Popular term for “phased-down state contribution” that describes how the federal government is recovering (o r”clawing” back, from the states’ perspective) money spent on Medicare-covered drugs for persons dually eligible for Medicare and Medicaid. Since January 2006, states have made monthly payments to the federal Medicare program, reflecting the amount of money they spent on prescription drugs for Medicaid-eligible seniors (known as dual eligibles) before the enactment of Medicare Part D. Payments were set at 90 percent of costs in FY 2006, decreasing to 75 percent by FY 2015. However, because of the recession of 2007-2009, the federal government reduced the amount each state had to pay from October 1, 2008 through the end of 2010. The Education, Jobs and Medicaid Assistance Act extended this provision through June 30, 2011.
A term that describes health plans in which enrollees are permitted to receive non-emergency services only through specified providers. Group- and staff-model HMOs are examples of closed panel plans.
A medical condition that exists at the same time as the primary condition in the same patient (e.g., hypertension is a co-morbidity of many conditions such as heart disease, end-stage renal disease and diabetes).
A portion of the bill for a medical service that is not covered by the patient’s health insurance policy and therefore must be paid out of pocket by the patient. Coinsurance refers to a percentage, for example 10 percent of the total charge up to a specified maximum. (Contrast with copayment, which is stated as a flat amount, for example $5 per office visit.)
A state plan option under Medicaid that encourages primary care practices to provide home- and community-based care to chronically-ill Medicare patients. States that take up this option receive a 6 percentage point increase in federal matching payments for costs associated with the program.
Organization providing comprehensive primary care, mostly to medically underserved populations, regardless of ability to pay. These public and non-profit entities receive federal funding under Section 330 of the Public Health Service Act, as amended.
Enacted as part of the Affordable Care Act (ACA), the CLASS program aimed to establish a national voluntary insurance program for purchasing non-medical services and supports necessary for individuals with functional limitations to maintain community residence. The Department of Health and Human Services (HHS) was to release details of the program by October 2012. The program was supposed to be financially self-sustaining. However, HHS found the program to be unfeasible. The CLASS Act was later repealed in January 2013 as part of the American Taxpayer Relief Act of 2012. (See Long-Term Services and Supports chapter)
Also known as the Mental Health Block Grant, it is provided by Substance Abuse and Mental Health Services Administration (SAMHSA) to establish or expand an organized community-based system of care for providing mental health services to people with serious emotional disturbances or mental illness.
A method for setting premiums at the same price for everyone, based on the average cost of providing health services to all. The premium is not adjusted for the individual beneficiary’s medical history or likelihood of using medical services. (Contrast with experience rating and modified community rating.)
Allows the Centers for Disease Control and Prevention to award state and local government agencies, tribes and territories, and nonprofit organization funding to design and implement community-level programs that prevent chronic diseases.
Research that compares clinical outcomes, or the “clinical effectiveness,” of alternative therapies for the same condition. Many analysts maintain that comparative effectiveness research evidence can lead to better health care decisions and thus to improved quality of care, improved efficiency, and ultimately, to the potential for cost savings throughout the health system.
This law includes one part that entitles former employees of companies with 20 or more workers to continue to receive their employer-sponsored coverage under the group plan for up to 18 months. Under the original legislation, individuals were required to pay the full premium to continue their insurance through COBRA. The American Recovery and Reinvestment Act provided a temporary subsidy of 65 percent of the premium cost for the purchase of COBRA coverage to people who lost their job between September 1, 2008 and May 31, 2010.
A statistical measure of the annual change in cost to workers of purchasing a market basket of goods and services. It is expressed as a percentage of the cost of these goods and services during a base period. CPI is also known as retail price index or cost-of-living index.
A form of health insurance that combines a high-deductible health plan with tax-favored health spending accounts into which employers or individuals contribute pre-tax dollars to be used for health care purchases. These mechanisms aim to change employees from receivers of health care into purchasers by having them participate more fully in health care and cost decisions. (Also see Health Reimbursement Arrangement and Health Savings Account.)
Housing community designed to provide different levels of long-term care under contract. Services usually include home care, support in an assisted living facility and care in a nursing home.
A set of mechanisms that ensure patients and clinicians have access to, and take into consideration, all required information on a patient’s conditions and treatments to ensure that the patient receives appropriate health care services.
A flat amount paid out of pocket per medical service, for example $5 per office visit. (Contrast with coinsurance, which is stated as a percentage, for example 10 percent of the total charge up to a specified maximum.)
Specific clinical measures that, when viewed together, permit a robust assessment of the quality of care provided in a given focus area, such as acute myocardial infarction.
Any out-of-pocket payment the patient makes for a portion of the costs of covered services. Deductibles, coinsurance, copayments and balance bills are types of cost sharing.
The practice by which a seller of a health service, such as a hospital, increases charges for some payers to offset losses due to uncompensated or indigent care or lower payments from other payers.
Households earning 100 percent 250 percent of the federal poverty level are eligible for cost-sharing reductions to help pay for out-of-pocket costs associated with a silver plan purchased through a health insurance marketplace. This provision lowers cost-sharing for enrollees by reducing deductibles, copayments, and/or out-of-pocket limits.
Limited-service hospitals located in rural areas and meeting certain size, location and other requirements. CAHs are subject to less rigorous staffing standards and receive reimbursement from Medicare based on their actual costs, rather than by the more common (and less favorable) payment tied to average costs for treating a particular diagnosis.
The concept of certain purchasers paying more for medical services than they otherwise would so that others can pay less (or nothing at all), so another activity can be funded. In the U.S. health system, this mechanism has been used to pay for medical services for the poor and uninsured, medical education and research.
A phenomenon whereby public health coverage programs encourage some employers to drop health coverage, urging their employees instead to take advantage of the subsidies available to them in the public program.
Long-term care services that do not seek to cure, provided during periods when the medical condition of the patient is not changing or does not require continued delivery by medical personnel.