Congress created the “Innovation Center” as part of the Affordable Care Act (ACA) to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care for those who receive Medicare, Medicaid or Children’s Health Insurance Program (CHIP) benefits.
Health care facilities selected to deliver specific services, often exclusively, based on criteria such as experience, outcomes, efficiency and effectiveness.
The requirement that a health care institution obtain permission from an oversight agency before making major changes to its facilities or facility-based services, or before building new facilities.
A tool increasingly used by physicians in hospitals as a reminder to follow certain steps to reduce hospital-acquired infections or surgical errors.
The practice of insurance companies taking only those businesses or individuals that are good health risks, and avoiding higher health risks. Also called”skimming.”The Affordable Care Act (ACA) includes provisions, such as guaranteed issue and risk corridors, to reduce any incentive insurers may have to engage in cherry picking.
A program created by a 1997 law to provide federal matching funds for states to spend on health coverage for uninsured kids. The program is designed to reach uninsured children whose families earn too much money to qualify for Medicaid but not enough to afford private coverage. Congress initially authorized CHIP for a 10-year period that expired at the end of September 2007. CHIP was reauthorized and enlarged early in 2009 in the Children’s Health Insurance Program Reauthorization Act (CHIPRA), which increased CHIP funding by about $32 billion through 2013 to cover an additional 4 million children. The Affordable Care Act (ACA) requires states to maintain existing income eligibility levels for children in CHIP (and Medicaid) until 2019, and it extended funding for CHIP through 2015. In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) extended funding for CHIP until September 2017. It funds a 23 percent increase in federal matching rates for each state until September 2017. (See Medicaid and CHIP chapter.)
An initiative of the American Board of Internal Medicine (ABIM) Foundation that promotes conversations between patients and physicians by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.
Medical services provided to those with long-term medical conditions. (Contrast with acute care.)
A condition that is not expected to improve, that lasts a year or longer or recurs, and may result in long-term care needs. Examples include Alzheimer’s disease, arthritis, diabetes, epilepsy and some mental illnesses.
An individual’s frequent movement in and out of Medicaid.
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.