Tag Archives: Reports!

Back on Track

We are back on track, discussing the improvement of Medicaid for both patients and providers.

Section 2701 sets up an adult health quality measurement process, complete with reports! The details of the quality measurements are not set forth here, but will be the first task undertaken by these people.

Section 2702 is a little weird. It identifies states that prohibit payments under Medicaid for health-care acquired conditions and then doesn’t pay the states for those conditions as well. So if you get sick, and whatever care you get leads to preventable condition, your provider won’t be paid for your initial care. The incentives there are a little weird – enough doctors don’t take Medicaid patients as it is and this seems like it would increase that number. I guess we will have to see.

Section 2703 allows the state to create “care homes” for chronic conditions. These aren’t physical homes, but rather designated care teams that can coordinate between multiple providers, and potentially improve health.

Section 2704 provides money to test out the use of bundled payments for hospitalization. That is, if you go into the hospital, they would get a single payment, no matter how much that “care episode” cost. Presumably this would create an incentive to improve quality of care.

Section 2705 tests out another type of payment system – a global capitated system, rather than fee-for-service – specifically for large safety-net type hospitals.

Section 2706 introduces the accountable care organization, similar to the care homes in section 2703, for pediatric care.

Section 2707 is another demonstration project, such as 2703, 2704, 2705, and 2706. This one is for private hospitals for psychiatric care.

Tomorrow – more improvements!

Advertisements

Leave a comment

Filed under PPACA

Mediwhat?

For those of you who don’t know – Medicaid is joint program between the federal government and the state to assist specific lower income populations pay for medical care. It was established in 1965 along with Medicare (a social insurance program for those over 65, fully funded by the federal government).

During the debate over the details of the PPACA in Congress, there was some suggestion of creating a national, single-payer, health care system by expanding Medicaid coverage to all people in the U.S. This was immediately denounced as “socialism” and therefore anathema. Instead, the PPACA expanded the coverage for some people.

Up until the passage of the Act, Medicaid eligibility was incomes at or below the poverty line. Section 2001 expands this coverage, starting in 2014, to those with incomes up to 133% of the poverty line. Additionally, whereas before childless or non-pregnant adults under 65 were not eligible unless they were disabled, those restrictions will be removed. The Congressional Budget Office estimates that this will be 16 million additional people. This increase is fully funded by the federal government for 3 years, decreasing each year after that until its final funding level of 90% starting in 20201.

You can’t enroll yourself, if you don’t enroll your children, or have them covered in some other way.

The states can’t limit enrollment until they have operating Exchanges.

Medicaid must offer the minimum essential coverage that is required by the PPACA in general.

Mental health services must be offered in the same manner as other medical services – known as mental health parity.

Reports shall be made!

Section 2002 says that adjusted gross income will be used, and you can’t leave out any income, but you can’t have an asset test. This doesn’t apply if you are getting other aid that makes you eligible, you are over 65, you are blind, or disabled. Current enrollees are grandfathered in.

Section 2003 says that if you are eligible for Medicaid, you, and your children, don’t lose that eligibility if you don’t apply for insurance through an employer.

Section 2004 increases the age limit for eligibility for Medicaid for former foster children, who wouldn’t have the opportunity, then, to be on a parent’s insurance.

Section 2005 gives more money to the US territories. Quick! Who can name them?? Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Island and American Samoa.

Section 2006 gives more money, for two years, to areas hit by natural disasters.

Section 2007 rescinds money due to the Medicaid Improvement Fund for years 2014 through 2018, if it isn’t spent. On a fascinating side note, go to this page http://www.ssa.gov/OP_Home/ssact/title19/1941.htm and read the foot notes about all the changes that have taken place in just this one section. Oh Congress.

1 it should be noted that Texas, or rather its governor, among other states, has already stated that it will not enact this portion of the PPACA. While we haven’t gotten to the portion that is the stick to this carrot, the Supreme Court struck down the portion of the PPACA that stated that if a state didn’t increase eligibility, that ALL of its Medicaid funding would be rescinded. Instead, only the portion for the increase will not be given. I leave it to the Legislatures of the various states to explain why they aren’t insuring their citizens.

Leave a comment

Filed under PPACA

Consumer Choice

Since the word on the street is that the Supremes will decide on this law by the end of June for sure – I am making a concerted effort to finish going through it before then.

Section 1312 is entitles Consumer Choice. Since one of the criticisms of this law is that it removes Consumer Choice – by forcing people to buy health insurance – let’s see what this section actually says.

The first part says that qualified individuals (defined below) may by qualified health care plans and that qualified employers (defined below) can provide qualified health plans. Those individuals can then pay the premiums. Oh boy.

All people who purchase individual insurance are considered part of a single risk pool. All people in the Small Group Market are part of a single risk pool. States can require that these plans be merged.

These Exchanges don’t prohibit individual insurance from being offered outside the Exchange and they don’t change what States already require to be offered.

It states then that the Exchanges are voluntary. No person has to participate in the Exchange. No person is compelled to purchase a qualified health plan. Unless you are a member of Congress. Members of Congress (and their staff) must purchase plans that are created by the PPACA, or are in an Exchange. Which of course leads me to the question – does this imply that members of Congress are not people?

There are no fees imposed if people choose minimum essential coverage outside of the Exchange. It creates brokers and agents to facilitate enrollment in the Exchanges.

Qualified individuals are people seeking insurance who are residents of the State they are seeking insurance in. Those people in prison or jail don’t count. Qualified employers are small employers who to choose to allow their employees to have access to the insurance plans in the Exchange. In 2017 the Exchanges are opened to large employers. You must be a citizen or lawful resident to participate in the Exchanges.

We still haven’t gotten to the fee portion of the PPACA – that will be exciting when we do.

Section 1313 relates to Financial Integrity of the Exchanges. They will keep receipts! They will be subject to investigations! Audits! If they are bad, the Feds will take away their allowance. (No really – they will reduce the payments they are eligible for under this Act). There will be GAO oversight about operations, administration, utilization, improvements, cost and affordability, and access.

We are 10% done! With 13 posts. You may end up seeing more than one a day as we get to the end. But onward!

Leave a comment

Filed under PPACA

Sorry for the hiatus – teething baby!

Subtitle C – Quality Health Insurance Coverage for All Americans

Section 1201

Here is the part that prohibits both denying coverage for pre-existing conditions, and prohibiting discriminatory health insurance rates. Insurance companies are still allowed to charge different rates for individuals or families, by geographic area, by age, and tobacco use. But not by gender. Or health status. Or medical condition. Or past medical claims. Or evidence of insurability. Or disability. Or genetic information! Or receiving health care at all.

It also requires that health insurance plans accept all employers and individuals, if they offer insurance to any employer or individual, although imposing enrollment time periods for changes are still ok. This coverage must also be renewable.

You can also still offer discounts for participating in wellness programs, subject to certain requirements, even if those wellness programs encourage things that could be described under the terms medical condition (like weight loss, or decreasing BMI). Reimbursements for fitness centers, diagnostic tests, encouraging preventative care, smoking cessation programs, and attendance at health seminars, as long as they are offered to everyone, are not subject to the requirements of other wellness programs.

Health insurance plans can also not discriminate against health care providers.

Individual and small-group plans must provide certain minimum “essential coverage“. Cost-sharing is subject to limitations. They have to provide child-only plans, if they offer any plans at all. And you can’t make people wait more than 90days for coverage.

There are also protections for people engaging in clinical trials, allowing them to participate in those trials, prohibiting conditions or limits on routine costs of participation, and prohibiting discrimination if they participate in the trial. It does not require them to cover the cost of whatever the clinical trial is studying, or the costs of creating data. NIH – you are still in the business of paying for that.

Section 1251

You don’t have to terminate any health care you had when the Act went into effect. Whatever insurance you had, you keep. Some of the provisions of the Act will apply to these plans, however (reducing excessive waiting periods, rescission elimination, extension of dependent coverage, and annual limits). Adult children provisions only apply if the adult child is not eligible for other group health insurance.

Section 1252 – Rating Reforms Must Apply Uniformly to all Health Insurance Issuers and Group Health Plans. The title says it all.

Section 1253 – Reports shall be generated for self-insurance plans. Reports I say!

Section 1254 – Studies shall be done! Of Large Group Markets! And to see if these reforms will cause more employers to self-insure. And whether self-insured health plans lead to lower costs. And whether insurance plans offer fewer benefits in economic downturns. And conflicts of interest of self-insured companies. Reports! That no one will probably ever read.

Section 1255 – effective dates!

Leave a comment

Filed under PPACA