A health benefit model that is considered by its designers to be a hybrid of the defined contribution and defined benefit approaches. This model requires general categories of health services to be covered, but benefits could be added or deleted within limits. The employer or government then contributes a set amount — or percentage of — the premium for the purchased plan. Plans could set premiums at whatever dollar level they choose, with beneficiaries liable for any costs above the employer or government contribution. A Medicare demonstration designed to test a model similar to premium support began in 2010.
A refundable credit that helps offset the costs of health insurance premiums for eligible individuals and families purchasing coverage through a health insurance marketplace. Under the Affordable Care Act, the credit is available for households with incomes between 100 percent and 400 percent of the federal poverty level. Within this range of eligibility the amount of the credit varies by income.
Established by the Affordable Care Act (ACA), the Prevention and Public Health Fund provides expanded and sustained national investments in prevention and public health, to improve health outcomes, and to enhance health care quality.
Services aimed at preventing a disease from occurring, or preventing or minimizing its consequences. This includes care aimed at warding off illnesses (immunizations, for example), at early detection of disease (Pap smears, for example), and at stopping further deterioration (cholesterol-lowering medication, for example).
Care at “first contact” with the health care system, including an array of non-specialist services provided by physicians, nurse practitioners, or physician’s assistants. More simply, the care that most people receive for most of their problems that bother them most of the time.
Established under the Affordable Care Act (ACA), a program that makes Medicare bonus payments to primary care physicians for primary care services. The ACA extablished that a typical office-based, general internist who qualifies for the bonus would get approximately $8,000 in Medicare revenue each year for five years, beginning in 2011.
A Medicaid managed care program in which an eligible individual may use services only with authorization from his or her assigned primary care provider. That provider is responsible for locating, coordinating, and monitoring all primary and other medical services for enrollees. Those services are usually paid on a fee-for-service basis.
A provider, usually a physician, specializing in internal medicine, family practice, pediatrics, or geriatrics (but can also be a nurse practitioner, physician assistant or health care clinic), who serves as the patient’s first point of contact with the health care system and coordinates the patient’s medical care.
A program for people who are eligible for Medicaid or Medicare, or both; age 55 or older; live in a PACE organization service area; are eligible for nursing home care, and are able to live safely in the community. It allows eligible persons to meet health care needs in the community instead of a nursing home or other care facility. Core services integrate acute and long-term services and supports, which include adult day care, social support, home health, hospital care, nursing home care, and case management. PACE is a capitated managed care benefit provided by a not-for-profit or public entity.
A method used by Medicare to pay for many services, including inpatient and outpatient hospital services as well as services provided at skilled nursing and rehabilitation facilities. Payment rates are linked to diagnosis and determined before services are rendered, rather than being based on actual costs or charges of a specific facility. Rates are intended to cover treatment costs for a typical patient with a given diagnosis and are adjusted for factors like wages and indigent care.
Any health care professional or institution that renders a health service or provides a health care product. Major providers are hospitals, nursing homes, physicians and nurses.
Those providers who agree by contract with a health insurance plan to be available for services and products to the plan’s members for agreed upon fees.
The protection and improvement of population health by organized community effort. Public health activities are very broad and include immunization, sanitation, preventive medicine, disease control, education about reducing personal risks, occupational health and safety, pollution control, water safety, food safety, and epidemiology. (See chapter on Public Health and Prevention.)
A government-run health care plan that would be an alternative to the private insurance plans offered under the Affordable Care Act (ACA) or provide a fallback in markets where insurers have pulled out.
A group of people, businesses or associations who come together to enhance their bargaining power and negotiate lower premiums from health insurance plans than they could on their own, while also pooling risks across sick and healthy individuals.
