In 1984, Congress enacted the Hatch-Waxman Act to spur the development of lower-cost generic drugs. The act provided manufacturers of innovative prescription drugs with patent protection and a period of marketing exclusivity, created a generic drug approval process to help companies bring products to the market more quickly once the patent for an original brand-name drug expired, and established procedures for resolving patent disputes arising from applications to market generic drugs. Only 19 percent of prescriptions were filled with generics when Hatch-Waxman was enacted. The generic market share rose to 86 percent in 2013 and accounted for 28 percent of U.S. drug spending.
A non-profit, member-run health insurance organization, governed by a board of directors elected by its members. Co-ops provide insurance coverage to individuals and small businesses and can operate at state, regional, and national levels. The ACA contains loans and grants for the development of new nonprofit health cooperatives to be sold as qualified health plans through state insurance exchanges in the individual and small group insurance markets.
Awarded by the Center for Medicare and Medicaid Innovation to organizations that are carrying out the most inventive ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid, and CHIP.
A refundable tax credit that is paid on a monthly basis, or on a yearly basis when a person files their tax return, to help certain workers, retirees and their families pay for health insurance premiums. Under the Affordable Care Act (ACA), certain small businesses are eligible for tax credits to offset part of the cost of covering their workers.
An umbrella term that encompasses electronic health records and personal health records, and indicates the use of computers, software programs, electronic devices and the Internet to store, retrieve, update and share information about patients’ health electronically.
A single marketplace facilitating the buying and selling of private health insurance. The Affordable Care Act (ACA) called for the creation in every state of exchanges through which individuals who are U.S. citizens or legal residents, and businesses, can buy coverage. At the end of 2016, 23 states including the District of Columbia were running their own marketplace or had built one in partnership with the federal government. The remaining states are using the healthcare.gov marketplace, which is run by the federal government.
A 1996 federal law that provides some protection for employed persons and their families against discrimination in health coverage based on past or present health. Generally, the law guarantees the right to renew health coverage, but does not restrict the premiums that insurers may charge. HIPAA does not replace the states’ role as primary regulators of insurance. HIPAA also requires the collection of certain health care information by providers and sets rules designed to protect the privacy of that information.
A managed care plan that combines the function of insurer and provider to give members comprehensive health care from a network of affiliated providers. Enrollees typically pay limited copayments and are usually required to select a primary care physician through whom all care must be coordinated. HMOs generally will not reimburse all costs for services obtained from a non-network provider or without a primary care physician’s referral. HMOs often emphasize prevention and careful assessment of medical necessity. (Also see group-model HMO, network-model HMO and staff-model HMO.)
A type of Health Savings Account for Medicaid beneficiaries created by the Deficit Reduction Act of 2005.States may deposit annual sums of up to $2,500 per adult and $1,000 per child into the account, to be used to pay for medical expenses not covered by the high deductible health plan with which the account is coupled. (Compare to Health Reimbursement Arrangement.)
A set of standardized measures of health plan performance allowing comparisons of quality, access, patient satisfaction, membership, utilization, finance and health plan management. HEDIS was developed by employers, health maintenance organizations and the National Committee on Quality Assurance.
A geographic area determined by the U.S. Public Health Service to have a shortage of physicians and other health professionals. Physicians who provide services in HPSAs qualify for a Medicare bonus payment or student loan forgiveness.
A type of health insurance plan also known as “health reimbursement account” or “personal care account,” HRAs are tax-preferred accounts with funds established by employers to reimburse employees for qualified medical expenses; often HRAs are paired with a high-deductible health plan. An HRA may be used by an employee to pay for medical coverage until funds are exhausted. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year, but do not follow the employee once he or she changes jobs. (Compare to Health Savings Account.)
An agency of the U.S. Department of Health and Human Services that works to improve access to health care services for people who are uninsured, isolated or medically vulnerable. Its goals, pursued through more than 100 programs, are to improve access, strengthen the health workforce, build healthy communities and improve health equity.
A type of health insurance plan similar to HRAs (see Health Reimbursement Arrangement), but which is owned by workers. An HSA is a tax-preferred savings account and is paired with a high-deductible health plan. Any employer can offer an HSA (or a self-employed individual can set one up on his or her own), and both employers and employees can contribute to it. The worker must pay for all services until the amount of the deductible is reached (in 2013, a minimum of $1,250 for an individual and $2,500 for family coverage). The worker can withdraw money from the HSA to pay for medical services under the deductible. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year. Unlike HRAs, HSAs follow an employee when he or she changes jobs. (Also see Medical Savings Account.)
Healthy People is a program created by the Department of Health and Human Services (HHS) aimed at meeting nationwide health-promotion and disease-prevention goals. The Healthy People program first set goals in 1979 for the following decade. These goals have been updated every 10 years for Healthy People 2000, Healthy People 2010, and Health People 2020.
Health insurance plans that havehigher deductiblesbut lower premiums than traditional plans. Qualified high-deductible plans that may be combined with a health savings account must have a deductible of at least $1,300 for single coverage and $2,600 for family coverage in 2017.
A health insurance pool organized as a source of coverage for individuals who have been denied health insurance because of a medical condition, or whose premiums are significantly higher than the average due to health status or claims experience. The Affordable Care Act (ACA) established the Pre-existing Condition Insurance Program, a temporary, national high-risk pool program to offer coverage for uninsured individuals with pre-existing conditions from 2010 to 2014, when private non-group policies became available under new market rules prohibiting insurance discrimination based on health status.
State-designed HCBS encompass case management, adult day care, home health aide assistance, personal care, assisted living services and respite care. Section 1915(c) of the Social Security Act permits the Department of Health and Human Services Secretary to approve Medicaid waivers that allow for long-term services and supports to be delivered in the community instead of institutional settings. The Deficit Reduction Act also created a capped HCBS option that allows states to offer these services without having to obtain administrative waiver approval. (See Program of All-Inclusive Care for the Elderly.) Provisions in the Affordable Care Act (ACA) give states incentives to expand their HCBS programs to balance spending between institutional care and HCBS.
Health services rendered in the home, including skilled nursing care, speech therapy, physical therapy, occupational therapy, rehabilitation therapy and social services. Medicare covers some home health care services if the beneficiary is homebound but does not require more than 35 hours of services per week. Medicaid pays for home health care services in 12 states.
Condition required to receive home health care services under Medicare and generally interpreted to mean that the beneficiary cannot leave home without excessive effort and does so only infrequently, for no more than 16 hours per month for non-medical reasons.
An organization providing medical, emotional, spiritual and social help, often in the patient’s own home, for those expected to live less than six months. If a person qualifies for Medicare Part A and has a terminal illness, Medicare pays for hospice care, including payment of drugs for symptom control and pain relief, hospice aide and homemaker service, and spiritual counseling, among other services.
The Part A Medicare trust fund that pays for inpatient hospital services; skilled nursing facility care for up to 100 days following hospitalization; and some care from home health providers, hospices and rehabilitation facilities for the elderly and permanently disabled.
A public-private collaboration seeking to improve the quality of care provided by the nation’s hospitals by measuring and publicly reporting on that care.