US HC System

State-Run Exchange

States manage core exchange functions, such as plan management, consumer assistance, eligibility and enrollment, financial management

What is the Federal Poverty Level for a 1 person household

$12,880

There is in-network, out-of-network, and tiered network. What is a Tiered Network?

-In network providers are segmented in tiers based on performance against quality and cost measures. -goal is to incentivize enrollees to use provider services in higher performing tiers.

Flow of $ in HC System

-Patient premium to payer, copay or coinsurance to provider -Payer formulary, negotiated payment to Provider -Provider payment to Wholesaler/Distributor -Wholesaler Payment to Manufacturer

What are mandatory covered services under medicaid?

-hospital care (inpatient and outpatient) -nursing home care -physician services -lab and xray service -immunizations, early and periodic screening, diagnosis, and treatment (EPSDT) -health center and rural health clinic services -nurse midwife and nurse practitioner services

FFS

-no network restrictions -PCP not necessary -higher deductibles, higher cost sharing/premiums

What did the Supreme Court decide about the individual mandate?

-the court concluded that the Individual Mandate was not a valid exercise of Congress' power to regulate commerce. The Commerce Clause allows Congress to regulate existing commercial activity, but not to compel individuals to participate in commerce. This would open a new realm of Congressional authority.

3 Ways Plans implement Utilization Management to Control Medical/Pharmacy Services

1) PA: requires that physician obtains approval from the health plan prior to providing a service or prescribing a drug 2) Step Therapy: Requires the member to try another cost effective drug before accessing a higher-cost drug 3) Quantity Limits: Restricts the amount of a drug that is covered over a time

What is the typical 4 tier structure?

1) generic drugs (minimal restrictions) 2) preferred brand (brands without a generic alternative or brands that have a contract betwen plan and manufacturer at a discounted price) 3) non-preferred brand (brands with a less expensive alternative 4) specialty (specialty drugs are pharmaceuticals that are classified as high-cost, high complexity and/or high touch)

What is an accountable care organization?

An entity and set of providers that agree to joint accountability for the cost and quality of care delivered to a defined patient population.

What is the most common type of plan?

Employer plans! (46% of Americans) Individual coverage is only 5% of Americans.

What is individual coverage?

Individual Insurance is a health policy that you can purchase for just yourself or for your family. (It is not through an employer.) -You can choose the insurance company, the plan and the options that meet your needs. -It's not tied to your job, so no lost HC if u lose job. -fed and state regulations apply

What was the Individual Mandate of the ACA?

The ACA contained a minimum coverage provision by amending the tax code and providing an individual mandate, stipulating that by 2014, non-exempt individuals who failed to purchase and maintain a minimum level of health insurance must pay a tax penalty.

What are the basic non-financial eligibility requirements for medicaid?

a medicaid beneficiary must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. -In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.

POS

higher premiums, have out of network benefits -PCP not necessary, specialist services don't need referral from PCP

As flexibility of plan increases, what else changes?

-cost sharing increases -member choice increases

Why would an employer choose a self-funded plan?

-The employer can customize the plan to meet the specific health care needs of its workforce, as opposed to purchasing a 'one-size-fits-all' insurance policy. -The employer maintains control over the health plan reserves, enabling maximization of interest income - income that would be otherwise generated by an insurance carrier through the investment of premium dollars. -The employer does not have to pre-pay for coverage, thereby providing for improved cash flow. -The employer is not subject to conflicting state health insurance regulations/benefit mandates, as self-insured health plans are regulated under federal law (ERISA). -The employer is not subject to state health insurance premium taxes, which are generally 2-3 percent of the premium's dollar value. -The employer is free to contract with the providers or provider network best suited to meet the health care needs of its employees.

HMO

-no/severely restricted out of network coverage, members must pay for all or almost all costs out of network -members must select PCP, specialist services need referral from PCP

PPO

-offers out of network benefits, but lower cost sharing for in network -PCP not necessary, specialist services don't need referral from PCP

What are optional covered services under medicaid?

-prescription drugs (but all 50 states and DC cover these under medicaid) -case management services -disease management -rehab care -home and community-based waiver services -personal care and other community based services for individuals with disabilities -dental -clinic services -prosthetic devices

4 types of common plans, from most rigid to most flexible

1) Health Maintenance Organization (HMO) 2) Preferred-Provider Organization (PPO) 3) Point-of-Service (POS) 4) Fee for Service (FFS)

What are states' 3 options of Exchange?

1) State-Run Exchange 2) State Partnership Exchange 3) Federally-Facilitated Exchange

what was the outcome of NFIB v Sebelius? (What did the Court uphold the constitutionality of? What did the court reject the constitutionality of?)

1) The Court upheld the constitutionality of the ACA's minimum essential coverage provision, known as the individual mandate, which requires most people to maintain a minimum level of health insurance coverage beginning in 2014 2) The Court found the ACA's Medicaid expansion unconstitutionally coercive of states because states did not have adequate notice to voluntarily consent to this change in the Medicaid program, and all of a state's existing federal Medicaid funds potentially were at risk for non-compliance

What is the more common type of employer plans

1) self-funded plans: A Self Funded, or Self-Insured plan, is one in which the employer assumes the financial risk for providing health care benefits to its employees. ... Typically, a self-insured employer will set up a special trust fund to earmark money (corporate and employee contributions) to pay incurred claims.

self-funded vs. fully-funded employer plans

2 methods of financing the costs of an employee benefit plan: self-funded: there is a fixed cost and variable cost. if variable (claims cost) less than what you paid, money stays with organization and there is a savings. Opportunity to save: if claims are favorable, you don't spend the money. Also flexibility of plan design. fully funded: employer pays a premium in return for a guarantee to pay claims. fixed costs. You can get anything you want as long as it's the plans insurer is specifically offering.

National Federation of Independent Business (NFIB) v. Sebelius

2012 Supreme Court case challenging the constitutionality of the Affordable Care Act

Formulary definition

A formulary is a list of generic and brand name prescription drugs covered by the health plan. The health plan may only help you pay for the drugs listed on its formulary. It's their way of providing a wide range of effective medications at the lowest possible cost. -Formularies have anywhere from 3 to 7 tiers, -Cost sharing increases and utilization management increases as tiers increase (in terms of copays or coinsurnace)

Federally Funded Exchange

ACA requires HHS to run a FFE in any state that doesn't set up an exchange. -states with FFE don't control key exchange functions, but federal government consults with state on the exchanges design -FFE states retain traditional responsibilities of their insurance departments

How much is federal medicaid spending projected to increase over the next decade? (2018-2028)

By more than 70%!

Exchanges: State vs. Federal

Each state chose to operate their own insurance market or participate in the federally-facilitated exchange -There are 15 state based exchanges, 6 state-based Exchanges on the Federal platform, meaning federally supported exchanges (SBE-FPs), 6 state-partnership exchanges, and 24 federally-facilitated exchanges -

Medicaid Eligibility varies

Eligibility for Medicaid benefits varies widely among the states - all states must meet federal minimum requirements, but they have options for expanding Medicaid beyond the minimum federal guidelines, the details are outlined

Who can use HC exchanges?

Families and small businesses

ObamaCare AKA Health Care Reform, the Affordable Care Act, ACA Goals

Goals: 1) Make affordable health insurance available to more people. The law provides consumers with subsidies ("premium tax credits") that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL). 2) Expand the Medicaid program to cover all adults with income below 138% of the FPL. (Not all states have expanded their Medicaid programs.) 3) Support innovative medical care delivery methods designed to lower the costs of health care generally.

State Partnership Exchange

HHS manages technical functions, including eligibility, enrollment, and financial management. States have options. 1) perform plan management only 2) perform consumer assistance only 3) perform plan management and consumer assistance

What is the shift to value-based care?

Instead of a fee for service design (separate payment for individual services rendered by a single provider), we're seeing a shift to bundle, episode, condition, and population care.

How is medicaid financial eligibility determined?

MAGI (Modified Adjusted Gross Income) is the basis for determining Medicaid income eligibility for most children, pregnant women, parents, and adults. -The MAGI-based methodology considers taxable income and tax filing relationships to determine financial eligibility for Medicaid.

Who were the plaintiffs in the NFIB v. Selibius?

Shortly after Congress passed the ACA, Florida and 12 other states brought actions in the United States District Court for the Northern District of Florida seeking a declaration that the ACA was unconstitutional on several grounds. These states were subsequently joined by 13 additional states, the National Federation of Independent businesses, and individual plaintiffs Kaj Ahburg and Mary Brown.

What is a medically needy person?

States have the option to establish a "medically needy program" for individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups. Medically needy individuals can still become eligible by "spending down" the amount of income that is above a state's medically needy income standard. Individuals spend down by incurring expenses for medical and remedial care for which they do not have health insurance.

ACA medicaid expansion

The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age 65. -The ACA expanded Medicaid coverage for most low-income adults to 138% of the federal poverty level (FPL) -Eligibility for children was extended to at least 133% of the federal poverty level (FPL) in every state (most states cover children to higher income levels), and states were given the option to extend eligibility to adults with income at or below 133% of the FPL.

Health Insurance Exchanges AKA HIX, ObamaCare Exchange, Health Benefits Exchange, Health Care Exchange, Health Insurance Marketplace and Affordable Insurance Exchanges.

The ObamaCare health insurance exchanges allow all Americans above the poverty line to be able to buy health insurance through providers via an online health insurance marketplace. The marketplace also offers subsidies for lower cost premiums, lower out-of-pocket costs, and Medicaid. The health insurance marketplace works similar to a car insurance website where side-by-side cost and benefit comparisons of different tiered plans are displayed to help the shopper purchase the best coverage for them and their family.

What were the 3 big arguments of the plaintiffs in NBIF?

The plaintiffs argued that: (1) the individual mandate exceeded Congress' enumerated powers under the Commerce Clause; (2) the Medicaid expansions were unconstitutionally coercive (3) the employer mandate impermissibly interfered with state sovereignty.

Low income definition USA (FPL)

The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount

How many states adopted medicaid expansion?

To date, 39 states (including DC) have adopted the Medicaid expansion and 12 states have not adopted the expansion.

What is value based care in terms of: 1) bundle 2) episode 3) condition 4) population

bundle: payment for a tightly-linked set of services provided by 1 or small # of providers episode: payment for all/most services delivered by related providers attendant to a time-delimited "episode of care" such as a hip replacement or a course of oncology care condition: payment for all/most services delivered by related providers attendant to a specified disease or condition, such as asthma, diabetes, etc. over a specified time population: payment for all/most services delivered by related providers to a heterogeneous population

What is the Coverage Gap in medicaid?

some individuals in states that chose not to expand medicaid experience a gap in coverage. Individuals with incomes greater than a state's medicaid eligibility but not at 100% of the FPL are ineligible for medicaid coverage and exchange subsidies.

What did the court decide about the coerciveness of medicaid expansion under the ACA?

the court concluded that the Medicaid expansion provisions was unconstitutionally coercive as written. Congress does not have authority under the Spending Clause to threaten the states with complete loss of Federal funding of Medicaid, if the states refuse to comply with the expansion.

What did the court leave in tact in ACA?

the remainder of the Medicaid expansion provision, without the unconstitutional threat to completely withdraw Medicaid funding, stands as a valid exercise of Congress' power under the Spending Clause. So basically the ACA is held in tact, but it's not mandatory for states to comply. There are huge incentives to comply, but they don't have to. To date, 39 states (including DC) have adopted the Medicaid expansion and 12 states have not adopted the expansion.