Group3 Health Policy And Group Insurance

Question 1

ACA: better health for populations

Answer 1

1. Health is physical, mental, social well-being. Not merely the absence of disease
2. Populations can be defined by geography, age, health insurance coverage, or race
3. Physical environment
   
   3. 1 Sanitized water, pollution, violence, unhealthy living environment, food-borne illnesses, lack of access to healthy foods
4. Community disease prevention
   
   4. 1 childhood immunization, free flu shots, preventive screenings, hand washing programs, public awareness campaigns
5. Lifestyle (eg obesity)
6. Smoking and substance abuse
7. Socioeconomic factors
   
   7. 1 income is directly related to poor health
   8. 2 Medicaid provides health care for low-income
   9. 3 access to quality providers can be challenging
8. Wellness and disease management solutions
   
   8. 1 common among ERs: programs around smoking, diet, fitness and weight loss

Question 2

The Triple Aim of ACA

Answer 2

1. Better care for individuals
   
   1. 1 must focus on health care quality
   2. 2 Quality programs which include:
      
      1. 2.1 Agency for Healthcare Research and Quality (AHRQ)
      2. 2.2 National Quality Forum (NQF)
      3. 2.3 NCQA administers Healthcare Effectiveness Data and Information Set (HEDIS)
      4. 2.4 Institute of Medicine’s characteristics of health care performance - safe, effective, patient-centered, timely, efficient and equitable
2. Better health for populations
3. Lower per capita costs
   
   3. 1 health expenditures to GDP higher in the US than in other countries of OECD
   4. 2 Health expenditures have grown faster than the rest of the economy
   5. 3 High costs have rendered health care unaffordable
   6. 4 for the cost, outcomes are no better in the US
   7. 5 Employers struggling to provide health insurance

Question 3

Financing of Health Care in US

Answer 3

1. Medicare (federal funding) covers elderly and disabled persons
2. Medicaid (federal and state funding) covers lower income children and adults
3. The majority of health care will be financed by public funds in a few years
4. Commercial insurance accounts for 1/3 US health expenditures
5. Health insurance: a portion of prem paid by the ER, and the remaining by EE

Question 4

The affordable care act
Individual and Group Market Reforms
Part 1 of 2

Answer 4

1. Individual Mandate
2. Employer Mandate: ERs with less than 50 EEs are exempt
3. Essential Benefit Package
   
   3. 1 Comprehensive set of services
   4. 2 Preventive services without cost-sharing
   5. 3 cover at least 60% of actuarial value of covered benefits
   6. 4 Limit annual cost-sharing to the current law HSA limits
4. Medical Loss Ratio (MLR) - must provide rebates if less than 85% (large group) or 80% (ind and small group)
5. Premium rate reviews
6. Benefit and Coverage requirements
   
   6. 1 Effective sept 2010
   7. 2 Dependent children to age 26
   8. 3 Rescission: prohibited except in cases of fraud
   9. 4 Pre-existing condition exclusions: for children are prohibited
   10. 5 Lifetime or annual coverage limits: not allowed
   11. 6 Preventive care: must be covered at 100%

Question 5

The affordable care act
Individual and group market reforms
Part 2 of 2

Answer 5

1. Rating requirements
   
   1. 1 effective 2014
   2. 2 guaranteed issue and Renewability
   3. 3 pre-existing condition exclusion and health status: not allowed
   4. 4 rating variation only allowed on: Age (limited to 3:1 ratio), geographic area, tobacco use, family composition
   5. 5 waiting periods: must not exceed 90 days
2. Benefit tiers: the Metallic Plan
3. Grandfathering of existing plans
   
   3. 1 existing plans keep their current provisions unchanged
   4. 2 required to extend dependent coverage up to age 26
   5. 3 prohibited from issuing recession coverage
   6. 4 eliminate life time limits on coverage
   7. 5 Eliminate pre-existing conditions for children
   8. 6 Beginning 2014, eliminate annual limits, pre-existing condition exclusions for adults and waiting periods > 90 days
4. States have the option to create a Basic health plan
5. State have the option of merging the indiv and small group markets

Question 6

Health Insurance Exchanges

Answer 6

1. Exchange for Individual and SHOP exchanges for business
2. A platform for the purchase of insurance
3. Benefit Tiers
   
   3. 1 Plans must cover essential benefits, must have an OOP limit less than or eq the HSA limit, and be one of the metallic tiers
   4. 2 insurers may offer, through exchanges, a catastrohpic plan
4. INdividual risk pool, small group risk pool
5. Other provisions of the exchanges
   
   5. 1 Governance, reporting and consumer interfaces
   6. 2 insurer qualification requirements
   7. 3 payment structures reward quality
   8. 4 CO-Ops

Question 7

The affordable care act

High risk pools and risk adjustment

Answer 7

1. National high risk pool
2. Transitional risk programs
   
   2. 1 transitional reinsurance
   3. 2 transitional risk corridors
3. Risk adjustment- states assess a charge to plans whose risk is less than average, and provide payment to plans greater than average

Question 8

The affordable care act

Premium and cost assistance

Answer 8

1. Premium and cost assistance for individual and families
   1.1 premium subsidies
   1.2 cost sharing subsidies
2. Premium subsidies for employers
   2.1 small business tax credits:
   ERs less than or eq 25 EEs receive a tax credit if they contribute at least 50% of the premium
   2.2 Early Retiree Reinsurance Program

Question 9

The affordable care act

Medicare provisions

Answer 9

1. Medicare Fee-for service (part A and B)
   1.1 adjustments to annual market basket updates
   1.2 freeze on the income threshold used to determine Medicare Part B
   1.3 Payment reductions for Disproportionate share hospitals
   1.4 preventable readmissions
   1.5 certain hospital-acquired conditions
2. Medicare Advantage (Part C) provisions
   2.1 blended benchmark determines payments for most MA plans, plans can receive bonus based on quality, subject to MLR requirement
3. Medicare part D: Coinsurance in the coverage gap reduce to 25% by 2020, ACA removed the income tax exemption of RDS
4. Cost sharing for preventive services has been eliminated
5. New demonstration programs
6. Coordination of Medicare/Medicaid dual eligibles
7. Additional payments to certain hospital
   8 provisions to improve accuracy of Medicare payments
8. Transparency rules
9. Provider screening, fraud and abuse

Question 10

The affordable care act

1. Medicare Payment reforms
2. Revenue provisions

Answer 10

1. Payment reforms
   
   1. 1 Medicare innovation center
   2. 2 bundled payment program
   3. 3 Medicare Shared Savings Program
   4. 4 Value-based purchasing program
2. Revenue Provisions
   
   2. 1 health insurer tax
   3. 2 excise tax for high cost health plans
   4. 3 new taxes on certain medical devices

Question 11

The Affordable Care Act

Medicaid Provisions

Answer 11

1. ACA expanded Medicaid threshold to 133% of FPL
2. Payments for primary care services will = Medicare rates
3. Other provisions: increase in the federal match to CHIP, increase in drug rebates, fraud and abuse screening, free-standing birth centers, hospice care for children, family planning, LTC services
4. New programs: Health homes, bundle payments, global capitation to safety net hospitals, pediatric ACO, emergency mental health services

Question 12

The affordable care act

Other provisions of ACA

Answer 12

1. Standards for explanations of coverage
2. Quality reporting requirements
3. Waste, fraud and abuse compliance
4. Provider financial relationships
5. FDA drug approval
6. State powers
7. Provisions to Monroe disparities due to race