services; keep young adults on their parents’ plans until the age of 26; choose their primary care physician, OB/GYN, and pediatrician; and use the nearest emergency department without penalty. Specific parts of the Act, like the establishment of outcomes-based measures, don’t mention care coordination and case management specifically, but how those are carried out and maintained depends on care coordination, which is a cornerstone of case management. |
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Case management
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is integral to the success of health care reform. As a result of the changes, case managers are increasingly utilized in more settings, and expansion of the programs under the Act requires utilizing case management as a central component for their operation.
knowledge on how to maximize necessary services based on patients’ insurance coverage and how to successfully transition a patient from one level of care to the next is key to reform success |
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Which coalition helped to bring much needed attention to the issue of improved care transitions during the development of Act?
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The National Transitions of Care Coalition (NTOCC), of which the Case Management Society of America is a major player
Note: This area is one where the skills and expertise of case managers can have the largest impact. |
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HITECH ACT
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This act was signed into law by President Obama as part of the American Recovery and Reinvestment Act (ARRA) and was designed to incentivize the nationwide adoption and effective utilization of health information technology (HIT) for the purpose of increasing health care quality, affordability, and outcomes.
Types of electronic exchange of health information supported by this act include electronic medical records (EMRs) and electronic health records (EHRs), which are discussed elsewhere in this course. According to the Centers for Medicare and Medicaid, providers have to demonstrate "meaningful use" of EHRs every year to receive incentive payments, and for those electing not to participate in the use EHRs, Medicare payment reductions would begin in 2015. |
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The Rehabilitation Act of 1973
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This is a basic federal law containing programs and civil rights for all people with disabilities4
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The Rehabilitation Act of 1973 Section 501:
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This section of the Act governs basic federal law containing programs and civil rights for all persons with disabilities. It prohibits employment discrimination against individuals with disabilities in the federal sector.
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The Rehabilitation Act of 1973 Section 502:
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This section pertains to the governance of the ATBCB (Architectural and Transportation Barriers Compliance Board), and accessibility laws provided by the ATBCB.
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The Rehabilitation Act of 1973 Section 503:
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This section pertains to affirmative action by the federal government for persons with disabilities. Compliance is required be federal employers, or by entities operating in federal locations, or funded with federal dollars.
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The Rehabilitation Act of 1973 Section 504:
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This section pertains to nondiscrimination of persons with disabilities by the federal government, or by entities operating in federal locations, or funded with federal dollars.
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Education for All Handicapped Children Act (EAHCA) 1975 and 1986
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This act pertains to the right of all disabled children to receive "free appropriate public education" and due process.
Individualized educational plans are mutually developed between parents and school officials. It establishes procedures by which disabled children are evaluated and their classifications determined. |
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Americans with Disabilities Act (ADA) Amendments Act of 2008
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• On September 25, 2008, President George W. Bush signed
• makes important changes to the definition of the term "disability" by rejecting the holdings in several Supreme Court decisions and portions of the Equal Employment Opportunity Commission (EEOC)'s ADA regulations. • retains the ADA's basic definition of "disability" as an impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment. However, it changes the way that these statutory terms should be interpreted in several ways. NOTE: In the rehabilitation setting is most commonly paired with worker's compensation issues. |
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More important focus on what the Americans with Disabilities Act (ADA) Amendments Act of 2008 established:
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• Directs the EEOC to revise that portion of its regulations defining the term "substantially limits"
• Expands the definition of "major life activities" by including two non-exhaustive lists: o The first list includes many activities that the EEOC has recognized (eg, walking) as well as activities that EEOC has not specifically recognized (eg, reading, bending, and communicating) o The second list includes major bodily functions (eg, "functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions") • States that mitigating measures other than "ordinary eyeglasses or contact lenses" shall not be considered in assessing whether an individual has a disability • Clarifies that an impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active • Provides that an individual subjected to an action prohibited by the ADA (eg, failure to hire) because of an actual or perceived impairment will meet the "regarded as" definition of disability, unless the impairment is transitory and minor • Provides that individuals covered only under the "regarded as" prong are not entitled to reasonable accommodation • Emphasizes that the definition of "disability" should be interpreted broadly |
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The Americans with Disabilities Act (ADA) was first signed
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into law by President George H.W. Bush in 1990, marking the single largest piece of legislation to protect the rights of disabled individuals in the history of the US.
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The ADA
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contains five sections
—Title I and Title III are the sections that most affect the rehabilitation industry. Title I of the ADA pertains to employment provisions and has been federally enforced since July 26, 1992 by the EEOC. Title III, pertaining to public access provisions, has been federally enforced since January 1, 1993, by the Department of Justice. Title II pertains to public transportation; Title IV applies to transmitting and telecommunication devices (TDDs), while Title V addresses the disabled individual's right of restitution. |
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Case managers
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can benefit from learning and understanding the basic provisions of Title I and III, as the ADA can be a useful tool in encouraging an employer to rehire an injured worker, or seek to hire a qualified disabled applicant.
These titles are also helpful to the occupational therapist, who often makes recommendations for workplace accommodations or adaptations in the social environment of a disabled individual for collaboration with CM. |
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ADA Facts
Essential Job Functions: The employer is responsible to identify those essential job functions that cannot be altered and must be physically and/or cognitively performed by the employee. Questions the employer or the evaluator should explore include: |
• Are employees in the position actually required to perform the function?
• Will removing that function fundamentally change the job? • Are there a limited number of employees available to perform the function, or among whom the function can be distributed? • Is the function highly specialized? |
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ADA Facts
Reasonable Accommodation: |
This term is defined in the Act as "any change to the work environment, or in the way things are usually done, that results in an equality employment opportunity for an individual with a disability."
Employers are obligated to make reasonable accommodation unless they can show that the accommodation would cause an undue hardship on the operation of the business. |
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ADA Facts
Undue Hardship: |
This term is defined as "excessively costly, extensive, substantial, or disruptive, or that would fundamentally alter the nature or operation of the business."
Tax credits are available for expenditures in making accommodations and hiring. |
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Architectural Barriers Act of 1968
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The federal agency responsible for enforcing the Architectural Barriers Act (ABA) of 1968 is the Architectural and Transportation Barriers Compliance Board (ATBCB); this agency is responsible for enforcing technological work related to accessibility.
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ECHO — TRICARE's Extended Care Health Option for Persons with Disabilities
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Effective September 1, 2005, this act pertains to coverage of persons under TRICARE in the US Military System and replaces the TRICARE Program for Persons with Disabilities. More information on ECHO can be found under the chapter on payer systems.
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Social Security Disability Income
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As part of the federal Social Security program, Social Security Disability Income (SSDI) provides for disability insurance.
This replaces a part of lost earnings due to any physical or mental impairment severe enough to prevent an individual from working. Monthly cash benefits are paid to eligible disabled persons and to eligible auxiliary beneficiaries throughout a period of disability after an initial five-month waiting period. Certain beneficiaries also receive costs of vocational rehabilitation. |
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Vocational Rehabilitation and Special Employment Services
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When compromised individuals apply under any one of the disability provisions of the Social Security law, they are automatically referred to state vocational rehabilitation.
agency has responsibility for providing counseling, training, and other services to return an individual to work for a trial period or for part-time or full-time status. An individual can continue to receive full disability for up to nine months while testing his or her ability to work. |
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(VR&E) Program
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Chapter 31 or Voc-Rehab.6
The program helps veterans with service-connected disabilities and employment handicaps prepare for, find, and keep suitable jobs. For veterans with service-connected disabilities so severe that they cannot immediately consider work, VR&E offers services to improve their ability to live as independently as possible. Certain eligibility criteria apply. |
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Administration on Developmental Disabilities
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plans and carries out programs for developmentally disabled persons with severe, chronic physical or mental handicaps who may require services over an entire lifetime.
works with state and community agencies to improve services and to maximize the use of federal, state, and local resources. mission is to improve and increase services and assure that individuals with developmental disabilities have opportunities to make their own choices, contribute to society, have support to live independently, and are free of abuse, neglect, financial and sexual exploitation, and violations of their legal and human rights. NOTE: Developmental disabilities (DD) are severe, life-long disabilities attributable to mental and/or physical impairments manifested before age 22. |
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US Department of Education Civil Rights Division
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responsible for the administration and enforcement of civil rights laws related to education of the disabled, whether primary or secondary education or in colleges, universities or vocational schools.
includes enforcing civil rights in state vocational rehabilitation agencies. responsible for ensuring compliance in programs and acts which receive federal financial assistance and by employers holding federal contracts. |
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Family and Medical Leave Act of 1993 (FMLA)
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requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to "eligible" employees for certain family and medical reasons in a 12-month period.
employees are eligible if they have worked for a covered employer for at least one year and for 1,250 hours over the previous 12 months, and if there are at least 50 employees within 75 miles. employer is not required to pay health benefits for the employee beyond the 12 weeks if the employee cannot return to work. Unpaid leave must be granted for ANY of the following reasons: • To care for the employee's spouse, son or daughter, or parent who has a serious health condition • To care for the employee's child after birth, or for the placement into adoption or foster care • To attend to a serious health condition that makes the employee unable to perform the job At the employee's or the employer's discretion, certain kinds of paid leave may be substituted for unpaid leave. FMLA is enforced by the US Department of Labor, which is authorized to investigate and resolve complaints of violations by the employee or by the employer. |
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ERISA (Employment Retirement Income Security Act) of 1974
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This act sets minimum standards for pension plans in private industry.
The Act applies two types of private employee benefit plans—pension plans and employee welfare benefit plans, which provide benefits in the event of sickness, hospitalization, surgery, accident, death, disability or unemployment. Millions of workers are protected by ERISA. |
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COBRA (Consolidated Omnibus Budget Reconciliation Act)
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In 1986, ERISA was amended by COBRA.
requires group health plans for covered employees to provide employees and certain family members the opportunity for temporary extensions of health coverage (usually for up to 18-months time) at group rates in certain instances where coverage would otherwise end, such as when an employee leaves a job. If dependents or spouses of an employee have coverage due to the an employee's death, divorce, legal separation, age limitation, or the employee's eligibility for Medicare, dependents or spouses are entitled to COBRA coverage for up to 36 months. |
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CARF (Commission on Accreditation of Rehabilitation Facilities)
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provides regular inspections of health care facilities to regulate quality and integrity for the protection of the health care community, to improve the quality of services that enhance the lives of the persons served. Accreditation and reaccreditation of facilities is required on a routine basis. Facilities and providers must maintain an aggressive policy model, which includes complex record keeping and documentation of CARF compliance standards.
also involved in developing standards for the industry, including standards for case management, which were developed in 1990. |
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The Health Insurance Portability and Accountability Act (HIPAA)
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also known as the Kennedy and Kassenbaum Act of 1996
• Limits the exclusion period for pre-existing conditions mandated by insurance companies to 12 months • Allows employees to be automatically eligible for benefits without pre-existing conditions when assuming new employment, providing there has not been a break in the employee's group coverage for more than 62 days • Provides for a qualified long-term care benefit • Allows Medical Savings Accounts (MSA) on a trial basis for employers with under 50 employees • Provides establishment of the Patient Privacy Regulations, which were released by the Health and Human Services (HHS) Department on December 20, 2000, and governs the confidentiality of medical records, including electronic records, printout of such records, paper records, and even oral communications |
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Workers' Compensation Act of 1991
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were originally developed in 10 states and were established as a no-fault system.
The essence is that the employer must assume the cost of occupational disability, death, or disease without regard to fault. All state workers' compensation systems provide wage replacement for both temporary and permanent disabilities, regardless of whether the employer or the worker is at fault for the injury or illness. |
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Smith-Hughes Act of 1917
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This act provides matching federal funds to states for vocational education programs that were enacted prior to permanent programs enacted through the Social Security Act (SSA).
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Longshore and Harbor Workers' Compensation Act (1928) and Amendment (1972)
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First enacted in 1928, and amended in 1972
broadened the list of those covered under the Act. It is administered by the Department of Labor through the Office of Workers' Compensation Program (OWCP). provides medical and financial benefits to Longshore and Harbor Workers while they are unable to work. When the employee is able to work, the program goal becomes modification of the existing job, or providing training to the injured worker. claims examiner at the OWCP acts as a case manager responsible for the medical and financial direction of the case. It is the claims examiner who refers the client to a rehabilitation specialist. Vocational rehabilitation is not mandatory under this act. Counselors are authorized to provide services up to but not exceeding $2,000. The counselor must first assess the client and determine if he/she is eligible for rehabilitation services. |
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The Mental Health Parity Act of 1996 (MHPA)
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a federal law that may prevent a group health plan from placing annual or lifetime dollar limits on mental health benefits that are lower—less favorable—than annual or lifetime dollar limits for medical and surgical benefits offered under the plan. For example, if your health plan has a $1 million lifetime limit on medical and surgical benefits, it cannot put a $100,000 lifetime limit on mental health benefits. The term "mental health benefits" means benefits for mental health services defined by the health plan or coverage.
does not recognize chemical dependency as a mental health issue, and does not require employers or group health plans to cover its treatment. Although the law requires "parity," or equivalence, with regard to dollar limits, does NOT require group health plans and their health insurance issuers to include mental health coverage in their benefits package. Law's requirements apply only to group health plans and their health insurance issuers that include mental health benefits in their benefits packages. MHPA applies to most employers with more than 50 workers, and those employers or plans that can demonstrate that parity would cause at least a 1% increase in health care benefits. Specific industries are not addressed in the legislation. |
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Restrictions Allowed under MHPA
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Group health plans may impose some restrictions on mental health benefits and still comply with the law. MHPA does NOT prohibit group health plans from :
• Covering mental health services within the network only, even though the plan will pay for out-of-network services for medical/surgical benefits (although with higher out-of-pocket cost to the subscriber) • Increasing co-payments or limiting the number of visits for mental health benefits • Imposing limits on the number of covered visits, even if the plan does not impose similar visit limits for medical and surgical benefits • Having a different cost-sharing arrangement, such as higher coinsurance payments, for mental health benefits as compared to medical and surgical benefits |
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Women's Health and Cancer Rights Act
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is a law that was enacted as part of an Omnibus Appropriation Bill and became effective for plan years beginning on or after October 21, 1998.
was amended by ERISA. includes protections for individuals who elect breast reconstruction in connection with a mastectomy. provides that group health plans, HMOs, including self-insured plans, and health insurance issuers that provide coverage for medical and surgical benefits with respect to mastectomies, are mandated to also cover certain post-mastectomy benefits, including reconstructive surgery and the treatment of complications (such as lymphedema). This required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema. NOTE: Despite its name, nothing in the law limits WHCRA rights to cancer patients, so if a woman needs a mastectomy due to other medical reasons, if the group health plan covers mastectomies, then it must be covered in the same way. |
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Two of HIPAA's main goals are to:
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• Make health insurance more portable when persons change employers
• Make the health care system more accountable for costs and try to reduce waste and fraud |
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HIPAA has four associated regulations or "rules":
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1. Standardized formats for all electronic data (computer-to-computer) information (EDI) exchanges, referred to as the "transactions standard"
2. Standardized "identifiers" for health providers and health plans 3. Information-system security standards 4. Privacy standards also referred to as the "HIPAA Privacy Rule" |
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Protected Health Information (PHI) may be used or disclosed:
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• For treatment, payment, or health care operations (TPO), without the individual's authorization
• For non-routine purposes, only with the individual's authorization • To the individual involved |
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Examples of TPO:
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• Treatment includes the coordination and management of an individual's health care
• Payment includes coverage, eligibility, COB and utilization reviews • Operation includes underwriting, rating, audits and most disease management programs |
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Under the provisions of the Privacy Rule, individuals have the right to:
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• Obtain a copy of their health records
• Have corrections added to their health information • Receive notices explaining how health information will be used and shared • Determine whether to give permission before private health information is used or shared for certain purposes, such as for marketing • Obtain a report on when and why health information was shared for certain purposes • File a complaint with a provider, health insurer or the US Government if there is cause to believe that rights are being denied, or health information is not being protected |
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Under the Patient Privacy Regulations of HIPAA, health care providers and systems are required
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to implement policies and procedures to uphold the privacy and exchange of PHI data.
to train every existing and new workplace employee and member on their respective HIPAA privacy policies and procedures. This requirement became effective April 14, 2003, and essentially requires every employee to minimally know the following: • What HIPAA is • Who is the entity's HIPAA Privacy Official • What are the entity's protected health information (PHI) limits pertaining to patients (what is each employee's level of access to PHI information) • Where to obtain a copy of the entity's Privacy Notice • What to do when a privacy violation is witnessed • Knowledge that the care of the patient always takes precedence |
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The HIPAA Privacy Rule
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Is a national set of standards for the protection of certain health information was established and known as the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule).
Privacy Rule under HIPAA Issued by the US Department of Health and Human Services (HHS) of 1996. intent of the Privacy Rule is to protect the use and disclosure of individuals' health information, known as protected health information (PHI) by organizations subject to the Privacy Rule. |
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With the HHS, the Office for Civil Rights (OCR) has responsibility to implement and enforce
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the Privacy Rule with respect to voluntary compliance activities and civil money penalties.
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One of the major objectives of the Privacy Rule is
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to protect individuals' health information while, at the same time, allowing the flow of health information required to provide and promote quality health care and to protect the public's health and well being.
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Entities and individuals required to comply with the Privacy Rule include, but are not limited to
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health care professionals, pharmacies, hospitals, clinics, home health care agencies, durable medical equipment companies, nursing homes, health plans, managed care organizations, employer groups and even certain government programs that pay for health care, such as Medicare and Medicaid.
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The Privacy Rule has a direct impact on case management as it limits how protected health information (PHI) is shared
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prevents employers from using PHI in employment decisions, and requires employers and covered entities to establish safeguards for handling PHI.
is the first comprehensive federal protection regulation implemented to safeguard private health information. creates national standards to protect the medical records and other personal health information of individuals. The Privacy Rule limits both the use and disclosure of PHI. |
