Health Admin Due in two hours

Describe the Issue

Key Concerns Regarding the Issue

How Was this Issue Addressed Prior to PPACA Implementation?

To What Extent Has This Issues Been Addressed by the PPACA?

Patient Bill of Rights

• Patients need to be more confident in their healthcare and this bill will allow medical providers and patients to know the rights available to them.

• This bill strengthens the weaknesses between provider and patients allowing strong relationships.

• One issue is that patients now have the right to make their own choices when it comes to their health and the care that they receive.

• Another issue is that patients now have more choices when it comes to insurance, and they have to find an insurance plan that meets the needs for their care.

• An issue that was addressed prior to PPACA was that patients would get denied care or coverage and would need to find ways to cover unrealistic high costs for their coverage that they can receive.

• Patients would be assigned doctors and medical providers.

• After reaching the age of an adult, children were not allowed to be covered through their parents’ insurance plan. They would need to receive their own coverage or stay uninsured.

• “Help children (and eventually all Americans) with pre-existing conditions gain coverage and keep it.” (Patients Bill of Rights, 2013)

• Children can now stay on their parents’ health insurance till the age of 26.

• Patients now have the right to choose their provider, as long as it is in code with the patients’ insurance.

Medical Loss Ratio

• “A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees.” (Medical Loss Ratio, n.d.)

• This measures the medical costs spent on clinical services and improvements.

• Inflation of health care costs will ruin the plan for the medical loss ratio. Including inflation of costs on purpose to partake in fraud schemes.

• Medical Loss Ratio can hurt high – deductible plans due to the eighty percent only counting towards the medical costs paid from the insurance company.

• Prior to ACA insurers used loss ratios to assess their profitability of an insurance policy, lower the ratio means the better performance.

• Traditional loss ratio included medical care claims and premiums, now the medical loss ratio includes medical care claims plus improvement expenses and regulatory fees.

• Medical Loss Ratio measurements applies to all licensed health insurances, including health maintenance organizations.

• “The Medical Loss Ratio provision of the ACA requires most insurance companies that cover individuals and small businesses to spend at least 80% of their premium income on health care claims and quality improvement, leaving the remaining 20% for administration, marketing, and profit.” (Explaining Health Care Reform, 2014)

State-Based Health Insurance Exchange

• Health insurance marketplaces offer online prices and comparisons, where consumers can purchase health care.

• States run the marketplace for their state in partnership with the federal marketplace.

• States run the marketplace based on their local needs and market conditions.

• States had to decide to either establish their own health insurance exchange or keep the federal options.

• States needed to find out what was the best way to implement and run the health insurance exchange.

• As the state based health insurance exchange becomes more common, the flexibility of the price plans became more of a competition due to the uncertainty of the marketplace itself.

• Before ACA, consumers who bought health care insurance had to personally deal with issues like being refused a policy and very high premiums.

• Allowed small and medium businesses shop with the larger businesses and save costs, they had a wide range of plans for employees.

• Consumers can purchase health care insurance plans online and have access to tax credits which help cover the costs of the insurance.

• The marketplace offers competition with online comparisons and promotes competition through participation of the insurers.

Federally Facilitated Insurance Exchange

• If people are unable to qualify for Medicaid or Medicare and also the Chip program what the can do is people can qualify for health plans through the different exchanges?

• This would be consider a one stop place for consumer to stop the different type of coverage that are available

• With issue regarding this would be very challenging when it comes making sure that all compliance are with standards making sure that everything is within the state laws and making sure that all market are under the federal law.

• With the insurance the state can either accept or refuse.

• “The ACA originally envisioned states as the creators and operators of Health Insurance Exchanges, the emerging emphasis on an FFE model has the potential to create significant implementation issues, given the extent to which the new Exchange market is really an extension of the state-regulated health insurance market” (Burke, T. (2014).

• What this is it helps any businesses or even small business find show for coverages.

• PPaca has mention that every state must have insurance.

In order for this to work it has to provide for low income providers

• PPACA, the state exchanges are not limited to government funded coverage and could evolve into a marketing channel for non-subsidized coverage.

Consumer Assistance Programs

• The consumer Assistance program is grant program help the state with health coverage.

• This also helps people register with health care “Consumer Assistance Programs have reached communities in rural and frontier areas that previously have not been served by health insurance consumer assistance advocates.” (CMS.gov)

• With the Consumer Assistant program it is there to help consumer with any issue they may have with their health insurance.

• They are also the front of the line people who may come with information with the insurance company

• The Affordable Care Act provides support for state-run consumer assistance programs to help privately insured consumers who experience problems with their coverage. ("Health Affairs", )

• They been around since 1990 what they do is help with and select private health insurance.

• Having the ACA it help lower the ranks of the uninsured since they started.

• Not only are the elderly are able to afford insurance it has even lower over the years as well

Pre-existing Condition Insurance Plan

• This was created by the ACA to help with people who were denied insurance with preexisting condition

• Everyone is able to afford different choices, the exchange. Even have pre-existing condition.

• The challenges they face before was people who had pre-existing were put in a “High-risk” and could barely get insurance.

• High risks pool there were some waiting periods for a year of coverage a pre-existing condition.

• Federal and State would be the one who are responsible for implementation.

• Different states can come up with their own high-risk for people. There have been some states who can choose have their HHS handle a PCIP program.

• “Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts” ("Pre-Existing Conditions", )

• Now with the ACA no one can’t deny a patient to be insure with any pre existing condition.

Annual Limits

• Annual limits are benefits the insurance company will only pay a year while enrolled in a health care insurance plan.

• Annual limits are restricted under the Department of Health and Human Services (HHS) regulations. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• There is a small amount of people that only have access to plans with a lower annual limits permitted by law and these plans provide very limited protection on a high health care cost.

• Employers and insurers estimated that requiring mini-med plans to comply with the new rules could cause mini-med premiums to increase, forcing employers to drop coverage and leaving some workers without even the minimal insurance coverage. (CMS.gov Center for Medicare & Medicaid Services 2017).

• In order to protect coverage for workers in mini-med plans until more affordable and valuable coverage is available, the law and regulation issued an annual limits allow the Department of Health and Human Services (HHS) to grant temporary waivers from this one provision of the law that phases out annual limits if compliance would result in significance decrease in access to benefits or an increase in premiums.

• Plans that receive the waiver had to comply with all other provisions of the law and must alert consumers that the plan had a restrictive coverage and includes low annual limits. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• The new guidance extended the duration of waivers that were granted back in 2013, if applicants submitted annual information about their plan and comply with requirements to ensure that they understood the limits of their coverage.

• On June 17, 2011, the Center for Medicare and Medicaid Services introduced a process for plans that have already received waivers and want to renew those waivers for plan or policy years beginning before January 1, 2014.

• A Health Reimbursement Arrangements (HRA) were subjected to the restricted annual limits, having apply individually for an annual limit waiver. (CMS.gov Center for Medicare & Medicaid Services, 2017).

Coverage for Young People

• There was a big estimate number of uninsured children ages 19-25 in each US County.

• Most of these children may be eligible to join their parent’s health plan if that plan offers dependent coverage. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• Young adults have the highest rate of uninsured of any age group.

• Nearly half of the uninsured young adults report problems paying medical bills.

• Young adults usually have an entry or part time job that does not offer health insurance. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• Secretary Kathleen Sebelius called on leading insurance companies to begin covering young adults before the implementation date of ACA.

• Early implementation would avoid gaps in coverage for new college graduates and other young adults and save on insurance company cost for dis-enrolling and re-enrolling them between May 2010 and September 23, 2010. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• The Affordable Care requires plans and issuers that offer dependent coverage available until a child reaches the age of 26.

• Even if the child is married children qualify for this coverage.

• Children up to age 26 can stay on their parent’s employers plan even if they have their own coverage through their employer. (CMS.gov Center for Medicare & Medicaid Services, 2017).

Grandfathered Plans

• The grandfather regulation includes a number of rules for determining when changes to a health plan cause the plan to lose its grandfathered status.

• A plan could lose grandfather status if the insured chooses to make certain significant changes that reduce benefits or increase costs to consumers. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• Employer’s group health plans could lose its grandfathered status if the employer changed issuers.

• The original regulation only allowed self-funded plans to change third-party administrators without necessary losing their grandfathered plan status. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• A change of issuer in the individual market would still result in the loss of grandfathered status.

• The grandfathered rule states that a group health plan would relinquish grandfathered status if it changed issuers or policies. (CMS.gov Center for Medicare & Medicaid Services, 2017).

• People can now keep existing health plans that are working for them and keep grandfathered status.

• Offering the same level of coverage through a new issuer and remain grandfathered, as long as the change in issuer does not result in cost increases.

• Helps protect American’s ability to keep their current plan if they like it. (CMS.gov Center for Medicare & Medicaid Services, 2017).

Prevention

• Preventive medicine occurs when tests are performed to provide and promote a patient's good health as well as their well-being.

• Conducted through annual check-ups which are done before a patient becomes symptomatic or shows any symptoms.

• One primary concern regarding preventive health care is, does it save the U.S. money overall or is the cost of annual testing costing more than the benefits that it provides.

• Another concern is that is there enough physicians to take care of everyone properly? Not having enough doctors to review patient's histories properly, can lead to many problems if they are overloaded with patients seeking care since they now have access to health insurance.

• Prior to the ACA, most insurances didn't cover preventive health care services, and patients either went without them or paid full price out of pocket.

• Preventive services were not covered 100%, and patients were required to meet their deductible, or pay a coinsurance which could be extremely high before being able to receive these services that could be life-saving.

• The ACA requires all insurance companies to cover preventative services which include mammograms, colonoscopies, well baby exams, vaccinations, etc.

• Since the ACA was enacted there, have been national campaigns for preventative health measures, especially those to combat smoking, and childhood obesity.

Review of Insurance Plans

• The marketplace was created for individuals to be able to review and purchase private insurance coverage through if they do not receive insurance through their employer. The marketplace offers cost sharing assistance for individuals and families who qualify based on income. (Tolbert, 2015).

• Different plans offer different levels of coverage based on what the participant chooses for themselves. All plans cover preventative health care, and it is the ACA's responsibility to make sure that the laws are followed within the marketplace and reinforce them with the different plans.

• Plans sold in the Marketplaces must also meet and fit into one of the four metal tiers. The plans must cover a certain percentage of the costs for care. The four levels are: Bronze: 60%, Silver: 70%, Gold: 80%, and Platinum: 90%.

• "ACA was structured to address the gaps and limitations of our public-private health insurance system. It builds on employer-based coverage, restructures the individual insurance market, and broadens access to and affordability of coverage by expanding Medicaid for the low-income population and extending tax subsidies for the purchase of private insurance to those with moderate incomes"(Tolbert, 2015, para. 2).

• Before the ACA was enacted insurance companies weren't required to provide the mandated coverage that they are now. Depending on the plan that you had you, you may be responsible for the majority of your health care costs before insurance would start to pay.

• Also, a lot of people were unable to get insurance before the ACA because they were unable to afford it, so they had to pay out of pocket for the care that they needed, or go without it.

• The ACA was created as a framework to be improved and to provide increased access to health coverage (Tolbert, 2015).

• Most health care plans are showing that patients are receiving high-quality care, within the improvement, and public disclosures.

Student Health Plans

• Student health plans qualify as insurance coverage.

• If a student qualifies for a student health plan, they will become exempt from the tax penalty that some people face for not carrying health insurance.

• Student health plans do not meet the ACA requirements and do not have to change to meet them as quickly as other policies. They were given a different time frame to meet requirements.

• "An annual study put out by Beckley's firm, Hodgkins Beckley Consulting, suggests that, in general, the ACA has pushed student premiums up slightly at schools which have historically offered good-quality plans"(Dame, 2014, para. 11).

• Before the ACA was enacted, students were not allowed to stay on their parent's insurance plans after they turned 22. Once they turned 18, they had to prove they were still full-time students to maintain coverage until the age of 22 too.

• Prior to the ACA, student health plans had inconsistent coverage and tended to provide meager benefits to those that carried them.

• The ACA instituted subsidies that made health care more affordable for lower income families and students.

• Many colleges and universities offer student plans that now cover ten vital benefits with no benefit maximums since the ACA was established.

Self-Funded, Non-Federal Government Plans

• Angelina

Medicaid Expansion

• Angelina