A range of services that states are required to include in their basic benefits package for all Medicaid-eligible children under age 21. EPSDT services include periodic screenings to identify physical and mental conditions, as well as vision, hearing, and dental problems. Services also include follow-up diagnostic and treatment services to correct conditions identified during a screening, whether or not the state Medicaid plan covers those services for adult beneficiaries.
Signed into law by President Barack Obama, the Affordable Care Act (ACA), requires that the Department of Health and Human Services oversee the development and management of federal resources to protect seniors from elder abuse.
Some in the health care field consider the term “electronic health record” to be virtually identical to “electronic medical record.” Others consider an electronic health record to be a more patient-oriented Web-based set of information about the patient and his or her care, easily accessible by the patient and owned by the patient.
A computer-based record containing details about a patient’s encounter with a health care provider or facility, such as the patient’s chief complaint, vital signs, medical history, medical orders, plans and prescriptions. An EMR is a legal document and must meet all of the statutory and regulatory requirements for paper medical records. It is owned by a professional practice, hospital or other health care facility. Also known as a computerized patient record. (Contrast with electronic health record.)
Enacted in 1974, ERISA was primarily designed to secure workers’ pension rights. The law established federal reporting and disclosure requirements for most private employee health plans. Under ERISA, companies that pay for their workers’ health benefits directly for example by self-insuring and assuming all or most financial risk, are exempt from state insurance regulations and taxes. ERISA also limits workers’ ability to sue their insurer.
An incentive mechanism designed to encourage employers, usually small employers, to offer health insurance to their employees. The tax credit enables employers to deduct an amount, usually a percentage of the contribution they make toward their employees’ premiums, from their federal taxes. These tax credits are typically “refundable,” so they are available to organizations with no federal tax liability. The ACA includes a tax credit for small employers that provide health coverage to their employees. The tax credit is available to employers with 25 or fewer employees and average annual wages of less than $50,000.
An approach that requires all employers to provide health care benefits to their workers or pay a fee (see employer pay-or-play) that contributes to the cost of covering them. The ACA creates a type of employer mandate, in that employers with 100 or more employees who didn’t offer coverage as of January 1, 2015 and employers with 50 or more employees who didn’t offer coverage as of January 1, 2016 had to begin paying a fee per full-time employee. There are two types of penalties, one for an employer failing to offer coverage and another for an employer failing to offer a health plan with a specified minimum value.
An approach requiring employers to offer and pay for health benefits on behalf of their employees, or to pay a specified dollar amount or percentage of payroll into a designated public fund. The fund would provide a source of financing for coverage for those who do not have employment-based coverage. Currently, two states, Massachusetts and Vermont, and the City of San Francisco impose pay-or-play requirements on employers.
A voluntary system in which employers choose to provide health insurance for employees.
Kidney disease that is severe enough to require lifetime dialysis or a kidney transplant. People of all ages who have ESRD are eligible for Medicare.
A program, such as Medicare or Medicaid, for which people who meet eligibility criteria have a right to benefits. Changes to eligibility criteria and benefits require legislation. For Medicare, the federal government is required to spend the funds necessary to provide benefits for individuals in these programs, unlike discretionary programs for which spending is set by Congress through the appropriations process. For Medicaid, the federal government must provide matching funds to the states. Enrollment in these programs cannot be capped, and neither states nor the federal government may establish waiting lists.
See Employee Retirement Income Security Act.
An employment-based plan covered under the Employee Retirement Income Security Act. Whether coverage is provided through insurance or a different method of employer coverage, there are certain essential requirements it must meet. These key elements include: a written plan that describes the benefit structure and guides action; a trust fund to hold the plan’s assets; a record keeping system to track all types of payments, maintain participant and beneficiary information, and to assist in preparing reporting documents; and documents to provide plan information to both the government and to employees participating in the plan
A benchmark level of benefits created by the Affordable Care Act (ACA) that is meant to ensure a health plan provides a comprehensive set of services. Plans both within and outside of the health insurance exchanges will be required to offer at least this level of coverage. Out-of-pocket expenses will be limited to the high-deductible health plan (HDHP) limits ($6,550 for individuals and $13,100 for families in 2017). The secretary of health and human services is required to define and annually update the benefit package.
The use of current best clinical research evidence in making decisions about the care of individual patients, often with the assistance of information technology.
See health insurance marketplace.
The period during which an original biologic drug has exclusive rights of production under its patent period. The exclusivity period for biologics is 12 years.
Currently, both members of a couple do not have to become impoverished for one to received long-term services and supports through Medicaid. This protection does not apply if the spouse needing care is not institutionalized. With the enactment of the Affordable Care Act (ACA), for five years beginning in 2014, states are required to extend the same spousal impoverishment protections that apply to institutional care to home- and community-based care.
Process of determining insurance premiums for a group that is based wholly or partially on that particular group’s past use of services and expenses incurred. (Contrast with community rating and modified community rating.)
