This document discusses various methods of health care financing in the United States including private insurance, public programs, and the Affordable Care Act. It covers key topics like the role of insurance, common health insurance terminology, types of private plans including employer-sponsored and individual plans, public programs like Medicare and Medicaid, and provisions and impacts of the ACA. The learning objectives are to understand concepts of health insurance, distinguish various plan types, examine public programs and insurance trends, and assess directions in health care financing.
Personal Finance Course Health Insurance Slides With ACA InfoBarbara O'Neill
This document summarizes key aspects of health and disability insurance. It discusses how insurance can ease the financial burden of illness or injury by transferring the risk of loss through premium payments. Different types of coverage are available including medical expense insurance and disability income insurance. The document also outlines important laws like COBRA, HIPAA, and the Affordable Care Act, as well as sources of health insurance like employers, private markets, and government programs. Major topics covered include health plan types, costs, benefits, and government programs like Medicare and Medicaid.
Social health insurance implementation function governanceNajibullah Safi
The document discusses governance in social health insurance. It defines governance and outlines key governance functions for social health insurance, including setting rules for coverage, benefits, financing and provider networks. It also provides examples of governance structures in Germany, Indonesia and Bangladesh, comparing features such as the role of government, regulatory frameworks, and organizational setups. The document emphasizes that there is no single best system and that countries develop their governance structures over time based on their unique situations and priorities.
This document discusses the scope and forms of healthcare insurance. It provides information on:
- Healthcare insurance normally covers treatment of acute conditions but not chronic or preventative care.
- The main forms of health insurance are medical insurance, personal accident/sickness, income protection, critical illness, and long-term care.
- Healthcare policies can be personal, covering individuals and families, or group policies arranged by employers to cover employees. Group policies are typically paid for by the employer.
1. The document discusses health insurance in India, including its principles, risks, and current status.
2. It defines health insurance as a method to finance healthcare and minimize uncertainty from illness and treatment costs through risk pooling.
3. Key values of health insurance include solidarity, risk pooling, equity, and participation. There are three main types - social health insurance, private health insurance, and community health insurance.
A document discusses the evolving role of captives within the changing healthcare environment. It notes rising healthcare costs and the growth of accountable care organizations (ACOs) and self-insurance. Captives are increasingly being used to manage ACO and employee healthcare risks. Case studies show how group captives can generate savings for employers by pooling stop-loss insurance and improving risk management. Forming a successful captive requires thorough planning and establishing sound fundamentals.
The document provides an overview of American health reform, including its rationale and key implications. It discusses three main parties in the healthcare system - individuals, insurers, and providers - and how their interactions were impacted by reform. Specifically, it summarizes changes to how individuals acquire insurance through the creation of state health insurance exchanges, expansion of Medicaid, and use of subsidies. It also reviews the new employer and individual mandates imposed by reform.
Health insurance provides coverage for medical expenses and loss of earnings due to illness or injury. It depends on the conditions, benefits, and treatment options covered by the policy. Premiums are paid in advance for future health coverage. There are different types of health insurance plans such as group, individual, and family floater plans. While perceptions of health insurance in India are mixed, it has become necessary due to rising medical costs, the need to share health risks, and securing one's family's health. Government initiatives aim to increase health insurance penetration and affordability, but challenges remain around healthcare delivery and costs, consumer awareness, and claim ratios.
Personal Finance Course Health Insurance Slides With ACA InfoBarbara O'Neill
This document summarizes key aspects of health and disability insurance. It discusses how insurance can ease the financial burden of illness or injury by transferring the risk of loss through premium payments. Different types of coverage are available including medical expense insurance and disability income insurance. The document also outlines important laws like COBRA, HIPAA, and the Affordable Care Act, as well as sources of health insurance like employers, private markets, and government programs. Major topics covered include health plan types, costs, benefits, and government programs like Medicare and Medicaid.
Social health insurance implementation function governanceNajibullah Safi
The document discusses governance in social health insurance. It defines governance and outlines key governance functions for social health insurance, including setting rules for coverage, benefits, financing and provider networks. It also provides examples of governance structures in Germany, Indonesia and Bangladesh, comparing features such as the role of government, regulatory frameworks, and organizational setups. The document emphasizes that there is no single best system and that countries develop their governance structures over time based on their unique situations and priorities.
This document discusses the scope and forms of healthcare insurance. It provides information on:
- Healthcare insurance normally covers treatment of acute conditions but not chronic or preventative care.
- The main forms of health insurance are medical insurance, personal accident/sickness, income protection, critical illness, and long-term care.
- Healthcare policies can be personal, covering individuals and families, or group policies arranged by employers to cover employees. Group policies are typically paid for by the employer.
1. The document discusses health insurance in India, including its principles, risks, and current status.
2. It defines health insurance as a method to finance healthcare and minimize uncertainty from illness and treatment costs through risk pooling.
3. Key values of health insurance include solidarity, risk pooling, equity, and participation. There are three main types - social health insurance, private health insurance, and community health insurance.
A document discusses the evolving role of captives within the changing healthcare environment. It notes rising healthcare costs and the growth of accountable care organizations (ACOs) and self-insurance. Captives are increasingly being used to manage ACO and employee healthcare risks. Case studies show how group captives can generate savings for employers by pooling stop-loss insurance and improving risk management. Forming a successful captive requires thorough planning and establishing sound fundamentals.
The document provides an overview of American health reform, including its rationale and key implications. It discusses three main parties in the healthcare system - individuals, insurers, and providers - and how their interactions were impacted by reform. Specifically, it summarizes changes to how individuals acquire insurance through the creation of state health insurance exchanges, expansion of Medicaid, and use of subsidies. It also reviews the new employer and individual mandates imposed by reform.
Health insurance provides coverage for medical expenses and loss of earnings due to illness or injury. It depends on the conditions, benefits, and treatment options covered by the policy. Premiums are paid in advance for future health coverage. There are different types of health insurance plans such as group, individual, and family floater plans. While perceptions of health insurance in India are mixed, it has become necessary due to rising medical costs, the need to share health risks, and securing one's family's health. Government initiatives aim to increase health insurance penetration and affordability, but challenges remain around healthcare delivery and costs, consumer awareness, and claim ratios.
Presentation from INTEGRATED's Chuck Gooder, senior advisor, and Blake Sternard, the business analyst. The presentation focuses on the ways to identify the major changes of healthcare, with specific attention to the potential challenges posed to enrollees, physicians, hospitals, and healthcare organizations associated with the implementation of Obamacare.
This document discusses the implications of the Mental Health Parity and Addiction Equity Act of 2008 for employer-provided health plans. It addresses whether moving mental health benefits to an employee assistance program (EAP) would avoid the Act's requirements and analyzes different types of excepted benefits that are not subject to the Act. The document also outlines potential cost exemptions and opt-out provisions for certain self-funded government plans.
1) The document summarizes key aspects of national health reform and its potential impact and challenges for implementing it in Florida. It outlines opportunities to expand Medicaid coverage to over 1 million newly eligible residents, create health insurance exchanges, and reform insurance markets.
2) Implementing the reforms successfully could improve access to care, reduce costs, and lower uncompensated care while posing challenges like ensuring adequate provider capacity and developing new regulatory systems.
3) The report recommends Florida take steps like innovative outreach and enrollment for Medicaid and exchange programs, applying for federal grants, enacting legislation, and monitoring insurance affordability and quality.
News Flash December 23, 2013—Agency Release Proposed Rules on Excepted BenefitsAnnette Wright, GBA, GBDS
The agencies charged with implementing the Affordable Care Act issued proposed rules that would amend the definition of excepted benefits, which are exempt from certain requirements of federal health care laws. The proposed rules would affect dental and vision benefits, wraparound coverage, and employee assistance programs. Specifically, the rules would eliminate premium requirements for limited dental and vision benefits and treat certain wraparound plans and employee assistance programs as excepted benefits if they meet specified criteria, such as not being an integral part of the primary health plan or providing significant medical benefits. Public comments are invited on how to define terms like "significant medical benefits."
This document discusses the market for health insurance. It explains that people buy insurance to transfer the risk of large medical costs to a third party in exchange for regular payments. However, insurance can increase healthcare utilization and costs through moral hazard. Insurers try to limit this effect through cost-sharing, managed care, and other strategies. The dominance of employer-based insurance is also discussed, along with its advantages and disadvantages.
This document provides an overview of principles of healthcare reimbursement. It discusses different national models of healthcare delivery, including social insurance, national health insurance, and private health insurance models. It also describes the size, complexity, and intricate payment methods of the US healthcare sector. The document defines key terms like health insurance, reimbursement, and risk pools. It examines retrospective reimbursement methodologies like fee schedules and percent of billed charges as well as prospective methodologies like capitation, case rates, global payments, and bundled payments. It also discusses trends in increasing healthcare spending in the US and efforts at healthcare reform through legislation like the Affordable Care Act.
The document discusses the benefits of establishing a group captive insurance program. It notes that previously the industry faced high pricing from insurers who did not recognize their focus on safety. By sharing loss information and forming a group captive, members saw premium rate reductions, more investment in safety programs, lower losses over time, and underwriting profits returned to the group. This led to expanded coverage options and a high member retention rate, providing a long-term, market-driven insurance solution for the industry.
This session focuses on Ed Health, a medical stop loss group captive consisting of 11 Boston-area colleges that Spring assisted in the development of. It details Ed Health’s success to date and lessons learned through the development and ongoing management of a medical stop loss group captive.
Navigating Health Insurance in the Health Care Reform Era lkennon
A presentation for large employers, small employers and individuals without employer-based insurance. The slides present the current state of health insurance for each group and the impending changes of Health Care Reform and their potential effects.
Pediatric Dental Benefits Under the ACA - What Employers (and dentists) Need ...Spring Consulting Group
This document provides an overview of pediatric dental benefits under the Affordable Care Act and how they may impact dental practices. It discusses how pediatric dental coverage is considered an essential health benefit and must be included in certain health plans. It describes the three structures for how pediatric dental benefits can be offered (embedded, stand alone, bundled). It also outlines some pediatric dental plan benefit options and issues dental practices may face in navigating these new benefits, such as deciding whether to credential with dental insurance providers and how to manage claims processing.
The document discusses the complexities and opportunities presented by public health insurance exchanges established under the Affordable Care Act. It finds that states have underestimated the costs and complexity of creating these exchanges. While new opportunities may emerge around health insurance distribution, significant challenges around technology, funding, and long-term sustainability complicate establishing exchanges that meet their goals.
Health insurance policies are broadly divided into 2 kinds on the basis of claims, Cashless Health Insurance policy and Reimbursement Health Insurance Policy.
When choosing a health insurance plan, make sure that you compare health insurance polices across different insurers. If you compare health insurance online, then it may be easier to list out the pros and cons of each plan and find the one that works for you.
Sheldon Weisgrau gave a presentation on health care reform and the Affordable Care Act to a group in Wichita. He discussed why health reform was needed due to the high number of uninsured, rising costs, and inconsistent quality of care. He explained provisions of the ACA including expanding Medicaid, prohibiting denial of coverage for pre-existing conditions, and creating health insurance marketplaces. He also covered enrollment in the marketplaces, financial assistance available, and when key parts of the law would take effect.
This presentation reviews: what information must be protected, what policies and procedures need to be in place, what disclosures have to be given to employees, what agreements have to be in place for business associates, and what breach procedures have to be followed.
Health insurance protects individuals from high medical costs by covering expenses. In India, health insurance reaches only 13% of the population through various schemes. These include private plans, employer-based coverage, community-based insurance, and government programs. The largest government scheme is the Central Government Health Scheme (CGHS), which provides services to central government employees and retirees in 17 cities. Another major program is Rashtriya Swasthya Bima Yojna (RSBY), which offers health insurance to below poverty line families. However, challenges remain in increasing awareness, improving claims processes, and reducing disputes over pre-existing conditions. Research shows that losing health insurance leads to 40% fewer emergency room visits and 61% fewer hospital
The document discusses paid sick leave compliance and best practices for employers. It provides an overview of the expansion of paid sick leave laws from one state and seven jurisdictions in 2014 to three states and eighteen jurisdictions currently. It reviews the key details and requirements of paid sick leave laws in states like California, Connecticut, and Massachusetts as well as various cities. These include eligibility, accrual, usage limits, family definitions, and certification processes. The document also discusses challenges employers face in managing paid sick leave and provides resources for continued compliance.
ISCEBS 2014 Presentation: Health Care Reform’s Impact on Disability ManagementSpring Consulting Group
The document discusses key trends in integrated disability management in light of healthcare reform. It notes that integration continues to progress across employers of all sizes, with programs becoming more mature and sophisticated. Health management programs are also broadening in scope. The document highlights expanding ADA accommodation management to be on par with FMLA as a top trend, as well as growing interest in voluntary benefits to fill coverage gaps. Centralizing absence management and standardizing approaches are also discussed as important trends to improve the employee experience and reduce costs. Formal return-to-work and stay-at-work programs are emphasized as best practices.
This document provides a summary of employee benefits for 2012, including medical, dental, vision, life and disability insurance. It outlines the various plan options for medical coverage through Health Plus, including HMO, PPO, and high deductible plans. Details are provided on costs, networks, deductibles, and out-of-pocket maximums. Other benefits like dental through Assurant, vision through NVA, and life and disability through Mutual of Omaha are also summarized. Information is included on enrollment timelines and carriers' contact information.
Understanding the Impact of Health Care Reform on Your Business in 2013Insperity
This document summarizes key provisions of the Affordable Care Act that will impact businesses in 2013 and beyond, including the individual mandate, employer shared responsibility requirements, reporting obligations, costs and fees, and state health insurance exchanges. It outlines compliance requirements and penalties businesses may face if they do not offer affordable health coverage or if employees receive subsidies through state exchanges. The increasing complexity of the regulations and their potential effects on a business's health care costs, administrative workload and competitiveness are also discussed.
Review all of the requirements of the Employee Retirement Income Security Act of 1974. Training will go over which employers have to comply, which benefits are subject to ERISA, what documentation employers must provide, and penalties for noncompliance.
Health and disability insurance help ease the financial burden of illness or injury by allowing individuals to pay premiums to transfer the risk of financial loss to an insurance company. There are various types of private and government health insurance plans available, each with different costs and benefits. The costs of health insurance and healthcare have been steadily increasing due to factors like new medical technologies, an aging population, and rising healthcare costs. Managing personal health and carefully reviewing medical bills can help reduce individual healthcare costs.
This document discusses the market for health insurance. It explains that people buy insurance to transfer the risk of large medical costs to a third party in exchange for regular payments. However, insurance can increase healthcare utilization and costs through moral hazard. Insurers try to limit this effect through cost-sharing, managed care, and other strategies. The dominance of employer-based insurance is also discussed, along with its advantages and disadvantages compared to other financing systems.
Presentation from INTEGRATED's Chuck Gooder, senior advisor, and Blake Sternard, the business analyst. The presentation focuses on the ways to identify the major changes of healthcare, with specific attention to the potential challenges posed to enrollees, physicians, hospitals, and healthcare organizations associated with the implementation of Obamacare.
This document discusses the implications of the Mental Health Parity and Addiction Equity Act of 2008 for employer-provided health plans. It addresses whether moving mental health benefits to an employee assistance program (EAP) would avoid the Act's requirements and analyzes different types of excepted benefits that are not subject to the Act. The document also outlines potential cost exemptions and opt-out provisions for certain self-funded government plans.
1) The document summarizes key aspects of national health reform and its potential impact and challenges for implementing it in Florida. It outlines opportunities to expand Medicaid coverage to over 1 million newly eligible residents, create health insurance exchanges, and reform insurance markets.
2) Implementing the reforms successfully could improve access to care, reduce costs, and lower uncompensated care while posing challenges like ensuring adequate provider capacity and developing new regulatory systems.
3) The report recommends Florida take steps like innovative outreach and enrollment for Medicaid and exchange programs, applying for federal grants, enacting legislation, and monitoring insurance affordability and quality.
News Flash December 23, 2013—Agency Release Proposed Rules on Excepted BenefitsAnnette Wright, GBA, GBDS
The agencies charged with implementing the Affordable Care Act issued proposed rules that would amend the definition of excepted benefits, which are exempt from certain requirements of federal health care laws. The proposed rules would affect dental and vision benefits, wraparound coverage, and employee assistance programs. Specifically, the rules would eliminate premium requirements for limited dental and vision benefits and treat certain wraparound plans and employee assistance programs as excepted benefits if they meet specified criteria, such as not being an integral part of the primary health plan or providing significant medical benefits. Public comments are invited on how to define terms like "significant medical benefits."
This document discusses the market for health insurance. It explains that people buy insurance to transfer the risk of large medical costs to a third party in exchange for regular payments. However, insurance can increase healthcare utilization and costs through moral hazard. Insurers try to limit this effect through cost-sharing, managed care, and other strategies. The dominance of employer-based insurance is also discussed, along with its advantages and disadvantages.
This document provides an overview of principles of healthcare reimbursement. It discusses different national models of healthcare delivery, including social insurance, national health insurance, and private health insurance models. It also describes the size, complexity, and intricate payment methods of the US healthcare sector. The document defines key terms like health insurance, reimbursement, and risk pools. It examines retrospective reimbursement methodologies like fee schedules and percent of billed charges as well as prospective methodologies like capitation, case rates, global payments, and bundled payments. It also discusses trends in increasing healthcare spending in the US and efforts at healthcare reform through legislation like the Affordable Care Act.
The document discusses the benefits of establishing a group captive insurance program. It notes that previously the industry faced high pricing from insurers who did not recognize their focus on safety. By sharing loss information and forming a group captive, members saw premium rate reductions, more investment in safety programs, lower losses over time, and underwriting profits returned to the group. This led to expanded coverage options and a high member retention rate, providing a long-term, market-driven insurance solution for the industry.
This session focuses on Ed Health, a medical stop loss group captive consisting of 11 Boston-area colleges that Spring assisted in the development of. It details Ed Health’s success to date and lessons learned through the development and ongoing management of a medical stop loss group captive.
Navigating Health Insurance in the Health Care Reform Era lkennon
A presentation for large employers, small employers and individuals without employer-based insurance. The slides present the current state of health insurance for each group and the impending changes of Health Care Reform and their potential effects.
Pediatric Dental Benefits Under the ACA - What Employers (and dentists) Need ...Spring Consulting Group
This document provides an overview of pediatric dental benefits under the Affordable Care Act and how they may impact dental practices. It discusses how pediatric dental coverage is considered an essential health benefit and must be included in certain health plans. It describes the three structures for how pediatric dental benefits can be offered (embedded, stand alone, bundled). It also outlines some pediatric dental plan benefit options and issues dental practices may face in navigating these new benefits, such as deciding whether to credential with dental insurance providers and how to manage claims processing.
The document discusses the complexities and opportunities presented by public health insurance exchanges established under the Affordable Care Act. It finds that states have underestimated the costs and complexity of creating these exchanges. While new opportunities may emerge around health insurance distribution, significant challenges around technology, funding, and long-term sustainability complicate establishing exchanges that meet their goals.
Health insurance policies are broadly divided into 2 kinds on the basis of claims, Cashless Health Insurance policy and Reimbursement Health Insurance Policy.
When choosing a health insurance plan, make sure that you compare health insurance polices across different insurers. If you compare health insurance online, then it may be easier to list out the pros and cons of each plan and find the one that works for you.
Sheldon Weisgrau gave a presentation on health care reform and the Affordable Care Act to a group in Wichita. He discussed why health reform was needed due to the high number of uninsured, rising costs, and inconsistent quality of care. He explained provisions of the ACA including expanding Medicaid, prohibiting denial of coverage for pre-existing conditions, and creating health insurance marketplaces. He also covered enrollment in the marketplaces, financial assistance available, and when key parts of the law would take effect.
This presentation reviews: what information must be protected, what policies and procedures need to be in place, what disclosures have to be given to employees, what agreements have to be in place for business associates, and what breach procedures have to be followed.
Health insurance protects individuals from high medical costs by covering expenses. In India, health insurance reaches only 13% of the population through various schemes. These include private plans, employer-based coverage, community-based insurance, and government programs. The largest government scheme is the Central Government Health Scheme (CGHS), which provides services to central government employees and retirees in 17 cities. Another major program is Rashtriya Swasthya Bima Yojna (RSBY), which offers health insurance to below poverty line families. However, challenges remain in increasing awareness, improving claims processes, and reducing disputes over pre-existing conditions. Research shows that losing health insurance leads to 40% fewer emergency room visits and 61% fewer hospital
The document discusses paid sick leave compliance and best practices for employers. It provides an overview of the expansion of paid sick leave laws from one state and seven jurisdictions in 2014 to three states and eighteen jurisdictions currently. It reviews the key details and requirements of paid sick leave laws in states like California, Connecticut, and Massachusetts as well as various cities. These include eligibility, accrual, usage limits, family definitions, and certification processes. The document also discusses challenges employers face in managing paid sick leave and provides resources for continued compliance.
ISCEBS 2014 Presentation: Health Care Reform’s Impact on Disability ManagementSpring Consulting Group
The document discusses key trends in integrated disability management in light of healthcare reform. It notes that integration continues to progress across employers of all sizes, with programs becoming more mature and sophisticated. Health management programs are also broadening in scope. The document highlights expanding ADA accommodation management to be on par with FMLA as a top trend, as well as growing interest in voluntary benefits to fill coverage gaps. Centralizing absence management and standardizing approaches are also discussed as important trends to improve the employee experience and reduce costs. Formal return-to-work and stay-at-work programs are emphasized as best practices.
This document provides a summary of employee benefits for 2012, including medical, dental, vision, life and disability insurance. It outlines the various plan options for medical coverage through Health Plus, including HMO, PPO, and high deductible plans. Details are provided on costs, networks, deductibles, and out-of-pocket maximums. Other benefits like dental through Assurant, vision through NVA, and life and disability through Mutual of Omaha are also summarized. Information is included on enrollment timelines and carriers' contact information.
Understanding the Impact of Health Care Reform on Your Business in 2013Insperity
This document summarizes key provisions of the Affordable Care Act that will impact businesses in 2013 and beyond, including the individual mandate, employer shared responsibility requirements, reporting obligations, costs and fees, and state health insurance exchanges. It outlines compliance requirements and penalties businesses may face if they do not offer affordable health coverage or if employees receive subsidies through state exchanges. The increasing complexity of the regulations and their potential effects on a business's health care costs, administrative workload and competitiveness are also discussed.
Review all of the requirements of the Employee Retirement Income Security Act of 1974. Training will go over which employers have to comply, which benefits are subject to ERISA, what documentation employers must provide, and penalties for noncompliance.
Health and disability insurance help ease the financial burden of illness or injury by allowing individuals to pay premiums to transfer the risk of financial loss to an insurance company. There are various types of private and government health insurance plans available, each with different costs and benefits. The costs of health insurance and healthcare have been steadily increasing due to factors like new medical technologies, an aging population, and rising healthcare costs. Managing personal health and carefully reviewing medical bills can help reduce individual healthcare costs.
This document discusses the market for health insurance. It explains that people buy insurance to transfer the risk of large medical costs to a third party in exchange for regular payments. However, insurance can increase healthcare utilization and costs through moral hazard. Insurers try to limit this effect through cost-sharing, managed care, and other strategies. The dominance of employer-based insurance is also discussed, along with its advantages and disadvantages compared to other financing systems.
This document provides an overview of various types of group insurance plans offered by employers as employee benefits, including group life, medical, dental, and disability insurance. It discusses key aspects of these plans such as eligibility, coverage amounts, funding structures, and recent trends affecting employer-sponsored health plans. Managed care plans like HMOs and PPOs are described as dominant models focusing on cost control. The impact of laws like COBRA, HIPAA, and the Affordable Care Act on group medical insurance is also summarized.
An Obamacare Primer -- cutting through the complexityAdrian Ho
Much of what is reported on re the ACA (or "Obamacare") is politically motivated, or is more about the politics than the actual content of the law itself. This deck is my attempt to cut through all the complexity and distortions and simply explain what is in the ACA and why it is in there.
An Overview of the ACA (aka Obamacare), October 2013Adrian Ho
Theres a lot of noise out there about Obamacare, much of it politically driven. This presentation is my attempt to focus on the facts and boil down the over 2000 page law into a short succinct summary
high value care to reduce waste in health caremukeshkakkar
This document discusses health care costs and payment models. It defines different types of health care costs including charges, reimbursements, and out-of-pocket costs. It describes how traditional payment models like fee-for-service can promote cost variation and lack transparency. It also discusses recent value-based reforms like accountable care organizations (ACOs) and pay for performance models that aim to improve quality and reduce costs. The document provides examples of estimating out-of-pocket costs and explores how insurance status impacts clinical recommendations and adherence.
This document provides an overview and definitions related to employer-sponsored health care plans. It discusses the origins and evolution of health care benefits provided by employers. It also reviews key regulations like the Affordable Care Act and the types of health care plan designs available, including fee-for-service, managed care (HMOs and PPOs), and consumer-driven plans. Specific topics covered include plan costs, covered benefits, and factors that influence health insurance premiums.
This document outlines the course content for a health insurance course. It will cover topics such as defining health insurance, the development of national health systems, the purpose of health insurance, relationships between public and private systems, underwriting principles and processes, and more. The course aims to provide a comprehensive overview of how health insurance works from both private insurer and public system perspectives internationally.
Chapter 10 Government Health Insurance Programs .docxketurahhazelhurst
Chapter 10:
Government Health Insurance
Programs: Medicaid, CHIP,
and Medicare
Chapter Overview
• Chapter 10 provides a basic overview of the
major public health insurance programs in the
United States, including changes to the
programs under the Affordable Care Act.
• Chapter 10 focuses on:
– Medicaid
– Children’s Health Insurance Program
– Medicare
Entitlements v. Block Grants
• Entitlement: Everyone who is eligible for and
enrolled in the program is legally entitled to receive
benefits from the program. Beneficiaries may not be
refused service for lack of funds or other reasons.
• Block Grants: A defined sum of money (often from
the federal government to the states) that is allocated
for a particular program over a certain amount of
time. Beneficiaries may be refused service for lack of
funds or other reasons.There is no legal entitlement to
the benefits.
Medicaid
• Overview: A federal-state public health insurance
program for the indigent.
• Program administration
– Federal: Center for Medicare and Medicaid
Services (CMS) outlines mandatory and optional
populations and benefits covered under Medicaid
– State: state Medicaid agencies run programs, select
which optional populations and benefits to cover in
the state program
• All states participate in Medicaid
Medicaid – Eligibility
• Medicaid generally covers low-income
• Pregnant women
• Children
• Adults in families with dependent children
• Individuals with disabilities
• Elderly
• Must meet 5 eligibility requirements: Categorical,
Income level, Resources, Residency and Immigration
status
Medicaid — Benefits
• Medicaid covers extensive acute care and Long-Term
Care benefits
– Some benefits are mandatory, others are optional
– Early and Periodic Screening Diagnostic and
Testing services are a comprehensive set of
mandatory services for children
• Deficit Reduction Act of 2006 (DRA) created a new
benefit option that allows states to use one of 5
benchmark or benchmark equivalent options to set
their benefit package
Medicaid — Financing
• Medicaid is jointly financed by the federal and state
governments
• Matching system
– Federal Medical Assistance Percentage determines the
matching rate; rate is tied to each state’s per capita
income with poorer states receive a higher federal
match, and must be at least 50/50
• Beneficiary cost-sharing
– Prior to DRA, very limited cost-sharing allowed
– DRA provides expanded cost-sharing options
Medicaid –
Provider Reimbursement
• Reimbursement levels vary by state and type of
provider
– States have a lot of discretion in setting rates
• Fee-for-service provides paid on a state-determined
fee schedule
• Managed care providers paid according to contracts
between the state and the managed care organization
• Medicaid reimbursement is typically much lower than
private insurance or Medicare reimbursement
Medicaid — Waivers
• States may appl ...
mHealth Israel_US Health Insurance Overview- An Insider's PerspectiveLevi Shapiro
Presentation about the US Health Insurance Sector by Lori Rund, VP, Product Management and Market Intelligence at Health Alliance Plan, a managed care organization owned by the Henry Ford Health System, with 650,000 lives. Lori is responsible for the identification, concept building, researching and business case developments for new products, services and markets. She develops and leads comprehensive market intelligence functions to help the organization better understand industry trends and identify business opportunities.
Prior to joining Health Alliance Plan, Lori was Director of Product Development and Market Intelligence at Health Alliance Medical Plans in Illinois and Director of Market Research and Strategy at Carle Clinic Association, also in Illinois.
This document discusses best practices for designing employee benefits packages. It recommends that employers consider benefits an important tool for retention, productivity and cost control. It also notes that healthcare costs are rising significantly and represent a large portion of the economy. The document provides guidance on choosing the right medical plans by balancing premium costs with benefits offered and considering all costs of coverage, including employee deductibles and coinsurance. It suggests strategies for controlling costs over time such as encouraging wellness programs and generic drug use. The benefits package should also include other offerings like dental, disability and supplemental insurance.
The document summarizes key provisions of the Affordable Care Act (ACA). It discusses how the ACA aims to reduce health care costs, provide Americans with access to affordable health coverage, strengthen Medicare and Medicaid, and modernize the health care system. It outlines significant changes to private health insurance including prohibiting denial of coverage for pre-existing conditions and requiring coverage of essential health benefits. The ACA also provides tax credits to help individuals and small businesses purchase insurance and strengthens Medicaid.
The document summarizes key provisions of the Affordable Care Act. It discusses how the legislation aims to reduce the number of uninsured through mandates on individuals and employers, and by establishing health insurance exchanges. It also outlines taxes and fees included in the legislation, such as excise taxes on high-cost health plans and fees on health insurers. Concerns raised include the complexity of the legislation, its impact on employer-provided coverage, and its long-term costs and economic impact.
This document discusses several topics related to health insurance and financing in the United States, including: two problems with the high number of uninsured Americans, how Medicare and Medicaid led to increased costs, and how financial incentives can make consumers more or less aware of healthcare costs. It also compares the cost concerns of healthcare providers to those of health insurance plans.
This document provides a summary of strategies for making health care more affordable for small businesses. It recaps health care reform changes through 2013 and changes coming in 2014 and beyond, including the individual and employer mandates. It then discusses the top 5 health care concerns for small businesses besides the Affordable Care Act, including rising costs. The document outlines strategies that work, including savvy plan design like partial self-funding, HRAs, and HDHP/HSAs. It also discusses wellness strategies that work through properly designed incentives and year-round communication. Finally, it discusses the importance of creating consumerism and proactive multi-year planning to control health care costs.
The affordable care act power point (updated) againRobin Lee
The document provides information about the Affordable Care Act (ACA) and enrolling in health insurance plans. It explains that the ACA provides protections like coverage for pre-existing conditions. It also details the essential health benefits that all plans must cover. The document guides readers through determining whether to enroll on or off the exchange marketplace and calculating subsidies. It describes the different metal-tiered plan levels (Bronze, Silver, Gold, Platinum) and their coverage amounts. Lastly, it provides contact information for RLee Insurance Solutions to assist with enrollment questions.
The document discusses employee benefits presented by a group including Naveed Mehdi Sheikh, Gul-e-Arzoo, Muzamil Ali, Bilawal Illyas, and Hamza Saqib. It defines employee benefits as additional non-financial rewards offered to attract and retain employees, such as health insurance, retirement plans, and paid time off. It then categorizes benefits as legally required (e.g. social security, unemployment), voluntary (e.g. health insurance, life insurance), and retirement benefits (e.g. 401k, pensions). Finally, it discusses integrating benefits through flexible spending accounts and modular/core-plus plans.
Every American is entitled and bound to avail Minimum Essential Coverage (MEC) under the Affordable Care Act (ACA) - also known as Obamacare. While some opt for individual health insurance plans offered by private institutions, more than 60% opt for Employer-Sponsored Health Insurance. Employer-Sponsored Health Insurance makes your work easy because you don't have to go through multiple insurance plans available online. Employers, on an average pay 82% of your premium for a single insurance policy. For employers also this is a win-win situation because it results in employee retention, better health of employees thus more productivity. Employers use good health benefits as a great tool to recruit sought-after talent in the industry.
The slide deck talks about Employer-Sponsored Health Insurance, its comparison to individual health insurance and the win-win situation for employee and employer.
This chapter discusses commercial healthcare insurance plans, including individual and employer-based plans. It describes the major types of commercial plans like HMOs, PPOs, and high-deductible plans. The chapter also covers risk pools, provisions of insurance policies like benefits, premiums, and cost-sharing. Elements of insurance identification cards and the claims submission and adjudication process are explained. The effects of rising healthcare costs like medical bankruptcy and value-based insurance models are also summarized.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
How to Manage Your Lost Opportunities in Odoo 17 CRMCeline George
Odoo 17 CRM allows us to track why we lose sales opportunities with "Lost Reasons." This helps analyze our sales process and identify areas for improvement. Here's how to configure lost reasons in Odoo 17 CRM
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
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ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
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Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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3. Learning Objectives
• To study the role of health care financing and its
impact on the delivery of health care
• To understand the basic concept of insurance and
how general insurance terminology applies to health
insurance
• To differentiate between group insurance, self-
insurance, individual health insurance, managed
care, high-deductible plans with savings, and
Medigap plans
• To explore trends in employer-based health
insurance
4. Learning Objectives
• To examine the distinctive features of public insurance
programs
• To understand the various methods of reimbursement
and developing trends
• To discuss national health care and personal health care
expenditures and trends in private and public financing
• To become familiar with the requirements of the
Affordable Care Act and their likely effects on financing
and insurance
• To assess current directions and issues in health care
financing
5. Introduction
• Complexity of financing in the US:
– many private plans
– many government programs
– many payment methods
– loss of insurance by many under the ACA
– government is expected to facilitate the
purchase of insurance under the ACA
6. Role and Scope of Health Care
Financing
• Financing is needed to pay health insurance
premiums
• Health insurance is the primary mechanism to
obtain health care services
• Despite the ACA, charity will play a noteworthy
role for the uninsured
• Insurance increases demand for health care
• Insurance lowers out-of-pocket costs
– patients consume more (moral hazard)
7. Role and Scope of Health Care
Financing
• Financing influences supply of health care
– Production of health care services – capital
expenditures, renovations, expansions
– New services and technology proliferate
when they are covered by health insurance
• New models of health care organization may
form
• Supply and distribution of health care
professionals is affected
• Effect on total health care expenditures
8. Financing and Cost Control
• Expenditures are increased by
– Expansion of health insurance
– Increase in health insurance premiums
• Expenditures can be reduced by
– Restricting insurance (demand-side rationing)
– Restricting reimbursement to providers
– Having fewer specialists
– Spending less on R&D
– Direct control over utilization (supply-side rationing)
– Designating certain services as noncovered (rationing)
9. The Insurance Function
• Insurance
– protects against risk
• Risk
– the possibility of substantial financial loss from
some event, where
– probability of occurrence is small
10. The Insurance Function
• Insured
– an individual protected by insurance
• Insurer
– an insurance agency that assumes the risk
• Underwriting
– evaluation, selection (or rejection), classification,
and rating of risk
11. The Insurance Function
Four Principles of Insurance:
1) Risk is unpredictable
2) Risk can be predicted with some accuracy in a
large group
3) Insurance can transfer risk from the individual to
group through pooling of resources
4) Losses are shared by all members
12. Private Health Insurance Concepts
• Beneficiary
– “the insured”
• Premium
– amount charged by insurer to insure against risk
– Employer-employee cost sharing
13. Health Insurance Terminology
• Premium
– amount charged by insurer to insure against risk
– Employer-employee cost sharing
• Risk Rating:
– Experience rating – premiums can be unaffordable
for high-risk groups
– Community rating – good risks subsidize poor risks
– Adjusted community rating – overcomes some of
the above drawbacks (required by the ACA)
14. Health Insurance Terminology
• Cost Sharing
– Deductible
•Amount the insured pays first before benefits
are paid by the plan
•Applied annually
– Copayment
•Flat amount paid per service
– Coinsurance
•Set proportion of medical costs
15. Why Cost Sharing?
Cost sharing reduces moral hazard
•Rand Health Insurance Experiment
Cost sharing had a material impact on
lowering utilization, without any
significant negative health consequences
16. Health Insurance Terminology
• Covered Services
– Benefits
•Services covered by an insurance plan
(medically necessary)
•Specified in a contract
•Vision and dental coverage are generally not
included in health insurance
17. Types of Private Insurance
• Group insurance
– Tax advantages when it is obtained through the
employer
– Comprehensive coverage is an anomaly to the
fundamental concepts of insurance
• Self-insurance
– Spurred by public policy
• No premium tax on employers
• ERISA 1974
• Exempt from some of the ACA requirements
18. Types of Private Insurance
• Individual private health insurance
– Nongroup plans
– Premiums based on individual’s health and
demographics
– Many lost coverage under the ACA
• Managed care plans
– Initially, these plans were different from
commercial health insurance
– Now, most health insurance is in the form of
managed care plans
19. Types of Private Insurance
• High-deductible health plans/savings options
– HRA:
•Funded by the employer
•HDHP is optional
– HSA:
•Employer contribution is optional
•HDHP is required
See Exhibit 6-1
20. Types of Private Insurance
• Medigap: Medicare supplement insurance
- To cover the high out-of-pocket costs in the
original Medicare program
- Not available to those covered by Medicare
Advantage (Part C of Medicare)
21. Trends in Employment-Based Health
Insurance
• 2005: 91.6% of private health insurance was
employment based
• 2011: The figure dropped to 89%
• The declining trend is shown in Fig. 6-4
• Other trends:
– Fewer small businesses offered health insurance
– Decreasing premium subsidies from employers
– Higher out-of-pocket costs
22. COBRA 1985
• Employment-based coverage can continue for 18
months after separation from a job
• 29 month coverage for individuals declared to be
disabled (HIPAA 1996)
• Family coverage for 36 months if the former
worker dies, enrolls in Medicare, or is divorced
• The individual must pay 102% of the group
premium
• The ACA does not affect COBRA
23. Other Trends
• The number of uninsured increased dramatically
between 2000 and 2009
• Ironically, despite tax credits under the ACA,
small business insurance coverage declined
(Figure 6-3)
• Premium increases between 2008 and 2013:
– 25% for single plans; 29% for family plans)
• Deductible increase between 2008 and 2013:
– Increased from $735 to $1,135 on an average
24. Private Health Insurance and the ACA
• Numerous employment-based plans are losing
their “grandfathered” status
• Fees imposed on insurers:
– A flat fee imposed on plans operating outside of
ERISA (self-insurance market)
– Additional fee is imposed on plans sold through
the exchanges
– These costs will be passed on in the form of
higher premiums
25. Compliance Requirements by Health
Plans
• Must cover young adults under 26 in their parents’
plans
• Coverage for preexisting conditions
Effects: Premiums will rise for everyone; the healthy
will subsidize the unhealthy
26. Compliance Requirements by
Health Plans
• Coverage for preventive services without cost
sharing
• No dollar limits on benefits
• Limits on out-of-pocket costs
• Set minimum medical loss ratios
Likely effects: Rise in premiums;
consolidation of the insurance industry and
less competition
27. The Individual Mandate
• All legal residents must have “minimum essential
coverage” or pay a penalty (individual shared
responsibility)
• To meet the definition of “minimum essential
coverage,” private and public plans must include
Essential Health Benefits in 10 categories (Exhibit 6-2)
• Exemptions from “individual shared responsibility”
– Having to spend more than 8% of household income on
health insurance
– Religious opposition to insurance
– Certain other exemptions
28. The Individual Mandate
• Healthy individuals may choose to pay the penalty
instead of buying health insurance
• Health insurance marketplaces: Exchanges
– Plans offered must be certified as “qualified health plans”
– Four tiers of standardized plans are offered – plans differ
by actuarial value; premiums costs; and level of cost
sharing
• Premium subsidies for people between 100% and
400% of the FPL
29. The Employer Mandate
“Employer shared responsibility”
• Postponed until January 2015
• Play or pay
• Applies to employers with 50 or more full-time
equivalent workers (full time is 30+ hours per week)
• Tests that health plans must meet:
– “Minimum value” test – plans must be at least equivalent
to the Bronze plan offered through the exchanges
– “Affordability” test – Employee’s share of the premium for
a single plan must not exceed 9.5% of household income –
it leaves plenty of room to shift cost to the employee (see
example on p. 213)
30. The Employer Mandate
• Penalties apply when an employee employed by a large
employer (50+ FTE employees) gets federal subsidy
• Another penalty applies when the health plan offered
fails the “minimum value” and “affordability” tests
• Businesses may reduce labor force, but will have to find a
balance between cost and compliance factors imposed
by the ACA and achieving production objectives
• Government projections: 3 to 5 million fewer people will
have employment-based health insurance
31. Public Health Insurance
• 2011: Almost ⅓ of Americans had public
health insurance
• Public financing supports categorical
programs
– Medicare
– Medicaid
– CHIP
– Military Health Services
– Veterans Health Administration
– Etc.
32. Medicare
– Title 18 of Social Security Act
– Beneficiaries
1) those 65 years old or older
2) disabled who are entitled to Social
Security
3) those with end-stage renal disease
– 83% are age 65 and older
– Federal program consistent across the nation
– A four-part program
33. Medicare – Part A (HI)
– Financed by mandatory payroll taxes
•Employer and employee pay equally into the
Hospital Insurance Trust Fund
– No premiums are required if a person or spouse
has worked and earned 40 credits
– A person can buy into Part A if accumulated
credits are below 40
34. Part A Benefits
Exhibit 6-3
• 90 days of inpatient hospital care per benefit period
(a lifetime reserve of 60 additional days)
• Lifetime care of 190 days in a psychiatric hospital
• Up to 100 days of care in a Medicare-certified SNF
• Home health care through a Medicare-certified
agency
• Hospice care
35. Medicare – Part B (SMI)
– A voluntary program paid partly by general
tax revenue and a premium
– In 2007, premiums became means-tested
(MMA 2003) - IRMAA
– Covers various outpatient services
• See Exhibit 6-4
36. Medicare – Part C
(Medicare Advantage)
• Created in 1997 as Medicare+Choice
• Current name adopted under MMA
• Voluntary enrollment in managed care for
both Parts A and B
• Otherwise the beneficiary remains in the
original Medicare program
• Does not add any specific benefits, but
managed care may provide some extras
• Additional premiums, but no need for
Medigap
37. Part C under the ACA
ACA aims to reduce payment to MA plans by
8% in 2014.
The goal is to achieve some level of parity
between the expenditures for Part C
compared to expenditures in the original
Medicare program.
The government has contended that MA
plans have been overpaid.
38. Medicare – Part D (Prescription Drug
Coverage)
• Created under MMA 2003; implemented in 2006
• Enrollees can choose between
» Stand-alone plans for prescriptions only
» Part C (all services through managed care)
• Voluntary enrollment
• Subsidized premiums; IRMAA imposed by ACA
• See Exhibit 6-5
39. Medicare Out-of-Pocket Costs
• No limits on out-of-pocket expenses in the original
Medicare program – a typical beneficiary spends
about 20% of income on cost sharing
• Nearly half of the MA plans have cost sharing limits
40. Medicare Financing and Spending
– Medicare consumes over one-fifth of national
health expenditures
– HI and SMI Trust Funds; both incurred deficits in
2012
– Medicare is financially sick and headed for
insolvency unless it is steered around
– Three main issues:
•Rising cost of delivering health care
•An aging population
•Shrinking workforce to support tax revenues
41. Medicaid
– Title 19 of Social Security Act
– Finances health care for the indigent as
determined by each state (means tested)
– Jointly financed by federal and state governments
42. Medicaid under the ACA
The Supreme Court’s Decision
• The US Supreme Court struck down the
mandates under the ACA, giving states a
choice to either expand or not expand their
Medicaid programs without any penalty from
the federal government.
• Hence, coverage and benefits for many low-
income people remain in a state of
uncertainty
43. Medicaid under the ACA
Two Ironies
• It appears that states can no longer use the
assets test to determine eligibility
• Preventive services are at the states’
discretion for existing beneficiaries
44. Old Medicaid Option
• For states that choose not to comply with the ACA
• Automatic eligibility:
•TANF recipients
•SSI recipients
•Children and pregnant women if income is at or
below 133% of FPL
•“Medically needy” designated by a state
45. Dual-Eligible Beneficiaries
– Eligible for both Medicare and Medicaid
•Full duals
•Partial duals
– Under the ACA
•Demonstration projects to integrate Medicare
and Medicaid for full duals
•Capitated model and managed care fee-for-
service model
46. Medicaid Enrollment and Spending
Enrollment and cost figures will not be
available until well into 2015
47. CHIP (Children’s Health Insurance
Program)
– Title 21 of Social Security Act
– Federal block grants to states to expand Medicaid
eligibility
– No federal income threshold, but states typically
cover children (up to age 19) in families with
incomes up to 200% of federal poverty level
– First enroll in Medicaid if qualify
48. Health Care for the Military
• U.S. Department of Defense
– Health care for active duty and retirees, their
dependents and survivors
– Each branch of the military operates its own
medical facilities; services are also obtained
through civilian providers
– TRICARE is the insurance arm
49. Veterans Health Administration (VHA)
– The largest integrated health service system in the
US
– Both service connected and other conditions are
treated on a priority basis
– Cost control through global budgets
– Services organized through 23 geographically
distributed Veterans Integrated Service Networks
(VISNs)
– CHAMPVA covers dependents of disabled veterans
50. Indian Health Service
• Federal program (IHS)
• Comprehensive care to Native Americans
living on reservations and in rural areas
• IHS operates its own hospitals, health centers,
and health stations
51. The Payment Function
• Third-party payers
– Insurance companies, managed care
organizations, BlueCross BlueShield, government
• Payment function has two facets:
1) Determine methods and amounts of
reimbursement in advance of the delivery
2) Actual payment after services have been
rendered
52. The Payment Function
• Charge
– Price set by provider
• Rate
– Price set by a third party payer
• Fee schedule
– An index of charges listing individual fees for each
type of service
53. Reimbursement
Numerous reimbursement methods exist and
used for different types of services
– Fee for service
– Bundled payments (package pricing)
– RBRVS
– Managed Care Approaches
– Cost-Plus Reimbursement
– Prospective Reimbursement
54. Fee for Service
– Charges are set by the provider
– Each service billed separately
– Later, insurers adopted UCR (usual, customary
and reasonable) charge
– Main drawback
•provider induced demand
55. Bundled Payments
(package pricing)
– A number of related services in one price
– Reduces provider-induced demand because fees are
inclusive of all bundled services
– There is evidence that prospectively set bundled fees
reduce health care spending without compromising
quality of care
– Bundled Payments for Care Improvement (BPCI)
initiative
56. Resource-Based Relative Value Scale
(RBRVS)
– To reimburse physicians
– RVUs are established for each CPT coded physician service
– RVUs reflect time, skill, intensity
– Separate RVUs are assigned for overhead costs and
malpractice insurance costs
57. Resource-Based Relative Value
Scale (RBRVS)
– RVUs are adjusted to reflect geographical cost
variations
– Each year, Medicare establishes a dollar
Conversion Factor (CF). Reimbursement for a
service = RVU x CF
– A type of fee for service; it has not addressed the
issue of volume-driven payment
58. Managed Care Approaches
– Preferred Provider
•Discounted Fee for Service
– Capitation
•Per member per month (PMPM) fee to cover
all needed services
•Monthly fee = PMPM rate x number of
enrollees
•Minimizes provider induced demand and
promotes prudence
– Salary combined with productivity-based
bonuses
59. Cost-Plus Reimbursement
– To reimburse health care institutions
– Per diem rate or per patient day rate (PPD)
– Based on total operating cost + a portion of
capital costs
– Also called retrospective reimbursement
– No incentive to control costs or judicious use of
services
– Largely replaced by prospective methods
– Critical access hospitals in rural areas are still paid
under cost-plus
60. Prospective Reimbursement
– Criteria established to determine in advance the
amount of reimbursement
– Removes incentives to be inefficient (present in
cost-plus)
– Enables Medicare to predict future health care
spending
– Organizations make a profit by keeping their
operating costs below the fixed prospective rates
61. Value-Based Reimbursement
– The ACA directs Medicare to develop “value-based
purchasing” methods that incorporate pay for
performance
– The goal is to reduce reimbursement while
improving quality and efficiency
– Most organizations are required to report quality
data to the CMS, or face penalties
62. Types of Prospective Reimbursement
• Diagnosis-Related Groups (DRGs)
• Psychiatric DRGs
• Outpatient Prospective Payment System
• Case-Mix Methods:
– Resource Utilization Groups
– Case Mix Groups
– Home Health Resource Groups
63. Diagnosis-Related Groups (DRGs)
Overview
– PPS for acute care hospital inpatient reimbursement
– Each DRG groups together principal diagnoses
requiring similar amounts of resources
– A predetermined fixed rate is paid per case
– Hospital must provide whatever services the patient
needs
– Certain adjustments are made, e.g., location,
teaching hospital, disproportionate share hospital,
outliers, etc.
64. Diagnosis-Related Groups (DRGs)
Refined Medicare Severity DRGs
– Patient severity was incorporated in 2007 to better
reflect resource use
– 335 base DRGs are split further into 751
MS-DRGs (in 2012) based on comorbidities or
complications
– MS-DRGs are weighted and reviewed annually
– 65% of bad debts are added to reimbursement
– Reimbursement is reduced for certain early
discharges
65. The ACA and Hospital Reimbursement
– The ACA imposes reimbursement penalties for
excessive readmissions – readmission to the same or
another hospital for the same condition within 30
days of discharge
– Readmissions are being viewed as a quality issue
– Hospitals are taking steps to reduce readmissions
– The CMS has been authorized to make value-based
incentive payments for performance on a set of quality
measures
66. Psychiatric DRGs
– Per-diem, not a case-specific, rate is based on
psychiatric DRGs to reimburse psychiatric hospitals
– A stop-loss provision to protect against significant
losses
67. Outpatient Prospective Payment
System (OPPS)
– For services provided by hospital outpatient
departments; OPPS for nonhospital ambulatory
surgery centers
– Ambulatory Payment Classifications (APCs):
• 300 procedural groups
• New technology APCs
• a bundled rate to include anesthesia, drugs, supplies,
recovery
• Physician services are reimbursed separately, based
on RBRVS
68. Case Mix Methods
– Case mix: Aggregate severity of conditions
– Determined through a comprehensive assessment
– Mutually exclusive case mix categories represent
resource use
•Resource Utilization Groups (RUGs) are used to
determine per-diem reimbursement for skilled
nursing facilities
•Case Mix Groups (CMGs) are used to reimburse
inpatient rehabilitation facilities
69. Home Health Resource Groups (HHRG)
– the PPS is fixed, pre-determined for each 60-day
episode of care regardless of specific services
delivered
– services are bundled under one payment on a per
patient basis
– durable medical equipment (DME) and drugs not
included
– Outcome and Assessment Information Set (OASIS)
is used to assign patients to one of 153 HHRG
categories
70. Disbursement of Funds
• Claims processing
– After services are delivered
– Verify and pay claims submitted
• Third-Party Administrator (TPA)
– Self insured employers contract the service
– Process and pay claims
– Monitor utilization
• Fiscal Intermediaries and Carriers
– Medicare and Medicaid
71. National Health Expenditures
• $2.6 trillion spent in 2010
• $8,402 average per capita
• 17.9% of GDP (share of total economic output
consumed by health care)
• 2020 projections:
– $4.4 trillion
– 19.2% of GDP
72. National and Personal Health
Expenditures
• National Health Expenditures: Aggregate of
– All health services, products, and supplies
(personal health exp. – see Table 6-4)
– Public health services
– Health care research
– Administrative costs
– Investments in structures and equipment
73. The Nation’s Health Care Dollar
• Figure 6-6 shows the ongoing proportional
shift from private spending to public spending
• The ACA will significantly shift the ratio toward
public financing starting 2014
• Figure 6-7 shows the sources of financing and
the services for which the funds were used
74. Current Directions and Issues
Value and affordability:
– CBO estimates – 30 million uninsured in 2017
– 10 year federal costs (2014-2023) are estimated
to be $1,375 billion, not including costs to be
borne by the states, employers, and individuals
– Health care utilization costs (by the newly insured)
are also left out
– Several of the ACA provisions will result in higher
insurance premiums and higher taxes
75. Current Directions and Issues
Favorable Risk Selection and Adverse Selection
• High-risk individuals have a greater incentive than
low-risk individuals to enroll in health insurance
• Because state high-risk pools have been abandoned
under the ACA, a large number of low-risk
individuals need to enroll in the ACA plans
• Employers with younger workforces are likely to
opt for self insurance – this could affect the small
group market in the exchanges
76. Current Directions and Issues
Intentional Churning:
Mulvany (2013) assumes that one potential unintended
consequence of the ACA could be individuals
purchasing insurance only after they have a health care
need and, subsequently, cancelling coverage once the
need no longer exists.
77. Current Directions and Issues
Cost shifting:
The ACA coverage expansion will be paid in part by
reducing payments to hospitals and other providers.
Hence, cost shifting will likely occur, which would have
the effect of premium increases for health insurance in
both employment-based and exchange-based plans.
78. Current Directions and Issues
Fraud and Abuse
– Fraudulent billing may amount to 3% to 10% of total
health care spending
– The ACA calls for penalties for delaying or refusing the
DHHS access to information in connection with audits
and investigations.
– Payments can be suspended when fraud is suspected.
– Eligibility for Medicaid and insurance subsidies are
two areas ripe for fraud