Chap 1 Key terms
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Valencia College *
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Medicine
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Apr 3, 2024
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So Why Is Managed Care Still Spreading? 43. Are fee-for-service health plans increasing or decreasing? Decreasing. Today, there are few available. 44. Did Medicare and Medicaid embrace managed care? Yes 45. Has managed care reduced healthcare spending? Yes Key Terms Affordable Care Act (ACA) = a federal law that made far-reaching changes to healthcare, most notably, insurance industry reforms and the expansion of public assistance to buy insurance (such as the Medicaid Expansion and Health Insurance Exchange). 2010 American Medical Association = an organization of American physicians with the mission of promoting the science and art of medicine and improving public health. The AMA did not support: early prepaid plans, national health insurance, and for many years, healthcare reform efforts at the national level. 1847 Balanced Budget Act of 1997 (BBA) = a federal law that made many changes to Medicare, including the creation of Part C of the Medicare program (named Medicare +Choice at the time and later changed the name to Medicare Advantage). Part C allows beneficiaries to choose a private managed care plan for receiving health insurance benefits instead of “traditional” fee-for-service Medicare (Parts A and B). The managed care Part C plans provide all Part A (inpatient) and Part B (outpatient) services, and many offer additional benefits beyond those covered under traditional Medicare. 1997 CH [P created also Blue Cross Blue Shield = Blue Cross, founded in 1929, was initially a prepaid plan to provide hospital services (21 days of inpatient care for a year) for a regular payment of 50 cents. One year later in 1930, Blue Shield began providing coverage of physician services, and eventually the two companies merged together in the 1940s. Consolidated Omnibus Budget Reconciliation Act (COBRA) = a federal law that amended ERISA to provide some workers and their families employer health coverage for a limited time after certain events (e.g. loss of a job). Individuals who use COBRA coverage typically pay their portion of costs, the employer’s portion of costs, and a 2 percent administrative fee; in other words, the individual or family pays 102 percent of the cost of the COBRA plan. 1985 Centers for Medicare and Medicaid Services (CMS) = a federal agency within the Department of Health and Human Services that regulates Medicare and works with
states to regulate Medicaid, the Children’s Health Insurance Program (CHIP), and health insurance exchanges. Emergency Medical Treatment and Active Labor Act (EMTALA) = a federal law that requires hospitals to treat anyone experiencing an emergency or active labor, regardless of their ability to pay. 1986 Employee Retirement Income Security Act (ERISA) = a federal law that sets minimum standards for employer health insurance and retirement plans. Specifically, the law protects employees by requiring that they receive information about plan features and funding, those who manage and control assets, and grievance and appeals processes. 1974 Health Insurance Portability and Accountability Act (HIPAA) = 5 federal law that amended ERISA to protect workers and their families that might otherwise face discrimination in health coverage due to health status. Specifically, this law requires that insurance companies provide a Certificate of Creditable Coverage (COCC) indicating when an individual had health insurance coverage and provides special enrollment periods for individuals with a qualifying life event (QLE). 1996 Health Maintenance Organization (HMO) = a type of managed care organization where members must use in-network providers for services. Any out-of-network services received will not be covered. This reduction in provider choice is usually offset by lower premiums as compared to preferred provider organizations (PPOs). These organizations often provide integrated care with a focus on prevention and wellness. The managed care organization controls the utilization/use of healthcare services in an effort to reduce costs. HMO Act = a federal law that authorized federal funds to support the development of health maintenance organizations (HMO), an alternative to fee-for-service insurance, in an effort to reduce the cost of healthcare. 1973 Insurer/Insurance Company = an organization that provides insurance to its members. McCarran-Ferguson Act = a law that gave states the authority to regulate health insurance. 1945 Medicaid = a program that provides health insurance for eligible low-income Americans including: pregnant women, children, people with disabilities, the elderly, and in some states, childless adults and parents. Eligibility for Medicaid programs varies by state. States administer the Medicaid program, but it is funded jointly by state and federal governments. 1965 Medicare = a federal health insurance program for individuals aged 65 or older, certain younger individuals with disabilities, and people with end-stage renal
disease (ESRD). Medicare covers different services: Part A (inpatient, skilled nursing, hospice, and some home health), Part B (physicians, outpatient, medical supplies, and preventive services), and Part D (prescription drugs). Beneficiaries can opt to receive benefits via private managed care plans through Part C of Medicare, which is known as Medicare Advantage. 1965 Medicare Prescription Drug, Improvement, and Modernization Act = a federal law that, among other things, created Medicare Part D to provide outpatient prescription drug coverage to those beneficiaries that opted to buy Part D coverage. 2003 Member/Insured = an individual who is enrolled with a health plan. National Committee for Quality Assurance (NCQA) = a national accreditation body for health insurance plans. This body is the only such program that uses clinical performance measures and consumer experience through the HEDIS and CAHPS data sets. This organization is also responsible for maintaining HEDIS and working jointly with the Agency for Healthcare Research and Quality (AHRQ) on maintaining CAHPS. 1979 Patient Protection and Affordable Care Act (PPACA) = a federal law that made far- reaching changes to healthcare, most notably, insurance industry reforms and the expansion of public assistance to buy insurance (such as the Medicaid Expansion and Health Insurance Exchange). 2010 Prepaid Groups = the earliest forms of managed care, similar to a health maintenance organization (HMO) of today as it combines the financing and service delivery through a single organization. Members of the prepaid group paid a predetermined capitated amount each month to access services. Social Security Act 1935= a federal law that established old-age benefits and allowed states to provide benefits for the unemployed and disabled. This law was amended in 1965 to create Medicare and Medicaid. Stabilization Act = a law that allowed the president to freeze wages and salaries for all American workers. This applied to all bonuses, compensation, gifts, and commissions. However, there was an exemption: insurance and pension benefits could grow “in a reasonable amount” during the freeze. As a result, employers began using health insurance as a recruitment measure, subsequently increasing the number of Americans with employer-sponsored insurance (ESI). 1942 Tax Equity and Fiscal Responsibility Act (TEFRA) = a federal law that amended the Social Security Act to create a Medicare prospective payment system for hospitals as an alternative to fee-for-service. This encouraged the development and use of managed care in the Medicare program. 1982
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