Health insurance in the United States

Question

This piglix contains articles or sub-piglix about Health insurance in the United States

Answer 1

Missouri Foundation for Health

Missouri Foundation for Health

Missouri Foundation for Health (MFH) is an independent philanthropic foundation formed as a “health conversion foundation” in February 2000, following Blue Cross Blue Shield Association of Missouri's transformation from a nonprofit to for-profit company. Federal law requires that proceeds from the sale of tax-exempt entities be directed toward charitable purposes. Using those proceeds, the Foundation was charged with "identifying and filling the gaps in the myriad of public and private health care services already available to the uninsured, the underinsured and the underserved in the 84 counties plus the City of St. Louis."

Since its founding the Foundation has cumulatively issued more than half-a-billion dollars in grants and awards. Each year approximately $45 million is awarded to health-focused nonprofits.

Robert Hughes, Ph.D., joined the Foundation in 2012 as president and chief executive officer. Hughes has nearly 30 years of philanthropic leadership, public health, and health policy experience. After his arrival, Hughes joined with his staff and the Board of Directors to refine and update the Foundation’s strategic plan and vision.

As the largest health foundation in Missouri, the Foundation works to maximize limited resources by identifying and funding health programs where it can have the greatest possible impact.

The Foundation’s strategy is broken into three main portfolios: Targeted, Responsive and Policy. The Targeted Portfolio focuses on making a measurable impact in four key health issues: childhood obesity prevention, increasing health insurance coverage, reducing infant mortality and improving access to oral health care.

The Responsive Portfolio seeks input from and collaborates with the community to meet self-identified health needs. The Portfolio supports communities and organizations in making a measurable impact on priority health needs of the uninsured and underserved.

The Policy Portfolio complements the Foundation's Targeted and Responsive work by addressing health issues from a systemic perspective. The Portfolio supports education advocacy, and analysis on issues significant to the health of uninsured and underserved Missourians.

...

Wikipedia

Answer 2

Nyman's model

...

Wikipedia

Answer 3

Oncology Care Model

The Oncology Care Model (OCM) is an episode-based payment system developed by the Center for Medicare and Medicaid Innovation. The multipayer model is designed for discrete instances of care, especially those involving chemotherapy, which triggers the six-month episode. The program combines fee-for-service (FFS) payments for established services, monthly payments for additional care under a structured guideline, and performance-based payments weighed against quality metrics and benchmarks.

OCM is part of a general move away from the FFS model, "which pays doctors and hospitals according to the number of procedures they do, toward value-based care, which pays based on what helps patients get better." This idea was advanced by the Affordable Care Act (ACA), which was signed into law on March 23, 2010. As of March 18, 2017^[ref], OCM is being utilized by 190 healthcare provider groups, which include over 3,000 physicians in the United States. Along with Centers for Medicare and Medicaid Services, the payment system is accepted by 16 other health care coverage programs in the US. The payment model went into operation in July 2016, and barring changes to the Affordable Care Act, is slated to run until 2021. Over this five-year period, it is estimated that the model will be used for $6 billion spent on medical care to 155,000 patients.

The program is a move by the CMS to shift its focus to include specialized care. The bundled design has been the source of praise and criticism for the payment system. The program has been criticized for not going far enough; that is not eliminating FFS altogether. Other criticisms include the lack of flexibility in allowing primary care physicians to conduct care as they see fit, the arbitrary nature of the time period or episode, the cumbersome burden of the reporting standards and how it penalizes practices for outcomes out of their control.

The Affordable Care Act mandated the creation of the Center for Medicare and Medicaid Innovation (CMMI) as part of the Centers for Medicare and Medicaid Services (CMS). It was created to test new "payment and delivery system models" to be used by "Medicare, Medicaid, and the Children’s Health Insurance Program." The legislation also created the accountable care organizations (ACO) model, which holds voluntarily-enrolled health care practitioners accountable to patients and third-party payers for the quality, appropriateness, and efficiency of its services. ACO introduced the concept of rewards based on savings or "shared savings," which would later be applied to OCM. However, the results were mixed, with "only 31 percent of the nearly 400 ACOs" being successful in seeing returns.

...

Wikipedia

Answer 4

National Uniform Billing Committee

The National Uniform Billing Committee (NUBC) is the governing body for forms and codes use in medical claims billing in the United States for institutional providers like hospitals, nursing homes, hospice, home health agencies, and other providers. The NUBC was formed by the American Hospital Association (AHA) in 1975. All the major national provider and payer organizations participate in discussions and decisions on policy and guidelines.

In 1982 after much work and debate the UB-82 emerged as the endorsed national uniform bill. After an 8 year moratorium on change, the UB-82 was replaced by UB-92, and became the standard for billing paper institutional medical claims in the United States, until creation of the UB-04. With the onset of HIPAA and the transition to electronic claims submission for reimbursement, NUBC has become the steward of the related data specifications for medical claims coding on electronic institutional claims.

...

Wikipedia

Answer 5

Oregon Medicaid health experiment

The Oregon health insurance experiment (sometimes abbreviated OHIE) was a research study looking at the effects of the 2008 Medicaid expansion in the U.S. state of Oregon, which occurred based on lottery drawings from a waiting list and thus offered an opportunity to conduct a randomized experiment by comparing a control group of lottery losers to a treatment group of winners who were eligible to apply for enrollment in the Medicaid expansion program after previously being uninsured.

The study's results have been published in the academic journals The Quarterly Journal of Economics, Science, The New England Journal of Medicine, and the The American Economic Review. In the first year after the lottery, Medicaid coverage was associated with higher rates of health care use, a lower probability of having medical debts sent to a collection agency, and higher self-reported mental and physical health. In the eighteen months following the lottery, researchers found that Medicaid increased emergency department visits. Approximately two years after the lottery, researchers found that Medicaid had no statistically significant impact on physical health measures, though "it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain."

Commentators in publications such as Forbes and RealClearPolitics cited the study as evidence that the Medicaid program doesn't fulfill its central cause of assisting the American poor, while other commentators in publications such as The New Republic and the Daily Kos stated that the evidence of improved financial security and mental health provided a significant social benefit.

In 2008, Oregon began an expansion of its Medicaid program for low-income adults. Because officials could not afford coverage for all those who wanted to enroll, they decided on the novel approach of allocating the limited number of available slots by lottery. Thus, a situation allowing for a randomized experiment occurred, with a control group of individuals not selected by the lottery and a treatment group of individuals selected by the lottery and thus eligible to apply for Medicaid.

...

Wikipedia

Answer 6

Patient Protection and Affordable Care Act Health Insurance Rate Review Program

The Patient Protection and Affordable Care Act (ACA) established the health insurance rate review program in order to protect consumers from unreasonable rate increases. Through this program, proposed premium increases in the small group and individual markets that are above a threshold amount (ten percent or more, as of February 2014) are reviewed by states or the federal government to determine whether the increases are reasonable.

Health insurance premiums have risen steadily from 2000 to 2009 and have outpaced general inflation and wages. A number of factors have contributed to rising premiums including increases in spending on hospital and physician services, changes in the benefits covered by health insurance policies, and changes in the demographics of insured individuals. Even before the passage of the ACA, many states already had existing health insurance rate review programs to review proposed increases in insurance premiums. However, there was marked variation between the states’ programs. Namely, there was variation in the review processes as well as the market segments (i.e. individual, small group) for which the review processes were applied. The type of information that was made available to the public also differed among the various states with review programs. Furthermore, there were differences in regards to the threshold amount that triggered a review. Some states, in fact, reviewed all proposed rate changes regardless of size. With passage of the ACA, much of this variability is reduced as it sets a minimum set of requirements for rate review programs. The ACA also allocates grants to states to enhance their rate review activities.

Under the rule, a rate review program was established to ensure that all rate increases that meet or exceed a specified threshold are reviewed by a state or the Department of Health and Human Services (DHHS) to determine if they are unreasonable and to publish these rate increases for public view. Rate increases are subject to review if they are an increase of ten percent or more and filed in a state on or after July 1, 2011. The choice of using 10 percent as a threshold was deemed to be appropriate based on the analysis of the trend in health care costs and rate increases before its enactment. It was also necessary to define an “unreasonable” rate increase and the initial 10 percent threshold was intended to be transitional, until state-specific thresholds are put in place. The 10 percent transitional threshold also balances the need to provide more disclosure to consumers while avoiding undue administrative burdens on other stakeholders.

Health insurers are required to submit justifications for “unreasonable” premium increases to the Secretary of the DHHS and the state before the implementation of the increase. If the insurer does not comply, DHHS could seek a court order to force compliance. If the justifications submitted by the insurer remain unreasonable, then some states have the power to deny the proposed increase in premium. These provisions apply to coverage sold to both individuals and small employers. The rule, however, does not apply to grandfathered health plan coverages, or plans that were purchased before July 2011. The three criteria used by DHHS to determine if the rate increase is unreasonable and excessive include:

...

Wikipedia

Answer 7

Point of service plan

A point of service plan, is a type of managed care health insurance plan in the United States. It combines characteristics of the health maintenance organization (HMO) and the preferred provider organization (PPO).

The POS is based on a managed care foundation---lower medical costs in exchange for more limited choice. But POS health insurance does differ from other managed care plans.

Enrollees in a POS plan are required to choose a primary care physician from within the health care network; this PCP becomes their "point of service". The PCP may make referrals outside the network, but with lesser compensation offered by the patient's health insurance company. For medical visits within the health care network, paperwork is usually completed for the patient. If the patient chooses to go outside the network, it is the patient's responsibility to fill out forms, send bills in for payment, and keep an accurate account of health care receipts.

...

Wikipedia

Answer 8

Pre-existing condition

In the context of healthcare in the United States, a pre-existing condition is a medical condition that started before a person's health insurance went into effect. Before 2014 some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the insurance industry were meant to cope with adverse selection by potential customers. Such exclusions are prohibited after January 1, 2014, by the Patient Protection and Affordable Care Act.

The University of Pittsburgh Medical Center defines a pre-existing condition as a "medical condition that occurred before a program of health benefits went into effect". J. James Rohack, president of the American Medical Association, has stated on a Fox News Sunday interview that exclusions, based upon these conditions, function as a form of "rationing" of health care.

Conditions can be broken down into two further categories, according to Lisa Smith of Investopedia:

Most insurance companies use one of two definitions to identify such conditions. Under the "objective standard" definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan. Under the broader, "prudent person" definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.

Which definition may be used was sometimes regulated by state laws. Some states required insurance companies to use the objective standard, while others required the prudent person standard. 10 states did not specify either definition, 21 required the "prudent person" standard, and 18 required the "objective" standard.

Regulation of pre-existing condition exclusions in individual (non-group) and small group (2 to 50 employees) health insurance plans in the United States is left to individual U.S. states as a result of the McCarran–Ferguson Act of 1945 which delegated insurance regulation to the states and the Employee Retirement Income Security Act of 1974 (ERISA) which exempted self-insured large group health insurance plans from state regulation. After most states had by the early 1990s implemented some limits on pre-existing condition exclusions by small group (2 to 50 employees) health insurance plans, the Health Insurance Portability and Accountability Act (Kassebaum-Kennedy Act) of 1996 (HIPAA) extended some minimal limits on pre-existing condition exclusions for all group health insurance plans—including the self-insured large group health insurance plans that cover half of those with employer-provided health insurance but are exempt from state insurance regulation.

...

Wikipedia

Answer 9

Pre-existing Condition Insurance Plan

The Pre-existing Condition Insurance Plan (PCIP) is a form of health insurance coverage offered to uninsured Americans who have been unable to obtain coverage because of a pre-existing condition. It will provide coverage to as many as 350,000 people and fill the gap until the Affordable Care Act goes into effect in 2014. The plan has been funded by congress through the Department of Health and Human Services to monitor and distribute. States are either individually run or administered by HHS with 23 states and the District of Columbia. The plan is open through an Association or Government Employees Health Association (GEHA). The program has since ceased in order to make certain funding would be sufficient to carry the existing approximately 100,000 members it has taken on since PCIP inception.

To be eligible, patients must have a pre-existing condition, be uninsured for at least 6 months, and be a US citizen or a legal resident.

The Affordable Care Act provides federal funding to support Pre-Existing Condition Insurance Plans in every state and downloadable applications are available in the states where the US Department of Health and Human Services is running the PCIP. In those states, coverage will begin on August 1, 2010 for applicants who apply by July 15, 2010.

Pre-Existing Condition Insurance Plans are designed to provide affordable insurance to Americans with pre-existing conditions. The premiums are based on the standard cost of an individual health insurance policy in the health insurance pool's geographic area and out-of-pocket maximums are limited to $5,950 for individuals and $11,900 for families.

It is not accepting new patients until further notice.

Pre-existing condition insurance is also relevant for Travel Insurance customers. A preexisting condition is a medical concern that a travel insurance customer already has prior to purchasing a policy. This concern will only be considered preexisting if it has not been stable for a certain period of time. The length of this period varies, but most travel insurance providers put it between 60-180 days. A stable condition is one that hasn't gotten worse or required medicine or treatment etc.

If a customer has to file a medical claim, the travel insurance provider will be able to look at the customer's medical records in order to assess if it involves a preexisting condition. If a claim is the result of such a condition, the provider may deny it unless the policy contains the waiver that applies to it. This is why it's important to be completely up front with a travel insurance provider when purchasing a policy.

...

Wikipedia

Answer 10

RAND Health Insurance Experiment

The RAND Health Insurance Experiment (RAND HIE) was an experimental study of health care costs, utilization and outcomes in the United States, which assigned people randomly to different kinds of plans and followed their behavior, from 1974 to 1982. Because it was a randomized controlled trial, it provided stronger evidence than the more common observational studies. It concluded that cost sharing reduced "inappropriate or unnecessary" medical care (overutilization), but also reduced "appropriate or needed" medical care.

The RAND HIE was begun in 1971 by a group led by health economist Joseph Newhouse and including health service researchers Robert Brook and John Ware; health economists Willard Manning, Emmett Keeler, Arleen Leibowitz, and Susan Marquis; and statisticians Carl Morris and Naihua Duan. The group set out to answer this question (among others): "Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost?".

The team established an insurance company using funding from the then-United States Department of Health, Education, and Welfare. The company randomly assigned 5809 people to insurance plans that either had no cost-sharing, 25%, 50% or 95% coinsurance rates with a maximum annual payment of $1000. It also randomly assigned 1,149 persons to a staff model health maintenance organization (HMO), the Group Health Cooperative of Puget Sound. That group faced no cost sharing and was compared with those in the fee-for-service system with no cost sharing as well as an additional 733 members of the Cooperative who were already enrolled in it.

...

Wikipedia