Affordable Care Act 2010

Affordable Care Act

In 2010, the Affordable Care Act  provides Americans with better health security by putting in place comprehensive health insurance reforms that would:
  • Expand coverage,
  • Hold insurance companies accountable,
  • Lower health care costs,
  • Guarantee more choice, and
  • Enhance the quality of care for all Americans.

The Affordable Care Act actually refers to two separate pieces of legislation — the Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) — that, together expanded Medicaid coverage to millions of low-income Americans and made numerous improvements to both Medicaid and the Children’s Health Insurance Program (CHIP).

https://www.youtube.com/watch?v=-58VD3z7ZiQ

Since the new law was enacted in March 2010, CMS worked together with state partners to identify key implementation priorities and provide the guidance needed to prepare for the significant changes to Medicaid and CHIP took effect on January 1, 2014.  In particular, CMS provided several forms of guidance and federal support for state efforts to develop new or upgrade existing eligibility systems.

In March 2012, CMS released two final rules defining the eligibility and enrollment policies needed to achieve a seamless system of coverage for individuals who became eligible for Medicaid in 2014, as well as eligibility and enrollment for the new Affordable Insurance Exchanges. The final rules establish the framework for States’ implementation of the eligibility expansion going forward.  A specific description of all of the major Medicaid and CHIP-related provisions of the Affordable Care Act as well as related policy guidance can be found below.

Affordable Care Act Provisions Description
Eligibility Fills in current gaps in coverage for the poorest Americans by creating a minimum Medicaid income eligibility level across the country.
Financing Beginning in 2014 coverage for the newly eligible adults will be fully funded by the federal government for three years.  It will phase down to 90% by 2020.
Information Technology Systems and Data Policy and financing structure designed to provide states with tools needed to achieve the immediate and substantial investment in information technology systems that is needed in order to ensure that Medicaid systems will be in place in time for the January 1, 2014 launch date or the new Affordable Insurance Exchanges as well as the expansion of Medicaid eligibility.
Coordination with Affordable Insurance Exchanges This system enables individuals and families to apply for coverage using a single application and have their eligibility determined for all insurance affordability programs through one simple process.
Benefits People newly eligible for Medicaid will receive a benchmark benefit or benchmark­ equivalent package that includes the minimum essential benefits provided in the Affordable Insurance Exchanges.
Community-Based Long-Term Services and Supports Includes a number of program and funding improvements to help ensure that people can receive long-term care services and supports in their home or the community.
Quality of Care and Delivery Systems Improvements will be made in the quality or care and the manner in which that care is delivered while at the same time reducing costs.
Prevention Promotes prevention, wellness and public health and supports health promotion efforts at the local, state and federal levels.
Children’s Health Insurance Program (CHIP) Extends funding for the Children’s Health Insurance Program (CHIP) through FY 2015 and continues the authority for the program through 2019.
Dual Eligibles A new office will be created within the Centers for Medicare & Medicaid Services to coordinate care for individuals who are eligible for both Medicaid and Medicare (“dual eligibles” or Medicare-Medicaid enrollees)
Provider Payments States will receive 100 percent federal matching funds for the increase in payments.
Program Transparency Promotes transparency about Medicaid policies and programs including establishing meaningful opportunities for public involvement in the development of state and federal Medicaid waivers.
Program Integrity Includes numerous provisions designed to increase program integrity in Medicaid, including terminating providers from Medicaid that have been terminated in other programs, suspending Medicaid payments based on pending investigations or credible allegations of fraud, and preventing inappropriate payment or claims under Medicaid.

Medicare

What’s Medicare?

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

The different parts of Medicare help cover specific services:

Medicare Part A (Hospital Insurance)

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)

Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Medicare Part C (Medicare Advantage Plans)

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. Most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Part D (prescription drug coverage)
Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

Original Medicare is coverage managed by the federal government. Generally, there’s a cost for each service. In most cases, you can go to any doctor, other health care provider, hospital, or other facility that’s enrolled in Medicare and is accepting new Medicare patients. With a few exceptions, most prescriptions aren’t covered in Original Medicare, drug coverage can be added by joining a Medicare Prescription Drug Plan (Part D). Employer or union coverage may pay costs that Original Medicare doesn’t. If not, it is possible to buy a Medicare Supplement Insurance (Medigap) policy. A set amount for health care (deductible) is paid before Medicare pays its share. Then, Medicare pays its share, and then (coinsurance / copayment) for covered services and supplies is paid. There’s no yearly limit for payments out-of-pocket. A monthly premium for Part B is paid, generally there is no need to file Medicare claims. The law requires providers (like doctors, hospitals, skilled nursing facilities, and home health agencies) and suppliers to file claims for the covered services and supplies.

Factors that affect Original Medicare out-of-pocket costs
  • Whether patient has Part A and/or Part B. Most people have both.
  • Whether doctor, other health care provider, or supplier accepts assignment.
  • The type of health care needed and how often it is needed.
  • Services or supplies Medicare doesn’t cover require payment of all the costs unless other insurance covers it.
  • Whether other health insurance works with Medicare.
  • Whether Medicaid or state help pay Medicare costs.
  • Whether a Medicare Supplement Insurance (Medigap) policy exists.
  • Whether patient and doctor or other health care provider sign a private contract.
What’s a Medicare health plan?
    • Medicare Advantage Plans
    • A type of Medicare health plan offered by a private company that contracts with Medicare to provide all Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
    • .Original Medicare coverage from the Medicare Advantage Plan and not Medicare Part B (Medical Insurance) and Medicare Part A (Hospital Insurance). Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

    • Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

How do MSA Plans work?
      1. High-deductible health plan: The first part is a special type of high-deductible Medicare Advantage Plan (Part C). The plan will only begin to cover costs once a high yearly deductible, which varies by plan, is paid.
      2. Medical Savings Account (MSA): The second part is a special type of savings account. The Medicare MSA Plan deposits money into an account.

    • Medicare MSA Plans combine a high-deductible insurance plan with a medical savings account that can be used to pay health care costs.

      Medicare MSA Plans have 2 parts

      Medicare works with private insurance companies to offer  ways to get health care coverage. These companies can choose to offer a consumer-directed Medicare Advantage Plan, called a Medicare MSA Plan. These plans are similar to Health Savings Account Plans available outside of Medicare. There is flexibility in choosing health care services and providers,

    • Generally, a plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. Medicare health plans include all Medicare Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. Programs of All-inclusive Care for the Elderly (PACE) organizations are special types of Medicare health plans. PACE plans can be offered by public or private entities and provide Part D and other benefits in addition to Part A and Part B benefits.

READ article on rising cost of Medicare premiums and deductibles: http://www.pbs.org/newshour/making-sense/2017-medicare-premiums-and-deductibles/

Medicaid

Medicaid

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements.  The program is funded jointly by states and the federal government.

Program History

The Center for Medicaid and CHIP Services (CMCS) serves as the focal point for all national program policies and operations related to Medicaid, the Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP). These critical health coverage programs serve millions of families, children, pregnant women, adults without children, and also seniors and people living with disabilities.

Medicaid

Authorized by Title XIX of the Social Security Act, Medicaid was signed into law in 1965 alongside Medicare. All states, the District of Columbia, and the U.S. territories have Medicaid programs designed to provide health coverage for low-income people. Although the Federal government establishes certain parameters for all states to follow, each state administers their Medicaid program differently, resulting in variations in Medicaid coverage across the country. Beginning in 2014, the Affordable Care Act provides states the authority to expand Medicaid eligibility to individuals under age 65 in families with incomes below 133 percent of the Federal Poverty Level (FPL) and standardizes the rules for determining eligibility and providing benefits through Medicaid, CHIP and the health insurance Marketplace.

In 2015, Medicaid celebrated its 50th birthday by posting program highlights, research findings and the voices of our beneficiaries in 50 days of postings.

Children’s Health Insurance Program (CHIP)

The Children’s Health Insurance Program (CHIP) was signed into law in 1997 and provides federal matching funds to states to provide health coverage to children in families with incomes too high to qualify for Medicaid, but who can’t afford private coverage. All states have expanded children’s coverage significantly through their CHIP programs, with nearly every state providing coverage for children up to at least 200 percent of the Federal Poverty Level (FPL).

Basic Health Program

The Basic Health Program was enacted by the Affordable Care Act and provides states the option to establish health benefits cover programs for low-income residents who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace, providing affordable coverage and better continuity of care for people whose income fluctuates above and below Medicaid and CHIP levels.

https://www.medicaid.gov/medicaid/cost-sharing/index.html

State Initiatives

State Programs

New York offers many state-sponsored programs aimed at ensuring New Yorkers have access to quality, affordable health care. New York Health Plan Association (HPA) members have long been partners with New York State, serving as the primary way eligible New Yorkers access these programs. HPA member plans are committed to the ongoing effort to bring high quality, affordable and accessible health care to all New Yorkers.

NYSHIP

NYSHIP—the “New York State Health Insurance Program”—is a benefit program established to provide health insurance coverage to state and local government employees. NYSHIP stands for the “New York State Health Insurance Program.” The New York State Health Insurance Program (NYSHIP) was established in 1957 for State employees. The next year, NYSHIP opened to local governments and school districts. Now, more than 50 years later, NYSHIP is one of the largest public employer health insurance programs in the country. NYSHIP protects over 1.2 million State and local government employees, retirees and their families.

New York State of Health: The Official Health Plan Marketplace

New York’s health benefit exchange, New York State of Health: The Official Health Plan Marketplace, helps New Yorkers—individuals and small businesses—shop for and enroll in health insurance coverage,

 NY State of Health is an organized marketplace designed to help people shop for and enroll in health insurance coverage.  Individuals, families and small businesses can use the Marketplace to help them compare insurance options, calculate costs and select coverage.  The Marketplace uses a single application that helps people to check their eligibility for health care programs like Medicaid, Child Health Plus, and the new Essential Plan and enroll in these programs if they are eligible.  The Marketplace also tells what type of financial assistance is available to applicants to help them afford health insurance purchased through the Marketplace.  New Yorkers can complete the Marketplace application online, in-person, over the phone or by mail.

Medicaid Managed Care

For more than two decades, New York’s Medicaid Managed Care program has been providing New Yorkers who cannot afford to pay for medical care with access to high quality health care. Eligible New Yorkers can enroll in a Medicaid Managed Care health plan. These plans focus on preventive health care and provide enrollees with a medical home for themselves and their families. Medicaid Managed Care offers many New Yorkers a chance to choose a Medicaid health plan. Managed Care plans focus on preventive health care and provide enrollees with a medical home for themselves and their families. In many counties, once you are eligible for Medicaid, you can join a plan if there is one available and you want to join. However, there are some counties where families will have to join a plan. In these counties there are some individuals who don’t have to join. Enrollment in Medicaid managed care is available at any local Department of Social Services.

New York’s Medicaid Managed Care program offers eligible New Yorkers a choice of Medicaid health plans. These plans focus on preventive health care and provide enrollees with a medical home for themselves and their families.

Managed care covers a wide array of benefits—including routine and emergency care, hospitalization, coverage of medicines, laboratory and X-ray services, and much more.

Over the two decades of New York’s Medicaid Managed Care program, it has been shown that these health plans are able to provide members with greater access to health care services—including greater numbers and varieties of providers—and to improve the overall quality of care.

Child Health Plus

New York’s Child Health Plus program has been helping families provide health insurance for their children since 1991 and has been a model for children’s health insurance programs across the nation.

New York State has a health insurance plan for kids, called Child Health Plus. All Child Health Plus participants enroll in a managed care plan. Families contribute to the cost of coverage on a sliding scale based on family income. Child Health Plus offers comprehensive health coverage including:

  • Well-child care
  • Physical exams
  • Immunizations
  • Diagnosis and treatment of illness and injury
  • X-ray and lab tests
  • Outpatient surgery
  • Emergency care prescription and non-prescription drugs if ordered
  • Inpatient hospital medical or surgical care
  • Short-term therapeutic outpatient services (chemotherapy, hemodialysis)
  • Limited inpatient and outpatient treatment for alcoholism and substance abuse, and mental health
  • Dental care
  • Vision care
  • Speech and hearing
  • Durable medical equipment
  • Emergency ambulance transportation to a hospital
  • Hospice

Healthy New York

Healthy New York is designed to assist small business owners in providing their employees and their employees’ families with the health insurance they need and deserve.

The Healthy New York program was created to assist individuals, sole proprietors and small business owners access health insurance for themselves and their employees.

Small Business Owners

Small business owners (50 or fewer employees) can buy coverage directly from their insurer or from New York State of Health Small Business Marketplace through the Small Business Health Options Program (SHOP). The Marketplace can help small businesses shop for and enroll in health insurance.

Managed Long Term Care (MLTC)

Managed Long Term Care (MLTC) is a program that helps people who are chronically ill or have disabilities and who need health and long-term care services stay in their homes and communities as long as possible. MLTC plans provide or arrange for and coordinate both the health care and long term care needs of their patients.

http://nyhpa.org/resources/state-programs/#nyship

Medical Coding & Billing

According to the AAPC, or American Academy of Professional Coders, Medical billing is the process by which health care providers submit claims to insurance providers (payers), government programs (Medicaid/Medicare), and/or patients directly in order to receive reimbursement for services. Besides invoicing and collecting payments, medical billers are involved with handling denied claims and processing appeals.

Medical coding standards have become increasingly complex. Regulations and requirements with the current healthcare delivery system are best met when medical coders, certified in specialty practice, provide medical coding. Medical coders achieve AAPC certification through specialized education, experience in an area of specialty, and a qualifying exam(s). Certification is a professional’s official recognition of achievement, expertise, and judgment. It is a mark of excellence requiring continued learning and skill development to maintain.

Over 155,000 healthcare professionals hold AAPC certifications in physician offices, clinics, outpatient facilities, and hospitals. These credentials represent the gold standard in medical coding, billing, auditing, documentation, compliance, and practice management, and are nationally recognized by employers, medical societies, and government organizations.Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory and radiologic results, etc. Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.

The main task of a medical coders is to review clinical statements and assign standard codes using CPT®, ICD-10-CM, and HCPCS Level II classification systems. Medical billers, on the other hand, process and follow up on claims sent to health insurance companies for reimbursement of services rendered by a healthcare provider. The medical coder and medical biller may be the same person or may work with each other to ensure invoices are paid properly. To help promote a smooth coding and billing process, the coder checks the patient’s medical record (i.e., the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies, and other sources) to verify the work that was done. Both work together to avoid insurance payment denials.

The medical coder and biller process a variety of physician services and claims on a daily basis. Medical codes must tell the whole story of the patient’s encounter with the physician and must be as specific as possible in regards to capturing reimbursement for rendered services

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HomeHealthPPS/coding_billing.html

Comparing Health Care Financing

SUPPLEMENTAL VIDEO:

http://www.pbs.org/newshour/updates/health-july-dec09-insurance_10-06/