1 1095 Forms (1095A, 1095B, 1095C, 109)See: ACA Compliance. Section 6055 and Section 6056 forms & filing requirements mandated under ACA. These forms detail information provided by one of the following: Federal Exchange/State Exchange/IRS/Employer for self funded plans, or Employers of fully insured plans offered to employees.
1095-A is sent to INDIVIDUALS from the Federal Marketplace.
1095-B is sent from self insuring employers or insurance providers and detail compliance with minimum essential health coverage.
1095-C is provided by (ALEs) employers to employees.
The tax filer must use the information on Form 1095-A to complete Form 8962 (Premium Tax Credit) and file it with his or her federal tax return.
https://www.irs.gov/pub/irs-drop/n-19-63.pdf 1099's (Subcontractors)Jargon used to describe subcontracted workers who are not paid as W2 (IRS tax filers with payroll paid to the state on their pay) employees. It can get confusing when some carriers allow 1099's onto a group health plan, and others prohibit it, or at least prohibit it on paper.
2 21st Century Cures Act (Medicare Advantage Risk Adjustment Payment Model)Legislation directing how CMS calculates patient risk scores for Medicare Advantage (Medicare HMO and PPO) reimbursements to medical providers.
"In 2016, CMS began using diagnoses from encounter data to calculate risk scores, by blending 10 percent of the encounter data-based risk scores with 90 percent of the risk-adjustment processing system, or RAPS-based risk scores.
In 2017, CMS continued to use a blend to calculate risk scores, by calculating risk scores with 25 percent encounter data and 75 percent RAPS. In 2018, it used 15 percent encounter data and 85 percent RAPS; and in 2019, 25 percent encounter data and 75 percent RAPS.
The new model will determine risk scores by adding 50 percent of the score calculated from diagnoses from encounter data, RAPS inpatient diagnoses and fee-for-service diagnoses, with 50 percent of the risk score calculated with diagnoses from RAPS and fee-for-service diagnoses." (Source: Healthcare Finance Magazine January 2019: Susan Morse)
4 401 plan (Defined Contribution Plan)See: Defined Contribution Plan
A ACA 6055 Reporting The forms ALE employers must file with IRS, to be in compliance with ACA law and tax regulations.
"Affordable Care Act 6055/6056 reporting for 2020
Nov. 12, 2019
Reform and Regulatory
Fully Insured and Self-Funded
UnitedHealthcare will send 1095-B forms to fully insured plan subscribers prior to the Jan. 31, 2020, filing deadline. The forms will begin mailing in mid-December, 2019, and should be fully distributed by Jan. 31, 2020.
Complying with 6055 requirements
Fully insured groups
Under the Affordable Care Act, employees with fully insured plans who were eligible for coverage for at least one month in 2019 must receive a 1095-B form from their insurance carrier.
For fully insured customers, UnitedHealthcare sends the 1095-B forms directly to employees; they are not mailed to employers. Employers may not request forms for their employees or receive a report of employees who receive a form.
If the member misplaces the form, they may obtain a copy of their 1095 on the myuhc.com® member site. They may also call the customer service phone number on the back of their health plan ID card.
Fully insured Applicable Large Employers (ALE) with 50+ full-time equivalent (FTE) employees must also send their employees a 1095-C.
Self-funded (ASO) customers must provide their employees, by Jan. 31, 2020, with a 1095-B if they are a small employer with one to 49 FTEs, or with a 1095-C if they are an ALE with 50 or more FTEs.
Complying with the IRS information reporting requirements
The following forms must be transmitted to the IRS by Feb. 29, 2020, if filing by paper, or by March 31, 2020, if filing electronically:
1094-B Transmittal of Health Coverage
1095-B Health Coverage
1094-C Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns
1095-C Employer-Provided Health Insurance Offer and Coverage
Note: Employers with 49 or fewer FTEs are not required to submit a report to the IRS.
New state requirements for individual coverage and associated reporting requirements
Individuals are no longer subject to a federal Internal Revenue Service (IRS) penalty if they did not comply with the shared responsibility requirements of the Affordable Care Act (ACA), sometimes referred to as the Individual Mandate. The penalties have been removed for those who do not have health insurance coverage. However, some states have initiated their own individual mandate requirement for residents of those states.
New: New Jersey and D.C. implemented state individual mandate requirement for 2019
Although the federal level penalties have been removed for those who do not have health insurance coverage, some states have initiated their own individual mandate requirement for residents of those states.
Individuals who have resided in New Jersey or Washington, D.C., for any time during 2019 will be required to report if and when they had minimum essential coverage (MEC) on their 2020 New Jersey or D.C. tax returns.
UnitedHealthcare will submit the required 1095 forms to the state tax departments by the deadlines below for fully insured groups:
New Jersey Tax Department: By March 31, 2020
Washington, D.C., Tax Department: By June 30, 2020
In addition, fully insured ALEs and self-funded groups will be required to submit copies of either the 1095-B (groups 1 to 50 FTE) or 1095-C (50+ FTE) to the state of New Jersey or D.C. tax departments.
There are penalties for individuals who have resided in New Jersey or D.C. beginning with the 2019 calendar year if they do not have insurance coverage as required by the state.
If needed, a self-funded group may request a custom eligibility report to include month by month coverage that is available for a fee. The group may also request a report for either the New Jersey or D.C. residents. For 2020, the report will include current residence only.
Several other states have indicated that they have legislation adding an individual mandate and penalty for 2020 that will require reporting in 2021. UnitedHealthcare will send out information as the states approve the legislation.
Summary of UnitedHealthcare’s approach
For fully insured groups: UnitedHealthcare will send the 1095 form to subscribers, to the IRS and where required to the NJ or DC state tax department by the due dates.
For fully insured ALEs: The group is required to send the IRS 1095-C forms and where required send to the NJ or DC state tax department by the due dates.
For All Savers®: UnitedHealthcare prepares the 1995-B forms, which the employer then provides to their subscribers and to the IRS and where required to the NJ or DC tax departments by the due dates.
For large self-funded groups: The customer prepares the 1095-C form, which they then submit to subscribers, to the IRS and where required to the NJ or DC tax departments by the due dates." Source: United Healthcare Agent Advisory ACA Final Rules (CMS issued ACA Final Rules)ACA law passed in 2010 is still in effect. Multiple Presidential Orders have effectively gutted ACA without repealing the law. The Supreme Court recently sided against Trump administration and declared the estimated $12 BILLION CSR related reinsurance payments are due to the carriers. Cigna, Aetna, United, Humana, etc have abandoned the Marketplace Individual and SHOP plan offerings. At least two million less marketplace insured INDIVIDUALS have abandoned buying insurance on the Marketplace since President Trump took office. See: APTC, CSR, Marketplace reinsurance (safety net).
See Trumping Healthcare Reform at www.providerrisk.com, Click on - ARTICALS.
ACA has not been repealed, but for the individual mandate tax penalty. In Dec 2019, most if not all insurance taxes mandated by ACA law were repealed as well, but individual Employer tax penalty is still in effect for employers over 50 lives. Enforcement is lax, or absent on many minimum statutory standards. Plans excluding preexisting medical conditions (prohibited by ACA law) are actively being sold.
Key unenforced ACA provisions now "apparently" avoidable include: MLR (Medical Loss Ratio) definition calculation related to plan costs and premium rebates, Individual/Group actuarial value minimum coverage, and carrier authorization to increase rates up to 15% without state filing or approval. (in 2018-2019, my Blue Cross Plan premium increased 45%) States appear to be obligated to create INDIVIDUAL plan minimum benefits equal to existing Employer "GROUP" plan limits and benefits. States now allowed to select or mix and match "any" plan accepted in "any" state versus plans meeting minimum ACA EHP QHP statutory mandate.
CMS is eliminating by rule: QHP certification process in INDIVIDUALLY offered marketplace plans distributed by the State Based Federal-faciliated Exchanges (SBE-FPs) to enforce FFE standards for network adequacy (re: Medicare lives) and essential cummunity providers. 14 states use FFE. Marketplace navigator budget is reduced from $27M to $10M in 2019, leaving big hole for customers struggling to find and understand plans and tax credits - especially in 14 states. Latest Trump agenda is to ask the Supreme Court to overturn the entire law, despite the Supreme Courts earlier decision upholding ACA. Stay tuned.
Not sure if 3.5% user (premium tax on insureds) fee tax still effective on members enrolling within SBE-FBs.
SHOP and INDIVIDUAL Marketplace enrollments now allowed directly with carrier/brokers inclusive APTC, without direct FFM or SBE-FP's exchange enrollment. 0 SHOP plans offered in Florida (most states) for any small businesses, and states now prohibited from creating platform to secure small group plan insurance for small employers. Commission to agents reduced so far ($18 - $20 per enrolled policy (not per person) has effectively eliminated agents, thereby relegating insured to fix their own multi-agency and tax credit issues after unlicensed navigator's employment ends after enrollment. See: Executive Orders, Price Transparancy, Public Law 111-148, Public law 111-152.
Meanwhile, New HHS regulations mandate hospitals provide accurate cost estimations to prospective patients.
Federal Info at HHS: ACA Risk Adjustment (ACA reinsurance) A term typically used to describe federal reinsurance to eligible Marketplace carriers, who have elected to participate (buy) federal reinsurance on Marketplace offered plan members, thereby insulating them from adverse selection from insuring super sick members. The term is ambiguous and gets confused with CSR and APTC. See: CSR and APTC.
The reinsurance applies to reimbursement (indemnity) of claims between $45,000 and $250,000, and NOT to an unlimited amount actually insured by each carrier per ACA QHP mandate. The program also limits (participating) carrier profits on individual marketplace enrolled members to 3% (in addition to mandated MLR rebates carriers must pay back on any INDIVIDUAL / SHOP plan whose INDIVIDUAL member claims are less than 80%/85%) of the premium charged.
Over $10 Billion (CSR) payments has already been paid since 2017 (under the Obama managed ACA). Exactly what has been paid is not certain, however the supreme court recently sided with the carriers April 2020 demanding $12B in reinsurance payments, and that the Trump administration denied.
Blue Cross was owed $5 billion.
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-9920-F-7-24-18-final.pdf ACA waivers CMS issued four new waiver concepts aimed at helping states develop options for using Section 1332 waivers under the Affordable Care Act. The waiver concepts, which follow Section 1332 waivers guidance released by the CMS, includes account-based subsidies, state-specific premium assistance, adjusted plan options and risk stabilization strategies. Source: AHIP Agents Smart Brief. See: APTC, CSR, MLR, etc. Accelerated Death Benefit A life insurance feature that allows a terminally ill diagnosed person to collect part of the death benefits before they expire. See Viatical for a potentially better option (for the terminally insured). Accellerated Payment See: CMS re C19 $175 payments to providers being suspended after $100 Billion distribution. Access See: SORN and application to an individual's right to access his PII, and/or direct who can use it.
Access is historically a central federal policy issue guaranteeing right to healthcare coverage at an affordable price by ACA law, and longstanding intervention and obligation. Accidental MEWA See: MEWA. A term used to describe an ERISA plan allowing insurance to 1099 subcontractor eligibility, and that may violate individual state's MEWA prohibitions.
Historically, some carriers would allow 1099's to be on an employers plan, but recently it appears that carriers are citing 30 hour work requirement, and/or 50% employer contribution rules.... There are participation and contribution rules (that are usually followed- i.e. 70% participation and 50% contribution) relative to member-employer plan eligibility, but if the carrier will allow it, they are the risk takers making final decision to make 1099 subcontractors eligible or not.
ERISA dominates state laws, but states will fight any MEWA without a Certificate of Authority. See: Trump's Executive Order on Associations and know it would have taken off a long time ago if it offered capitalistic opportunity - insulated from state authority - regardless of cross state "Executive Order" authority. Accountable Care Act of 2010 (ACA)See: Patient Protection and Affordability Act
See: Republican Agenda
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08017.pdf Accountable Care Organization (ACO)See: Next Generation ACO's
An organization allowed by CMS that allows medical providers to enter into risk /non-risk bearing contracts to care for assigned Medicare lives.
ACO’s generally provide full range of medical services. Central to ACO purpose is to transform provider payment to a value based system that copensates providers for keeping members well, and revamping fee-for service production incented compensation by episode/procedure. Central to ACO purpose is the elimination of traditional FFS provider compensation within optional "Shared Services" at-risk 3 year term contracts. (See: Direct Contracting changes that do not affect previous ACO's yet) FFS contracts are also offered by demonstration project (HHS, CMI, LAN CMMI initiatives) approval for multiple "chronic" (expensive) care-managment catagories (knee replacements, diabetes, back pain, hypertension, asthma, etc.). ACO goals are said to actively focus upon outcomes of care and bundling of care surrounding chronic disease and high cost procedures case management. FYI: in 2015 the OIG estimated that 29% of the federal budget was spent on major medical programs by the Federal Government. see Next Generation ACO. See Federal healthcare policy with goal of value based reimbursement (i.e. exiting FFS and moving to EBM outcome enphasizing keeping people healthy versus incenting production of medical procedures, and keeping hospital beds full at any cost.)
ACO Risk Contract/CMS Fact Sheet Accountable Health Communities (AHC)C.” The Accountable Health Communities (AHC) Model assesses whether bridging the gap between clinical care and social services can reduce health care utilization and costs for high risk Medicare and Medicaid beneficiaries. In November 2019, CMS convened 29 bridge organizations participating in the AHC Model and key partners for the second annual AHC meeting to brainstorm and share promising strategies to address beneficiaries’ health-related social needs. performance period.
To view a list of the Assistance and Alignment Tracks bridge organizations, please visit the Accountable Health Communities Model web page. (Source CMS)
ACO Next Generation (Next Generation ACO)A term referring to medical provider organizations accepting Medicare managed care risk contracts exposing them to 40%-100% of "shared savings" budget over-runs (after typically 3 years) for NOT effectively managing care.
https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/ ACO Performance
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html ACO Stop Loss (Stop Loss)A medical excess of loss coverage purchased by ACO in track 2 or 3 of the Medicare ACO shared risk contract. It is typically viewed as a type of Provider Excess Loss (stop loss). Actively at Work A SPD provision stipulating eligibility for medical benefits. Actuarial Hope (Career Insurance)A term coined by Ann Richards of Fidelity Investments used to establish an estimated investment (interest) return on a modeled outcome. See: Fudge Factor Actuarial Rule 49 (AG49)An rule used in preparing IUL illustrations (using a variable loan rate interest option) that limits the spread between Variable Loan Interest rates and Cash value interest crediting to 1%. Generally, the rule is intended to balance reasonable estimates of future Index growth with loan interest charges in retirement and to death. IUl's offer fixed rate interest charges too - I.e. 4% fixed for life, but (as far as I can tell) that does not apply to the rule because it is fixed. What I can say is one major carrier allows S&P growth rates to 6% (2020), but also shows S&P growth at 3.5%. Actuarial Value (AV)An MLR legislated ACA value requirement of "metallic" level plan pricing. "Issuers in the Individual Marketplace can choose to offer one or more “standardized options” with a specific cost-sharing structure at the Bronze, Silver, and Gold levels.
Each standardized option consists of a fixed deductible, fixed annual limit on cost-sharing, and a fixed copayment or coinsurance with specified applicability of the deductible for a key set of essential health benefits that comprise a large percentage of the total allowable costs for an average enrollee. Issuers that offer a Silver standardized option must also offer the three associated standardized Silver plan variations for cost-sharing reductions (i.e., 73% actuarial value, 87% actuarial value, and 94%" actuarial value). (source: Source: MLM training by CMS
The QHP levels of coverage correspond to different levels of actuarial value (AV) based on how enrollees and the plan can expect to share the costs for health care.
The category an employer chooses affects, on average, how much enrollees pay for things like premiums, deductibles, and copayments, and the total amount they have to spend out-of-pocket for the year if they need a lot of care.
•Bronze. The health plan covers about 60% of the total costs of care on average. An average enrollee can expect to pay about 40%.
•Silver. The health plan covers about 70% of the total costs of care on average. An average enrollee can expect to pay about 30%.
•Gold. The health plan covers about 80% of the total costs of care on average. An average enrollee can expect to pay about 20%.
•Platinum.The health plan covers about 90% of the total costs of care on average. An average enrollee can expect to pay about 10%.
By Trump Presidential order, HHS is instructed to change ACA and/or previous HHS AV, and multiple ACA minimum coverage standards to gut the law, without passing a new law. Businesses are now subject to their respective state's minimum AV standard that can now be based on the lowest plan (EHB and/or QHP) coverage offering in any state.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08017.pdf Adjusted Clinical Groups (ACGs)Johns Hopkins Adjusted Clinical Groups System Adjusted Gross Income (AGI)The amount used by a single person to calculate tax credits on ACA compliant plans for people earning between 100%- 400% of FPL. AGI is reduced by child support and student loan interest. Administrative Services Agreement (ASO, MSA)In context to ERISA eligible plans: A term generally used to describe TPA functions that include at minimum: claims processing, and perhaps case management, eligibility determinations, stop loss acquisition and management, etc. ASO options are many.
Some carriers refer to the actual contract as a MSA for "Level-Funded" (ERISA) plans stipulating services and programs scheduled by fees charged. MSA can also mean Medical Savings Account. Admitted (Authorized)A term used to describe a carrier that is both Eligible and Authorized to issues insurance in a specific state. See: Surplus Lines. Advance Beneficiary Notice (ABN)See: Dual Eligibles Advance Beneficiary Notice of Noncoverage (ABN)A CMS declaration to an individual Medicare beneficiary an individual provider (i.e. physician) being no longer participating (in Medicare), and that if care is received, it is not insured. See: PFFS and Medicare Part C Advance Payment A term CMMI uses for payments to providers subject to the type of contract (risk versus FFS) related to Direct Contracts managing either total care or just primary care. Advance Payments of the Premium Tax Credit (APTC)Advance Premium Tax Credit: The premium discount amount a person earning between 100% - 400% of FPL is eligible. The credit is paid by the federal government directly to the health insurance company each month.
see Periodic Data Matching (PDM) Advanced Aggregate Advanced Aggregate is reinsurance provided to ERISA exempt entities. Reinsurance over multiple self funded employers is provided by advancing aggregated coverage recoveries for risk between specific retention and a percentage of the fully funded and underwritten major medical insurance premium. Advanced Alternative Payment Models (APMs or Alternative Payment Contracts)See QPP Advanced Premium Tax Credit (APTC)ACA authorized entitlement Tax credits that reduce the members monthly premium costs by the amount of credit. Enrolled members earning between 100% - 400% of Federal Poverty Level (FPL) are eligible for the credits. It can also refer to Medicare eligible beneficiaries that may also be purchasing a tax-credited eligible plan.
APTC is not CSR, Cost Sharing or Federal Marketplace reinsurance.
Total advance premium tax credit payments increased to $20 billion, from $12 billion in 2014. (Source: Think Advisor May 2017) APTC is not CSR or Federal Reinsurance. Advancing Care Information (ACI)Advancing Care Information (ACI), which replaces the Meaningful Use program is one of four components CMS will use to make payment adjustments under MIPS. ACI looks at EHR use as it relates to patient engagement and healthcare quality and is 25% of your MIPS score for 2017.
See QPP, MACRA, MIPS Affordability (Insurance Affordability Program)An ACA legislated term defining eligibility for tax credits to individuals/families purchasing "On- Exchange" or "Marketplace" plans who earn between 100% - 400% of the Federal Poverty Level, (and in context to what an individual or Employee must pay for insurance premiums as a percentage of AGI/MAGI (household). Citizens and non US citizens who file tax returns are eligible. Or, a Legislated maximum percentage rate (of AGI / MAGI) set by CMS to determine eligible tax credit for purchasing Individual or SHOP commercial health insurance.
For Individuals, affordability for a Marketplace QHP means, if insurance premiums cost the insured more than 8.24% of AGI (individually Adjusted Gross Income) for 2020. Double check the percentage as it goes up each year following FPL adjustments. Rules and employer penalties related to employees electing to buy INDIVIDUAL marketplace coverage over "unaffordable" employer offered coverage are different, and also have a penalty to the (ALE) employer for a proportion of their employees receiving APTC.
See: Applied Premium Tax Credits, and 2010 ACA law.
"Some states rely on HealthCare.gov for all ACA exchange services.
Others, such as Nevada, have been using HealthCare.gov enrollment and account administration systems but manage their own marketing programs.
HealthCare.gov managers want to cut the user fee plan issuers pay to 3 percent of premiums, from 3.5 percent, for issuers in the states in which HealthCare.gov handles all exchange services, and to 2.5 percent, from 3 percent, for issuers in “partnership” states.
Cost-sharing (see: CSR) and affordability limits:
Here’s what could happen to some parameters that affect whether your clients have access to coverage considered “affordable,” and what out-of-pocket costs for an exchange plan user might look like.
Employer plan affordability cut-off: Self-only coverage will be considered affordable if it costs up to 8.39 percent of projected household income (MAGI), up from 8.3 percent this year.
Maximum annual Individual OUT of Pocket costs for 2020 are $8,150 single / $16,300 Family. Note: care received out of network exposes the insured to an unlimited (OON) out-of-pocket liability costs exposure.
See: State Medicaid Program under title XIX of the Social Security Act, CHIP under title XXI, and State basic heath program established under section 1331 of ACA act.
https://www.federalregister.gov/documents/2019/01/24/2019-00077/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2020 Affordability Contribution Percentage Term used to calculate if a Group (QHP employer offered plan) is affordable for purposes of avoiding an employer tax penalty, or Individual employee eligibility for a ACA available tax credit. (for 2019) Mainland FPL for 2019 affordability determination is $12,140 (9.66%) = est $115. Means if employee earing $12,140 is required to pay more than $115 per month for QHP, that employee is eligible for INDIVIDUAL marketplace tax credit, and the (ALE) employer gets fined about $3,300 for EACH employee getting who actually buys an INDIVIDUAL marketplace plan and receives (APTC) tax credit. Affordable Care Act (ACA, PPACA, Obama Care)The Patient Protection Affordable Care Act is referred to as the Affordable Care Act/ACA/PPACA. The ACA (Affordable Care Act) is a 800+ page law encompassing all medical care in the US, but with very limited application to Veterans affairs, approved Limited Medical Plans and underwritten Medicare Supplemental plans. ACA compliant plans mandate: 10 minimum essential benefits (MEB) without annual benefit limits (that comprise a QHP), tax credits for individuals earning below 400% of Federal Poverty Level (FPL), Cost Sharing for people earning between 100%-250% of FPL and reinsurance safety net. CRS and reinsurance were/are regulatory enforced and not part of original ACA. CSR lowers deductibles and max-out-of- pocket costs, and limits personal total annual health expense (spend) from (about) 2% to a maximum of 9.66% (2017) AGI/MAGI. Small employers (under 25 FTEs) are now offered tax credited plans through SHOP, where commercial sponsor offers them (which is practically nil). Shop tax credits can be 50% for year one, and 35% for year 2. Insurance is provided by commercial carriers, not the government. See Eligibility for Advance Payment. Similar to Medicare Advantage plans, Individual and Small Group Insurance is offered and managed by commercial carriers, not the government.
Source AHIP SmartBrief: "The latest figures from the CMS showed enrollment in the individual insurance market dropped by 1.2 million, or 24%, between 2017 and 2018 among people whose incomes are too high to qualify for Affordable Care Act subsidies, while enrollment increased by 300,000 among those eligible for financial help. As of February 2019, 10.6 million people had coverage on ACA exchanges, about the same as last year, while average premiums fell by 1% between 2018 and 2019 after years of increases." Source AHIP SmartBrief Aug. 2019
Means: Patient Protection and Affordable Care Act
(Public Law 111-148), as amended by the Health Care and Education Reconciliation Act
of 2010 (Public Law 111-152), which are referred to collectively as the Affordable Care
Act. Info is not tax advice. Age Compression Rule (spending cap ratio)A provision in the Patient Protection and Affordable Care Act (ACA) that mandates premiums be not more than 3:1 difference between young and older people . Meaning, ACA QHP premiums charged to older people (i.e. aged 64) cannot be more than three times the price of premium charged to a young person. (i.e. age 5) . See Medicare-for-all, and Medicaid-for-all.
FYI there is no agreement on what the rule is called, and the Trump administration is allowing the carriers to price plans in violation of ACA precedent. See: Silver Loading.
Age Banding... (per ACA regulation)
Health insurance issuers in the individual and small group markets generally are not allowed to charge an older adult more than three times the rate of a 21-year-old based on age.
States can establish their own age curve or default to the federal age curve.
Federal age bands:
One-year bands between ages 15-63
64 and older Aggregate Claims Bases (In context to a liability contract) A liability policy coverage term defining if the policy limit applies to all claims, or to each and every claim (restored limits for each loss) incurred in a policy period. Some Policies also detail separate limits for "incident response" as a separate limit to the policy limit. Same would apply to most if not all defense costs that may be stipulated by state law as available in excess to the policy limit.
Aggregate in stoop loss, reinsurance or excess of loss is not the same definition. In general, when aggregates trigger in excess of loss types of contracts, the specific coverage turns off, and claims are payable at 100% of every dollar of loss. These are very rare events of less then 1:1000. This does not hold constant for stand-alone aggregate policies. Aggregate Pharmacy Reinsurance Aggregate Pharmacy Reinsurance is stop loss or reinsurance coverage triggering at 110%-125% of last year's trended claims history. Typically, not all Specialty drugs are insured. Infusion therapies, cost bases, and reimbursement schedules can dramatically effect coverage. Aggregate Stop Loss/Reinsurance A second-dollar insurance triggering payment after (typically) 125% of last year's trended medical claims history. It is a per population per year coverage, that once triggered pays out without additional (specific) deductible application. Competing premium offered can range more than 100% in cost for same ERISA related coverage. Aggregate Stop Loss can provide coverage against an entire population's budget overrun in a calendar year. Typically, Aggregate coverage is not available without also purchasing Specific coverage. See: Pharmacy Aggregate insurance which is available without Specific cover. Aggregating Specific Deductible (ASD, Inner Ag, Split Funded Arrangment)A "second" deductible on top of the "specific" deductible that must be paid by the insured to "itself", and that must be satisfied before a policy owner gets stop loss or reinsurance recovery paid by the carrier. I.e. If the Specific (per person per year deductible) is $50K and the ASD is $100K, then the insured will pay up to $100K (to itself) of all eligible stop loss claims excess of $50K until it reaches $100K. At that point, the reinsurer then reimburses "all" eligible claims excess of $50K to the terms of the stop loss policy. Properly done, the insured "self-funds" (deposits in a separate personal account each month), an amount equal to 1/12th of the $100K to be available for "expected" claims payment.
This process effectively eliminates: Premium tax, agent commission, and carrier overhead profit margin, carrier overhead load, reinsurance costs, and actuarial fudge factor thereby lowering "expected" costs" on an additional $100K of premium (that was not directly paid by the employer to the carrier to fund the first $100K of stop loss claims.
There are derivatives of these arrangements where the stop loss premium is "fully funded" (entire premium is paid at the single deductible level) each month, but that a portion (equivalent to the ASD rated premium - "second deductible trigger" part of the premium) is held by the reinsurer instead of the insured to pay claims timely.
See: Finite reinsurance, but don't make too many parallels. Alarm Fatigue A term used to describe medical providers simultaneous monitoring of multiple high technology alarms, and becoming numb to which one(s) that require immediate intervention. As the iOT - 5 billion devices become connected over the next two years becomes reality, AI programed alerts promise some solution to alarm-fatigue. All Other Perils (AOP or Open Risks Policy)In context to property policies (typically residential), means All other perils, or causes of loss. Depending on the state and/or policy (HO3, HO4, HO8, HO5, DP1, DP3, etc) perils (sometimes referred to as hazards) may be excluded, or specifically included in their own separate coverage (and added premium) under separate deductible SIR. For example, a house policy would have Wind/Hail (hurricane) coverage AND AOP (that includes fire, but not Flood coverage). All-Care Readmission (ACR)See: MACRA, MIPS, QPP Alternative Payment Models (contracts) (APM)A term used by LAN (CMS or Medicare administrators under HHS) to describe the identification, reporting and/or creation of new provider payment methodologies (that almost never traditional Medicare DRG, Medicare allowable FFS, etc), and whose goals include increasing (private payers, providers, employers, state partners, consumer groups, individual consumers, etc) engagement, to drive lower (Medicare, Medicaid, Commercial, Workers Comp, Auto, etc) medical costs and better medical outcomes. Many are watching as republicans move to scrap many methods being tested to align better outcomes with hospital and physician accountability and reimbursement incentives. One goal is to try to change prevailing medical provider FFS procedure maximization behavior driving premium costs beyond what is affordable.
Primary contracting types include: Fee for service, Management Fee, Bundled Payment, Shared Savings or Shared Savings & Risk, Performance Incentives (See MIPS, QPP, MACRA, Pioneer ACO's, etc) Ambulatory Care Sensitive Condition (ACSC) Ambulatory Payment Classification (APC) Ambulatory Payment Classifications (APCs) Ambulatory Surgical Center (ASC)What CMS calls outpatient surgery centers
https://www.federalregister.gov/documents/2017/07/21/2017-14639/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions American Association of Insurance Services (AAIS)An agency that standardizes P&C policy forms. See: ISO American Hospital Association (AHA)See: MGMA, AMA American Medical Association (AMA) Annual Benefit Limits A maximum annual insured amount specified in the policy contract. Within context to ACA law defining QHP, 10 essential healthcare benefits (EHB, aka minimum healthcare benefits) are unlimited. The Trump administration has essentially ignored the law, and is allowing less expensive plan offerings (see: Scheduled Medical plans Plans) limiting benefits, as well as preexisting medical condition exclusion previously prohibited under ACA law. Annual Enrollment Period (AEP)A CMS defined period allowing people to enroll in ACA compliant medical plans. Enrollment periods are not the same. Group plans administering "Open Enrollment Period" is not the same. Annual Notice of Change (ANOC)The required annual update made to CMS insured lives explaining changing conditions of coverage, and network access. See: OON Annual Payment Update (APU)Annual Payment Update (APU) is calculated. See the Hospice Quality Reporting Spotlight webpage for details related to nursing home reimbursement rates and updates (HQRS) Annuity Generally, its a fixed sum of money paid to someone for the rest of their life. Annuities have surrender charges for early cancelation. People buy annuities primarily for safety, and potential hedge against running out of money in old age. Annuities come in two basic forms: Fixed and Variable. Fixed annuities contractually promise an annualized rate of interest crediting (i.e. flat 2%) for life. Fixed Indexed Annuities contractually promise a capped-range. I.e. 0% - 10.5% cap* based on if the S&P goes up, or down over a year. If the S&P goes down, the annuity owner loses no principal (safety), but earns no interest (i.e. 0% interest crediting that year). See IUL, which is life insurance that can be explained as a fixed indexed annuity (FIA)(contractually promised interest crediting 0% - 10.5% range) inside of their life insurance policy guaranteeing a death benefit. Yes, FIA contractually promises "potential future" INDEXED interest crediting up to a capped rate*), but without being directly invested in the market subject to market crashes that reduce the contract "fund or principal". I.e. Safety means a "floor" of 0% interest crediting without a loss of annuity total value. Variable annuities ARE directly invested in the market, so when the selected index crashes, the annuity owner does lose contract value in their annuity. (Same is true for Variable life insurance policies). Each annuity contract must be read to understand how the interest crediting works. Typical annuity crediting (safety) "floors at 0% interest crediting" minimum interest guarantees at about 85 bases points to 2%, depending on the terms and annuity contract. Contractually "guaranteed" rates typically refer to the entire life of an annuity, or life insurance product. Contractually promised interest crediting (in an annuity or a life insurance policy like IUL) come in three basic forms: for the life of the product, for the annual interest crediting cycle elected, and/or for what is known as the (annual interest crediting) "income roll up", when an "income for life" option is elected. Yes, three different "contractually promised" interest crediting in one potential life insurance policy, or annuity. Income roll up contractually promised (or "guaranteed") interest crediting can be as high as 8%, but must be weighed with limits of how much each contract allows the annuity owner to withdraw each year at specific ages. Typical "income distribution LIMITS" might be 4% at age 65, and 5% at age 70, to earning 8% may be of limited value if the contract limits total income distributions to 4%, so understand what you are buying, or ask questions until you do. See: Forced Annuitization which can mean that standard allowed right to withdraw a maximum of up to 10% (of annuity "principal" value) is forfeited, and not available for emergencies. Caveat Emptor Anti-Concurrent - Causation Theories (ACCD)In context to property policies and theories of recovery - it is a rule or policy provision denying coverage when the sequence of an uninsured peril causes an insured peril's loss. Means, none of the loss is contractually insured. Some states limit or prohibit the rule. A provision limiting or denying coverage when an uninsured or excluded peril causes an insured peril to trigger a loss. It assumes the initial cause of loss is known.
See: EPC & CCD.
Applicable Federal Rate (AFR)The applicable federal rate (AFR) is set monthly by the IRS and used for various purposes under the Internal Revenue Code, including for imputed interest and original issue discount rules. The AFR is normally available during the third or fourth week of the month. It is used for purposes of establishing a loan interest rate applied to Collateral Assignment Split dollar Life Insurance ( see SERP) Applicable Large Employer (ALE)An employer of sufficient size (typically involving groups over 50 FTEs, but can also include smaller groups) to fall under section 6055 or 6066 of the ACA law, and who is required to file forms 1095B and 1095C (health plan and employee information) with the government. Applied Medical Software (AMS) Applied Premium Tax Credit (APTC)An ACA authorized tax credit paid by the federal government directly to a commercial carrier that reduces premiums for people earning between 100% and 400% of FPL.
The Treasury Department is reported to estimate 2017 payments totalling $40 BILLION.
APTC is not CSR, or federal reinsurance (on individual Marketplace participating plans).
Form 1095-A must be submitted annually with each tax return to qualify for the credit. The Form is provided by the commercial carrier, and attached to the individual tax return to maintain eligibility for the tax credit.
https://www.kff.org/interactive/subsidy-calculator/ Appropriate Use Criteria (AUC)See: QPP, MACRA, MIPS, PAMA, APMs Area Health Resources File (AHRF) Artificial Intellegence (AI)An new generation of "learning" software able to detect, garner, and update it's own data sets, and purpose (goals) maximization. Lets pray its designers program safeguards preventing machine learned conclusions identifying humans as the minimized value preventing optimized goal(s). Assignment of Benefits (Assignment)A contractual insurance policy provision allowing payment for services directly to the medical provider, and not directly to the insured. See: AOB
The term can have additional contractual requirements/meaning within accepted P&C policy terms. Association Health Plan (AHP)See MEWA
HHS Final Rules under President Trump's Executive Order allowing expanded "association" health plans operating across state borders, and without solvency standards established under existing state law. A recent federal court ruling has placed an injunction over such plans declaring they violate existing state laws - i.e. ERISA (federal and combining state laws) authority, are still subject to state compliance and prosecution regardless of federal agenda. 12 states are suing DOL for overstepping their ERISA administration authority, (and not enforcing ACA law) and to stop these kinds of plans from offering plans that do not offer unlimited EHB and QHP compliant insurance coverage.
That said their are Association sponsored health plans that follow ERISA guidelines, and that are not prosecuted by state authorities. Many types of plans are sponsored by various "associations" including limited medical plans, etc. Major Medical (QHP) plans must be heavily scrutinized by competent expertise to assure against uninsured perils.
https://www.gpo.gov/fdsys/pkg/FR-2018-06-21/pdf/2018-12992.pdf Automated Clearing House (ACH)A payment method Typically referring to automatically paid items by checking account or credit card granted authority. Automatic Extreme and Uncontrollable Circumstances See: MIPS Automatic Reinsurance See Treaty Reinsurance
A reinsurance policy that automatically accepts each new policy or risk written by an authorized underwriter, agent, agency or carrier. In other words, each new policy sold does NOT require reinsurer approval. Sometimes there are risks that must be vetted and separately approved by the reinsurer, prior to binding if they materially violate the character, underwriting protocols or treaty risk transfer terms. Average Wholesale Price Term used to calculate regional drug pricing, that is also associated with a total cost per script filled inclusive of an administration fee typically at $.5 + per script.
B Bad Faith In context to insurance: A legal term describing a carrier's intentional, obstructive, and/or inappropriate act(s) to avoid paying a legitimate claim. Association and Joint Underwriting Associations cannot be sued for Bad Faith. In other words, and association member cannot sue (himself), even if he personally does not have anything to do with claims administration. See: ERISA Balance Billing Balance billing is the difference between an (out of network - non contracted) provider billed charge, and "contracted rate" (or maximum insured amount) a carrier pays, and that gets charged to the patient. Many laws and regulations apply. Balance billing amounts do not attribute to deductibles, out of pocket expenses, or maximum limits in a policy, and can create substantial uninsured liability for members receiving Out Of Network (OON) care. ACA law protects compliant QHP insureds. Balance billing issues can be contentious. Benchmarking (Reference Based Pricing)See RBP Beneficiary Engagement and Incentives (BEI)Beneficiary Engagement and Incentives
https://innovation.cms.gov/initiatives/Beneficiary-Engagement/ Benefit Package The amount and limit of medical insurance provided within an insurance plan document, or Summary of Benefits. Benefits are typically summarized by: Deductible , Co Insurance, Copay, and out of pocket maximum. Additional benefits may also be part of the Package such as Dental, Life, LTC, STD, etc at customer option. Best Interest Contract (BIC)On April 6, 2016 the DOL published the Conflicts of interest - retirement Investment Advice regulation Implementation of a fiduciary standard for investement advisors, AND plain insurance agent's duty was determined by DOL without distinction to products that can, or cannot crash in the (stock) market, or that are, or are not guaranteed safe by each state's Insurance Guarantee Association. Authorized insurance policies are guaranteed safe (to each state's Insurance Guarantee Association limits). Marketable securities (Stocks, bonds, etc,), are not guaranteed safe, and do crash in bad markets. The after shock caused at least two investment houses to stop offereing (marketable securities) services to non-wealthy people who ironically are the same people that need advice the most to avoid running out of money in old age.
A fiduciary standard recognizing no distinction between products at risk to market crashes, and those guaranteed safe by state insurance guarantee associations, along with contractually promised interest crediting (i.e. 0% - 10% range S&P ETF) promises (like life insurance products with fixed and fixed indexed annuities - IUL) - or, practically makes impossible - defending an allegation that, "It should have earned more interest" 5-30 years down the road - from the same person who cannot remember what they had for dinner, let alone what they considered and accepted 10+ years prior.
Our strong recommendation is take the time to ask questions about any investment with or without (Guarantee Association) safety, or contractually assigned interest crediting. If you do not understand it, ask questions until you do, or don't accept the offering. As always, caveat emptor applies. Do the work.
http://webapps.dol.gov/FederalRegister/HtmlDisplay.aspx?DocId=28807&AgencyId=8&DocumentType=2 Better Care Reconcilliation Act Proposed Republican lead Senate replacement to ACA.
https://www.cbo.gov/publication/52849 BIC (Best Interest Contract)A term whose meaning has come under extreme review by state and federal authorities to determine a financial planner's obligation, or duty to his client - especially in context to retirement account rollovers and advice. "Reg BI" is the DOL higher obligation, versus a lesser obligation when state-level fiduciary rules are considered. "Both Reg BI and the DOL’s fiduciary standard require "advisors" act in the client’s best interests, but the two standards are not exactly the same when it comes to (retirement account balance) rollover recommendations. Each rule requires that the advisor conduct a detailed analysis to determine whether the rollover is in the client’s best interest—meaning that the advisor must evaluate "all" potential options, such as taking a distribution or leaving the funds in the current plan, in comparison to rolling the funds into another "plan", in light of the client’s goals and financial position.
Insurance professionals are not under the same standard. See: Senior Suitability in context to annuity sales and explicitly required (by most states) completed forms that must be processed detailing key questions.
However, the DOL rule applies only if the advisor, or firm is a fiduciary to the plan in question, or a "fiduciary" with respect to the plan participant. Reg BI, on the other hand, applies anytime that a rollover recommendation is made to a retail investor, regardless of fiduciary status and regardless of whether the plan in question is an ERISA-covered plan.
Further, if the rollover recommendation could trigger a conflict of interest, Reg BI requires that the advisor deliver Form CRS to the customer. Form CRS is a short—no more than four-page—summary detailing the relationship between the advisor and client, the applicable standard of conduct under Reg BI and the fees and compensation structure generally associated with the relationship. CRS is not a Senior Suitability form. Form CRS must also contain a section detailing the firm’s disciplinary history and direct the client where to look for additional relevant information. (I have not seen one of these yet)
Under the DOL standard, conflicts of interest are generally not permitted at all—regardless of disclosure—unless a specific exemption applies (remembering that the best interest contract exemption was vacated along with the rest of the most recent DOL fiduciary rule). If no exemption applies, the receipt of additional compensation because of the fiduciary recommendation could cause the advisor to commit a prohibited transaction." (Source Think Advisor September 2019, "Reconciling Rollover Advice With Reg BI and DOL Fiduciary Standard.")
See: Fiduciary, Senior Suitability.
This is not legal advice. Pay a lawyer to get that advice.
https://www.federalregister.gov/documents/2017/01/19/2017-01316/proposed-best-interest-contract-exemption-for-insurance-intermediaries Biosimilars An ambiguous section of ACA law creating a kind of regulatory path for "copies" of expensive, already FDA-approved biologic drugs to reach the market. Biologic drugs are among the most expensive medications and treat life-threatening ailments such as cancer. See: Orphaned Drugs
https://khn.org/news/healthbent-what-would-happen-if-the-aca-went-away/ Book Rate See Manual Rate Book to Manual (BTW)Jargon typically used by underwriters to express the percentage discounted from the manual rating filed with the state. Broker Brokers are licensed agents who represent multiple carriers, and who are legally obligated to serve their client’s best interest. Brokerage General Agencies (BGO)See: FMO, IMO, MGA, MGU, Master Producer, NMO, GA, etc
Builders Risk Insurance (Course of Construction Insurance)(Zurich's definition: September 2019)
"Its coverage protects a person’s or organization’s insurable interest in materials, fixtures and/or equipment to be installed during the construction or
renovation of a building or structure should those items sustain physical loss or damage from a covered cause."
Policy coverages and limits apply.
See: Course of Construction endorsement Bundled Payments or Care Payments (BBCP)A single medical reimbursement amount defined however a medical provider wants to offer there services, or a payer (CMS, commercial insurers, etc) want to contract its providers. (i.e. OB deliveries, dialysis, factor therapy, transplants, or accepted reimbursement amount with and without bonus incentives, etc.) Services are typically stated in terms of a fixed reimbursement amount by specific diagnosis, or episode (period of time) of care. Some refer to them as "full value-based reimbursement". Implied goals of the "value-based" amounts are tied to EBM directing healthier outcomes of care at lowest cost. The Trump Administration has unilaterally decided by CMS regulatory rule to bundle payments for ALL Medicare beneficiaries for 32 types or “episodes” of care. These include hip and knee replacement operations, heart bypass surgery and procedures to open clogged coronary arteries, as well as treatments for heart attacks, stroke, pneumonia and chronic obstructive pulmonary disease. See MACRA, MIPS, PQRS, etc. Note a recent decision agreed with a lower appellate court finding that CMS cannot unilaterally change its billing methodology without 60 day mandated public comment period. The saga continues. See: Federal (ACA) reinsurance liability estimated at $12 BILLION.
For qualifying Medicare beneficiaries participating or being treated under qualifying NGACO or Bundled Payments for Care Payments by CMS, the 3 day inpatient care requirement for SNF care is waived.
See: Bundled Payments for Care Improvement (BPCI)
https://innovation.cms.gov/initiatives/bpci-advanced Business Interuption (BI)In General Liability policies, its Business Interruption, sometimes called Business Income. In context to financial markets, its Best Interest related to broker representing the clients best interests, or BIC. Business Owners Policy (BOP)Slang term for commercial General Liability policy inclusive of "packaged" coverages that can include sundry and ancillary requested coverages. Most standard BOP policies include $1M/$2M minimum coverage requests.
C Cadallic Tax Jargon used to describe a 40% ACA tax on far richer benefit plans offered to senior executives. (i.e. overfunded life insurance policies, expensive disability insurance the regular employees are not offered, etc.)
See: Golden Handcuffs. Cafeteria Plan (125 plans)See Section 125 plans Calorie Counts ACA registered and required values printed on menus as mandated by ACA law. Capital Aggregate Program An aggregate reinsurance program offering two major features:
The product offers very competitive alternative to venture capital that typically requires equity assignment, 15%-20%+ return, repayment in less than three years, and 10% interest. Capital Reserves The amount of Assets less Liabilities. (ie.Net worth) Capital Surplus See: Capital Reserves.
The statutorily defined funding minium mandated for eligible and authorized carrier solvency. It is also a term frequently used in "off-shore" risk bearing entities (i.e. Captives?), whose meaning may be defined very differently than "on-shore" eligible and authorized carriers working in compliance with state insurance solvency laws and regulations. Pay special attention to how assets may be accounted as liabilities, and how surplus reserves may not be liquid, or anything close to on shore regulated risk assumption. Be conservative. Capitation A Capitation is a fixed dollar amount per member per month (PMPM) paid to providers regardless of medical utilization. This contract shifts the catastrophic financial risk from the insurance company to the physician and/or hospital. Provider Excess Loss is purchased to pay potential catastrophic claims and prevent insolvency.
See: Medicare Advantage Capitation Payment.
SEE: Direct Contracting, TCC, PCC. DCE receives monthly amount representing the estimated total cost of care less a withhold. CDE's receive 7% of the benchmark, divided between the Base primary Care Capitation and the Enhanced Primary Care Capitation, which enables DCEs to invest in expanding their primary care capabilities.
See: Risk Corridors (Stop loss Global or Professional options offered under Direct Contracting) Captive A risk bearing entity regulated "eligible" (not typically "authorized") by each state, whose organization is located in a sponsoring state (DE, SC, VT, etc), and/or an offshore island (Caymans, Bermuda, Isle of Mann, etc). Captives typically use surplus lines paper, and require annual management fees in additional to capital, capital surplus, and reinsurance. See Fronted and reinsured assignments that may offer better solution for risk transfer than traditional admitted paper.
Captives and Captive-cell "rental or leasing" may offer beneficial solution.
Captives may offer favorable accounting of taxable asset, liability, and income calculation. We recommend licensed CPA and legal advice before acting.
Legal "assessable liability" is a key consideration. We recommend getting licensed legal and/or advice on this in writing. Same goes for Accrued Liabilities, Capital Surplus, and Surplus reserves accounting for purposes of applicable income tax calculation, and asset reserving. If you are not sure, ask questions until your legal and/or licensed accounting advisor responds to your satisfaction. Care Management Organizations (CMO's)An aligned primary care physician network that actively engages specialist physicians in targeted chronic (and expensive) patient care treatment plans. See: Disease management Career Limiting Move (CLM)A Career Limiting Move is defined as bankruptcy or insolvency. Stop Loss and reinsurance policy holders have an obligation to understand the coverages they buy, and to adequately fund any self insured retention. Carrier (Insurance Company)In context to a competently run company: A risk seeker, not taker. Carry Forward A Carry Forward is a negotiated endorsement to a policy allowing a member's medical charges incurred in the last 31 days of the expiring policy year to accrue toward the new policy year deductible. Carve Out In the context of medical second dollar risk contracts, it refers to deleted risk exposures like Transplant, Neonatal, Cancer, ESRD, out-of-network risk, pharmacy, or any medical benefit exclusion within a managed care agreement.
In context of SPD's, it typically refers to things like surrogate pregnancy benefits, fertility treatments, dependent children paternity, etc., and now with ACA final rules out circumventing (or giving green lights to states to allow plans that do not insure) ACA EHB QHP expensive care. Many laws interact with this area (ADA, ACA, EEOC perhaps workers compensation, etc. Case Management A process directed by a licensed nurse or physician, or an unlicensed administrative specialist trained to manage, coordinate, and/or influence efficacious and efficient care in conjunction with an insured member’s physician. Goal is to increase patient well being, improve medical outcomes and reduce cost.
Conflicting contractual prohibitions/interventions questioning medical necessity, and billing pose extreme challenge, liability and dilemma. Out-of-Network care/billing is forefront, and contentious. Case Manager A qualified nurse, physician, or trained professional overseeing medically care as defined by the plan document, administrative services agreement, subject to additional managed care provider contracts delineating specific disease state management to contracted payment terms. Case Rates A fixed hospital reimbursement by episode or diagnosis, and inclusive of all care. Outlier codes for extra complicated cases can and do increase payments for recognized comorbidity issues and challenges. Typical case rates are promulgated by HHS on Medicare patients as defined Diagnostic Related Group (DRG codes). See: bundled payments
One standard does not exist, and multiple entities continue refining contracted reimbursements with EBM. Caveat Emptor Greek for, "Let the buyer beware". Do the work. CBT Information and instructions for the Medicare Secondary Payer (MSP) Group Health Plan (GHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 MSP Mandatory Reporting GHP User Guide (GHP User Guide). See: GHP, MSP
- Aggregate reinsurance attaching at 100% (not 125%, as is typical).
- Capital placed on the client's Balance Sheet of $1-$2 million. Capital is typically priced 5% of placement.
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/GHP-User-Guide/GHP-User-Guide Center for Clinical Standards and Quality A CMS section assigned as a kind of umpire to establish, estimate, report and publically publish EBM "outcomes" measurements. See QPP Center for Consumer Information and Insurance Oversight (CCIIO)See: CFR 155.20 Center for Medicare and Medicaid Services (CMS) Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH)CMS office concerned with negative disparities by race. Centers for Medicare and Medicaid Innovation (CMMI)"Under the authority of the Affordable Care Act, CMS established CMMI to design, implement, and test alternative payment and care delivery models that aim to reduce costs, improve quality, and support patient-centered care.
Since its inception, the Innovation Center has implemented 37 models, including the Medicare Shared Savings Program (MSSP), Bundled Payments for Care Improvement (BPCI), and the Comprehensive Primary Care (CPC) Initiative. The models have involved approximately 18 million CMS beneficiaries and individuals with private insurance as well as over 200,000 providers.
A 2018 Government Accountability Office (GAO) report showed that only four of the alternative payment models run by the Innovation Center had reduced costs while maintaining or enhancing care quality, or improved care quality while maintaining or decreasing costs." Source Revcycle Intellegence. Jaquline LaPointe.
See: Link of 90 payment models from CMMI
https://innovation.cms.gov/initiatives/#views=models Centers of Excellence (COE)Medical centers offering disease or procedure specific care that are known for favorable medical outcomes and or pricing. i.e. Transplants, Cardiac, Cancer, ESRD, Neonatal. These centers are typically defined by "condition specific nurse case management teams' that can also include hands on reinsurer personal "support" and steerage. Certificates of Public Advantage (COPA)See Thirteen states have laws allowing cooperative agreement that create conditions that merged entities must abide by post merger, including limits on rate increases and investments in the community. See TN, VA, and W VA actively use COPA's. Source: The Source: State Policies on Provider Market Power Feb 2020 report Certification Typically means carrier acceptance of liability in context to a received claim. Certification of a claim is not verification of a claim. Certification and Survey Provider Enhanced Reporting application. (CASPER)See IRF and QRP:
Providers can access these reports by selecting CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage. NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.
• Contain quality measure information at the facility level
• Allow providers to obtain aggregate performance for the past four full quarters (when data is available)
• Include data submitted prior to the applicable quarterly data submission deadlines
• Display whether the data correction period for a given CY quarter is “open” or “closed”
Source: CMS Certified (CEHRT)See: HITECH
Certified Application Counselors (COC's)A HHS/Marketplace defined terms referencing an individual who may or may not be licensed by any state to process insurance, and that get some type of certification Marketplace calls ample to assist people trying to understand and enroll in complex Marketplace medical insurance. Certified Associate Healthcare Information & Management (CAHIMS)Certified Associate Healthcare Information & Management. Its one of many certifications available to people forecasting medical care claims costs. See: FLMI, CPU, CPCU, ARe, FSA, ASA, etc Certified EHR technology (CEHRT)See: interoperability Charge Master (Super Bill)Relative to hospital billing, it is an arbitrary schedule of maximum charges billed to a customer. Charge Master amounts are limited to contractual limits agreed to by hospitals. Customers without insurance (PPO contracted providers) get hit with the maximum amount which can exceed 300% - 1000%+ more than a typical contracted rate charge. Hospitals routinely "account" inflated superbill charges for indigent care. A charge master can also refer to the schedule a provider is obligated to accept as full payment aka the "contracted rate". See UCR, R&C or referenced based pricing. Charlson Comorbidity Index (CCI)a scoring method of 1-20 detailing presence or absence of 17 diagnosis related medical conditions designed to predict one-year mortality rates. Chief Medical Officer (CMO) Child Health Insurance Program (CHIP)Medicaid insurance managed under HHS for minors of parents who typically earn below 100% of FPL. Premium costs charged to parents are subsidized according to income. Child Rider (CIR)Child Insurance rider is a life insurance endorsement typically insuring a dependent child. Chronic Care Management A program of medical care usually directed at members with: asthma, diabetes, high blood pressure, ESRD, back pain, and/or high cost or chronic disease conditions. The goal of these programs is for early intervention and management to improve medical outcomes as lower costs. ================== Term used by CMS to accurately code for a reimbursement. See CAC Chronic Comorbidity Count (CCC) The sum of "selected" medical conditions (diagnosis) grouped into six categories. Chronic Condition Data Warehouse (CCDW) Chronic Illness Conversion Agreement (CICA)An optional TERM life insurance policy feature that acts almost identically to a Long Term Care benefit allowing 2% - 4%/yr of death benefit payout in the event of satisfying pay out trigger. The insured qualifies when 2 out of 6 ADL's produce "significant cognitive impairment" thereby allowing BOTH coverage for unexpected death, AND a long-term-care-like benefit within the same policy. Citizens Insurance A Florida association that is technically a Joint Underwriting Association (JUA), not a rated carrier, or an "admitted" carrier insured by the Florida Insurance Guarantee Association. THE JUA is assessable for underfunded (premiums to losses) losses against its members - unlike authorized insurance companies. JUA does not enjoy Florida Insurance Guarantee Association fund protection. The JUA cannot be sued (by it's own association member) for bad faith, so limited legal recourse is available to it's insureds in claims disputes. Current rules (Jan 2019) mandate Citizens is not required to offer coverage where comparable coverage is available under 115% of Citizens pricing. "Citizens Property Insurance Corporation
Citizens’ Assessments Citizens Property Insurance Corporation (Citizens) provides property insurance for individuals and businesses unable to obtain such insurance in the private market (Florida Rules Chapter 2012-80). Citizens has three discrete funds providing coverage for personal lines, and coastal accounts. A new law (HB 1127) has altered Citizens’ ability to raise money by adjusting:
· the conditions under which assessments can be levied
· the type and amount of assessments
· the mechanics of the payment process
· the ability to raise money by issuing bonds
While Citizens may raise money through premiums, investments, and issuing bonds, it may still experience deficits because its mission is to cover high-risk properties at a manageable, predictable cost. Prior to the passage of the new law, Citizens used three assessment methods for raising funds needed to cover deficits in each of its three funds:
Policyholder assessments of up to 15 percent of current premiums on Citizens policyholders, paid in the current year as policies renewed and new policies were issued. Assessments apply independently to each of the three funds.
Regular assessments of up to 6 percent of current premiums on all insurance policies issued by private insurers (other than Citizens), which are of the same coverage type written by the relevant Citizens fund (personal, commercial, or coastal). Assessments apply independently to each of the three funds.
Emergency assessments of up to 10 percent for each of the three funds may be applied to all policyholders throughout the state (Citizens and non-Citizens) owning the applicable class of policy. Unlike regular assessments, these assessments may be spread out over multiple years. Citizens collects funds as policies renew and new policies are issued. Like the other assessments, these apply independently to each of the three funds.
The Florida legislature was concerned about the impact regular assessments would have on the solvency of insurers in what had become a less than robust property insurance market. Regular assessments depleted insurer reserves because they were paid in advance. Private insurers then had to recoup assessments over time from policyholders in a single year, which negatively impacted policyholders.
The new law changed the assessment process as follows:
· It eliminated regular assessments for the personal lines account and the commercial lines account.
· It reduced the maximum 6 percent regular assessment on the coastal account to 2 percent (HB 1127, Florida Statute 627.351).
Overall, the new law significantly reduced the amount of prepayments and spread the impact of severe losses over time. In addition, the law allows Citizens to make assessments based on projections instead of actual deficits, with the idea of improving funding in emergencies by being proactive (HB 1127, Florida Statute 627.351). By obtaining funding in advance of projected deficits, Citizens will be better able to leverage those funds by using them as a basis for issuing bonds for funds to cover the immediate or upcoming needs that precipitated the assessment in the first place.
Citizens’ Property Insurance Reform – SB 1770
After addressing issues arising from assessments, the Florida legislature took action to reduce the size of taxpayer risk exposure to property losses from hurricanes and other perils that would be covered by Citizens. This law reduces the amount and scope of coverage Citizens may offer (Florida Statute 627.351, Rules 2013-60, page 16 & 23).
Coverage limits – The maximum policy limit for personal residences has been reduced to $1 million from $2 million. This amount decreases further over a three-year period to $700,000. Citizens is also prevented from insuring new condo association construction projects in Coastal Control zones (Florida Statute 627.351, Rules 2013-60, page 16 & 23).
Transition to private insurance –The law requires consumers who are offered private insurance rates within 15 percent of Citizen’s rate for a new policy to accept private insurance (Florida Statute 627.351, Rules 2013-60, page 16 & 23).
Creation of an exchange – The law requires that an exchange (also known as a clearinghouse) be established through which all new policies and renewals will be evaluated for coverage by Citizens, and, if possible, diverted to the private market. Agents placing policies through the exchange do not need to be appointed by each insurer with whom a policy is placed. (Florida Statute 626.3518 and Rules Chapter 2013-60, Section 10, pages 36-40).
Other provisions -
Citizens will now offer an HO-8 policy (Florida Statute 627.351).
Agents must obtain an “Acknowledgement of Potential Surcharge and Assessment Liability” from applicants. The acknowledgement states that policyholders understand they may be subject to a surcharge if Citizens sustains a deficit as a result of hurricane losses or other reasons, and that policyholders can avoid the surcharge by obtaining coverage from a private insurer.
Agents must maintain ownership of records, including policies placed with Citizens (Florida Statute 626.3518).
Citizens’ Coverage of Mobile Homes – HB 573 (Florida Statute 626.351).
Florida also made changes to the coverage Citizens provides for mobile homes. The minimum insured value is reduced to $3,000, and policies must cover attached structures that are not substantially the same material, including
· screened enclosures that are aluminum framed or other materials
· car ports that are aluminum or carports
· patios that have a roof covering constructed of other materials
Changes to License Application and Renewal Procedures
Pursuant to Florida Statute 626.171, the state of Florida has made several important changes to the insurance laws and rules, discussed next, which affect agents’ licensing and renewal requirements.
Changes to Application and Renewal Procedures
Pursuant to Florida Statute 626.171, a person who is applying for a license as an agent or adjuster can now have a third party complete, submit, and sign the application, as long as the applicant agrees. However, the applicant remains responsible for any misstatements or misrepresentations in the application. Previously, third parties did not have authority to complete a license application on behalf of an applicant." CETrack Licensing (CE) Exam material Jan 2019
Claw Back A contractual provision used in many kinds of contracts. In context to medical reimbursement agreements, is a term typically used to describe funds reduced from future-payable claims to the same provider, as a result of a claim filing overpayment, or inappropriate payment process.
Some examples are:1. Upcoding, the practice of consistently coding
services at a too-high level
2. Technical denials, wherein a payer,
sometimes automatically, rejects a claim out
of hand for an administrative reason
3. Overpayment clawbacks as an expected
budget line item on the part of payers
4. Stacking post-payment audits, wherein
multiple programs audit the same claim or set
of claims, duplicating requests for the same
backup material (often using multiple outside
vendors or contractors) Source: Change Healthcare, payment Accuracy and the American Healthcare System Clinical Document Improvement (CDI)Term used by "physician advisors" who work with physicians in recommending better care for better EMB outcomes and reimbursement. Clinical Integrated Netoworks (CIN)See: IDS, CMO, Episode Based Care (EBC), DM. Clinical Practice Improvement Activities (CPIA)See MACRA and MIPS Clinical Quality Language (CQL)
CMS Alliance to Modernize Healthcare FFRDC (CAMH)Achieving large-scale connected integration—of transforming the health sector into a health system—is a systems engineering challenge of enormous scale. Sponsors and clients engaged in health functions within the federal government have an unprecedented need for the kinds of systems engineering and integration expertise, organizational and cross-boundary change management, and objective, trustworthy advice provided by (Federally Funded Research and Development Centers) FFRDCs.
CAMH objectively analyzes long-term health system problems, addresses complex technical questions, and generates creative and cost-effective solutions in strategic areas such as quality of care, new payment models, and business transformation. Source : MITRE
https://www.mitre.org/centers/cms-alliances-to-modernize-healthcare/who-we-are CMS Date Services Hub (CMS Hub)CMS managed system "service" designed to share and verify PII among multiple federal agencies (HHS, IRS, Medicaid (and who knows who?) for primary purposes of confirming: income, APTC, CSR, Medicaid eligibility, Marketplace insurance eligibility, etc.
See: PII, and Authorized Representative in context to 45 CFR 155.27 CMS Final Rules 2020 Benefit Payments (For federal Marketplace Individual and SHOP plans)
"Rule lowers user fees for first time, encourages use of lower cost generic drugs, promotes market stability and consumer choice
The Centers for Medicare & Medicaid Services (CMS) today released the final annual Notice of Benefit and Payment Parameters for the 2020 benefit year, also known as the 2020 Payment Notice. The rule reduces user fees for plans offered on HealthCare.gov, and encourages the use of lower-cost generic drugs, while improving market stability and consumer choice.
“The rule issued today will give consumers immediate premium relief by reducing the Exchange user fees in the Federally-facilitated Exchanges (FFEs) and State-based Exchanges (SBEs) using the federal platform for 2020 thanks to successful efforts to improve the efficiency of the Exchange,” said CMS Administrator Seema Verma. “At CMS we have improved the operations of the Exchange to deliver a better consumer experience at a lower cost.”
Generally, Exchange user fees are passed directly on to the consumer in the form of higher premiums, and this reduction in the user fee allows issuers to pass along savings to consumers in 2020. The 0.5 percent reduction in the user fee rate comes as a result of CMS’ focus on reducing costs through increased operational efficiency, including successful efforts to upgrade IT functionality, a more efficient approach to outreach, and investments focused on proven methods to achieve a seamless enrollment experience and high consumer satisfaction.
This follows the first ever 1.5 percent drop in average premiums for plans selected through HealthCare.gov for the 2019 coverage year. With consumers facing rising premiums and limited choice in their health coverage leading up to 2017, the Trump Administration introduced a series of actions to encourage competition and bring down the price of healthcare for people in the individual market. The final 2020 Payment Notice builds on these prior actions to further strengthen America’s health insurance markets.
Building on the President’s American Patients First blueprint, the final rule also supports lower premiums by promoting the use of lower-cost generic drugs. Drug companies can offer consumers coupons to incentivize them to purchase the company’s brand name drugs even when an appropriate, less-expensive generic medication is available. This rule allows issuers to stop applying the value of these coupons towards an enrollee’s maximum-out-of-pocket costs in situations where a generic medication is available and medically appropriate, in order to encourage generic use and result in lower drug spending.
To improve market stability, a key element of this final rule refines the risk adjustment program to improve the accuracy of the data used to calculate the program’s charges and payments to issuers. This program is designed to reduce incentives for insurers to avoid enrolling people with expensive health conditions. The rule finalizes several proposals regarding the validation of the accuracy of the diagnosis codes, prescription drug data and codifies a number of exemptions to lessen burden on small issuers.
This rule also aims to increase the choices available to consumers for trusted enrollment pathways. Last fall CMS successfully launched Enhanced Direct Enrollment (EDE), which allows consumers to shop for and enroll in the Exchange plan of their choice through an approved partner website. In regards to enrollment, the final rule streamlines and updates regulations to accommodate future innovation and improve the consumer experience.
The EDE pathway allows CMS to partner with the private sector to provide a more user-friendly and seamless enrollment experience for consumers by allowing them to apply for, and enroll in, an Exchange plan directly through an approved issuer or web-broker without the need to be redirected to HealthCare.gov. In recognition of the new pathway, the final rule increases transparency as well as the privacy and security of consumer data by allowing CMS to require web-brokers to provide lists of the agents and brokers who use their websites.
The rule also enhances consumer protections and improves program integrity by allowing CMS to more easily suspend or terminate agents, brokers and web-brokers that violate applicable Marketplace requirements. As EDE continues to expand, to guarantee consumers continue to receive a high level of service, being able to more easily suspend or terminate agents, brokers and web-brokers that violate rules will better enable CMS to ensure agent/broker and web-broker compliance, respond to cases of noncompliance, and to protect sensitive Exchange data and systems.
Further, the rule finalizes a technical change to the premium index for the 2020 benefit year in order to better align our premium adjustment percentage methodology with the experience of the individual markets and premiums overall. Under the new methodology, CMS would use the CMS Office of the Actuary (OACT) estimates of projected health insurance premiums for both the private individual and group market (excluding expenditures for Medigap and property and casualty insurance). This change would replace the current methodology which utilizes only employer-sponsored group market insurance (ESI) premiums, which do not reflect the situation of the individual market premiums. This technical change in the premium adjustment percentage methodology will provide a more comprehensive and accurate measure of private market premiums. This change will have little impact on gross individual market premiums, but it will provide savings for taxpayers.
Today, CMS also issued the Final 2020 Letter to Issuers in the FFE which provides guidance to issuers that want to offer Qualified Health Plans (QHPs) on the FFE, as well as the Key Dates Charts for the 2019 Calendar Year."
https://www.cms.gov/newsroom/press-releases/cms-issues-final-rule-2020-annual-notice-benefit-and-payment-parameters Co Insurance In Stop Loss, Co Insurance is the percentage of eligible charges reimbursed to the stop loss policyholder after the deductible has been satisfied. In major medical insurance, Co Insurance is percentage of eligible charges the individual policy holder is required to pay the medical provider for services rendered after the deductible has been satisfied. In primary medical insurance, co insurance can be the percentage of medical claims paid by the insured up to the maximum allowed by ACA Co Payment Co-payment is a fixed (flat) dollar fee an individual insured pays each time he accesses care from physicians, hospitals and medical services providers. CO-OP The Affordable Care Act established the Consumer Operated and Oriented Plan (CO-OP) program, which created a new type of private nonprofit, member-run health insurer. CO-OP health plans are governed by their members, must operate with a strong consumer focus, and reinvest any profits into lowering premiums, improving benefits, or otherwise improving the quality of health care delivered to their members. CO-OPs offer health plans through the Individual Marketplace and SHOP, but may also offer health plans outside of the Marketplace. COBRA COBRA requires continuation coverage to be offered to covered employees, their spouses, their former spouses, and the dependent children when group health coverage would otherwise have been lost due to specific events. Those events include the death of a covered employee, termination or reduction in the hours of a covered employee’s employment for reasons other than gross misconduct, divorce or legal separation from a covered employee, a covered employee’s becoming entitled to Medicare benefits, and a child’s loss of dependent status under the plan. Those who are eligible may be required to pay for COBRA continuation coverage and are generally entitled to coverage for a limited period of time (from 18 months to 36 months), depending on certain circumstances. COBRA does not apply to employers with fewer than 20 employees. The Department anticipates future guidance on the application of COBRA to AHPs that provide coverage to member employers with fewer than 20 employees. (See: Mini COBRA) Source: DOL
http://dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/publications/an-employers-guide-to-group-health-continuation-coverage-under-cobra.pdf. Collateralized Loan Obligation (CLO)A term used by various entities to describe loans from life insurance policies. A recent article represented that life CLO's represent about 15% of US CLO assets. (typically) "retirement spent loans (to oneself) are not taxed as income because they meet IRS guidelines. Businesses, may also use CLO's outside of life insurance policies to fund various kinds of loans. Commercial Package Policy (CPP)Term typically used for GL policies including additional coverages such as commercial auto, Property, wind, etc Commercial Repayment Center (CRC)See: CMS - New documents titled Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Recovery Town Hall Questions and Answers and Commercial Repayment Center (CRC) Group Health Plan (GHP) Recovery Town Hall Questions and Answers Overview
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Whats-New/Whats-New Commission Ordinary Tables (CSO)A new concept for compensation disclosure in Life insurance policy agent compensation. See: BIC, and try to keep up with what DOL is suggesting, mandating, or requiring in context to potential fiduciary standard(s).
The trend is generally to sometimes require gents, or advisors declare their compensation - especially when dealing with retirement account sources of funds. See overrides, contingency fees, profit commissions, profit share, etc.
https://www.soa.org/resources/experience-studies/2015/2017-cso-tables/ Commission Standard Ordinary (SCO/PBR)• The 2017 Commissioners Standard Ordinary (CSO) Table — a new mortality table used in Life insurance) product pricing.
• Principle-Based Reserving (PBR) — a new or different way of calculating reserves to pay future claims specific to each carrier. See: Underwriting.
Commissioners Standard Ordinary Table (CSO)One mortality table used by some underwriters started about 2017. Community Living Assistance Services and Supports (CLASS)Affordable Care Act (ACA) included an optional program called Community Living Assistance Services and Supports, or CLASS, that would have paid caregivers, including family members with no professional training in caregiving, to help older Americans stay in their own home and not access long-term care in institutional settings.
The CLASS program was fashioned, however, as a voluntary endeavor with enrollees choosing whether or not to enroll, unlike traditional social insurance programs such as Medicare that mandate enrollment. But this voluntary enrollment feature, when combined with the ACA’s explicit mandate that the CLASS program be self-financing, made that program unsustainable and it was repealed in early 2013. Nevertheless, a publicly administered and funded social insurance program that would pay family caregivers remains an option beyond its present Medicaid context.
Community Rating An employer premium rating method based on claims history by region (zip code). ACA promulgates rules employers (over 50 FTE) MUST apply (higher priced) community rating, thereby eliminating potential premium discounts associated with favorable claims experience.
Comparison Group (CG)See: Covid Orders Complex and Chronic Care Improvement Program (CCCIP) Compliance A general term used to loosely or accurately convey meeting or addressing regulatory standards/reporting. Composit Performance Score (CPS)See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Compound Annual Growth Rate (CAGR)In contexed to ESL and Group medical plans: The percentage increase in "large" group medical premiums. "...ESL market has accelerated from a compound annual growth rate of 7 percent from 2006 - 2011 to a 12 percent CAGR from 2011 - 2015, with annual ESL premiums now totaling $17 billion." Source: BenefitsPRO Magazine March 2020
As a rule that sometimes gets followed but that most ESL underwriters hang their hat - comparing "1st dollar" medical cost inflation to "2nd dollar" stop loss trend (inflation factors) is roughly double. i.e. If someone quotes a 4% medical cost inflation for fully-insured large group (5,000 lives or more), then the stop loss premium increases is supposed to price at about 8%. Competition in the markets drastically changes what actually gets accepted in the end. Enter brokers who add real value. This is not simple and straight forward - coverage and price are proportional, and involve more than front end data. Comprehensive End-Stage Renal Disease Care Model (CEC)A CMMI payment/care initiative for Medicare members. Comprehensive Joint Replacement (CJR)Term used by Medicare to study and produce EBM at best medical outcome and lowest cost. Joint replacements costs the Medicare fund hundreds of millions each year, and can be expected to increase going forward.
"The CJR model continues to demonstrate promising reductions in Medicare payments, while maintaining quality of care. After two performance years, average episode payments decreased by 3.7 percent or $146 million, predominantly by changing post acute care use. After accounting for reconciliation payments earned by participants, the CJR model likely resulted in net savings to the Medicare program of $17.4 million, although we cannot conclude this with statistical certainty. A range of hospitals, with a range of resources and circumstances, can and do respond to the incentives under a mandatory episode - based payment approach. In future reports, we will expand our understanding of how the changes to the model impacted payment, utilization and quality outcomes." Source: CMS
https://innovation.cms.gov/Files/reports/cjr-fg-secondannrpt.pdf Comprehensive Primary Care Plus (CPC+)CPC+ is a five-year model that will begin in January 2017. CMS has provisionally selected 57 payer partners, including commercial insurers, state Medicaid agencies, Medicaid managed care organizations, and Medicare Advantage plans in 14 regions across the nation. Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that aims to strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation. CPC+ will include two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States (U.S.). The care delivery redesign ensures practices in each track have the infrastructure to deliver better care to result in a healthier patient population. The multi-payer payment redesign will give practices greater financial resources and flexibility to make appropriate investments to improve the quality and efficiency of care, and reduce unnecessary health care utilization. CPC+ will provide practices with a robust learning system, as well as actionable patient-level cost and utilization data feedback, to guide their decision making. http://www.medscape.com/viewarticle/867084?Comprehensive Primary Care Plus (CPC+), the Medicare Shared Savings Program, and the NextGen Accountable Care Organization (ACO) program. - See MACRA
https://www.cms.gov/newsroom/press-releases/hhs-news-hhs-deliver-value-based-transformation-primary-care Comprehensve Joint Replacement (CJR)a Value based or bundled payment initiative by CMS.
A mandatory risk based provider reimbursement model inclusive of complete treatment with outcome reporting. Computer Assited Coding (CAC)Term used by CMS related to coding care for MA patient reimbursements. Concurrent Causation Doctrine (CCD)A rule and / or policy provision applying insurance to a loss when both insured and Excluded peril(s) (concurrently) cause the loss. Means, if cause of loss is insured, then sequence of the cause of loss does not matter, and the loss is insured.
See: Anti-Concurrent-Causation, Efficient Proximate Cause Condition of Participation (CoP)Medicare condition of participation (CoP). See: MACRA, QPP Congenital Heart Disease (CHD) Conscience Rule Jargon termed to describe medical a provider's "right" to choose not to provide medical services (like abortion) they find ethically abhorrent. The practical issue is when care is denied by federally or state supported facilities obligated to follow our constitution and actual law, one person's rule that is not a law (vetted through the separation of powers). A federal judge invalidated a Trump administration rule declaring it was OK to deny services. Consent to Rate A strange term sometimes used to convey underwriting of non-ACA compliant (ERISA) plan offerings. The underlying purpose is to get a premium that is about 40% less than ACA QHP rated plans. See: STM Consequential Damages A legal theory used to sue for damages caused secondarily to a valid primary contract breach. Consumer Assessment of Healthcare Providers & Systems (CAHPS)• Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS Survey – Sample PDF: The CAHPS for MIPS Survey measures patient experience and care within a group. The data collected on these surveys will be submitted on behalf of the group by the CMS-approved survey vendor. (The CAHPS for MIPS Survey is optional for groups with two or more MIPS clinicians and is not provided as an option for individual clinicians.) See QPP
http://links.govdelivery.com/track?type=click&enid=ZWFzPTEmbXNpZD0mYXVpZD0mbWFpbGluZ2lkPTIwMTcwNTMxLjc0MDA0NTQxJm1lc3NhZ2VpZD1NREItUFJELUJVTC0yMDE3MDUzMS43NDAwNDU0MSZkYXRhYmFzZWlkPTEwMDEmc2VyaWFsPTE3OTgxNjA4JmVtYWlsaWQ9c3RlcGhlbmNnZW9yZ2VAYmVsbHNvdXRoLm5l Consumer Operated and Oriented Plan (CO-OP)An ACA designated health plan authorized to sell insurance, and predicated on a community of care givers designed to lower cost and improve evidence based medical outcomes or quality. Many CO-OP's have failed leaving their insureds scrambling for coverage mid year, and leaving area medical providers with large unpaid bills.
http://www.gao.gov/products/GAO-16-326 Contingency Fees A Contingency Fee is compensation to the agent above the commission. This fee is not usually discussed with the client. It can be similar or identical to an underwriting profit or override on profitable business sales. In larger brokerages, these "fees" are usually negotiated by senior management, where the local agent is unaware the fees exist. RIMS recently mandated a policy statement that these fees be clearly divulged by all agents to avoid the appearance of impropriety. Continuety of Care Application An application filed with the insurer to allow continued medical treatment for patients receiving advanced care/therapy at a facility that becomes an out of network (OON) provider DURING treatment. Certain patient protections may apply that require carriers to pay for ongoing episode(s) of care, at the higher rates This is a grey area of ACA mandates, and practice standards. Continuing Education Unit (CEU) Contribution Requirements The minimum percentage of employer paid premium for (QHP) group major medical benefits, typically set at 50%. Controlled Master Program (CMP)See Global Master Policy. CMP primarily allows for the placement of locally-issued admitted policies along with a U.S. master policy, while keeping the administration, claims and risk management functions with one single carrier. These are large complex- package coverages. Controlling Health Plan See: 45 CFR 162.103 Coordination of Benefits (COB, COB&R)See: Subrogation
https://www.cob.cms.hhs.gov/Section111/LoginWarning.action Copay Assistance (Patient Assistance)A $0 Copay card from the manufacturer (pharmacy) that may conflict with MOOP attribution in ERISA plans, and rules governing claims processing. Some view it as a PR program to get patient to choose Brand name over Generic, and effectively causing prices to increase for the plan, but not necessarily for the individual member. This gets complicated as the SPD groups drugs by wellness, illness, etc. Cost of ACA to Taxpayers According to the Congressional Budget OFfice
https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385-HealthInsuranceBaseline_OneCol.pdf#page=31 Cost of Living (COLA)The inflation percentage number Social Security uses to increase payments to beneficiaries. See: CPI Cost Performance Catagory (CPC)See: QPP Cost Share Plan See Ministry Health plans, Healthcare Cost Sharing plan Cost Share Reduction (CSRs or Risk Reduction Payments)In context to the enrolled Marketplace member, it is the reduction of deductible, co-insurance and MOOP a member is eligible as directed by the members income level. Remember, premiums are already reduced by eligible APTC. In context to a carrier, CSR is a Federal reinsurance program participating carriers elect to pay premium into (protecting themselves from adverse selection of guarantee issue policies) to receive reinsurance recoveries for claims between $45,000 and $250,000 (not unlimited like ACA QHP insures). April 2020 The Supreme Court sided with the carriers and against the Trump administration to reimburse carriers an estimated $12 Billion.
October 2017: President Trump issued an Executive Order (EO) removing many ACA requirements, and consumer protections (without passing a law). i.e. Undoing preexisting medical condition exclusion prohibition on plans sold during SEP, Eliminating statutory QHP defined in ACA law. For now, HHS has ended CSR "reimbursements" to carriers thereby destabilizing a precarious INDIVIDUAL market that has already seen: Aetna, United, Humana, Coventry and Cigna abandon both Individual and SHOP offerings.
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Proposed-2019-HHS-Fact-Sheet.pdf?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery Cost Sharing Reduction (CSR)See: 45 CFR 155.20
CSR is federal program that lowers: premiums, deductibles and maximum out of pocket costs an INDIVIDUAL (Marketplace enrolled) member pays for their insured medical care. Members eligible for CSR earn between 100% and 250% of federal poverty level (FPL). CSR is not APTC, or (reinsurance) risk adjustment. See: Risk Adjustment.
CSR costs big dollars to fund. April 2020 the Supreme court sided with the carriers and directed the government to reimburse an estimated $12 BILLION.
http://us.milliman.com/uploadedFiles/insight/2017/2015-commercial-health-insurance.pdf Course of Construction Endorsement (Change Order Endorsement )A Builders Risk policy endorsement (rated at 10%-30% of the total completed project value) that can provide additional limits that may be warranted where "completed change orders'" added value is necessary to insure the project to the policy owner's changing perceived (increasing valuation) needs, and at a cost the insured is willing to pay for the added coverage. (Added completed total value can be a squirrelly estimate.) CPHIMS Certified Professional in Healthcare Information & Management Systems. Its one of many certifications available to people trying to forecast medical care claims costs. See: CAHIMS Credit Life Reinsurance Credit Life Reinsurance is coverage provided to insurance companies writing mortgage payment insurance. It can take the form of Specific, Aggregate, Quota Share and/or Surplus Relief depending on the needs of the insurance company being served. Critical Access Hospitals (CAH)In 2018, the Centers for Medicare & Medicaid Services (CMS) required that all critical access hospitals (CAHs) use either 2014 or 2015 Edition certified electronic health record technology (CEHRT) to meet the reporting requirements of the Medicare Promoting Interoperability Program and successfully demonstrate meaningful use. The law requires that downward payment adjustments be applied to CAHs that are not meaningful users of CEHRT." See Hardship Exception Application. Source: CMS Critical Illness Plans (Cancer, Cardiac, Transplant plans)An insurance triggered by a disease specific diagnosis, and that typically pays out directly to the insured in a fixed lump sum, and in addition to (not subrogated) primary medical coverage. Transplant coverage is typically case rated reimbursement directly to the medical provider. Current Procedure Terminology A 5 digit code for Hospital procedures. See: ICD-10 Custodial Care Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, toileting, check writing, shopping, etc. These are formal triggers in long term care policies, and typically not paid for by Medicare.
See: LTC Cyber Security: Medical: HHS Tast Force Recommendations
D de novo A legal term meaning from the beginning - in context to SPD, and Plan Administrator defference. Deadline Deadlines means different things in different policies (I.e. claims submission, enrollment periods, appeals, waiting periods, elimination periods, etc). In context to ACA OEP/SEP, it means December 15th for enrolling in a plan eligible for an APTC. For a Marketplace offered plan not electing APTC entitlement, the deadline is December 31. Declaration A Declaration is an addendum to all stop loss and reinsurance policies which warrants all members expected to exceed 50% of retention have been reported prior to binding coverage. Dedicated Privacy Official See: Marketplace agent/agency PII protection Deductible Sometimes referred to as Retention, or threshold, a Deductible is the dollar amount exceeded before a policy pays all, or part of an eligible claim. In most Stop Loss and Reinsurance, deductibles accrue independently of any co insurance or copays. In most individual and Group major medical insurance, a deductible includes most Copays and OOP spent on eligible care. Defined Benefit Plans (DBP)See: retirement Plans. Golden Handcuffs, Vesting. Defined Contribution Retirement Plan (401(k) Retirement Plan)A plan funded with pre-tax dollars from employees, and that can be matched by their employer. Remember, when no-tax is paid on these contributions going in (seeds), then INCOME tax is due when withdrawn in retirement (harvest) - and no one knows what Income Tax will be in 10 - 30 years..? Roth IRA contributions are AFTER tax, and are not taxed as INCOME when withdrawn in retirement within IRS compliance. Traditional 401 and IRA contributions are not taxed going in...
See: Retirement Plans (Employer sponsored)
For 2020: (Source Benefits Pro)
Defined contribution plans: The contribution limit on self-directed workplace retirement plans including 401(k)s, 403(b)s, most 457 plans, and the federal government’s Thrift Savings Plan will increase by $500 in 2020, from $19,000 to $19,500, according to the IRS.
The catch-up contribution limit for employees age 50 and over in defined contribution plans will increase from $6,000 to $6,500.
Related: IRS announces 2020 HSA limits
IRA plans: Individual retirement investors will not realize an increase to the savings limit next year; the limit on IRA contributions will remain at $6,000, and the catch up contribution cap will remain at $1,000.
Total DC contributions: The limit on total contributions to a defined contribution plan, including elective employee deferrals, employer matches, and non-elective deferrals, increases $1,000, to $57,000.
Cap on SIMPLE plans: The cost of living adjustment to the cap on SIMPLE workplace plans will also increase, from $13,000 to $13,500.
–For single taxpayers covered by a workplace retirement plan, the phase-out range is $65,000 to $75,000, up from $64,000 to $74,000.
–For married couples filing jointly, where the spouse making the IRA contribution is covered by a workplace retirement plan, the phase-out range is $104,000 to $124,000, up from $103,000 to $123,000.
–For an IRA contributor who is not covered by a workplace retirement plan and is married to someone who is covered, the deduction is phased out if the couple’s income is between $196,000 and $206,000, up from $193,000 and $203,000.
–For a married individual filing a separate return who is covered by a workplace retirement plan, the phase-out range is not subject to an annual cost-of-living adjustment and remains $0 to $10,000.
Individuals and heads of households can contribute to a Roth IRA if their income is below a set threshold. The phase-out range will increase to $124,000 to $139,000, up from $122,000 to $137,000. For married couples filing jointly, the phase out range increases to $196,000 to $206,000, up from $193,000 to $203,000.
Defined benefit plan changes:
Beginning January 1, 2020, the limit on annual benefits from defined benefit plans will increase $5,000, to $230,000.
The annual compensation limit to determine defined benefit payments increases from $280,000 to $285,000.
The “key employee” dollar definition in a top-heavy plan increases from $180,000 to $185,000.
The dollar limit for defining a “highly compensated employee” increases from $125,000 to $130,000.
The level of plan assets that determine whether a collectively bargained multi-employer plan is systemically important increases $38 million, to $1.097 billion. Source: Benefits Pro
Some states are offering 401 plans where employers are not, and to give eligible "employees" opportunity to save for retirement.
https://www.irs.gov/retirement-plans/401k-plans Demographics A term typically referring to age, and gender of a targeted market. See: Market Share. Age Compression Rule. Denial A term used when 100% of the claim is not paid as billed. See SPD, proper definition and description of what is excluded, specifically stated is insured and at what amount are applicable. We recommend speaking with your attorney about federal fiduciary rules. ERISA plans are allowed to use internal Plan Administrator rules and
discretion. Department of Insurance (DOI) State agency or regulatory authority that,
among other things, licenses, oversees, and regulates Issuers, Agents, and Brokers, as
applicable. Dependency and Indemnity Compensation (DIC)A veteran's survivor's pension, aid and attendance long-term care, and burial program.
https://www.va.gov/COMMUNITYCARE/docs/pubfiles/programguides/champva_guide.pdf Designated State Health Programs (DSHP)Federal Medicaid money to states used to fund various healthcare programs for the poor. Trump administration is ending the program currently used by Arizona, California, New York, New Hampshire, Rhode Island and Washington now have waivers that include DSHP funds. Source: Modern Healthcare Diagnostic Related Group (DRG - see Bundled Payment)A Medicare assigned reimbursement by diagnosis code. Many rules apply. Some DRGs allow for "outlier" modifier codes causing certain events to qualify for greatly increased eligible reimbursement to reflect comorbidity events. Diminution A term typically used in auto claims meaning the lost resale value of a car that has been repaired after an accident. Unless statutorily mandated, many carriers ignore indemnifying the insured more than the actual (actual cash value) repair cost. See: Replacement costs, Indemnity Direct Care Organization (DCO)An amorphous terms sometime used to describe coordinated medical care within contracted (HMO/EPO/PPO) networks that improves quality and hopes for lower costs. See: DM See: referenced based pricing, concierge medicine, and medical tourism. Direct Contracting (DCE)A term that can mean many things. In ERISA self-funding it means contracting directly between the employer and various providers for things like advanced primary care, high dollar procedures frequently used, and/or hospital care from facilities not already under PPO-like contract, etc. See: Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey, 2020 Large Employers Health Care Strategy and Plan Design Survey by National Business Group on Health, Kaiser Family Foundation employer Health Benefits Survey, etc. See: Steerage, Ambulatory care on site care/centers.
Medicare: A Medicare contracting term typically describing physician-care under bonus/penalty contract over a defined period of time, and whose goal is to use EBM to improve quality outcomes at lower costs.
See: DCE (Direct Contracting Entity) re Preferred and Participating providers, and Professional and Global risk contracts (under PCP capitation or not, etc), and choice for just Primary care or total care contracts. See: CMMI, and below.
Professional shared risk (surplus) is 100% to physicians.
Total Care Capitation (TCC) available to for DCE in total risk (is reconciled), and DCE in Primary Care Capitation (PCP), that is not reconciled at year end against FFS. Advanced Payment Mechanisms offer additional payments by care category, and are reconciled to benchmark.
Direct contracting is between PCE and independent providers dependent upon if DCE is Preferred Provider paid $0 FFS (but cap), or DC Participant, or Non Associated Providers (paid 100% FFS).
All claims must be submitted electronically to CMS. Lots of reporting required.
The term is also used for Commercial and Medicare population(s) contracting of professional services. Contracting can also include facilities charges from hospitals and various medical facilities. The trend is to identify the costliest medical diagnosis/treatments/procedures, establish EBM, and measure improved wellness at a lower cost. I.e. ESRD, Palliative Care, Cancer, Knee replacements, hip replacements, back pain, diabetes management. Medicare is leading this charge, but many commercial and Medicaid contracts have been targeted as well. See: Shared Savings, CMMI, Direct Contracting, DCE, Pioneer ACO, ACO, PMO, DCO, MSSP, NGACO, etc.
(From CMS): "Under Direct Contracting, there will be three types of DCEs with different characteristics and operational parameters. These three types of DCEs are:
Standard DCEs - DCEs comprised of organizations that generally have experience serving Medicare FFS beneficiaries, including Medicare-only and also dually eligible beneficiaries, who are aligned to a DCE through voluntary alignment or claims-based alignment. These organizations may have previously participated in section 1115A shared savings models (e.g., Next Generation ACO Model and Pioneer ACO Model) and/or the Shared Savings Program. Alternatively, new organizations, composed of existing Medicare FFS providers and suppliers, may be created in order to participate in this DCE type. In either case, clinicians participating within these organizations would have substantial experience serving Medicare FFS beneficiaries.
New Entrant DCEs - DCEs comprised of organizations that have not traditionally provided services to a Medicare FFS population and who will primarily rely on voluntary alignment, at least in the first few performance years of the model. Claims-based alignment will also be utilized.
High Needs Population DCEs - DCEs that serve Medicare FFS beneficiaries with complex needs, including dually eligible beneficiaries, who are aligned to the DCE through voluntary alignment or claims-based alignment. These DCEs are expected to use a model of care designed to serve individuals with complex needs, such as the one employed by the Programs of All-Inclusive Care for the Elderly (PACE), to coordinate care for their aligned beneficiaries."
https://innovation.cms.gov/initiatives/direct-contracting-model-options/ Direct Contracting Entity (DCO)See: Direct Contracting. Direct Pay A term loosely used to reference payment directly from the consumer to the medical provider, before the claim is sent into a carrier or TPA for payment. See Value Based Pricing. The history goes back to when HSA's had much bigger deductibles (and supposedly lower utilization keeping premiums down), but todays common deductibles over $5,000 cause patients to act the same way outside of what IRS calls an HSA qualified plan. Direct to Consumers (DTC)Jargon typically used to describe pharmacy advertising directly to consumers. Recent Federal action seeks to make more transparent drug pricing for therapies costing over $35 a month. See: AWP No question the advertising increases demand for expensive brand name drugs. Disclosure In context to medical stop loss or reinsurance, disclosure means the transparent presentation of KNOWN "large claimants" (or trigger diagnoses) as guided by relevant document(s), warrantees, and/or standard. Typical reporting includes reporting membership with defined trigger-diagnosis status, or who have exceeded a defined claim amount - in context to retention.
"Actively at work" provisions can complicate transparent disclosure, prior to policy offer/acceptance and risk transfer. We recommend having experienced people handling disclosure issues. This information is provided only as a courtesy. Carrier underwriting standards guide accepted disclosure. Discretion See: Deference in context to Plan Administrator interpretation of SPD. Disease Management (DM, or Chronic Disease Medicine)A 20 year old term used mostly to describe chronic medical care managed using EBM to improve quality and lower costs. CMS issued a report indicating their study did not show savings, however, most people believe the focused process can and does improve care. See: MACRA, QPP, PQRS, etc. Disproportionate Share Hospitals (DSH)Hospitals who serve "more" of the poor, and in context to a recent supreme court decision upholding a lower court ruling prohibiting CMS from reducing payments to DSH hospitals (by including Medicare Part C lower reimbursements in their calculation), without proper 60 day public notice and comment period. Distressed cases (High Risk)A risk characterized by a history of high losses, and/or poor risk management. Some lines like workers compensation revel in this space. I.e. MODS above 1.0, and certainly above 1.3. Distressed can mean different things on first and second dollar perils. Dividend Plans (Premium Rebating plans)A term used to describe a policy allowing premium refunds contingent upon lower than expected claims. Workers Compensation is one of the most common examples. ACA reinsurance mandates premium refunding back to insureds where MLR is less then 80%/85%. Using terms like Profit Sharing a premium rebate can cause practical accounting issues as to a taxable event upon "income". We recommend experienced brokerage, legal and accounting advice be garnered. This is not tax advice. Double Dipper See: Medicare Double Dipper Doughnut Hole (Part D (Pharmacy Benefit Plan))Source: AARP
"The doughnut hole has been narrowing each year since the Affordable Care Act (ACA) was passed in 2010. The gap was scheduled to close in 2020, when beneficiaries would be expected to pay 25 percent of the cost of all their prescriptions while they were in the gap.
Under Trump's budget deal, the doughnut hole will now close next year. Beginning in 2019, Part D enrollees will pay 25 percent of the cost of all their prescription drugs from the time they enter the gap until they reach catastrophic coverage.
For 2018, the threshold for entering the doughnut hole remains at $3,750 worth of drug costs. Once a Medicare enrollee passes that limit, he or she is in the coverage gap and will have to pay 35 percent of the cost of brand-name drugs and 44 percent of generics. They will continue to pay those costs until their out-of-pocket spending reaches $5,000. Once they hit that limit, they’ll no longer be in the doughnut hole and will pay no more than 5 percent of their drug costs for the rest of the year.
Congress made the early close of the doughnut hole possible by requiring certain pharmaceutical manufacturers to pay more of the costs for enrollees who are in the coverage gap. Currently, brand-name drugmakers pay 50 percent of enrollees’ brand name drug costs while they are in the coverage gap. Under the new budget "law", they will now pay 70 percent."
Donut hole goes away in 2020 Dual Eligible’s A term generally used to identify an individual eligible, and insured by both for both Medicare and Medicaid. These rules are somewhat complex and may also impact potential social security classification. See: Subrogation
E Early Lock Down A renewal feature offered by some carriers to renew stop loss coverage early, and avoid last minute potential lasers on sick employees who present illness within 60 days of renewal. Early Retiree Reimbursement Program (ERRP)Early Retiree Reimbursement Program. $63 (2014) PMPM charge to employers for the program. Earned Premium A term typically used in P&C policies providing notice to the policy owner of being charged (i.e. 25% of the annual premium), regardless of if the policy owner cancels the policy mid year. These get squirrelly if the policy is canceled for non-payment of premium in the first 3 months (25% of the coverage period). Policy terms can be longer than one year.
Earned premium is calculated by the number of months a policy is in force, relative to if the premium (for greater than 25% of policy period) has been paid by the policy owner. Efficient Proximate Cause (EPC)In context to theories of recovery in property policies, and losses caused by multiple insured and uninsured perils, the rule generally applies coverage to the entire loss.
In context to property policies, and theories of recovery, it applies to the "chain of causation" or initiating cause of an insured peril and loss. Where the original peril causing the loss cannot be discerned from "concurrent" perils causing a loss, insurance generally applies to the entire loss. See: CCD & ACCD
It assumes the initiating cause of loss is known. electroinic Data Interchange (EDI)See :RRE.
https://www.cob.cms.hhs.gov/Section111/LoginWarning.action Electronic Clinical Quality Measure (eCQM)The Centers for Medicare & Medicaid Services (CMS) developed and published the 2020 performance period electronic clinical quality measure (eCQM) flows for eligible clinicians and eligible professionals to the eCQI Resource Center. The eCQM flows are designed to assist in interpretation of the eCQM logic and calculation methodology for performance rates. eCQM flows provide an overview of each of the population criteria components and associated data elements that lead to the inclusion or exclusions into the eCQM’s quality action (numerator).
eCQM flows supplement eCQM specifications for eligible clinicians and eligible professionals for the following programs:
• Quality Payment Program: The Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs)
• Advanced APM: Comprehensive Primary Care Plus (CPC+)
• Medicaid Promoting Interoperability Program for Eligible Professionals
These flows are intended to be used as an additional resource when implementing eCQMs and should not be used in place of the eCQM specification or for reporting purposes.
Questions on the eCQM flows should be directed to the ONC Project Tracking System eCQM Issue Tracker.
https://ecqi.healthit.gov/ep-ec-ecqms?field_year_value=1 Electronic Health Record (EHR)A computer stored file consisting of a member’s personal medical information.
See: Health Care Exchange Interoperability, a term used by CMS to define how different stored data bases communicate or not. According to extelligent Healthcare Media, the federal government has spent over $36 Billion dollars since 2010 on EHR technology, reporting, etc. No question AI can do more here. No question mandatory reporting to the feds has real purpose, but real expense. Electronic Personal Health Information (e-PHI)
https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html?language=es Eligibility Determination Notices (EDN)Health Insurance Marketplace explanation of what may qualify for SEP, OEP, etc. It may also be referring to the official letter HHS sends each applicant detailing APTC. Eligibility for catastrophic plans under ACA In addition to the level of coverage plans, issuers in the individual market can offer catastrophic plans. Eligibility for catastrophic plans is limited to:
Eligibility: Method of Determining Eligibility for Insurance Affordability Programs As part of the application process, the Marketplace determines an individual’s eligibility for advance payments of the premium tax credit and cost-sharing reductions based on projected household income relative to the FPL. Household income is the sum of a tax filer’s MAGI, and the MAGI of the tax filer’s dependents who are included in the tax filer’s family and required to file a federal income tax return. Additionally, the Affordable Care Act requires all states to determine eligibility for Medicaid and CHIP for the majority of individuals (essentially, all non-disabled, non-elderly individuals) based on their MAGI. MAGI is adjusted gross income within the meaning of the Internal Revenue Code, plus any excluded foreign earned income, tax-exempt interest received or accrued during the taxable year, and non-taxable Social Security benefits. Assets are not considered in determining eligibility. This income methodology is the same for determining eligibility for advance payments of the premium tax credit and cost-sharing reductions, and determining eligibility for Medicaid and CHIP, with the following exceptions:
- Individuals under age 30 before the plan year begins
- Individuals who have a certification from the Marketplace that they are exempt from the responsibility requirement because they do not have an affordable coverage option, or because they qualify for a hardship exemption (Source Healthcare.com)
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/ARR-2017-Guidance-051016-508.pdf Eligible (Eligibility)A term frequently used to describe insured status of perils defined in the policy. See: Certification, Verification Eligible Clinician ((Replaces Eligible Professional))See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
Emergency Triage, Treat & Transport (ET3)"Under the ET3 model, the Centers for Medicare & Medicaid Services (CMS) will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth." Source: CMS
https://innovation.cms.gov/initiatives/et3/ Employee Benefits Security Administration (EBSA)Employee Benefits Security Administration.
In Context to C19: EBSA is an agency directed by HHS. "EBSA and IRS officials write in the new final rule draft that the rule will ease the:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) coverage access request deadline.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) group coverage continuation request deadline.
The COBRA coverage continuation premium payment deadline.
The Patient Protection and Affordable Care Act of 2010 (PPACA) benefits claim decision appeal and external review deadlines.
A benefit plan’s benefit claim filing deadlines." (Source: Allison Bell of ThinkAdvisor April 2020 Employee Retirement Income Security Act (ERISA)The ERISA Act provides federal laws and regulations pertaining to the operation of self funded health plans for single employers, unions, trusts, and associations. ERISA laws can be interpretated and enforced differently by different administrations. Although ERISA law purpose is to create greater choice and savings for employers by superceding various state solvency/capitalization mandates, it also holds language requiring state regulatory solvency/capitalization compliance within various time limits. Plans sponsored by municipalities may be regulated by the domiciled state. These plans may include Life, Health, Dissability, Gap, Dental, etc as part of the Plan Sponsor offerings. The purchase of Specific and Aggregate reinsurance is optional, but usually done to transfer the risk of unpredictable catastrophic losses. ERISA is regulated by the EBSA (Employee Benefits Security Administration). ERISA is complex, and typically requires legal advice to negociate wisely. See MEWA related to President Trump's Association Health Plan initiative.
Employee-Pay-REB Split Dollar Plan (REB)Employee-Pay-REB Split Dollar Plan
When the employer owns the life insurance policy and pays the entire premium for it in a split dollar plan—the insured employee must pay the income tax on the reportable economic benefit (REB) which is the amount of premium paid by the employer each year. Employer In context to medical insurance - An single entity offering medical insurance to W2 employees, and who posses a FEIN #. Recent Executive Orders soften the definition to avail (non-ACA compliant - health insurance "association") plan offerings to regionally located small employers across state lines, and potentially in violation of state insurance law(s). Federal ERISA law is supposed to supersede state law (at least initially), however, states routinely challenge plans not meeting state guidelines. Eee: State of New York et al. v. the U.S. Department of Labor et al. Case Number 19-5125, AHP, Executive Orders, MEWA, ERISA, etc. We recommend experienced legal, insurance and reinsurance expert assistance be obtained prior to launching an ERISA or Association Health Plan using the Executive Order authority. Employer Group Waiver Plans (ESWP)Employer Group Waiver Plans ("Egg Whips") Pharmacy plans available to fully insured or self-funded plans offering cost savings for the pharmacy fees associated with capitation based PBP Employer Mandate ACA mandate requiring employers with more than 50 full time equivalent full-time-employees (FTEs) to buy medical insurance for their employees, or Pay $2,000 per head (after 30 FTE’s “deductible”). FTE is defined as an employee working more than 30 hours. ACA requires employers with sister corporations to count all their allied companies employees toward the 50 FTE mandate. Employer Mandate – aka Play or Pay ACA mandate requiring employers with more than 50 full time equivalent full-time-employees (FTEs) to buy medical insurance for their employees, or Pay $2,000 per head (after 30 FTE’s “deductible”). FTE is defined as an employee working more than 30 hours. ACA requires employers with sister corporations to count all their allied companies employees toward the 50 FTE mandate. Employer Practices Liability (EPL or EPLI)A stand alone policy coverage, or coverage added into, or part of General Liability "package" policy. When it is automatically offered, as in some Hartford policies, limits are very low at $5,000.
EPLI is not workers compensation insurance. Examples of coverage insured in a standard contract may include: wrongful discharge, sexual harassment, sexual molestation, age discrimination, sexual discrimination, disability discrimination, etc. This is by no means a full description of EPLI coverages, limits, exclusions, etc. Complex issues related to umbrella coverage and exclusions may apply. Employers are responsible for determining their exposure Employer Stop Loss (ESL) Enhanced Direct Enrollment System (EDE)A term use by an "approved" Marketplace FMO that essentially allows people to enroll in ACA compliant medical plans, and receive APTC without directly enrolling in the Federal Marketplace system. In short, you can apply on the site of a private company and still get premium tax credits from healthcare.gov or your state exchange. Some of these sites work faster and easier than FFM website enrollment. (They make is easier to see things like SPB, get tax credit, print out formularies, and to compare ALL available plans versus just what an agent is "appointed" to sell.) See Navigator, FFM, APTC. EDE sites can also "complete" enrollment after Open Enrollment within the rules. Enrollee See: 45 CFR 155.20
See: Enrollment Reconciliation Ensuing Loss Clause A policy provision defining coverage pay out on an individual peril and loss, caused in part by an Excluded (in the policy) and uninsured peril, or loss.
In short: The EPC must be an insured peril (cause of loss) , and the ensuing loss must not otherwise be an Excluded peril for coverage to apply.
Ensuing Loss Clauses coverage eligibility is guided by the entire insurance policy contract - inclusive of each policy's "theory of recovery", and generally accepted practices and standards.
Enterprice Entity Management (EEM)HHS/CMS sub agency function involved with Marketplace data security. Enterprise Identity Management (EIDM)See PQRS
An Enterprise Identity Management (EIDM) account with the appropriate role is required for participants to obtain PQRS Feedback Reports and Annual QRURs. Both reports can be accessed on the CMS Enterprise Portal using the same EIDM account. Visit the How to Obtain a QRUR webpage for instructions on accessing both reports. Enterprise Identity Menagement System (EIDM)See: Marketplace data matching Episode of Care A term used to denote a fixed contracted reimbursement based on agreed diagnosis, and tied to "supported and agreed" EBM outcome. Episode of care is the vernacular being used by Payors attempting to fashion reimbursement schedules or contracts with providers inclusive of all services delivered over a treatment period by diagnosis tied to EBM outcome.
Key elements involved are definitions of: Episode (by diagnosis or outcome), Pre and post care defined bundled Payments, compensation model (actual to target goal), contracted rates (many and varying types including "risk sharing"), triggering event (defined by ICD10 or HCPS/CPT in context to an indexing for severity), warranty period (good luck?), comorbidity/readmission outlier balance on penalty versus additional reimbursement.
See McKesson, Prometheus payment 5.0, and ERC Logic (Evidence-informed Case Rate), Bundled Payments, DRG, etc.
Episode Payment Models (EPM)
Episode Payment Models (EPMs); Cardiac Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model
On August 2, 2016, the Centers for Medicare & Medicaid Services (CMS) published four new payment models and refinements to a current model through a notice of proposed rulemaking to further advance care coordination for Medicare fee-for-service (FFS) beneficiaries, which will begin on July 1, 2017.
Three new episode payment models (EPMs) would test making participants financially accountable for the quality and cost of episodes of care helping achieve the goal of higher quality at a lower cost for the following episodes:
• An acute myocardial infarction (AMI), including both medical therapy and percutaneous coronary intervention (PCI),
• A coronary artery bypass graft (CABG), and
• A surgical hip/femur fracture treatment, excluding lower extremity joint replacements (SHFFT).
The Cardiac Rehabilitation (CR) incentive payment model for EPMs and Medicare FFS participants would test financial incentives for Inpatient Prospective Payment System (IPPS) hospitals that encourage the management of beneficiaries following an AMI or CABG toward greater utilization of CR services.
The proposed rule can be found on the Federal Register. See CMS fact sheet and press release.
https://innovation.cms.gov/initiatives/epm/index.html ESRD Seemless Care Organizations (ESCOs)CMS has released a public ACO Care Coordination Toolkit showing the work of ACOs and End-Stage Renal Disease Care (ESRD) Seamless Care Organizations (ESCOs) participating in the Shared Savings Program, Next Generation ACO Model, and the Comprehensive ESRD Care Model. See: ACO Essential Community Providers (ECPs) Essential community providers (ECPs) include providers that serve predominantly low income
and medically underserved individuals, and specifically include providers described in
section 340B of the PHS Act and section 1927(c)(1)(D)(i)(IV) of the Social Security Act.
"The first of these proposals relates to network adequacy
review for QHPs. The modified approach would not only lessen the regulatory burden on
issuers, but also would recognize the primary role of States in regulating this area. The second
change would allow issuers to use a write-in process to identify essential community providers
(ECPs) who are not on the HHS list of available ECPs for the 2018 plan year; and lower the ECP
standard to 20 percent (rather than 30 percent), which we believe would make it easier for a QHP
issuer to build networks that comply with the ECP standard."
Also relates to Network Adequacy standards Source HHS
https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-03027.pdf?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery Essential Health Benefits (EHB)10 categories of unlimited insurance coverage defined under ACA that create a Qualified Health Plan. Categories include: Maternity & Newborn care, Hospitalization, Emergency Services, Pharmacy, Laboratory, Pediatric Vision & Dental, Rehabilitative Services and devices, Emergency Services and Preventive/Chronic disease medical treatment.
https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html Evidence Based Medicine (EBM)Scientifically produced medical care outcomes derived by refereed interpretation of medical treatment and cure data. Evidence of Coverage (EOC)See: Credible Coverage Excess & Surplus Lines (ESL)Excess of loss insurance or reinsurance typically called stop loss. Second dollar coverage triggering after eligible claims exceed a typically large deductible. Coverage can be specific and or aggregate. Surplus lines is "eligible" coverage sold in a specific state, but is not "authorized" (no COI, and not insured by state guarantee fund) Excess and Surplus Clause This is a standard Clause that means coverage is afforded after all other available insurances have been exhausted. It can also be associated with language stating coverage being applied to all medical charges the client is at risk for unless specifically excluded by design.
Excess of Loss Excess of Loss is a type of Stop Loss or Reinsurance coverage that triggers after a specific and or aggregate deductible is satisfied. These policies take many forms, and insure many types of risk. This coverage may employ a Specific deductible or variations within an aggregating specific deductible. It is “second dollar” coverage. Exchange (Marketplace)Meaning set forth in 45 CFR 155.20 An online site accessing ACA compliant medical and dental plans that is managed/funded by the federal government (HHS).
14 states did not expand Medicaid or create their own commercial insurance exchange or Marketplace, and have relegated administration to the federal government.
The word MarketPlace or Exchange means the same. Technically, the exchange was detailed in the original ACA law, and can be referred to as the Federally Facilitated Market place, or Exchange. Most refer to it as the Marketplace. All but 14 states manage their own INDIVIDUAL and SMALL GROUP (SHOP) "marketplace" (on line access) to plans. CO-OP or Cooperative may have different distribution, and plan access parameters. See: FFE, FF-SHOP, FFM, and multiple state based (managed) (SB- FFM) exchanges definitions offering different types of major medical products approved by CMS Exclusive Provider Network (EPO)A network of physicians and hospitals offered to members for In Network care. EPO plans typically do not insure care received out of network, and look similar or identical to HMO Gatekeeper model plans. Beware what is and is not insured, and for big balance billing issues. Executive Order (Medicare Executive Order)See: ACA, ACA Executive Order, price transparency, Immigrant insurance requirement injunction, Conscience Rule injunction, etc.
https://www.whitehouse.gov/presidential-actions/executive-order-protecting-improving-medicare-nations-seniors/ Executive Order (Presidential) (EO 13765 (Jan 24, 2017))ACA law applies where "enforced", but without Individual Mandate Penalty. Pay special attention to EHB, QHP, CSR, and carrier safety net. Read Trump-ing Health Care Reform at www/providerrisk.com and click on Articles. See: Medicare Executive Order
https://www.federalregister.gov/documents/2017/01/24/2017-01799/minimizing-the-economic-burden-of-the-patient-protection-and-affordable-care-act-pending-repeal Expected Claim Value The underwritten expected annual claim value used to rate specific and aggregate insurance premium. Experience A term used to describe verifiable claims history over a period the underwriter defines as important. It can also refer to the length of time an individual or group has been in the insurance business for purposes of qualifying carrier appointments and wide ranging rating and binding, etc, privileges. Experience Credit Experience Credit aka Premium Refund aka Minimum Premium aka Profit Commission aka Terminal liability aka Alternate Funding aka Experience Refund policy. A premium rebating feature that returns excess premium when claims are lower than a negotiated loss ratio typically under 70%.
Experience credit can sometimes be an underwriting term establishing the weight of the past year's 3-5 claims experience weighting (credibility) to future premium rating.
Experience Modifier An underwriting term. In context of workers compensation, it is a (multiple or factor) measures loss experience relative to that of other employers in the same industry.
Can be used as an underwriting term for major medical claims data creditability as expressed as a percentage for each years experience. Expert Medical Advisor (EMA)A highly qualified medical professional accepted by a workers compensation court for purposes of determining the percentage of medical claims an injury event was caused by a work related activity, v the percentage caused by a preexisting medical condition. Expert Medical Advisors report on the "Major Contributing Cause" (MCC) of medical claims loss. Findings of cause being 51%+ work related means the claim is eligible for workers compensation insurance response provided the court accepts the findings.
Orthopedic Surgeons are considered EMA's.
See MCC, IME, DWC25 form, MSA, MMI Explanation of Benefits (EOB)A carrier generated medical bill itemization detailing the billed charge, contracted rate, and insured payment responsibility. EOB detail maximum "accepted" contract rate(s), carrier reimbursements, and patient payment responsibility. Errors in medical billings are common. Extended Non-Network Reimbursement Program (MNRP)A United Healthcare RBP claims payment protocol. External Review A process that meets minimum standards set forth under ACA/HHS regulation related mostly to coverage exclusions or insurance denials. ACA details greater consumer appeal rights for denied or under-reimbursed medical claims. Self Funded (ERISA) plans are held to a different standard than Individual plans, mostly limited to review of insurance eligibility.
F Facultative Reinsurance Facultative reinsurance is coverage where a Reinsurer evaluates a specific risk on a case- by-case basis. Typically, the primary insurer has no obligation to submit NEW risks to the reinsurer, and the reinsurer is free to accept or reject any risks submitted by the primary insurer or ceding company. Facultative reinsurance can also be referred to as Pro Rata or Excess of Loss coverage. Typically, the reinsurer accepts the same percentage of claim liability as billed premium. Each policy is different. Fair Access to Insurance Requirements (FAIR) Fair Rate (Benchmarking)See R&C. Very contentious Faith Based Plan See Ministry Health Plans Fari Labor Standards Act (FSLO)See: Detailed Assessment of the (each states) DOL Overtime Rules. Important because of what ACA calls full time (30 hours per week), and what states call full time, and existing IRS alternatives to employ 1099 subcontractors, or PEO... Get advice from a licensed person. Federal Budget 2017 - 2018 2017-2018
http://www.budget.senate.gov/imo/media/doc/HEN17065.pdf Federal Information Security Management Act (FISMA)Federal Information Security Management Act Federal insurance Office (FIO)"The FIO’s authority extends to all lines of insurance except health insurance, crop insurance, and certain types of long-term care insurance.
The FIO is also responsible for:
· identifying activities that could pose systemic risk to the insurance industry;
· declaring state insurance laws to be preempted by international agreements regulating insurance;
· reviewing inconsistencies in state insurance laws that impact the national market and preempting such laws where appropriate;
· monitoring whether underserved communities have access to affordable insurance products;
· consulting with states about national and international insurance matters; and
· coordinating federal efforts and developing federal policy on international insurance matters, including representing the United States in the International Association of Insurance Supervisors.103
· Although Congress gave considerable power to the FIO, it left state-based insurance regulation undisturbed for the most part. Notably, the FIO does not have general supervisory or regulatory authority over the business of insurance, which remains in the province of state regulators. Instead, the FIO focuses on national and international insurance matters, and it is authorized to represent the United States internationally at insurance regulatory meetings." Source: CE Track Licensing Exam Jan 2019 Federal platform for eligibility and enrollment functions (SBM-FPs)A federal term used to denote various sites the public can access for price and medical quality metrics. Federal Poverty Level (FPL)FPL is an income (AGI/MAGI) number HHS defines is above or below "poverty", or sufficient income to afford basic living expenses. In context to ACA, it is the amount where an eligible person seeking QHP qualifies for Medicaid (under 100%), or APTC (income between 100% - 400%).
ACA law authorizes substantial APTC for eligible people earning between 100% and 400% FPL. People earning between 100% - 250% also qualify for cost sharing. See: CSR
Federal Poverty Level Guidelines Federal Provider Penalties HHS Increases Civil Monetary Penalties
September 6, 2016 by Heather Landi
The U.S. Department of Health and Human Services (HHS) issued an interim final rule Sept. 2nd that raises various civil monetary penalty amounts to adjust for years of inflation.
“The Department of Health and Human Services (HHS) is promulgating this interim final rule to ensure that the amount of civil monetary penalties authorized to be assessed or enforced by HHS reflect the statutorily mandated amounts and ranges as adjusted for inflation. Pursuant to Section 4(b) of the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (the 2015 Act), HHS is required to promulgate a “catch-up adjustment” through an interim final rule. The 2015 Act specifies that the adjustments shall take effect not later than August 1, 2016,” HHS stated in the interim final rule.
The rule noted the new maximum penalties apply to any fines assessed after Aug. 1, 2016, as well as all penalties stemming from violations that took place after Nov. 2, 2015.
Under the interim final rule, some civil monetary penalties will nearly double due to inflation adjustments.
HHS increased the penalty for a HMO or competitive medical plan that implements practices to discourage enrollment of individuals needing services in the future by 106 percent from $100,000 to $206,000. Hospitals with 100 beds or more now face penalties of more than $103,000 if they dump patients needing emergency medical care. That’s up from the $50,000 penalty established in 1987.
Circumventing Stark Law’s restrictions on physician self-referrals will now cost $159,000, a 59 percent increase from the original $100,000 penalty established in 1994.
Some penalties are relatively small, such as the penalty for payments by a hospital or critical access hospital to induce a physician to reduce or limit services to individuals under the direct care of the physician or who are entitled to certain medical assistance, which increased 115 percent from $2,000 to $4,300.
Many updated penalties affect both Medicare and Medicaid managed-care companies. HHS raised the penalty for a Medicare Advantage organization that improperly expels or refuses to reenroll a beneficiary by 47 percent, from $25,000 to $36,794. Medicare Advantage organization that substantially fail to provide medically necessary, required items and services will now face penalties of more than $37,000, an increase from $25,000. The penalty for a Medicare Advantage organization that charges excessive premiums went up from $25,000 to $36,794.
And, a Medicaid MCO that improperly expels or refuses to reenroll a beneficiary now faces a $197,000 monetary penalty, up from $100,000.
Federally Facilitated Marketplace (FFM)First called Federally Facility Exchanges, now called FFM. The federally created and managed platform designed for accessing ACA eligible INDIVIDUAL and SHOP plans in states that opted out of creating their own state based exchange / Marketplace for medical insurance. Federally-Qualified Health Centers (FQHC)Federally-Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs). Centers providing heavily subsidized or free medical care for the poor or vulnerable population in the US. Fee For Service Fee For Service is the full billed charge a provider invoices an insurer for services rendered.
Fee Schedule A Fee Schedule is an explicitly detailed schedule used by the carrier to determine the eligible amount charged. In many stop loss coverages, the RBRVS schedule is used for re-pricing physician fees The Medicare maximum allowable amount, and or DRG's are commonly used as well in pricing the hospital reimbursement. The fee schedule used dramatically effects eligible and reimbursable charges. Commonplace are variations of charges for the same service rendered by medical providers, contract and insurance type. Variations in what is considered the eligible and reasonable charge can be contentious. Fiduciary Duty (Fediciary "rule")A legal standard of service epitomized by selfless noble action(s) in best interests of the customer. It's how one would treat their beloved mother. DOL is struggling to adopt language assigning clear fiduciary duty. In sequence and context of "best interests contracts (BIC) it may follow an increasing progression standard characterized by an: obligation, responsibility, duty, and fiduciary-duty. Many laws already apply such "standard", like ERISA. See: Reg BI
In context to self funded employer medical plans, a breach of fiduciary duty can result in treble damages.
See Final Draft from SEC link.
"D. Broker-dealers and investment advisers have disclosure and reporting obligations
under state and federal laws, including, but not limited to, obligations under the
Exchange Act, the Advisers Act, and the respective rules thereunder. Brokerdealers are also subject to disclosure obligations under the rules of self-regulatory
organizations. Delivery of the relationship summary will not necessarily satisfy
the additional requirements that you have under the federal securities laws and
regulations or other laws or regulations."
Licensed Insurance Agents are not Brokerdealers or Investment Advisors.
https://www.federalregister.gov/documents/2017/01/19/2017-01316/proposed-best-interest-contract-exemption-for-insurance-intermediaries Field Marketing Organization (FMO)A sales and marketing organization typically organized to sell various kinds of insurance policies. FMO's can be called by several different terms, and can require exclusively, or non exclusivity of their contracted agents. These organizations can take many forms and functions. See: IMO, MLM, and Web-Broker Final Expense Policy A policy designed to pay funeral bills, and medical expenses of the insured, but only pays out a percentage of the death benefit based on how long the policy has been in force. In other words, if a person buys a guarantee issue policy, and dies the next year, only a small percentage of the face amount is paid to that person's beneficiaries. Finite Reinsurance Finite Reinsurance is defined by the Reinsurance Association of America as "a highly structured reinsurance contract where structured elements reduce the amount of risk assumed by reinsurers to the point that it may not meet the accounting requirements of risk transfer." Finite reinsurance is typically coverage transferring little or no risk, and is designed to pay known losses, or improve issues related to cash flow from irregular market conditions involving interest rates, and asset values. It typically improves financial ratios related to compliance, and capital surplus reserves. There are many types of finite loss development coverages. The essence of coverage may amount to a line of credit to pay known losses today and reimburse the reinsurer by amortized future premium payments. NAIC has recently agreed on a uniform policy form. Firm Rate Sometimes called firm quote, or "a bindable" quote. It is the underwritten rate offered by an carrier who has priced a given policy premium (and quote deadline). This rate typically does not change if the policy proposal is accepted by the customer by deadline. Rules governing last minute claims disclosure & underwriting acceptance are specific to each carrier, and are subject to offering terms, conditions, deadlines, and coverage, etc. First Dollar Risk A dollar amount most underwriters consider a likely claim value (i.e. under $50,000 for inpatient hospital charges) per calendar year for each insured member. Second Dollar risk is typically medical claims risk above $50,000. Risk like beauty (and retention levels) is in the eye of the beholder.
Fiscal Year (FY) Flexible Spending Accounts (FSAs)Flexible spending accounts (FSAs) enable workers to contribute pre-tax dollars to use towards eligible medical expenses typically related to deductibles, copays, and maximum out of pocket costs. Defined unused remaining balances at year end are forfeited. A small amount may be rolled over for use in future years. See IRS guidelines. FSA's (Section 125 plans) are not HRA's. FSA's get funded by the employee, and HRA's get funded by the employer
For FSAs, up to $2,650 a year; for HSAs, up to $3,450 annually for individuals and $6,900 for families. (Limits change each year) See HSA.
Fraud An intentional act to mislead. Fronting Assignment Fronting can refer to multiple types of reinsurance and insurance. Fronting can be the leasing of an authorized insurance policy form in an individual state. Sponsoring carriers may elect to assume all, part, or none of the risk being assumed by the entity attempting to establish an insurance program. Fronting carriers may, or may not act as reinsurers. A fronted and reinsured assignment can be a program of transferring an existing book ($1+M) of insurance into an existing authorized policy form that creates a less expensive "compliant" insurance alternative to a fully insured premium, and that allows agents to both commission on the sale, and share in profits. Assumption of “some” risk by the sponsoring agency/entity/ company/broker is usually required to assure a true risk partnership and comfort reinsurers.
Fronting and "reinsured" assignments take MANY forms. Where a larger company establishes a (n offshore captive, or on shore "compliant") program to assume and manage their own risk (General Liability, Major Medical, ERISA, Workers Compensation, etc.), the primary purpose is to fund "1st dollar" risk and cede "second dollar" (unpredictable) risk at a cost that can be much less than buying a fully insured coverage to satisfy compliance and/or manage risk. Program managers strive to balance premium savings and liquid-surplus-reserves- funding for known and unknown claims risk. There are many types reinsurance coverages designed to manage unpredictable risk, and/or help improve compliance ratios, and/or solvency risk management. See Finite Reinsurance. Fudge Factor A percentage increase applied to the coming year's premium renewal by actuaries and/or underwriters (or their superiors). Some may refer to it as employment, or career-insurance. ======================== A slang term used to describe a seventh item used to increase premiums within (and also before) the underwriting process. See: Underwriting Full Time employee A term defined under ACA meaning an employee working more than 30 hours per week. It is calculated by summing all part time employee hours and dividing by 30hrs to determine a FTE for purposes of ACA employer-employee count being above or below 50 FTE. Under ACA, the number is used to assess ACA tax penalties for employers employing over 50 FTEs. Employers over 50 FTE not providing ACA compliant medical insurance to their employees get fined $2,000 per employee (after the first 30 FTE exemptions). Full Time Equivalent (FTE)An employee working more then 30 hours a week. It should be noted that ACA law calculates part time employees working under 30 hours a week – summed and in total to determine if an employer has over 50 full time employee “equivalents” and is subject to either a $2,000 or $3,000 penalty tax for non compliance. Fully Disabled Limitation A Fully Disabled Limitation is a condition of a self funded stop loss policy that excludes members not actively at work, and/or who might be in the hospital at time of “disclosure”. This provision is typically waived by the carrier by proper claims declaration. Fully Insured A term to describe an "eligible" and "Authorized" ( or "admitted") insurance policy approved in a state characterized by a significantly LOWER deductible than a Self Funded Plan. The term fully-insured-rate can be associated with an "admitted" insurance policy form and cover offering premium rebates for favorable claims experience. See Minimum Premium Plans, which are a type of fully insured plan that charges the "fully-underwritten-rate", and rebates premium for favorable claims experience while adding no unfunded risk to the policy holder. Functional Capacity Evaluation (FCE)
G GAP Many meanings:
1. A hole in coverage- be it in time, and/or coverage.
2. A Gap plan is a separate insurance plan from a major medical plan whose purpose is to help reimburse the insured for high eligible out-of pocket medical charges like deductibles, copays and coinsurance amounts.
3. In ERISA related matters, it can refer to holes in (1st or 2nd dollar) coverage caused when SPD conflicts between the plan document and any other document – including network contracts, ASAs, stop-loss policies, employee handbooks, PBM agreements, etc.,
4. Some Accident only plans can be considered a kind of Gap plan.
Gatekeeper Plan A term used to identify medical plans requiring a primary care physician referral requirement before accessing specialty physician care. Traditionally, HMO's were well known to employ this extra step to see a Specialist physician, but now we see it in PPO's COOP's and EPO's.
See: Open Access plans. General Agent (GA)A GA is a General Agent for a single carrier. A GA is bound contractually to represent the best interest of their appointing carrier, and sometimes earn commissions, overrides and/or profit sharing. An Agent can be a GA with multiple carriers simultaneously. GA's are sometimes referred to as Managing General Agents.
Geriatric Resources for Assessment and Care of Elders (GRACE)An ACO program designed to study low income elderly people to determine reductions in ER visits, hospitalization and readmissions by using in home assessments & better-monitored plans. Global Budget Review (GBR) Global Master Policy (GMP)See: Controlled Master Policy. GMP's help internationally organized business(es) administer their polices in better affect to varying laws (requiring "authorized" local insurers) in each domiciled location, and tax preferred claims recovery administration. Global Risk Contract A fixed budget (or capitated) managed care provider contract that including all, or essentially all care provided to an insured member both in and out of network. PEL is typically purchased to mitigate most if not all of catastrophic expense risk providers accept within these capitated contracts. Global Risk Contract A fixed budget (or capitated) managed care provider contract that including all, or essentially all care provided to an insured member both in and out of network. PEL is typically purchased to mitigate most if not all of catastrophic expense risk providers accept within these capitated contracts. Golden Handcuffs See: Defined Contribution & Defined Benefit plans Grace Period A Grace Period is the number of days past the premium due date the premium will be accepted before canceling the policy for non-payment of premium. A typical grace period is 30 days. Marketplace plans have an ACA mandated 90 day grace period. Grandfathered or Grandmothered Plan An ACA compliant plan allowed that is not ACA compliant (QHP - 10 unlimited EHB)
Under the new CCIIO notice, in states that let grandmothered coverage stay in force, an insurer can renew grandmothered coverage up until Oct. 1, 2018. The grandmothered coverage can stay in effect until Dec. 31, 2018
Failure to comply with ACA means individuals and employers are subject to tax penalties for NOT having ACA compliant coverage. Grandfathered Plan INDIVIDUAL Plans started before 3/23/10 are allowed to remain in effect until September 2017. Grandfathered plan members do not get fined 2.5% for ACA non compliance. Many Grandfathered plans have materially less coverage than ACA compliant plans. Group plans issued after 1/1/16 are ACA compliant. Grandfathered plans are exempted from ACA mandated changes like unlimited benefits for 10 essential health benefits. Grandfathered plans are typically prohibited from making any changes that increase MOOP. (Source Healthcare.com) Greatest of Three Rule DOL rule establishing provider reimbursement amount floor related to out-of-network emergency services. New guidance gives states greater (statutory/regulatory) authority to establish reasonableness of charges. Federal Register details, "“The Departments believe that the November 2015 final rule provides a reasonable methodology to determine appropriate payments by group health plans and health insurance issuers for out-of-network emergency services, in light of the statutory language in section 2719A of the PHS Act and the totality of the comments received in response to the June 2010 IFR. The Departments also believe that the three prongs of the GOT regulation are sufficiently transparent.”
https://www.federalregister.gov/documents/2018/05/03/2018-09369/clarification-of-final-rules-for-grandfathered-plans-preexisting-condition-exclusions-lifetime-and#print Group Health Plan A plan sponsored by an employer and requiring a minimum of 50% employer premium contribution, and 70-75% of employee participation, and that is guarantee issue without underwriting and outside of OEP (individual and Medicare) mandates and limitations.
Group Health Plan (GHP)How CMS refers to employer medical plans, as they relate to coverage of Medicare beneficiaries' Rx.
Group health plan generally means a medical plan provided by the employer (ERISA, Fully insured, groups over and under 40 full time employees)
The Group Health Plan (GHP) Reporting for Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act – Frequently Asked Questions and Answers document has been updated and is available in the Download section of the Mandatory Insurer Reporting for Group Health Plans What’s New page on CMS.gov" Source: CMS
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Whats-New/Whats-New Guarantee Association (Florida Insurance Guatantee Assoc)All 50 states have state sponsored insurance guarantee associations. Florida's is called the Florida Guarantee Insurance Assoc.
Florida Insurance Guaranty Association
"Each state has created mechanisms, called guaranty associations, for protecting consumers if their insurance company becomes insolvent. Florida, like other states, has created several of these organizations geared to the particular needs of the covered lines of insurance. Guaranty associations only cover policies issued by authorized insurers in the covered lines of authority.
There are three guaranty associations in Florida:
· The Florida Insurance Guaranty Association (Association), which covers general lines of insurance, excluding ocean marine and surety bonds
· The Florida Workers’ Compensation Insurance Guaranty Association, which covers workers’ compensation claims
· The Florida Life and Health Insurance Guaranty Association
Each association consists of all authorized insurers writing the lines of insurance covered by the association. The members are assessed as needed to provide a backstop for consumer losses in cases of insurer insolvency.
The Association covers claims that exist at the time that an insurer is determined to be insolvent, or that occur in the next 30 days, unless the insured replaces or cancels the policy in less than 30 days. In general, the Association covers claims in excess of $100 and less than $300,000. Homeowner’s insurance claims are covered up to an additional $200,000 for the portion of a covered claim that relates only to the damage to the structure and contents. Regardless of the situation, the Association is never obligated to pay out more than the insolvent insurer would have paid under the terms of the insured’s policy.
The Association also plays a role in preventing insolvencies. Pursuant to Florida Statute 631.62, the board of directors may, upon majority vote, make recommendations to the Office to help detect and prevent insurer insolvencies." Source CE Tracker Agent Licensing CE exam study. Jan 2019
Guarantee Issue / Guarantee Renewability A term typically referring to a plan or policy issued without underwriting, and availale to people under 65. It can be a policy provision specifying renewability of a policy under contingent provisions that limit a renewing premium increase to a capped limit. =============ACA offers guarantee issue policies during OEP and SEP only each year. Stop loss policies can be offered with multi-year guarantee renewability features as well. I.e. MLR ratios below 60% -65%, etc., and or renewing premium increases over a 1-3 year time period. It is a negotiated process. Guaranteed Purchase Option (GPO)A life insurance rider guaranteeing option to purchase additional permanent protection in the future without providing evidence of insurability. Guaranteed Universal Life (GUL)See: IUL, Whole Life
H H.R.1 Act to provide for Reconciliation pursuant to Title II and V of the Concurrent Resolution on the Budget for the Fiscal Year 2018.
See PPACA, ACA
https://www.congress.gov/bill/115th-congress/house-bill/1 HAC Scores (HACRP)Hospital Acquired Conditions and programs scoring good and bad performance by CMS, and that can materially affect Medicare reimbursement(s).
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html Hammer Clause A policy provision, typically in a P&C policy replacement stating any claims will be paid at (typically) 70%. These are provisions that protect the carrier when a higher risk insured is offered a new policy, and (typically) whose policy does not match the previous policy's retroactive date. These types of offerings are only made after the person who caused the insured to have a high claims history (or currently disputed claim) is no longer employed going forward. Hanlon's Razor A method of explaining cause and effect, and to: Never attribute to malice that which is adequately explained by stupidity. Or: The simplest explanation of direct facts directing cause and effect is superior to a complicated explanation (especially when emotions are involved). See: Ad Obcertum Hardship Exception Application Relates to CAH (Medicare and Medicaid).
Not to be confused with getting a hardship approval from Marketplace for a catastrophic coverage ACA QHP eligibility.
https://cmsqualitysupport.service-now.com/nav_to.do?uri=%2Fcom.glideapp.servicecatalog_cat_item_view.do%3Fv%3D1%26sysparm_id%3Dcdcd71c0dbdf2700277d30ca7c96191e HCC Risk Adjustment (HCC)See: CAHIMS, CPHIMS, VBM
An underwriting tool that measures expected claims for individuals (and possibly groups). Note: Above professional designations are not universally accepted as standard. HCPCS Pharmacy billing codes. Health and Human Resources (HHS)Federal Department of Health and Human Resources - the agency charged with managing ACA and CMS, etc. Health Care Payment Learning and Action Network (LAN)A HHS-CMS department assigned with tracking & communicating alternative (non FFS) medical provider reimbursement contract successes in lowering cost and maximizing evidence based medicine outcomes. “CMS is proud to achieve the 30% target almost a year ahead of schedule. Moreover, true transformation of our health system cannot be done through Medicare alone, and so CMS looks forward to continuing to work with partners across the country to achieve the goals of tying 30% of spending to APMs by the end of 2016 and 50% by the end of 2018 for the entire U.S. health care system.” “The Health Care Payment Learning and Action Network will bring together private payers, providers, employers, state partners, consumer groups, individual consumers, and many others to accelerate the transition to alternative payment models.” “HHS has set a goal (PDF) of tying 30 percent of Medicare fee-for-service payments to quality (PDF) or value through alternative payment models by 2016 and 50 percent by 2018. HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018.” (source: Health Care Payment Learning and Action Network (LAN)) Health Care Transformation Task Force (HCTTF)See QPP, MACRA, LAN, PQRS Health Cost Sharing Plan An association plan that is typically not insurance, and provides referenced based repricing, and claims payment to providers, or directly to the member. Various states may or may not have statutes regulating such entities. ERISA Plan Sponsors are advised to seek licensed legal advice. See Ministry Cost Sharing Plan. Health Information Exchange (HIE) Health Information Technology (HIT)Section 1561 of the Affordable Care Act requires the Department of Health and Human Services (HHS), in consultation with the Health Information Technology (HIT) Policy Committee and the HIT Standards Committee (the Committees), Health Information Technology for Economic and Clinical Health Act (HITECH)see: CEHRT, NEHRS, ONC, EHR, MACRA, etc.
Digital data review from various EHR designed to review EBM, QPP, and medical outcomes with "interoperability" (multi-discipline cross communication on agreed upon criteria) goal of improving patient care at lower costs. Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) promotes the adoption and meaningful use of HIT. State statutes, such as the California Senate Bill CSB 1381, protect in varying degrees the privacy of PII and PHI. Health Information Technoloty ofr Economic and Clinical Health Act (HITECH)See HIPPA, and PHI and how protected private information is to be handled in context to reasonable professional standards of "Business Associates", and law. In short, the laws are not intended to disrupt medical care management or claims payments in best interests of the patient administration. Health Insurance Claim Number (HICN)See MBI
Health Insurance Claim Number (HICN) in context to a Medicare patient claim patient identifier number. Health Insurance Claim Numbers (HICNs)See: MBI
Numbers Medicare uses to adjudicate eligibility and claims, that are not MBIs. Health Insurance Exchange Program (HIX)means system of records CMS uses in the administration of FFE's, SBE-FP's, See: Privacy Act of 1974, 45 CFR Part 5b, and "routine uses" established for HIX in the Federal Register at 78 .Reg 8538 as amended by 78 Red.Reg. 32256, and 78 Fed.reg. 63211. Good luck! Health Insurance Issuer Health insurance issuer means an authorized insurance company licensed to sell insurance in a state, and is subject to state law that regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act (ERISA)). This term does not include a group health plan. (Source Healthcare.com) Health Insurance Marketplace (HIM)The name HHS gives to Exchange plans available on the federal or state marketplace. See: (Federally Facilitated) Marketplace Health Insurance Portability and Accountability Act of 1996 (HIPPA)Federal Law created to help people keep their insurance between different employers, and ended up adding massive electronic personal information security requirements and (civil and criminal) penalties. Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, as amended, and its implementing regulations. (source MLN Learning) A law that sets standards for securing privacy of personal health information, and affording people changing jobs guaranteed insurance without preexisting medical condition exclusion or waiting period. Health Insurance Portability and Accountability Act of 1996 (HIPAA), which establishes national standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and employers, and sets forth privacy and security standards for handling health information Public Law 111–148, Patient Protection and Affordable Care Act, March 23, 2010, 124 Stat. 119, http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html http://www.healthreform.gov/health_reform_and_hhs.html Minimum Acceptable Risk Standards for Exchanges – Exchange Reference Architecture Supplement i Version 1.0 August 1, 2012 1 Centers for Medicare & Medicaid Services Executive Overview • Department of Health and Human Services Final Rule on Exchange Establishment Standards and Other Related Standards under the Affordable Care Act, 45 CFR Parts 155, 156, and 157, March 12, 2012, which establishes privacy and security controls required for processing Exchange applicant information • Internal Revenue Code (IRC), 26 U.S.C. §6103, which establishes criteria for handling Federal Tax Information (FTI) In addition, numerous other federal and state regulations impact the processes for securing information. For example, the Privacy Act of 1974 places limitations on the collection, disclosure, and use of certain personal information, including PHI. The e-Government Act of 2002 requires federal agencies to conduct privacy impact assessments (PIA) associated with collecting, maintaining, and disseminating PII. The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) promotes the adoption and meaningful use of HIT. State statutes, such as the California Senate Bill CSB 1381, protect in varying degrees the privacy of PII and PHI. There is no integrated, comprehensive approach to security. (Source HHS)
PII Data as defined by CMS, and Marketplace agent training 2019
• APTC percentage and amount applied
• Auto disenrollment information
• Applicant Name
• Applicant Address
• Applicant Birthdate
• Applicant Telephone number
• Applicant Email
• Applicant Social Security number
• Applicant spoken and written language preference
• Applicant Medicaid Eligibility indicator, start and end dates
• Applicant CHIP eligibility indicator, start and end dates
• Applicant QHP eligibility indicator, start and end dates
• Applicant APTC percentage and amount applied eligibility indicator, start and end dates
• Applicant household income
• Applicant Maximum APTC amount
• Applicant CSRs eligibility indicator, start and end dates
• Applicant CSRs level
• Applicant QHP eligibility status change
• Applicant APTC eligibility status change
• Applicant CSRs eligibility status change
• Applicant Initial or Annual Open Enrollment Indicator, start and end dates
• Applicant special enrollment period eligibility indicator and reason code
• Contact Name
• Contact Address
• Contact Birthdate
• Contact Telephone number
• Contact Email address
• Contact spoken and written language preference
• Enrollment group history (past six months)
• Enrollment type period
• FFE Applicant ID
• FFE Member ID
• Issuer Member ID
• Net premium amount
• Premium Amount, start and end dates
• Credit or Debit Card Number, Name on Card
• Checking account and routing number
• Special enrollment period reason
• Subscriber Indicator and relationship to subscriber
• Tobacco use indicator and last date of tobacco use
• Custodial parent
• Health coverage
• American Indian/Alaska Native status and name of tribe
• Marital status
• Requesting financial assistance
• Responsible person
• Applicant/Employee/dependent sex and name
• Student status
• Subscriber indicator and relationship to subscriber
• Total individual responsibility amount
Employee Applicant Name
Employee Unique Employer Code
Employee Home Address
Employee Applicant Mailing Address
Employee Applicant Birthdate
Employee Social Security Number
Employee Applicant Telephone Number (and type)
Employee Applicant Email Address
Employee Applicant Spoken and Written Language Preference
Employee Tobacco Use Indicator and Last Date of Tobacco Use
Employee Race and Ethnicity
Employer Business Name
If American Indian/Alaska Native: Name and Location of Tribe
Health Coverage Type (Individual or Family, if offered)
Health Plan Name and ID Number
Dental Plan Name and ID Number
Other Sources of Coverage
Accepting or Waiving Coverage
Dependent information, if applicable, including
• Dependent Name
• Dependent Date of Birth
• Dependent Social Security Number
• Dependent Relationship to Employee
• Dependent Sex
• Dependent Spoken and Written Language Preference
• Dependent Race and Ethnicity
• If American Indian/Alaska Native: Name and Location of Tribe
• Dependent Tobacco Use Indicator and Last Date of Tobacco Use
• If individual is living outside of home; name of individual, address, phone, e-mail address
• Dependent Other Sources of Coverage
• Dependent Accepting or Waiving Coverage
• Special Circumstances for Employees and Dependents, i.e., marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth
Employer Name/"Doing Business As”
Employer Federal Tax ID Number
See: PHI, PII, PIA
https://www.dol.gov/ebsa/newsroom/fshipaa.html Health Maintenance Organization (HMO)A Health Maintenance Organization (HMO) is a state-designated insurance entity authorized to sell commercial, Medicare or Medicaid health insurance in certain counties. HMO's are known for emphasizing preventative medicine, and paying their doctors and hospitals a fixed dollar “capitation” for each member assigned to a provider group. An HMO is typically separated from a PPO or Indemnity Health Insurance by two major things: a capitated primary care physician (PCP), and required referral from a PCP for specialty physician access. Health Professional Shortage Area See Medicare A and B, and what each covers. May also relate to what TRICARE will also insure where VA services are inadequate. See: Network Adaquacy Health Reimbursement Account (HRA)A tax exempt account used to pay eligible health expenses (now including employers giving "pretax" premium amounts to employees purchasing INDIVIDUAL coverage on the Marketplace), typically paired with higher deductible plans, and funded (tax-preferred) by the employer. (This is the use it, or lose it account, but for about $500 per year that can rollover to the new year.) It is not HSA, MSA. FSA.
Recent HHS advisory effective January 2020 will allow HRA account "reimbursement" to employees for INDIVIDUAL medical insurance for employees not insured under the group plan.
See HRA, FSA, MSA, MEWA, Minimum premium plans, SHOP, Small Group plans, MSA...
We recommend speaking with experienced broker and CPA before moving.
HRA's have been targeted by Trump Executive Order to HHS resulting in loosening rules governing eligible HRA medical expenses, and making eligible reimbursements for non ACA compliant plan premiums and out-of-pocket expenses.
See IRS requirements & limitations
https://www.hhs.gov/about/news/2019/06/13/hhs-labor-treasury-expand-access-quality-affordable-health-coverage.html Health Resources Account (HRA, Cafateria Plan)An HRA is a medical savings account typically funded by the employer tax preferred (not taxed). Funds are eligible to pay for (typically using a debit card) medical expenses such as deductibles, co insurance, Co Pays, and other eligible out-of-pocket medical expenses during a calendar plan year. Funds are typically "use ir or lose it" during the year.
Total annual deposits are regulated and limited per calendar year. Tax considerations and regulations are many, and must be confirmed with Licensed CPA’s or attorneys.
Recently the Trump administration has changed the rules to allow use of funds for short term plans - see link. Exactly how state and federal authorities will permit use of funds for non ACA compliant QHP remains to be vetted. We recommend caution. ACA tax credit penalties may apply to unwary employers whose low income employees leave their plan and buy a tax credited individual plan.
Effective Jan 2020, HRA accounts can be funded by employers to pay for INDIVIDUAL (not group) insurance purchased on the Marketplace as well. See HHS link: https://www.hhs.gov/about/news/2019/06/13/hhs-labor-treasury-expand-access-quality-affordable-health-coverage.html?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery
HRA's are not HSA's, or FSA's.
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Health-Reimbursement-Arrangements?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery Health Risk Assessment (HRA)See: ICHRA, FSA, HSA, MSP, Section 125 plans, Cafeteria plans, etc. (view this in terms of prepaid, untaxed revenue into a IRS compliant dedicated account to pay for eligible medical expenses.)
Some use the term to mean Health Risk Assessment involving employee benefit chronic disease evaluation and treatment to avoid higher costs associated with not managing conditions. i.e. Bone Marrow testing CA 15-3 (breast cancer), Chest x-ray, stress testing, serum protein electrophoresis (Myeloma), breast ultrasound, CEO (colon cancer blood test), PSA (prostate screening), thermography, etc. Health Savings Account (HSA)A health savings account (HSA) is a special tax-exempt (not taxed) account an INDIVIDUAL ( not Group or employee) establishes with untaxed funds to pay for qualified medical expenses. When these were established many years ago, they required high deductibles to be eligible. ACA "wellness/preventive" care being mandated at no OOP costs, undercuts original HDHP HSA purpose, as does the new reality of massive deductibles most people have to now shoulder. HSAs are typically used in conjunction with high-deductible health plans (HDHPs) offered by many insurance companies that IRS accepts as eligible. The maximum amount that may be contributed to an HSA is set by law and subject to change each year.
Under Sec. 223, individuals who participate in a high-deductible health plan (HDHP) are permitted a deduction for contributions to HSAs set up to help pay their medical expenses.
The IRS adjusts contribution limits for HSAs yearly based on inflation. For 2021, those limits will be:
$3,600 for individual coverage (an increase of $50 from 2020)
$7,200 for family coverage (an increase of $100 from 2020)
See: FSA (For Groups)
https://www.irs.gov/pub/irs-drop/rp-20-32.pdf Health Sharing Ministry Organization (HSMO, Health Care Sharing Ministry)A "faith-based association health "plan" that costs less than ACA compliant INSURANCE available to Individuals, and perhaps some employers. ====================May go by many names: Faith Based Healthcare
Christian Medical Sharing
Christian Medical insurance
Christian Healthcare Insurance
Christian Medical Cost Sharing
Christian Ministries Healthcare
Christian Healthcare Sharing Ministries
May require signed statement of faith. Plans are typically not QHP ACA compliant, and are not usually authorized as insurance - but, offer reimbursement to a RBP for eligible medical care. Most plans (Like STM, that are typically authorized) offer little if any ER, Rx, etc coverages, and/or at minimal limits. PreX is handled differently. See: Ministry Health plans, Limited Medical Plans, Balance Billing, Eligible and authorized plans, Authorized plans, etc. Know the differences. See: PIVOT, Reahlm Health, OneShare Health, Aliera, SGH SafeGuard Health, etc. These plans can be insurance, discount plans, health cost sharing, Gap, etc and take an expert to vet by state guidelines. Caveat emptor. Healthcare Common Procedure Coding System (HCPS)Effective January 1, 2020, the Centers for Medicare & Medicaid Services and the American Medical Association have approved the use of the CPT Category II 8P modifier with HCPCS codes included in Quality ID #117’s measure specifications to report Performance Not Met.
BACKGROUND: In their October 2019 coding update, CMS revised 3 CPT Category II codes that the AMA released on July 8, 2019, for implementation on October 1, 2019. These revisions had a substantive impact on the numerator definitions for Quality Measure 117: Diabetes: Eye Exam. To avoid impact to PY 2020, CMS replaced the affected CPT Category II codes with 3 new HCPCS codes. To report Performance Not Met for this measure, reporters should append CPT Category II modifier 8P to the HCPCS codes found in the numerator. The new HCPCS codes and descriptions for this measure are found below. The QPP 2020 measure specifications contain the correct codes and instructions for reporting this measure. The 2020 measure specifications may be found at https://qpp.cms.gov/about/resource-library.
Performance Met: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed (G2102)
Performance Met: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed (G2103)
Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed (G2104)
Performance Not Met: Dilated eye exam was not performed, reason not otherwise specified (G2102 with 8P or G2103 with 8P or G2104 with 8P)
https://qpp.cms.gov/about/resource-library. Healthcare Effectiveness and Information Set (HEDIS)A good set of clinical measures and rules
that can help (along with others like NQF measures) used to identify gaps in care or
potentially unnecessary care occurring, and/or who is experiencing it, and/or optimal clinical intervention timing. Healthcare Inflation (Medical inflation)A term that can mean several things. It typically refers LARGE group premium increases, and ignores small Group and or Individual premium increases per year. There are 2o million individuals who do not have access to large group coverage or, premiums. The better index is Healthcare SPENDING inflation that tells the story of what it really costs people to buy health insurance and pay their: Deductibles, Co-insurances, Copays, MOOP. Know that over the past 20 or so years, in almost all years, whatever CPI is, quoted healthcare (Group premium) inflation is (200% - 600%) at least double CPI, and that index is understated. Typically sited Group Health Premium increases are always less then Individual premium increases, and do not add-in out-of-pocket patient responsibility costs each person has to pay to actually buy healthcare, and that are well beyond any wage increase. Sustainable - not?
Note that in 2019 CPI is well under 1.8%, and for the Obama years, it was 1%/yr every year (8 years) while Group inflation reported was 4%-7%. Means hospitals doctors and pharmaceutical companies, etc., were increasing their prices 400%-700% faster than the rest of the economy's goods and services.
For 2019, inflation is about 1.8%, and medical (group premiums) inflation is over 4%.
"An analysis from the CMS Office of the Actuary showed US health care spending increased by 4.6% to $3.6 trillion last year, compared with 4.2% growth in 2017 and 4.6% in 2016. The increase was driven in part by faster spending growth in government-sponsored and private health insurance, largely because the Affordable Care Act's health insurance tax was reinstated." Source: AHIP Smart brief. Healthcare Innovation Awards (HCIA) Healthcare Protection Integrety Data Bank (HIPDP)See: MACRA, NPDB Healthcare Research and Quality (AHRQ)An agency under CMS that uses Clinical Classification Software (CCC) to detail co-morbid conditions grouped into six categories. Healthcare Transformation Task Force (HCTTF)
An organization that evalauates data from over 900+ ACO's to determine their effectiveness in providing effective care at efficient cost and outcome. See ACO's.
Healthcare Transparancy See: Price Transparency
President Trump calls it: A+ Healthcare transparency. HELP (Senate Health, Education, Pension Committee)See: Senate Health, Education Pension Committee Hierarchical Condition Categories (HCC)HCCs will continue to
play a role in CMS alternative payment models
(APMs), such as shared-savings contracts and
accountable care organizations (ACOs).
CMS originally developed HCCs in 2004 to adjust capitated payments for its Medicare Advantage (Part C) plans based on risk.
See: MACRA, QPP HIT New & increasing tax ($11.3 B) on Fully-Insured medical carriers, but not ERISA plans.
Home Health Medical care delivered in a persons home that may or may not be insured. The term is not related to natural or homeopathic cures and treatments. By most coverage definitions, home health care relates to in-home care needed to fully rehabilitate from an insured event. Home health is not long term (custodial) care. See: CMS final rules for Home health, cut know that what is insured with Medicare may not be insured, or an available option for commercially insured lives.
https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html Home Health Agencies (HHA's)What CMS calls/regulates/measures quality of entities providing home health services. Home value 85% rule (85% Rule)A property insurance rule requiring a minimum of 85% of fair market REPLACEMENT COST value be insured. This protects the carrier from taking more than a standard level of risk by insuring the smaller value at lower premium, while insuring the biggest part of the 1st dollar most common loss - when there is a loss. Hospice Quality Reporting (HQRP)See: MACRA, QPP, MIPS
The Hospice Quality Reporting Program (HQRP) Requirements and Best Practices web page provides updates regarding reporting requirements, and announcements focusing on best practice methods to help hospices be successful specific to the HQRP. In section 3004(c) of the Affordable Care Act, the Secretary is directed to establish quality reporting requirements for Hospice Programs. Currently, there are two requirements for the HQRP:
•The Hospice Item Set (HIS) is a component of the HQRP for the FY 2016 annual payment update (APU) and subsequent years. For more information on the HIS, please visit the “Hospice Item Set (HIS)” portion of this webpage.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices.html Hospital Compare "First available in 2005 and closely aligned with CMS’s recently launched eMedicare initiative to unlock the power of information for consumers, Hospital Compare provides access to quality measures on more than 4,000 Medicare-certified hospitals as well as Veterans Health Administration and Military Health System hospitals. Easy-to-understand and based on more than 100 rigorously tested measures, Hospital Compare is the go-to resource for anyone deciding where to schedule a surgery or other inpatient or outpatient service." Source: CMS Hospital Indemnity Plan A non ACA compliant (QHP) medical insurance plan that typically insures a limited amount of inpatient hospital services. There are may types, and some include sophisticated Section 125 (HRA) tax preferred premium management, and wellness care designed to meet risk transfer, wellness, chronic care medical case management, and what IRS considers legitimate insurance. Hospital Inpatient Quality Reporting (IQR)IMPORTANT
https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf Hospital Inpatient Quality Reporting Program (IQR)See eCQM Hospital Outpatient Prospective Payment System (OPPS)CMS issued a proposed rule that updates payment rates and policy changes in the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The proposed rule is one of several for 2018 that reflect a broader strategy to relieve regulatory burdens for providers; support the patient-doctor relationship in healthcare; and promote transparency, flexibility and innovation in the delivery of care.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14883.pdf Hospital Readmission Reduction Program (HRRP)A (dreaded) Medicare and Medicaid "quality" program that denies or reduces payment for hospital readmissions (with same/similar diagnosis) within 30 days of discharge. In other words, hospitals get paid less when Medicare and Medicaid patients get readmitted with the same or similar diagnosis within 30 days of discharge.
"The HRRP aims to lower Medicare and Medicaid expenditures by reducing the burden of preventable repeated hospitalizations within 30 days while simultaneously improving the quality of postacute care." "Among hospitals classified in the lowest socioeconomic-status quintile, 91.64% would have been subject to penalties in fiscal year 2019 using the old method, compared with 77.60% using the new method. The median net penalty payment decreased from 0.46% in fiscal year 2018 to 0.28% in fiscal year 2019.
Even hospitals higher quintiles experienced a small net down-classification in penalty status from 75.94% with the old method to 74.40% with the new method. Their median net penalty payment increased modestly from 0.32% in fiscal year 2018 to 0.35% in fiscal year 2019." Source: Medscape
Central to this dispute are cries of foul from teaching hospitals charged treating the super beat-up poor people under federal "safety net" agenda. Hospital Readmissions Reduction Program (HRRP)A generic term aimed at measuring (reductions in) readmission rates within 30 days for discharge. Hospital Referral Region (HRR)
A term sometimes used to reference regionally organized hospitals that work together with potential pricing discounts under ACO, and other managed care contracts.
A tern CMS wants to use to get hospitals with city-state mentalities to work with other not-for-profit (and for profit) hospitals to better serve their communities with better medical outcomes at lower (or more efficiently focused) use of available funding.
Hospital Service Area (HSA) Hospitals Star Ratings Program A contentious one to five star quality rating published on 3662 hospitals by Centers for Medicare and Medicaid Services (CMS) being released later in 2016. Teaching hospitals and hospitals dealing with the poor typically rank lower because of higher (previously untreated) comorbidity care. HR Human Resources
I I-9 Employment Eligibility Verification Form From Required by Department of Homeland Security
https://www.uscis.gov/sites/default/files/files/form/i-9.pdf ICD- 10 codes (ICD 10)A 5 digit hospital procedure coding system for billing purposes.
https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html Independent Marketing Organizations (IMO)see: FMO, BGO Independent Medical Exam (IME)A medical report from a qualified medical professional detailing percentage of work related injury and claim caused by a work related injury, and potentially insured by workers compensation insurance. See EMA & MCC & DWC25 form Independent Medical Examination (IME) Independent Practice Association (IPA)An Independent Practice Association (IPA) is typically a group of physicians who organize themselves into a contracting entity to care for an HMO's and PPO's members. It can also be a licensed HMO owned by its member physicians. Indexed Universal Life (IUL)A life insurance policy that essentially packages Term life insurance with a Fixed indexed annuity. Like any Fixed annuity, premium deposits are not directly invested in the market by the policy holder, so if the market crashes, the policy holder loses no value. Where the market (i.e. S&P index) grows, the product contractually credits 0% (safety floor) to (currently) 10.5% cap. Carriers accomplish this by buying one year US Treasury notes, and gambling with the one year guaranteed interest by buying one year options betting the market will go up. IRS compliant policies allow "pension" loans (i.e. current charging a fixed rate of 4%)collateralized by cash value (accumulation value). Compliant loans are not taxed as income. Collateral used for loans remains in the policy holders Cash Value (Accumulation Value) and simultaneously earns interest crediting (i.e. 0% floor to 10.5% cap) - for life. Compliant loans require being paid off after death with tax free life insurance death benefit proceeds. Any remaining Death Benefit value goes to benificiaries.
Most IUL contracts additionally credit (about 1%) BONUS from year 10 to death. These policys must stay in force for life or risk all loans being taxed as income. Primary benefit is protection of family, but "living benefits" are quite attractive to the policy owner.
This is not tax advice. Provider Risk, LLC., recommends directing tax related questions to licensed CPA's or attorneys specializing in tax. Individual Coverage HRA (ICHRA)The Trump executive order allowing employers to reimburse employees with un-taxed payroll funds to pay for INDIVIDUAL (not Group) health insurance premiums paid directly by the employee for medical insurance. "The ICHRA differs from other currently available HRAs in several ways:
• Businesses of all sizes can offer the ICHRA.
• Applicable Large Employers (ALEs) can meet the employer mandate
with an ICHRA.
• Businesses can offer both the ICHRA and a group health insurance
policy, but not to the same group (or class) of employees.
• Businesses can define benefit eligibility and offer different
allowance amounts based on 11 employee classes.
• There are no caps on the allowances made available through the
• Employees have the option of collecting premium tax credits or
participating in the ICHRA.
With these features, the ICHRA appeals to businesses in unique ways
not seen in the existing HRA landscape. Businesses without access
to an HRA currently will be able to offer one for the first time in
2020." "In an effort to expand HRAs even further, President Donald Trump
issued an executive order in 2017 directing the Departments of the
Treasury, Labor, and Health and Human Services to review IRS Notice
2013-54 and find ways to further integrate individual health insurance
The Departments responded with a final rule in June, 2019. The rule
is a direct revision of the IRS Notice and states that, if certain rules
are followed, HRAs may integrate with individual health insurance for
businesses of any size.
The result was the creation of the individual coverage health
reimbursement arrangement, or ICHRA, which will be available starting
January 1, 2020." " ICHRA affordability example
In 2020, Derrick, an employee
at Big Build Construction, has a
household income of $45,000. His
employer is offering an ICHRA.
The lowest-cost silver plan in his
area is $550. The calculation for
affordability in this case is:
$45,000 * .0978 = $4,401
$4,401 / 12 = $366.75
$550 - $366.75 = $183.22
In this scenario, the lowest
allowance that can be considered
affordable to the employee is
Wayne is another Big Build
Construction Company employee
who qualifies for premium tax
credits. His total annual household
income for 2020 is $30,000 a
year. One-twelfth of his income is
$2,500; multiplied by 9.78 percent,
the figure is about $245. Because
$245 is less than the company’s
required HRA contribution of
$300, Wayne’s ICHRA benefit is
not considered affordable. Wayne
can waive ICHRA participation and
collect his premium tax credits
instead." Just know that ACA applies to the affordability component and if an employee can access APTC. Complying with ACA law directing employer mandate (tax penalty) versus Trump Executive Order gets squirrelly. One way to think of this is it's Trump's trying to help employers reimburse low income people purchasing tax credited plans (on Marketplace the employee is eligible for because the employee's monthly premium contribution for their EMPLOYER plan exceeds 9.78% of monthly household income). ICHRA is for employers under 50 employees, and can include part time employees. Source: People Keep White paper Oct 2019 Plan is available to 11 employee classes." Source: see link.
See: HRA, HFA, HSA, etc.
https://www.peoplekeep.com/hubfs/The_Complete_Guide_to_Offering_the_ICHRA_In_2020-ebook%20(1).pdf Individual Mandate (Shared Responsibility)A repealed provision of the (federal) ACA law penalizing individuals for not buying compliant coverage.
Several other states have indicated that they have legislation adding an individual mandate and penalty for 2020 that will require reporting in 2021. Individual Medical Questionairs (IMQ)A term Aetna uses for applications (voluntarily elected by the broker and or his client) to :underwrite "Level-Funded" plans for potential 10% GRX discount. Inflation (Medical Cost Inflation)See: CAGR Inflation Adjustment Rate (Growth rate)Means many things. For Medicare commissions, it is the rate CMS uses to increase the rate.
Inflation adjustment figures are commonly used when underwriters rate renewals, and factor into trend percentage increases. Injured Worker (IW)A potential workers compensation eligible claimant in process of determining maximum medical improvement and major contribution cause of the injury. Inner Agg See Aggregating Specific Deductible Inpatient Prospective Payment System (IPPS)See IQR
CMS term used for updating hospital and LTC inpatient rates that by final rule must be updated each year.
CMS states, "We also are establishing new
requirements or revising existing
requirements for eligible professionals
(EPs), eligible hospitals, and critical
access hospitals (CAHs) participating in
the Medicare and Medicaid Electronic
Health Record (EHR) Incentive
Programs. We are updating policies
relating to the Hospital Value-Based
Purchasing (VBP) Program, the Hospital
Readmissions Reduction Program, and
the Hospital-Acquired Condition (HAC)
2018 Medicare Medicare Hospital Inpatient Prospective Payment System Inpatient Psychatritric Facility (IPF)
https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-proposed-medicare-payment-and-policy-changes-inpatient-psychiatric-facilities-cms Inpatient Quality Reporting (IQR)"Now Available: Updated 2019 CMS QRDA I Schematron for HQR
The Centers for Medicare & Medicaid Services (CMS) has released an updated 2019 CMS Quality Reporting Document Architecture (QRDA) Category I Schematron for Hospital Quality Reporting (HQR). The updated Schematron provides technical instructions for reporting electronic clinical quality measures (eCQMs) for the calendar year 2019 reporting period for the:
• Hospital Inpatient Quality Reporting (IQR) Program
• Medicare and Medicaid Promoting Interoperability (PI) Programs for Eligible Hospitals and Critical Access Hospitals (CAHs)"
https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf Inpatient Rehabilitation Facility Quality Public Reporting (IRF QPB)see Preview Report Access link first.
"The data contained within the Preview Reports is based on quality data submitted by IRFs between Quarter 3 – 2018 and Quarter 2 – 2019, and reflects what will be published on IRF Compare during the March 2020 refresh of the website. Providers have 30 days (12/9/19 to 1/9/20) to review their performance data. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate." Source: CMS
https://www.medicare.gov/inpatientrehabilitationfacilitycompare/ Insurance Certifications See: CPCU, FLMI, AAI, ARe, CPIA, CLU, CSR, HIA. Some take very little to get, and others take a typical two years of exam taking/passing... Not to be confused with MBA, FSA, MAAA, RN, MD, DO, ... formal post graduate degrees. Insurance Professional Designations Many: Commonly earned titles include: CPCU, FLMI, CLU, ARe, etc. See: Underwriting Insurance Services Office (ISO)Insurance Services Office: Provides many insurance services, forms, and standards. There are many insurance bureaus, such as the American Association of Insurance Services, etc.
See: American Association of Insurance Services (AAIS) Integrated Delivery Systems (IDS)Integrated Delivery Systems (IDS) are physician, hospital and insurance company joint ventures which are authorized to sell health insurance in a state. Sometimes simple unorganized Physician and Hospital groups refer to themselves as integrated despite their inability to coordinate care, manage their physicians or reduce cost.
Interim Final Rule (IFR)A term CMS uses to try and differentiate a Final Rule from one they are going to use until they publish the FR. Good Luck. Internal Revenue Code (IRC) Internal Revenue Code § 162 bonus plans ( IRC § 162 bonus plans )An IRC § 162 bonus plan is a nonqualified retirement type of plan where an employer pays a bonus to a participating executive and directs the bonus toward payment of premiums on a life insurance policy owned by and covering the executive. Monies used to pay the premium are taxed prior to paying the premiums, and the death benefits are generally recovered tax free. Cash value is instantly available - generally without tax as well (through loans on the policy). See SERP International Classification of Diseases (ICD-10 )A highly complex coding of medical care. Interroperability (Medicare Interoperability)See MIPS, and EHR in context to merging both.
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index?redirect=/EHRIncentivePrograms/ Irrevocable Letter of Credit (ILC)An Irrevocable Letter of Credit is a bank document guaranteeing funds on accounts payable to the obligee in the event a contractor is unable to meet their obligations.
IRS Internal Revenue Services Issuer See: ACA Law
J Joint Underwriting Association (JUA)An association authorized to rate and bind insurance coverage, and that is not a rated entity, or Florida Insurance Guarantee Association insured. See: Citizens
L Learning and Action Network framework (LAN)See Health Care Transformation Task Force (HCTTF) A CMS directed entity aligned to improve QPP. Leased Paper See: Fronted and Reinsured assignments Length of Stay (LOS)A common quality measurement. See: Outlier Letter of Credit (LOC)Could also mean Line of Credit Letter of Intent (LOI) Level Funding (Minimum Premium)
A higher deductible group medical plan that allows for a premium refund when TOTAL GROUP claims (aggregated) cost under a terget value - typically 120% of the previous years underwritten claims cost. Level Funded plans price about 15%-20% less than lower deductible tratidional medical plans. These plans typically do not enjoy material premium reductions because they off
Essentially, these plans offer employers with good claims experience the opportunity to pay up front, and get some back if claims remain under an expected value.
These plans are not construed as traditional ERISA self funded plans which typically require deductibles in excess of $50,000 per person per year. Typical ERISA self funded plans insure both specific (per person per year), AND aggregate (per population per year) risk.
Life Expectancy (LE)The length of time or age a person is expected to live. In Life Settlements, it is the length of time in months an insured person is expected to live. LE's are commonly estimated by physicians and entities involved with buying and/or selling life insurance policies. These estimations help entities purchasing life settlements budget expected premium cost through policy execution. See: Life Settlements Life Insurance There are three to four basic types of life insurance: Term, Universal Life, Whole Life, and Variable life. Only Variable life policies can put cash values at risk to market crashes. Policies goals are typically designed to maximize or balance death benefits, debt relief and/or retirement distributions. Universal Life, Indexed Universal Life and Whole life can guarantee Principal safety & accumulated interest being locked-in MONTHLY. UL, IUL and WL also allow for tax deferred loans up to about 95% of their surrender value. Loans are available without penalty prior to age 59.5, and are pre-planned to remain IRS compliant and generally enjoy tax preferred spending (taken as loans againstt the Surrender Value). All loans are repaid after death with tax free death benefits while the policy remains IRS compliant. Because policy loans do NOT reduce Cash Value, the insured enjoys spending up to his policy Surrender Value in retirement, while still earning interest on the same values spent (taken as loans) for life. IUL, UL and Whole life never place an insured's cash value in the market, and have historically outperformed indexed investments exposed to market-crash risk. Our opinion is these policies generally offer exceptional "tax preferred" retirement benefits without market crash risk, WITH interest guarantees. Life Settlements A term referring to the business of buying and selling life insurance policies from policy owners. It can also be used interchangeably with the process of determining a market value for a given life insurance policy, or portfolio of policies being purchased by investors. See STOLI, Prohibited Premium Financing schemes, Viatical. Limited Medical Plan (MiniMed Plan, Scheduled Medical Plan)See: Short Term Plan
https://www.hhs.gov/sites/default/files/CMS-9924-F-STLDI-Final-Rule.pdf List Bill (Charge Master)A fee-for-service invoice sent by a medical provider to an insured for services rendered. List Bills may be limited to the contracted rate, or may be whatever the provider decides to bill - subject to R&C. Living Benefits A term used by some life insurers featuring early death benefit payouts for terminally ill insureds. See: Viatical Local Coverage Determination (LCD)An ICD-10 term used to classify and charge for care. Locum Tenens A physician who is typically employed under contract for a period of under one year, and while a permanent physician employee is being sought to fill a position. locum tenens physicians are routinely used for several types of hospital based physician (ER, Pathology, Radiology, Anesthesiology) functions.
http://www.medscape.com/viewarticle/874743?src=wnl_mdplsnews_170127_mscpedit_wir&uac=166293CV&impID=1279832&faf=1 Long Term Care (LTC)A policy that insures Activities of Daily Life that are considered “custodial", and excluded under typical medical insurance policies.
see: Custodial Care, http://www.americanbar.org/publications/voice_of_experience/20160/december-2016/improving-the-long-term-care-system-by-compensating-family-careg.html Long Term Care Insurance An insurance policy triggered by a member’s inability to perform 2 or more activities of daily life (ADL). ADL’s can include: bathing, shopping, transporting, toileting, check writing, cleaning, cooking, housework, banking, etc. These are explicitly defined in long term care policies. Long term care is considered custodial and not acute care, and is not insured by most major medical or Medicare plans beyond the period defined in the policy for rehabilitation. Coverage is generally of two types: lump sum to spend as needed, or lump budget doled out by a daily limit schedule (i.e. $250 per day up to $150,000 limit). Long Term Care Quality Public Reporting (LTCH QPR)See Instructions here first:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/LTCH-Quality-Public-Reporting.html Long-term and Post-acute Care (LTPAC) Loss Conversion Factor (LCF)A multiple or factor used to assign good or bad experience when rating premiums typically used in rating workers compensation, premium.
NCCI manages major responsibility for overseeing application of retrospective rating. Application of LCF and retrospective ratings can become central to charged premium disputes. Loss Reserves The actual or actuarially/regulatorily defined amount a carrier books as a liability in preparation of a pending claim. Love Love is effortful, not effortless. There is no great love without great sacrifice. Radical inclusion of all of God's creation. Unconditional forgiveness. Human love is a work in progress. (A humble journey whose truth is relative to an individual's time.) I credit Richard Rohr for many of these conclusions. If you have not studied his book "Falling Upward", be prepared to be changed. Lower Healthcare Costs Act Federal bill centered on eliminating Surprise Billing, and federal prohibition against "federal (as opposed to exclusive health plan) negotiating pharmacy pricing discounts, and physicians gage order rule prohibiting Rx (generic or alternative) substitution. See: HELP Committee
M Maintenance of Certification (MOC)See: American Board of Internal Medicine (ABIM) over its maintenance-of-certification (MOC) program. Recent Supreme court ruling for ABIM. Major Contributing Cause (MCC)A term used to determine potential compensability (eligibility) of a medical claim insured under workers compensation. The term addresses a determination of a medical claim being 51% or more caused by the job related injury event, and not from an uninsured preexisting medical condition.
IME's and EMA's can be used to determine if treatment is appropriate.
See IME, EMA, SA, MMI. These determinations are subject to contentious debate. Major Extended Diagnostic Groups (MEDC)A five tier method of categorizing patients from basic to complex medical conditions. Managed Care Organization (MCO)An ambiguous term for many types of organizations managing medical, and / or financial care/risk &non-risk contracted and care, for all types of insurance and populations. (I.e Commercial, Medicare, Medicaid, Workers Comp, Auto PIP, STM, PEO, clinic, public/private Critical Care) and contracts, . Managed Fee For Service (MFFS)The Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO) is pleased to share the following updates:
• Washington Managed Fee-for-Service: Final DY2 and Preliminary DY3 Medicare Savings Report
• Training Opportunity: Palliative Care for Older Adults Dually Eligible for Medicare and Medicaid
Washington Managed Fee-for-Service (MFFS): Final DY2 and Preliminary DY3 Medicare Savings Report
On November 16th, CMS released the Washington final Demonstration Year 2 and preliminary Demonstration Year 3 Medicare savings report, containing Medicare savings results for the Washington Health Home managed fee-for-service demonstration under the Financial Alignment Initiative.
The report is on the Innovation Center website: https://innovation.cms.gov/Files/reports/fai-wa-finalyr2preyr3.pdf
Managing General Underwriter (MGU or Full Stack)A Managing General Underwriter (MGU), sometimes called an MGA -- Managing General Agent, is an independent facility authorized by a carrier to rate, bind and/or issue policies. MGU's are contractually bound to represent the best interests of their sponsoring carrier. They typically share in contingency fees and overrides on profitable business. It is not uncommon for MGU's to be called MGA's (Managing General Agents) which is inaccurate because MGA's almost never have rating and binding authority, let alone claims responsibilities common under MGA contracts.
The difference between a MGA and MGU is that most MGU's have some level of capital on deposit with a sponsoring carrier, or assume a level of deductible risk (see ASD type of structure). In short, MGU's have real incentive to maximize rates for the risk assumed. See: Contingency fees Mandated Quality Reporting ACA promulgated Federal Government position as umpire regarding Evidence Based Medicine (EBM) to certify efficacy of care standards for given alleged treatments. Carriers and self funded employers are charged a tax each year to fund NQOI management. Mandatory Benefits Minimum insurance benefits allowed in an insurance policy that are required by statute for compliance. Unlimited EHB are an example of compliant ACA benefits. Manual Rate aka Book Rate A schedule of rates typically created by actuaries that are filed and approved by state as required by each state. Underwriters use these "maximized" rating schedule(s) to rate individual opportunities for insurance. Sometimes underwriters refer to the "discounted" and underwritten rate at Book Rate". Sometimes underwriters refer to underwritten rate (s) as "Book to Manual" (BTM). Manuel for State Payment of Medicare Premiums (State Buy-in Manual)On December 13, 2019, the Centers for Medicare & Medicaid Services (CMS) released a draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) to states and other stakeholders for review and comment. The draft manual updates information and instructions to states on federal policy, operations, and systems concerning the payment of Medicare Parts A and B premiums (or buy-in) for individuals dually eligible for Medicare and Medicaid. States pay Medicare Part B premiums each month for over 10 million individuals and Part A premium for over 700,000 individuals.
This process promotes access to Medicare coverage for low-income older adults and people with disabilities, and it helps states ensure that Medicare pays primary to Medicaid for its dually eligible beneficiaries. Despite the importance of this process, federal guidance on buy-in is out of date. The draft manual reflects current statute, regulation, operations, and systems changes that have evolved over time. Additionally, the draft manual re-organizes content to make it easier for states to discern federal requirements and find information.
https://www.cms.gov/medicare-medicaid-coordination/medicare-medicaid-coordination-office/state-payment-medicare-premiums Manuscripted Coverage A customized coverage rated to specifically desired coverage(s) and risk appetite. See: Private Label Marketplace (Federally facilitated exchange)In context of medical insurance, marketplace means a federally facilitated exchange, or a state managed place where individuals and small groups can purchase medical insurance during OEP and SEP, and with APTC.
See: ACA final Rules
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/CMS-9926-F-Fact-Sheet.pdf Marketplace Learning Management System (MLMS)Federally managed continuing education courses and certification for (licensed agents, and unlicensed Navigators)agents selling ACA compliant tax credited plans. Marketplace Open Enrollment Notice (MOEN)A notice sent to a Marketplace insured plan member that must be responded to prior to year end to maintain eligibility and or APTC. Marketplace Open Enrollment Period Noticies (MOENs)Federal notices to the public of Marketplace plans eligibility (for EHB and QHP plan(s)- without preexisting conditions exclusions). Maryland All Payor Model (MAPM)Take note:
Medicare QPP model achieving results.
https://downloads.cms.gov/files/md-allpayer-finalevalrpt.pdf#page=15 Master Services Agreement (MSA)MSA can mean many things. Some carriers offering level funded plans call ASO contracts, MSA's. See: ASO, and Medical Savings Accounts Matallic plans A federal government term for Individual Marketplace or SHOP (employer plans) insuring a minimum level of benefits to a HHS defined actuarial value. For example, INDIVIDUAL Marketplace sold "Silver" level (70% Actuarial Value) plan(s) qualify for both APTC AND Cost Sharing. Employers QHP's require "Bronze" (or 60% Actuarial Value) plans to avoid potential penalty. Maximum efficient Contract (MEC)A life insurance term used to differentiate IRS compliant life insurance coverage benefits that are taxed versus Life insurance benefits (loans and death benefits) that are not taxed. IRS has two tests for determining compliant Life insurance meets statutory minimum standard. In short, IRS requires a minimum death benefit to premium deposit ratio for compliant coverage and tax free death benefits. We recommend legal opinion from licensed legal counsel if you are unsure your policy is, and will remain compliant during the entire policy period. Maximum Medical Improvement (MMI)Term used in workers compensation to represent an injured worker's maximum recovery/medical state and expence for purposes of settling the medical claim payout. Generally, the file is closed after final medical bills are paid. Maximum Non-network Reimbursement Program (MNRP)See: ENRP Maximum Out Of Pocket (MOOP)The total annual limit an insured person pay for eligible medical care before their policy pays 100% of medical charges. This can be very different from ACA (law) QHP with EHB, than for STM.
Deductibles, Co Insurance, and Copay amounts typically attribute to MOOP. ACA regulations set MOOP each year (I.e. 2020 $8,150). See: Balance Billing. Note: ineligible medical care, or balance billing above the "insured amount" does not accrue to MOOP. See: RBP Maximum Per Diem This term is used to convey the maximum reimbursement of hospital charges a policy holder will recover each day. It is a figure compared to the average cost per day derived by dividing the total charges by the length of stay. Almost all HMO reinsurance and PEL policies have this provision that can tend to reduce coverage. Meaningful Access ACA "Meaningful Access" Time Line
September 13, 2016
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Section 1557 of the Affordable Care Act (ACA) applies to protected classes of individuals whose health coverage may not be denied, cancelled, limited or refused on the basis of race, color, national origin, sex, age, or disability and it builds on other federal civil rights laws to do so. The rule was effective July 18, 2016, with a couple of exceptions.
•First, provisions that require changes in health insurance or group health benefits design are applicable on the first day of the plan or policy year beginning on or after January 1, 2017.
•Second, portions of the law that address meaningful access for persons with limited English proficiency are effective beginning on Oct. 16, 2016.
The law is broad and will affect health insurance issuers and employers that receive federal financial assistance from Health and Human Services (HHS). One part of the law provides expanded protection for transgender individuals, which we covered in the July Broker Connection. The other parts cover meaningful access regulations that address the following requirements.
Access to Language Assistance
Covered entities must provide language assistance services free of charge, and the services must be accurate, timely, and protect the privacy of an individual with limited English Proficiency. Language assistance includes interpretation (oral) and translation (written). Covered entities must offer a qualified interpreter to an individual with limited English proficiency free of charge and use a qualified translator when translating written content in paper or electronic forms.
Access to Auxiliary Aids and Services
The Final Rule also requires covered entities to make communications with individuals with disabilities as effective as communications with others, including the use of appropriate auxiliary aids and services to persons with impaired sensory, manual, or speaking skills.
Assess to Electronic and Information Technology
Covered entities must ensure their health programs or activities provided through electronic and information technology are accessible to individuals with disabilities. This includes technology used by individuals on portals and mobile phone applications. The disabilities contemplated in the final rule include vision, hearing or sensory impairments, such as a person who in unable to use a mouse or keyboard.
Distribution of Nondiscrimination Notice and Taglines
Covered entities must take appropriate initial and continuing steps to notify beneficiaries, enrollees, applicants, and members of the public:
1.That the covered entity does not discriminate on the basis of race, color, national origin, sex, age, or disability in its health programs or activities;
2.How to request assistance in another language or format and that these services are free of charge;
3.How to file a discrimination complaint and get assistance;
4.How to file a discrimination complaint with OCR.
This “non-discrimination notice” is required to be included for all significant communications sent by the covered entity whether written, electronic or both.
Covered entities must also post the non-discrimination notice and taglines to alert individuals that language assistance services are available.
•The regulations uses a state threshold, requiring covered entities, generally, to post taglines in at least the top 15 non-English languages spoken in the state in which the entity is located or does business.
•Covered entities that serve individuals in more than one state can aggregate the top languages to determine the top 15, or for small sized communications such as postcards or tri-fold brochures, to the top two languages. Languages are determined by census data.
A covered entity must submit an assurance on a form specified by the Director of the Office of Civil Rights of HHS that its health programs and activities will be operated in compliance with Section 1557.
Access to Buildings and Facilities
Each facility or part of a facility in which health programs or activities are conducted that is constructed or altered by or on behalf of, or for the use of, a recipient, must comply with the 2010 Americans with Disabilities Act (ADA) standards for accessible design if the construction or alteration was commenced on or after July 18, 2016. There are exceptions related to facilities that depend on the date of building construction and compliance with ADA standards. Requirements are limited to the public facing areas of entities.
Oversight and Grievance Procedures
Each covered entity that employs 15 or more persons has to:
•Designate at least one employee to coordinate its efforts to comply with and carry out its responsibilities, including the investigation of any grievance alleging noncompliance with Section 1557.
•Adopt grievance procedures that incorporate appro Meaningful Use A term used by CMS to reduce Hospital Medicare reimbursement in 2018, based upon CMS conclusion if Hospitals have used Electronic Health Record (EHR) data to improve outcomes, lower cost or both.
The Quality Payment Program is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and includes two tracks — Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).
MIPS has replaced three Medicare reporting programs:
• EHR Incentive Program (Meaningful Use)
• Physician Quality Reporting System
• Value-Based Payment Modifier
The Quality Payment Program listserv will provide news and updates on:
• New resources and website updates
• Upcoming milestones and deadlines
• CMS trainings and webinars
The Quality Payment Program’s first performance period began on January 1, 2017 and ends on December 31, 2017. Starting January 2019, providers who do not submit performance data get their Medicare reimbursements cut about 5%, and those that do get about a modest increase. Meaningful Use ( Re: MACRA) (MU)See MACRA
One of two payment options Physicians accepting Medicare Part B patients will choose to be reimbursed.
MIPS uses MU, PQRS and VM to score performance across four areas, and modifies Part B reimbursement.
APMs use two-sided risk-based payment methodologies, inclusive of Next Generation ACO, and Comprehensive Primary Care Plus (CPC+) value to adjust reimbursement and potential bonus for meeting guidelines. See: QPP, Shared Services Medi-share Plans See: Ministry Health plans that are not insurance. Medicaid A state health insurance program for people earning under 100% of FPL, and eligible for Medicaid. Medicaid is different in each state. Medicaid can have about 15 categories of eligible people, and coverage. Typically, the federal government gives 50% of a state’s Medicaid budget. Under ACA, Medicaid eligibility was expanded from 100% to 133% of FPL for eligibility in states electing to expand Medicaid eligibility. 13 states elected not to expand Medicaid eligibility (make available to people earning a little over 133% FPL).
An estimated 75 million people are Medicaid beneficiaries. Source: Benefits Pro. Medicaid disproportionate share hospital (MDH)Relates to a controversial CMS regulation apportioning Medicaid reimbursements to hospitals. Medicaid Expansion A voluntary state expansion of Medicaid eligibility offered under ACA by the Federal Government for three years. The provision allows poor people access to free or less expensive Medicaid insurance by increasing income cut-off eligibility from 100% to 138% of FPL.
A program that the Supreme Court allowed individual (13) states to opt out, despite the federal government funding the first three years of added cost. Under the Affordable Care Act, states have the option to expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19-64 with a household MAGI at or below 138% of the FPL. This is known as "Medicaid expansion."
However, some states have chosen not to expand Medicaid eligibility. Regardless of whether a state chooses to expand its Medicaid eligibility, all state Medicaid programs:
Use MAGI as the income methodology for the majority of applicants (generally, all non-elderly, non- disabled populations). Do not consider assets in determining eligibility for individuals whose financial eligibility is based on MAGI.
Streamline income-based rules, systems, and verification procedures (Source Healthcare.com) Medicaid Expansion Under the Patient Protection and Affordable Care Act, states may expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19-64 with a household MAGI at or below 138% of the FPL who are not otherwise eligible for and enrolled in mandatory Medicaid coverage, and are not entitled to or enrolled in Medicare Part A or B. This is known as "Medicaid expansion."
However, some states have not expanded Medicaid eligibility. Regardless of whether a state expands its Medicaid eligibility, all state Medicaid programs must:
Use MAGI as the income methodology for the majority of applicants (generally, all non-elderly, non-disabled populations);
Not consider assets in determining eligibility for individuals whose financial eligibility is based on MAGI; and
Streamline income-based rules, systems, and verification procedures.
Source: Marketplace Agent Certification Exam Medicaid For All A ambiguous term typically used to describe Medicare eligible beneficiaries (as yet not) granted right to see a Medicaid participating provider where Medicare participating providers are unavailable in rural areas. See: Medicare For All. Medical Cost Inflation A term usually reported as increases to large group premiums without adding in massively increasing deductible and out-of-pocket costs the same insured group must pay. As a rule, its at least 200%-400% more than CPI. In many years past, it has been more than 4 times (400%) CPI for Individual and small group premium increases. See: The Medicare link below.
Milliman report. =====================
Milliman is a company specializing in advanced medical cost analysis and trend. Milliman is well known for establishing underwriting parameters.
2018 Average Medical Plan (premium) cost for family of four $28,000 (Plus deductible, copays and Maximum out of pocket costs)
In 2018, my personal (Individual) insurance with Blue Cross (Solver plan) increased 45% in one year. Cost for my family of two in 2020 will be about $18,000 for a $8,000 deductible policy. In other words, if we have an accident with both people incurring full deductible, the plan does not pay 100% of medical costs until after we satisfy $16,000 deductible, plus $18,000 premium = $34,000.... And I am insured? The reckoning is coming - See: Executive Orders affecting hospital reporting.
http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2018-milliman-medical-index.pdf Medical Cost Sharing Plan See: Health Cost Sharing plan Medical Insurance Bureau (MIB)A permanent medical record consisting of claims reported by insurers detailing health status of a potential insured. MIB is an underwriting tool used by carriers to decline or offer new insurance coverage to individuals. MIB is accessible only to entities securing proper HIPAA signed release. Medical Loss Ratio (MLR)Medical Loss Ratio is typically defined as Total Premiums/Total claims. ACA mandates premium rebates where the percentage of PAID claims are less than 80%/85% of Individual/Group (employer) collected premium. MLR rebates (if PAID claims did not exceed 80%/85%) apply to Marketplace plans. The law requires insurers to spend a minimum percentage of premium dollars (80 percent for individual and small group (1-50, or 1-100 depending on the market) markets and 85 percent for large group (51+ or 101+ depending on the market) on medical services and activities designed to improve health care quality.
Commissions and profit margin are not part of MLR. But, apparently, carrier's quality assurance expenses over a three year period do reduce "premium" in the calculation.
For the 2017 rebate reporting year (2018 payout year), California, Colorado, New York and Vermont define small group as 1-100 and large group as 101+.
Recent Trump inspired rule changes are modifying the calculation to allow carriers to add into the claims calculation various administrative services like "quality improvements" the affect a lower refund liability - without repealing ACA law.
(source: United Healthcare Agent advisory)
See Link for 2019 record payouts- meaning the premiums charged were much higher than needed for solvent plan operations at $2.7 Billion in 2020 v. $1.4B for 2019.
https://www.benefitspro.com/2020/04/20/private-insurers-expected-on-track-to-pay-out-2-7-billion-in-mlr-rebates/?kw=Private%20insurers%20on%20track%20to%20pay%20out%20%242.7%20billion%20in%20MLR%20rebates&utm_source=email&utm_medium=enl&utm_campaign=healt Medical Savings Account (MSA)A federally authorized account funded with pre-tax dollars for INDIVIDUALS (including Medicare beneficiaries) used to pay eligible medical expenses. Funds are typically used to pay eligible deductibles, co insurance and max out of pocket costs. MSA accounts allow for reimbursement of some costs of care that are not insured, and are outside of the major medical "insured" coverages. (I.e. AC expenses for asthmatic children. See HHS/IRS list of eligible uses of funds.
See: HSA, ASO, HRA
MSA can also refer to the Medicare Set-Aside program offered by CMS and related to workers compensation insurance.
https://www.cms.gov/Medicare/...Medicare-Set-Aside.../WCMSA-Reference- Guide-Version-2_6.pdf Medically Necessary A legal term defined by ERISA, and modified by state statute where applicable. a.k.a. Medical care that is not experimental or prohibited by the FDA, that is appropriate for the diagnosis, treatment, cure or relief of health condition, illness, injury, disease, or its symptoms, within generally accepted standards of medical care in the professional community. Some definitions add that it does not include care solely for the convenience of the insured, or the insured's family. Examples of care that is not medically necessary might include keeping an elderly person in the hospital because the family does not want to deal with home rehabilitation because they failed to buy a long term care policy. Some cosmetic medical care is medically necessary. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)A bipartisan bill signed in 2015 that stopped the automatic 21% discount of Medicare reimbursements, and replaced it with value based reimbursements.
See: MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
QPP does not change hospital or Medicaid MU. Medicaid MU participants who also bill
Medicare will need to participate in both Medicaid MU (through 2021) and MIPS. (Source: Athenahealth)
MACRA bonuses (Medicare Part B)physicians up to 4% in 2017 and up to 9% by 2022 for "performance" based on meeting or exceeding quality metrics IF same physicians submitted the annual quality metrics. Unresponsive physicians get penalized up to same percentages of the "at risk portion of their Medicare reimbursement" for procedures.
MIPS offers essentially four avenues to entice physician engagement. Submitting nothing in the MIPS program means reimbursements go down (-4% in 2018), or do not get annual increases, or "bonus" assigned to Medicare Part B by meeting or exceeding "quality measures" being defined now.
What is MACRA?
MACRA is an acronym for Medicare Access and CHIP Reauthorization Act, legislation signed into law in 2015.
It is a law that states that anyone who is “newly eligible” for Medicare starting January 1, 2020, and beyond may not enroll in a Medicare Supplement Plan that covers the Part B deductible, such as plan C, F, or High Deductible F. (Source Humana Agent Advisory)
CIGNA Agent Advisory
1. What is the Medicare Access and CHIP Reauthorization Act of 2015? (MACRA)
MACRA has many components, one of which is a limit on first dollar coverage in certain Medicare supplement insurance plans for individuals considered “newly eligible” and a transition away from using Social Security numbers as identifiers. It also includes a change to the way Medicare pays healthcare professionals. Currently, healthcare professionals are paid based on the number of services they perform. MACRA allows for healthcare professionals to be compensated on quality of care as opposed to the number of services they perform.
2. Who is considered newly eligible?
“Newly eligible” is defined as anyone who is turning 65 on or after January 1, 2020 or anyone who is eligible for Medicare benefits due to age or disability as defined by the Centers for Medicare and Medicaid Services (CMS) on or after January 1, 2020.
3. What does MACRA require?
As of January 1, 2020 MACRA does the following:
Prohibits first dollar Part B deductible coverage on Medicare Supplement so Plans C and F cannot be sold to those “newly eligible” for Medicare.
Makes Plans D and G the new guaranteed issue plans for those who are “newly eligible” within the guaranteed acceptance rules for Medicare Supplement plans.
Mandates that a Social Security Number can no longer be used as an identifier.
4. How are enrollees in current Plans C and F affected?
No change. Plans C and F can still be sold after January 1, 2020 BUT only to Medicare beneficiaries who were age 65 PRIOR to 1/1/2020 or first became eligible for Medicare PRIOR to 1/1/2020 regardless of what plan they had previously.
Plans C and F are NOT going away. Current policyholders can continue with their Plan C or Plan F and may continue to buy Plans C and F beyond January 1, 2020. Example: A customer who bought Plan F (or any other plan) in 2018 can purchase any plan, including C and F, prior to January 1, 2020 or thereafter.
5. What will the new Medicare card design be?
MACRA mandates the removal of Social Security Number (SSN) based Health Insurance Claim Number (HICN) from Medicare Cards to address the risk of beneficiary medical identity theft and fraud.
New numbers are unique and randomly assigned
The new number will be referred to as the Medicare Beneficiary Identifier Number (MBI)
Beginning April 2018 new cards will be issued and will continue through April 2019.
Review the new Medicare card design and press release to learn more.
KEY TAKEAWAYS (Source Healthcare Leaders Dec 2018)
More than 1,550 hospitals (over 55%) will share higher Medicare payments totaling about $1.9 billion in fiscal year 2019.
The average net increase in payment adjustments is 0.61%, and the average net decrease is -0.39%.
For 2019, average Total Performance Score across all participating hospitals increased to 38.1 from 37.4 in 2018
See: LAN, HCTTF
https://qpp.cms.gov/ Medicare Advanced / Accellerated Payments (Advanced Payments)
https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf Medicare Advantage (MA Plans)HMO and PPO plans offered by commercial carriers, but paid for by the HHS to people over 65 years of age. Unlike Original Medicare Part A (stand alone), or Medicare Supplemental plans, MA plans mandate in-network provider access to reduce or eliminate out of pocket costs. See MAPD
...An estimated 21 million people elect Medicare Advantage plan participation. Source: Benefits Pro. Medicare Advantage County-Level monthly capitation payment A somewhat mysteriously calculated fixed monthly "premium" payment directly to carriers from the federal government to carriers offering Medicare Advantage (HMO/PPO) plans by county. "2020 county-level averages range from $755 per month, in Presidio, Texas, up to $1,609, in Nome, Alaska. The 2020 state-level averages ranged from $883 per month, in Hawaii, up to $1,168, in Alaska." Source:ThinkAdvisor - Oct 2019
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Ratebooks-and-Supporting-Data.html?DLSort=0&DLEntries=10&DLPage=1&DLSortDir=descending Medicare Advantage Organization (MAOs)see: VBID@cms.hh.gov Medicare Advantage Pharmacy Benefit (MAPB)Pharmacy Plans attached to MA plans. Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration (MAQI)See MIPS
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12.html Medicare Advantage Risk Adjustment (MARAP)See: 21st Century Cures Act Medicare Advantage Value-based Insurance Design (VBID)See: Medicare Part D Medicare Advantage Value-Based Insurance Design (VBID)See: MACRA, QPP.
https://innovation.cms.gov/Files/x/vbid-rfa2020.pdf Medicare Beneficiary Identifier (MBI)CMS announced a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars. The new cards will use a unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI), to replace the Social Security-based Health Insurance Claim Number (HICN) currently used on the Medicare card. CMS will begin mailing new cards in April 2018 and will meet the congressional deadline for replacing all Medicare cards by April 2019. Work on this important initiative began many years ago, and was accelerated following passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). ================ A special number Medicare uses to adjudicate claims that is not the HICN. See: HICNs. Just know there are exceptions, and good luck! (Source: CMS)
SEE: NGHP, CMS, RREs
Medicare Coordination of Benefits See: NGHP
https://innovation.cms.gov/initiatives/direct-contracting-model-options/ Medicare Coverage Gap Discount Program A manufacturer discounting on brand name drugs to Part D member sho have reached the coverage gap (Donut Hole), and to are not receiving Medicare Extra Help. For Brand name drugs, the 70% discount provided does not include dispensing fee. Members pay 25% of the negotiated price and a portion of the dispensing fee for brand name drugs. 9Plan paid 55 does not count towards your MOOP. Some help is also available for Generic Drugs. Contact Customer care at you carrier.
Beware: formularies and tier assignments can change suddenly and retroactively. Medicare Critical Access hospital (CAHs)See: Payment interoperability.
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index?redirect=/EHRIncentivePrograms/ Medicare Diabetes Prevention Prog (MDPP)See: CMS, QPP, MIPS, ACO Medicare Diabetes Prevention Program (MDPP)On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Physician Fee Schedule (PFS) proposed rule that would make additional proposals to implement the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018. The MDPP expanded model was announced in early 2016, when it was determined that the Diabetes Prevention Program (DPP) model test through the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards met the statutory criteria for expansion. Through expansion of this model test, more Medicare beneficiaries will be able to access evidence-based diabetes prevention services, potentially resulting in a lowered rate of progression to type 2 diabetes, improved health, and reduced costs.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14639.pdf Medicare Disproportionate Share (MDS)CMS programs to help guarantee rural hospital access to Medicare and Medicaid lives.
Share Hospital (DSH) Payment
Adjustment, Medicare-Dependent Small
Rural Hospital (MDH) Program, and
Low-Volume Hospital Payment
Adjustment Issues. Medicare Double Dipper (Double Dibber)A CMS term used to describe a Medicare Part A eligible person who purchased an Individual Marketplace plan, instead of purchasing Medicare Part B. CMS recently decided to "help" people avoid the late Part B penalty by allowing people to buy Part B, drop the Marketplace plan and waive (1% per month LIFETIME penalty - after age 65) penalty. CMS will not help people who owe APTC tax credits in arrears. Medicare Evidence Development & Coverage Advisory Committee (MEDCAC)Health Outcomes After Bariatric Surgical Therapies in the Medicare Population
Posted materials for meeting.
https://www.cms.gov/medicare-coverage-database/details/medcac-meeting-details.aspx?MEDCACId=74 Medicare Executive Order Pay attention to EO that contradict / violate ACA law, along with many regulations guiding FFS, PFFS, Shared Services risk based contracts and ACO demonstration projects, etc.
https://www.whitehouse.gov/presidential-actions/executive-order-protecting-improving-medicare-nations-seniors/ Medicare Extra-Help A department to call to get help paying for drugs when the beneficiary is not already able to get Medicaid Dual Eligibility. It essentially looks at assets (not including your house, car or life insurance) to see if you qualify for extra financial assistance on high cost drugs.
Medicare Fee for Service Regulations (PFFS)
https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/Medicare-Fee-for-Service-Payment-Regulations/index.html Medicare For All (M4ALL)A contentious initiative supported by "single-payer" (national medical insurance) advocates that would allow INDIVIDUALS under age 65 to enroll in a plan allowing access to medical providers participating in the Medicare program, and reimbursing medical providers at a Medicare Allowable rate versus (much higher - about 120% - 240% of Medicare allowable) 100% of the Medicare (RBRVS) schedule participating providers cannot balance bill (above). Most do not understand that "Original Medicare" insures only 150 plus about 20 more days per LIFETIME (not unlimited QHP), so the benefits are not certain at this point in the discussion. Lots of smoke and mirrors from both parties, especially conservatives mischaracterizing it at a totally paid for entitlement by taxing people, versus a voluntary "Buy into Medicare" plan administered by commercial carriers (like Medicare Supplemental plans). Bottom line: If people under 65 can get a plan whose claims costs cause the premiums to be rated well below Marketplace priced plans (paying providers a lot more), "participating" providers will have to function on less revenue from Medicare For All plan members. We all know how the AMA will act to protect their special interest group. The AHA will act to try protect their constituency as well. There is no question premiums would be less expensive than plans paying providers a lot more - regardless of APTC and CSR. There is also little doubt it would have real effect on small town hospital closings, and viability of competing commercially offered plans. We would not bet on hospitals being able to cost-shift higher commercial premiums to broke people, so it means getting lots better at reducing costs to keep the small town hospital solvent.... Medicare For All (Medicare buy in)A Democratic party Bill to allow people over 50 to buy-into an ACA (QHP) qualified plan using existing Medicare participating medical providers. A program that would directly compete with commercial carriers for these super high premium customers. (President Trump's non enforcement of the Age-Compression-Regulation) Medicare For All plan A political plan supported mainly by democrats, but not yet available, to allow people under 65 years of age same or similar ACA qualified (unlimited EHB) insurance buy-in that uses existing Medicare participating providers. Medicare MCMSA (Workers Comp Set Aside)
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Self-Administration Medicare Modernization Act (MMA)A term frequently used by The Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO) when updating:
• Interoperability and Patient Access Proposed Rules. (related to dual eligible Medicare and Medicare beneficiaries.
Medicare OOPS / ASC Medicare Hospital OPPS and ASC Payment System Final Rule for CY 2020
On November 1, CMS finalized policies that aim to increase choices, encourage medical innovation, empower patients, and eliminate waste, fraud, and abuse to protect seniors and taxpayers. The changes build on existing efforts to increase patient choice by making Medicare payment available for more services in different sites of services and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.
In accordance with Medicare law, CMS is updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6 percent. This update is based on the projected hospital market basket increase of 3.0 percent minus a 0.4 percentage point adjustment for Multi-Factor Productivity (MFP).
Using the hospital market basket, CMS is finalizing an update to the ASC rates for CY 2020 equal to 2.6 percent. The update applies to ASCs meeting relevant quality reporting requirements. This change is based on the projected hospital market basket increase of 3.0 percent minus a 0.4 percentage point adjustment for MFP. This change will also help to promote site-neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting.
This directly affects providers who are and are not sending quality data to CMS.
https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other Medicare Outpatient Observation Notice (MOON)See CDI, and QIO
Physician Advisor used term to help improve medical outcomes and reimbursements for Medicare eligible patients. The goal here is to improve medical outcomes, efficacy of care, and reimbursements. The key is efficiently giving treating physicians well supported information that benefits the patient, and timely reduces administrative burdens. The other key is physicians donating their time to inform people who did not go to medical school what type of information meets their goal. Medicare PACE plans A plan offering Part A & B benefits. These are "Programs of all-inclusive Care for Elderly (PACE) organization are special types of Medicare health plans, PACE plans can be offered by public or private companies and provide Part D and other benefits in addition to Part A and B benefits. They are also referred to as Demonstration plans, and/or some ACO plans, etc. Source: Medicare & You handbook 2020 Medicare Part A (Original Medicare (Hospital coverage only))A federal entitlement available to people over 65, (or who are disabled, or who have ESRD, etc) who have paid 40 or more quarters of tax (FICA) into the system. Original Part A insures up to 150 days of acute-inpatient-hospital care (plus potentially 20 more inpatient hospital days) per LIFETIME (not per year), and that also insures eligible hospital-outpatient care, up to 100 days of eligible restorative SNF, Hospice and up to 100 days of SNF. Medicare Part A does not insure Long term (custodial-non restorative SNF) care. It insures acute-hospital-care (where the person is getting better). Part A is a pure entitlement which does not require a monthly premium (reduction from social security) by the eligible member who paid 40 quarters of Medicare taxes.
Medicare part A does not pay for most out-patient drugs (except under Part D), or annual physical exams beyond one physical a year. Does not insure most dental care, routine foot care, eye care, hearing aids, personal comfort items or cosmetic surgery. Most importantly, it does not insure long Term Care (custodial care). Coverage out of country gets squirrelly to figure out.=================
People who have not paid into the system can purchase Part A for $437/m, and can purchase Part B as well for about $100-$125/m depending on age and location. These rates are massively subsidized by the government.
http://www.ssa.gov/medicare/mediinfo.html Medicare Part B (Part B)A Federal medical insurance entitlement program available to people over age 65, and some Medicaid eligible lives that insures physician (and some devices, and many medical-technician's professional) services. Coverage insures both inpatient. Eligible oupatient professional charges inclusive of Home Health, DME, in-home hospital beds, and other qualifying medically necessary equipment. Cost for Part B coverage is about $145 for 2020, up from $135.50 in 2019. There is also an annual deductible
($185 in 2019) that must be meet before coverage starts.
Part B premiums: Medicare Part B pays for doctor visits and other outpatient services.
• If you are collecting Social Security, which automatically pays your Part B premium (by monthly deduction). Those that fail to elect to start the monthly deductions are penalized about 1% per month for every month they fail to elect coverage. That 1% is added to the premium when they do start, and for life.
Eligible persons wishing to elect a low cost Medicare Advantage (Medicare part C plan: HMO/PPO that insure Hospital, Physician, and typically Rx coverage - Part D), must first enroll in part B, and pay the additional premium which reduces a person's social security monthly "pension" check. Some HMO and PPO (Part C plans) may require part D plan purchase as well. See: AARP explanation.
http://www.medicare.gov Medicare Part C Legislation enacted to offer HMO & PPO options to Medicare eligible people, and that typically cost $0 to under $50/m.
The law also authorizes PSO's (Provider Services Organizations) designed to engage physicians into contracts under that compensate a fixed budget with goal of improving outcomes, and reducing costs. See: Provider Maintenance Organizations
MA plans typically come with a Part D (pharmacy) plan attached, and at no additional premium, unlike Medicare Supplemental plans (A-N) that mandate selection of a drug plan at an additional monthly cost of about $30 - $45 (in addition to the $250-350/m Supplemental plan premium, and Part B premiums). MA plans typically insure more things than Medigap plans, like some food, in-home care, some transportation, etc., that Original Medicare (Part A only stand alone), or Medicare Supplemental plans may not insure / reimburse.
Selecting a MA plan can mean big differences in monthly Pharmacy out of pocket costs. Find a qualified agent, or do the work to figure out Rx copay and network access differences between MA, and Medicare Supplemental plans. Medicare Part D (MA-PD, Medicare Prescription Drugs coverage)A stand alone Drug plan (offered commercially, but supervised by the federal government) purchased by people over 65 who choose to insures themselves with a Medicare Supplemental plan (major medical plan A-N). Formularies and Copay Tiers are different among the carriers. In some instances, it also can be elected by PPO insureds as well. Medicare Part D offers optional prescription drug benefits for those entitled to Medicare Part A and Part B (or, that need to add a drug plan to a Medicare Supplemental policy). Most Medicare Advantage plans provide insured pharmacy coverage, and do not require Part D separate election. and monthly premium obligation.
"Drug out of pocket costs (to the member) in 2020 for people who qualify will be no more than $3.60 for each generic drug and $8.95 for each brand-name drug". (Source 2020 Medicare and You handbook) Be careful not to disenroll from employer or Union paid for Rx insurance before confirming what total out of pocket costs may change.
Prescription drug (Part D) premiums run about $30 - $37 per month when attached to a Medicare Supplemental (plans A-N) , PPO, or Medicare Part A & B plan election. Premiums vary by region. Remember, Rx Tier copays can change retroactively, and out-of-pocket Rx costs can get wild - especially for specialty drugs - so ask before you buy.
High-income surcharges: Medicare beneficiaries with incomes at designated levels pay higher Part B and D premiums. What’s different since 2019 is that more people will be subject to these surcharges because the income thresholds have changed.
Know that there are significant differences in formularies, copays and what attributes to maximum out of pocket cost (liability) between plans. Find an experienced agent. Do the work to understand what you are buying.
The Medicare and You 2020 handbook was not clear if, who or how the donut hole exists. Call CMS.
See: Credible Coverage Medicare Coverage Gap Discount Program.
https://www.healthleadersmedia.com/strategy/whats-trumps-american-patients-first-plan Medicare Path Finder A controversial web link that can be used to compare the cost of Medicare Advantage plans with the cost of combining what CMS calls ‘Original Medicare’ coverage (Medicare part A stand alone or with Part B, and/or D) with Medicare supplement insurance. The biggies to try and estimate are out of pocket costs related to Pharmacy (Part D), and copays. Remember, Pharmacy can change retroactively to a higher tier. Medicare Private Fee for Service plans (PFFS)A Medicare entitlement plan option that "insures" care from non-contracted (non-participating) medical providers - up to the "Medicare Allowable" amount, and that allows balance billing to people choosing to go out of network and pay it. These are generally not available in most areas, but for small towns with no contracted (participating) medical providers. Medicare QMB People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing. Medicare providers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1128.pdf Medicare Secondary Payer (MSP)Jargon used to highlight accurate subrogation of claims on dual eligible and multi-insured eligible people. See : Information and instructions for the Medicare Secondary Payer (MSP) Group Health Plan (GHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 MSP Mandatory Reporting GHP User Guide (GHP User Guide).
Section 111 GHP Alerts
Frequently, CMS will publish new guidance in the form of an alert on the GHP Alerts page. These alerts are incorporated into subsequent versions of the GHP User Guide and supersede information published in the GHP User Guide. To obtain the most up to date information and requirements related to Section 111 reporting, be sure to review not only the GHP User Guide, but also any pertinent alerts published after the current version of the GHP User Guide.
Section 111 Coordination of Benefits Secure Website User Guide
The Section 111 Coordination of Benefits Secure Website (COBSW) is used by GHP RREs to register for Section 111 reporting, monitor file submissions, and submit online queries of Medicare entitlement. The user guide for this Web portal can be viewed and downloaded after logging in to the Section 111 COBSW. The link to the Section 111 COBSW can be found in the Related Links section below.
X12 270/271 Companion Guide
Section 111 GHP RREs have the ability to transmit a query file to request information regarding Medicare status and Medicare Part A entitlement and Parts B and C enrollment of individuals covered by the GHP. This query file is submitted in the form of an ANSI X12 270/271 Entitlement Query transaction set. If you choose to use your own ANSI X12 translator to create the X12 270 files for the Section 111 Query Only File and process the X12 271 response, please refer to the companion document which is available in the Downloads section below. This is to be used in conjunction with the National Electronic Data Interchange Transaction Set Implementation Guide and the Health Care Eligibility Benefit Inquiry and Response, ASC X12N 270/271 Implementation Guide. Please refer to the Query Only Input and Response File requirements in the GHP User Guide for more information.
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/GHP-User-Guide/GHP-User-Guide Medicare Secondary Payer Act (MSP)MSP regulation is recently fortified. See updates to the act
Know that Medicare lien resolutions both plaintiff and defendant are big business, and a negotiated process of hospitals trying to get paid timely to an acceptable reimbursement.
See: NGHP for subrogation.
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Medicare-Secondary-Payer/Medicare-Secondary-Payer.html Medicare Secondary Payer Mandatory Liability Insurance (MMSEA)Subrogation rules relative to Medicare beneficiaries COB of No-Fault, Workers Compensation, and INDIVIDUAL insurance.
"Information and instructions for the Medicare Secondary Payer (MSP) Non-Group Health Plan (NGHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation User Guide (NGHP User Guide). The NGHP User Guide is your primary source for Section 111 reporting requirements." Source CMS.
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-User-Guide/NGHP-User-Guide.html Medicare Secondary Payer Recovery Portal (MSPRP)See: CMS Medicare Set Aside (MSA)In contexts to workers compensation claim and the total estimated medical expense to establish maxium medical improvement (MMI), of a Medicare eligible injured worker (IW), it is the amount NOT paid directly to the worker available to pay medical bills. This is done to avoid workers pocketing the cash, and not paying the medical providers, exposing Medicare to the liability. Medicare Shared Savings Program (MSSP)A contract offered by the federal government that shares savings from the successful management of Medicare or Medicaid members with physicians and or hospitals who are able to manage care under the expected budget for that population. These contracts are typically over a three year term. See ACO contract. See: Medicare Shared Savings. See: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html
https://qpp.cms.gov/docs/QPP_MSSP_and_QPP.pdf Medicare Site Neutral payments Payments typically to hospitals for Medicare member care delivered off site, but billed at the higher hospital (on-site) facility rates, that (apparently) Medicare is going to retroactively pay hospitals. Medicare Summary Notices (eMSN's) Medicare Supplemental Insurance (MediGap)Federally stipulated plans A-N that are identical in coverage regardless of the Commercial carrier offering them. MediGap plans do not have PPO or HMO networks per say, so insureds can go to any "participating" (doctor/hospital contracted provider). Going to a non-"participating" provider means being exposed to balance billing liability. Supplemental plans can deny coverage offer under the guidelines. Most common plan is Plan F. Note: New regulations prohibits any plan from waiving Part B deductibles, on new plans in 2020.
"In practice, the MACRA Medigap deductible provision means that many people who, in the past, would have bought Medigap Plan F policies now will have to buy Medigap Plan G policies. Medigap Plan G policies are like Medigap Plan F policies, except that they require the enrollee to pay the Medicare Part B deductible.
Consumers were able to buy a high-deductible version of Medigap Plan F.
Medigap Plan F High-Deductible coverage will become Medigap Plan G High-Deductible coverage. Users of Medigap Plan G High-Deductible coverage will have to pay the Medicare Part B deductible themselves, but the amount paid to satisfy the Medicare Part B deductible will now go toward satisfying the Medicare Part G deductible.
The MACRA changes also affect sales of new Medigap Plan C policies.
Medigap Plan C policies are similar to Medicare Plan F policies, except that they offer no coverage for “Medicare Part B excess charges,” or the extra amounts charged by providers who don’t participate in Medicare. Many people who would have bought Medigap Plan C policies will now have to buy Medigap Plan D policies." Source: Think Advisor 1/2/20
https://www.cms.gov/Medicare/Health-Plans/Medigap/index.html Medicare Trump Executive Order (EO 13813 (Oct 3, 2019))Executive Orders that may violate ACA law and patient protections, and that require very flexible administration of risk. Note effect on Medicare Supplemental reimbursements (or Original Medicare FFS) to hospitals and well known results. See Network Adequacy, PFFS, etc.
https://www.whitehouse.gov/presidential-actions/executive-order-protecting-improving-medicare-nations-seniors/ Medicare WCMSA A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is an agreement between Medicare and the Medicare beneficiary to take a portion of a Workers’ Compensation (WC) settlement and set those funds aside for all future work-injury-related medical expenses that are covered and would normally be paid by Medicare. The goal of creating a WCMSA is to set aside money from the settlement to cover those injury-related medical expenses for which Medicare may not make payment. Source: CMS
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Self-Administration Medicare-Medicaid Coordination Office (MMCO)See: Dual Eigibles Member Shared Responsibility Amount (MSRA)A nonstandard term to describe out of pocket costs of a medical plan that may, or may not be ACA compliant. Merrit Based Incentive Payment System (MIPS)The successor to meaningful use, known as Advancing Care Information. See MU, PQRD, & VM. The Quality Payment Program is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and includes two tracks — Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). MIPS has replaced three Medicare reporting programs: • EHR Incentive Program (Meaningful Use) • Physician Quality Reporting System • Value-Based Payment Modifier. The Quality Payment Program listserv will provide news and updates on: • New resources and website updates • Upcoming milestones and deadlines • CMS trainings and webinars The Quality Payment Program’s first performance period began on January 1, 2017 and ends on December 31, 2017. The first payment adjustments based on performance go into effect on January 1, 2019. Under MIPS, providers have to report a range of performance metrics and then have their payment amount adjusted based on their performance. Under Advanced APMs, providers take on financial risk ( i.e. Shared Services contracts) to earn the Advanced APM incentive payment. See: MU, PQRS, VM, CPC+, QPP, & Bundled Payment QPP does not change hospital or Medicaid MU. Medicaid MU participants who also bill Medicare will need to participate in both Medicaid MU (through 2021) and MIPS. (Source: Athenahealth)
https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other Milliman Medical Index (MMI)Milliman is a medical actuarial company estimating medical costs inflation of many things. i.e. Premiums, medical provider costs, etc. Milliman also publishes a subscription only underwriting manual used to rate premiums. MiniMed or Limited Medical Insurance Plans MiniMed is non ACA compliant insurance offering a limited medical benefit typically under $50,000 a year. It typically limits hospital, pharmacy, surgical and physician charges to a maximum amount or per diem. Vision, Mental, Dental and Pharmacy benefits may be included within the insured benefit schedule, or as a discounted network access benefit or feature. The program is generally purchased by groups unable to afford traditional major medical insurance. Minimum Essential Benefits (MEB)The actuarial value percentage a QHP plan must pay of claims as defined by HHS MLR. See: QHP Minimum Essential Coverage See: QHP, PPACA law Minimum Participation Rate (MPR)The minimum percentage of eligible (FTE) employees counted and/or enrolling in major medical group insurance - typically defined as 75% of the group size. See Contribution requirements. Minimum Premium A terms used to describe the lowest premium amount a carrier feels is worth bothering about underwriting, or accepting a prescribed risk. Minimum Premium plans
See Level Funding
Minimum Savings Rate (MSR)MSR is the percentage of claims saved under an ACO Shared Savings contract period (typically three years), and is used to convey how efficient and effective medical care was delivered under budget, MSR denotes a Shared Savings provider bonus. See MSSP. Ministry Health Plan (Medi-Share Plans)A non compliant QHP that is typically not insurance in most states. State law(s) determines if it is insurance. (See: PSO, COOP, risk bearing entities, etc.) Premium cost is typically 50%-60% less than ACA QHP, but is neither major medical insurance, nor discount plan. Some states have specific classifications for "shared medical discounting association plans". Preexisting medical conditions are almost always excluded, along limited benefits in key areas of EHB. These plans typically REIMBURSE the member up to a maximum limit RBP - typically a percentage of the Medicare Allowable that is typically well below the billed (non-discounted PPO contracted rate) "self pay, or Bad Debt" amount charged by many providers who do not accepting RBP. Religious affiliation may not be a requirement, but is part of the marketing process. See: Balance billing, RBP, Medicare Authorized charge, STM, Risk Bearing Entities, etc. There is no set definition for these plans. Successfully vetting sometimes ambiguous state law compliance can take a lawyer, politician. and insurance expert. Lower pricing for these plans comes with strings attached, and may not warrant effective ACA QHP (and APTC, etc) plan substitute. See: Healthcare Sharing (cost sharing) plans/associations.================= Ministry Health Plan (Healthcare Cost sharing plans, Faith Based Pl)An individual or group major medical plan that may not be insurance, or Discount plan, and is in fact a RBP "association" "reimbursement" plan. Assignment of benefits can cause unexpected "insurance" compliance issues. Be cautious.
These plans operate in "sometimes" nebulous (or unenforced ACA prohibitions against) non-ACA compliant QHP coverage, rules and regulations. See: ACA QHP, EHB, Preventive Care, Actuarial Value, PreX prohibition, underwriting, community rating, etc. See: (companies): Trinity Healthshare, STM, Health Insurance Innovations, PIVOT, MEDEK, Reahlm health, One Source, etc.
MOD A numerical value calculated by NCCI to rate classes of employee risk for workers compensation premiums. The higher the number, the higher the premiums/risk. Values excess o 1.0 are considered greater risk, and are charged higher premiums. See: Distressed Risk. Modified Endowement Contract (MEC)A modified endowment contract is a life insurance contract entered into on or after June 21, 1988, that fails to meet the seven-pay test. Meaning the cumulative premiums paid into the policy during the first seven years exceed the amount needed to produce a paid-up policy based on seven net level annual premiums.
If the policy is considered a modified endowment contract, FIFO tax treatment is forfeited, and last in, first out (LIFO) tax treatment takes its place—causing withdrawals to be taxed on an income-first basis.
Meaning that if you plan to borrow funds from life insurance surrender values in retirement, any loans must remain in compliance with what IRS considers legitimate life insurance contracts. IRS uses two primary tests to determine if a policy is, or is not life insurance.
Monoline Policy A policy with essentially one coverage like liability, or just Commercial Auto, or just property. See: CPP Most Favored Nations A Most Favored Nations clause in a managed care contract guarantees that the lowest charge master will be used when filing claims. Stop Loss reimbursements typically follow the lowest contracted rate competently paid by the administrator of the claim. Most Favored Nations Clause (MFN (see report))A contractual provision declaring the lowest amount paid, scheduled, or contracted for billed charges is accepted as full payment. In context to hospital bills, about twenty states have attempted to limit providers influence though banning these clauses. Source: "State Policies on Provider market Power Feb 2020"
See: CON, price fixing, antitrust, reprice
https://www.catalyze.org/wp-content/uploads/woocommerce_uploads/2020/02/State-Policies-on-Provider-Market-Power_2020-Update_Published.pdf Most Favored Nations Clause (MFN (see report))A contractual provision declaring the lowest amount paid, scheduled, or contracted for billed charges is accepted as full payment. In context to hospital bills, about twenty states have attempted to limit providers influence though banning these clauses. Source: "State Policies on Provider market Power Feb 2020"
See: CON, price fixing, antitrust, reprice
https://www.catalyze.org/wp-content/uploads/woocommerce_uploads/2020/02/State-Policies-on-Provider-Market-Power_2020-Update_Published.pdf Motor Truck Cargo (MTC program)A commercial (cargo) trucking insurance package plan.This coverage insures against the risks of direct physical loss to covered property while in transit, loading or unloading, and while at a terminal or dock awaiting final distribution. There are many types and special attention needs to be paid to ports and transportation through and in between covered service areas. See: BI MSSP Track 1
Shared Risk CMS provider contract option that essentially allows medical providers to assume 4-8% of the contract (total Medicare A+B) budget savings on medicare contracts.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/New-Accountable-Care-Organization-Model-Opportunity-Fact-Sheet.pdf MSSP Track 3
See MSSP Track 1. See MACRA
https://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2015-fact-sheets-items/2015-06-04.html Multi Level Marketing (MLM)See: FMO Multi-factor Authentication A term or system of follow-up by the insured to mitigate potential fraud. i.e. calling the customer back on a prearranged phone number to confirm the order, policy change, or funds transfer, texting a password change code, etc. It can be a kind of warranty expressed in the policy conditions, exclusions and definitions or sometimes as part of the application form. These can be very contentious. See theories of proximate cause. See first party, secondary party losses. Multip State Plan (MSP)See: Presidential Orders, and / or certain types of plans offered in specific states in compliance with ACA, state law, and federal law... Its get complicated... Multiple Chronic Conditions (MCC) Multiple Employer Plan (MEP)See: MEWA Multiple Employer Welfare Association (MEWA)A MEWA is a Multiple Employer Welfare Association. It is a federally protected class of health plan organized to provide health insurance to multiple employers not organized under the same federal tax ID. It is regulated by DOL, and by it's Employee Benefits Security Administration (EBSA) - under ERISA legislation that allows employers to take financial (medical) risk on their own employees in the form of stop loss deductibles both aggregate and specific. ERISA applies to any self funded plan such as General Liability and/or self funded workers compensation. ERISA provides various exemptions from state insurance regulation. Practically speaking, most states despise MEWA’s (and MEPs), and will challenge them regardless of ERISA federal superseding exemption. The grey area is where state law prohibits plans without Certificates Of Authority, and federal law(s) allow them. Of the protected classes ERISA legislation govern: (Associations, Trusts, Self funded Employers and Unions), MEWAs are rare, and so are MEPs. The over-reaching purpose of self funding any of these organizations is to reduce insurance costs by assuming a higher deductible (risk), and hoping for average medical claims being lower than the (trended) "fully-insured" (higher priced) plan.
Two types of stop loss are purchased by the Plan Sponsor (employer) to mitigate unexpected catastrophic claims. Self funded MEWAs can offer multiple employers a group medical plan structure to command greater buying power, and even risk management functions worthy of serious consideration. But, where each "member employer" is small in number of employees, MEWA's may not be capitalized (up front) to sustain unexpected (specific and aggregated) losses by their "association" - which is one reason states dislike undercapitalized MEWA’s. Many small employers are also not completly aware that they will share the "group's" risk. ERISA self funded plans can carry risks and obligations of Plan Sponsors, and Plan Administrators (TPA's) that are not insured by stop loss. Additional financial risk-taking is part of any self funded plan. A Fully Insured Health Plan MEWA may, or may not be federally required to possess a state issued Certificate of Authority of stipulated "transfer" (or direct reinsurance pass through) and/or transparency. Most states mandate it. There is long history of states aggressively moving to eliminate MEWA's not meeting state solvency and transparency standards compliance, regardless of federal supersession of quidding law. Material legal assistance is required to set these up and maintain them successfully within state guidelines, despite ERISA exemption.
Prudent management of any ERISA self funded plan mandates purchase of stop loss, and / or funding predictable first and second dollar risk positions. Structuring reinsurance (or stop loss) placement takes real experience, and carrier appetite to insure economically.
ERISA mandates a fiduciary duty of Plan Sponsors in context to primary member (employee) protection. ERISA plans enjoy greater flexibility of insured benefit options, in context to federal laws guiding minimum benefit levels designed to protect the public. Presidential Executive Orders, and DOL agency non-enforcement of ACA law agenda cloud legal compliance consideration(s).
We recommend licensed-seasoned stop loss and legal advice to anyone considering MEWA, or AHP plan offerings.
Most recently, DOL is considering letting (authorized) carriers offer MEP's to small employers. Few carriers will offer competing plans that compete with existing fully insured (low deductible) plans. Almost all major carriers offer "Level-Funded, or Minimum premium plans" targeting small and mid sized groups, and offer "contingent" bonus for lower than expected medical claims experience over a 12-15 month period. These plans typically have very low deductibles that typically fail to make cost savings versus maximum premium savings versus risk assumption trade-off financially attractive.
This blog is offered as a courtesy, and is not tax advice.
https://www.gpo.gov/fdsys/pkg/FR-2018-06-21/pdf/2018-12992.pdf Multiple Loss Medical Reinsurance Multiple Loss Medical Reinsurance is a feature found in high deductible employer stop loss policies. It provides additional coverage for medical charges incurred from the same trauma, or within a 50-mile radius, or within a period of 7 days. I.e. On a traditional $500,000 specific policy, the deductible drops from $500,000 to $10,000, and pays a benefit up to $490,000. Coverage is defined in terms of a maximum, minimum and 3 life warrants.
N N0-Fault (PIP)A term typically related to statutorily mandated auto insurance that pays the medical or property damage expenses caused by a car accident without assigning fault. It does not insure collision, comprehensive damages, or liability. PIP limits are statutorily assigned at $10,000 per person and $20,000 per accident. National Association of ACOs (NAACOS) NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)One of the main federal committees charged with establishing and certifying medical care standards. National Council on Compensation Insurance (NCCI)An agency funded by carriers responsible for setting workers compensation employee Class Codes, and rules, and that set individual employer (class codes) MOD factor that determines cost of workers compensation rates for employer.
NCCI recently reported that hospital mergers (oligopolies) result in average price increases of 6-18%. See below
"NCCI, which serves as the filing agency and rating organization for workers compensation insurance in the majority of states, promulgates a standard workers compensation and employers liability insurance policy (WC 00 00 00 C). The 2015 edition of that policy is in use in all 46 states (and the District of Columbia) that allow private insurers to write workers compensation insurance. (The other four states require all workers compensation insurance to be purchased from a monopolistic state fund.) Most states allow insurers to file their own forms, although few insurers choose to do so. Consequently, almost all workers compensation policies issued in the United States are written on the 2015 NCCI form." (Source Web CE for Florida Agent licensing exam)
"By NCCI Insights
July 11, 2018
Healthcare consolidation improves integration of care and reduces duplication of clinical services. Hospital mergers can lead to operating cost reductions for acquired hospitals of 15%−30%.
Reductions in hospital operating costs do not translate into price decreases. Research to date shows that hospital mergers increase the average price of hospital services by 6%−18%.
For Medicare, hospital concentration increases costs by increasing the quantity of care rather than the price of care.
In addition to mergers, hospitals are also buying up provider practices. Between 2015 and 2016, hospitals acquired 5,000 physician practices.
For workers compensation, hospital consolidation is likely to affect both the quantity and price of medical services. Forthcoming NCCI research will investigate the effect of hospital consolidation on prices and utilization of medical services in workers compensation.
The Impact of Hospital Consolidation on Medical Costs
The year 2017 was a record one for merger and acquisition activity among hospitals and health systems, and this momentum is staying strong in 2018. This Drill Down describes the wave of hospital consolidation since 2010, identifies observed effects of hospital consolidation on utilization and prices of healthcare services, and discusses NCCI’s research in progress on the impact of hospital consolidation in workers compensation insurance. " Source: NCCI National Coverage Determiniation (NCD)In ICD-10 coding term promulgated by a CMS lead group that is used to set medical coding and reimbursement. National Drug Codes (NDC)Pharmacy billing codes National Flood Insurance Policy (NFIP) National Insurance Producer Registry (NIPR)Federal Listing of agents tied to NPN administration National Practioner Data Bank (NPDB)Medical provider data bank tracking histories of medical provider performance. Exactly how this interfaces with MACRA is not known. See: Healthcare integrity Protection Data Bank.
National Producer Number (NPN)Federal ID number assigned to each state licensed agent who sells medical insurance. National Quality Forum (NQF)A medical expert forum that publishes maximized clinical practice standards. See HEDIS Navigator (Authorized Representative)An unlicensed employee who helps people enroll in an ACA QHP, and that is prohibited from commissioning on the sale. Navigators will never give their contact information or last name, so problems have to be handled with different people every time one calls. Good luck!
See: 45 CFR 155.227, Non Exchange Entity, Agents, Brokers, web-Brokers, and OEID - Other Entity Identifier as Enumeration System identifies them in 45 CFR 162.508. (and call your lawyer to explain it) NCCI Workers Compensation Statistical Plan Manual (NCCI Stat Manual)NCCI Workers Compensation Statistical Plan manual governs how the losses are reported to the NCCI and what effect the deductible plan has on the insured’s experience modifier. Network Adequacy Federal and or State defined minimum standard for QHP eligibility.
"To show that the QHP’s network meets the requirement in §156.230(a)(2), the
access plan would need to demonstrate that an issuer has standards and procedures in place to
maintain an adequate network consistent with the National Association of Insurance
Commissioners’ Health Benefit Plan Network Access and Adequacy Model Act (the Model Act
is available at http://www.naic.org/store/free/MDL-74.pdf). This approach would supersede the
time and distance criteria described in the 2018 Letter to Issuers in the Federally-facilitated
Marketplaces." (Source HHS)
For QHP certification, a plan that uses a provider network must have an adequate provider network available to its enrollees. A QHP must:
For QHP certification, a plan that uses a provider network must have an adequate provider network available to its enrollees. A QHP must:
Offer a network that is sufficient in number and types of providers, including mental health and substance abuse disorder providers, to ensure access to all services without unreasonable delay
Make a good faith effort to provide written notice of discontinuation of a provider 30 days prior to the effective date of the change or otherwise as soon as practicable to enrollees who are patients seen on a regular basis by or who receive primary care from a provider whose contract is being discontinued and, if the provider is terminated without cause, allow an enrollee in an active course of treatment with that provider to continue treatment until it is complete or for 90 days, whichever is shorter, at in-network cost-sharing rates
Include a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income and medically underserved populations in the QHP’s service area
Standards for network adequacy and essential community providers may differ in SBM-FP states. Source MLN Training/Certification Exam.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-03027.pdf?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery Next Generation ACO (NGACO)The Next Generation ACO Model created by CMS consists of 44 NEXT GENERATION ACO's. Total ACO's (Jan 2019) is 561. ACO's are CMS's attempt to get medical providers to take financial risk for fair budget deficits caring for Medicare members. The goal of the Next Generation ACO Model is to test whether strong financial incentives for ACOs can improve health outcomes and lower expenditures for Original Medicare fee-for-service beneficiaries. Additionally, it allows participating providers to assume higher levels of financial risk and reward a percentage of the "Shared Savings" budget. The program started with "Pioneer ACOs". Next Generation ACO (44 ACO's) accept "Shared Risk" contracts for Medicare members, and share 50% of the savings, - with some also sharing up to 100% of losses (deficit from the shared services budget). Regular ACO's share roughly 40% of the savings and under the January 2019 CMS "Pathways to Success" (directed at rural practices) mandate about 40%-100% (shared services budget) risk be accepted within one, two or three years. Non Exchange Entity See 45 CFR 155.26(b), including but not limited to Navigators, Agents, Brokers, and Web-brokers. See: IMO, FMO, etc. Non Group Health Plan (NGHP)See: MSP for subrogation, MMSEA rules. "Information and instructions for the Medicare Secondary Payer (MSP) Non-Group Health Plan (NGHP) reporting requirements mandated by Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (P.L. 110-173) are documented in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation User Guide (NGHP User Guide). The NGHP User Guide is your primary source for Section 111 reporting requirements." Source :CMS Non Public Personal Information (NPPI)See: HIPPA, and PI Non Renewal In context to insurance policies, it is notice from the carrier of not offering a renewal offer. Lots of rules apply. Non-Group Health Plan (NGHP)See: CMS, MBI, RREs
See: CMS - Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Recovery Town Hall Questions and Answers and Commercial Repayment Center (CRC) Group Health Plan (GHP) Recovery Town Hall Questions and Answers Overview
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-Alerts/NGHP-Alerts Nursing Home Quality Measures (NHQM)See related measures
16 Quality Measures
O Occam's Razor The principle of minimizing assumptions when explaining cause of effect. Or, The principle guiding the simplest explanation with least amount of assumptions is the best explanation of cause and effect. See Hanlon's Razor, and Ad Abcertum Office of the National Coordinator for Health Information Technology (ONC)A federal office whosepurpose is to refine data collection and disbursement into more effective information public delivery. Office of the National Coordinator of Health IT (ONC)Federal Office charged with making (mostly medical data) information available and meaningful to consumers. See HIPPA, MACRA, VBP, RBP, etc. Open Access A type of medical insurance plan offering access to specialty physician care without the requirement of a primary care physician referral. Plans requiring referral from a primary care provider to access specialty care are called Gatekeeper plans.
Open Access refers to plans that typically do not require PCP referral for SCP appointment scheduling. OA also refer to plans having no PPO network, and insure charges from any provider. See: R&C or Referenced based pricing. It's important to ask the balance billing questions before receiving care to avoid unpleasant and unexpected large balance billing issues. See STM plans.
Open Enrollment See Enrollment periods for Federal Marketplace plans available to INDIVIDUALs and SMALL GROUPS (SHOP), Employer Open Enrollment periods, Medicare Open Enrollment periods for Medicare Advantage and/or Medicare Supplemental plans.
Marketplace OE is typically November 1st through December 15th, but many times get extended with various rules, and exceptions. Medicare plans are different.
Employer Open Enrollment means that employees can elect to become enrolled/insured, (and/or elect additional voluntary benefits) within a specified 30 day period prior to new plan start (and old plan expiration as applicable) Lots of rules governing guarantee issue coverages apply.
See: Special Enrollment periods Open MEP AN open multiple employer plan typically refers to a 401 (retirement) plan offered among multiple employers that typically have a common interest and/or business purpose function. Latest efforts are to get DOL to eliminate existing requirements allowing companies that want to manage and profit from the administration of them a bigger market. Open Payments (Federal) ( Dollars for Docs)A term used in reference to ACA reporting mandate (where enforced by HHS) of payments to medical providers for using or advocating use of brand name drugs and medical devices. According to ProPublica, from 2014-2018, drug and medical device companies paid providers over $2 BILLION. Source: ProPublica
https://www.propublica.org/article/we-found-over-700-doctors-who-were-paid-more-than-a-million-dollars-by-drug-and-medical-device-companies Opiod Treatment Providers (OPT)The Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office (MMCO) is pleased to announce the following update:
• Training Opportunity: Supporting Individuals with Intellectual and Developmental Disabilities (I/DD) as they Age
• Draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) for Public Comment
• Tip Sheet on State Coverage of Medicare Part B Deductible for Dually Eligible Patients
• Third Annual Report of the Evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents—Payment Reform
Training Opportunity: Supporting Individuals with Intellectual and Developmental Disabilities (I/DD) as they Age
Date/Time: Wednesday, December 18, 2019, 12:30 PM to 1:45 PM (EST)
This interactive webinar will discuss strategies for providing care to dually eligible individuals with I/DD across the lifespan. Participants will learn about the physical, cognitive, and behavioral changes typical of the aging process, and how these changes may manifest for someone with I/DD. Speakers will share key supports families, health plans, providers and individuals with I/DD may need to manage these types of changes across the life span, as well as describe an integrated approach for responding to the needs of individuals with I/DD as they age
Register at: https://www.resourcesforintegratedcare.com/IntellectualandDevelopmentalDisabilities/2019_IDD_Webinar/Supporting_Individuals_with_IDD_as_they_Age
Intended Audience: This webinar is intended for a wide range of stakeholders – health plan leaders, primary care providers, social workers, care coordinators, case managers, caregivers, and organizations that provide services for dually eligible beneficiaries with I/DD.
Education Credits: Please see the registration link above for detailed information on continuing education opportunities with this training.
Draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) for Public Comment
On December 13, 2019, the Centers for Medicare & Medicaid Services (CMS) released a draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) to states and other stakeholders for review and comment. The draft manual updates information and instructions to states on federal policy, operations, and systems concerning the payment of Medicare Parts A and B premiums (or buy-in) for individuals dually eligible for Medicare and Medicaid. States pay Medicare Part B premiums each month for over 10 million individuals and Part A premium for over 700,000 individuals.
This process promotes access to Medicare coverage for low-income older adults and people with disabilities, and it helps states ensure that Medicare pays primary to Medicaid for its dually eligible beneficiaries. Despite the importance of this process, federal guidance on buy-in is out of date. The draft manual reflects current statute, regulation, operations, and systems changes that have evolved over time. Additionally, the draft manual re-organizes content to make it easier for states to discern federal requirements and find information.
The draft manual is available at: https://www.cms.gov/medicare-medicaid-coordination/medicare-medicaid-coordination-office/state-payment-medicare-premiums.
We are welcoming comments through 5:00 p.m. EST on February 29, 2020.
Read the New Tip Sheet on State Coverage of Medicare Part B Deductible for Dually Eligible Patients
The Medicare Part B annual deductible applies to opioid use disorder treatment services. For the majority of individuals dually eligible for Medicaid and Medicare, state Medicaid agencies are liable for the Medicare Part B deductible, subject to certain limits. The new Tip Sheet for Opioid Treatment Program (OTP) Providers Serving Dually Eligible Individuals: State Coverage of the Medicare Part B Deductible gives an introduction to the Part B deductible and how OTPs can get Medicaid payment for this deductible when treating dually eligible individuals. It also gives information about enrolling in Medicare and Medicaid, the Medicare claims crossover process, and how to find additional information.
https://www.cms.gov/files/document/otp-crossover-tip-sheet Orphaned Drug (Specialty Drug)"Drug makers have built a lucrative business around drugs developed to treat rare diseases, according to an AHIP study that found prices for orphan drugs are 25 times higher than prices for traditional drugs. Average annual orphan drug prices increased from $7,136 in 1997 to $186,758 in 2017, 88% of them cost more than $10,000 per patient each year, and drug makers are increasingly focused on rare diseases." AHIP update September 2019)
Specialty Drug is a super expensive "Brand" name drug that is either not insured, or insured in a 4th or 5th tier at very high out of pocket costs to the insured. This area of insurance can be highly contentious. Other Entity Identifier (OEID)See: Navigator Out of Network (OON)A term used for medical claims billed from non-contracted (HMO/PPO/ EPO/etc.), network providers, subject to a higher deductible, co insurance, and maximum out-of- pocket patient claims liability. ACA does not limit OON patient liability. Very contentious issue(s). Out of Pocket Maximum (OOP)The annual total liability an individual, or family must pay before the plan pays 100% of the eligible medical charges, including the deductible, co-insurance, Copays. ACA QHP mandates OOP limit for in-network care, but not OON care. Premium is not part of OOP. See: Balance Billing
Note: Link relates to Group OOP, not Individual OOP. No mystery, deductibles and MOOP has increased to $8,150 for 2020 by ACA QHP standard
https://www.benefitspro.com/2020/05/01/who-shoulders-the-greatest-burden-of-out-of-pocket-health-care-costs/?kw=Who%20shoulders%20the%20greatest%20burden%20of%20out-of-pocket%20health%20care%20costs?&utm_source=email&utm_medium=enl&utm_campaign=healthcare Outlier A term typically used to denote a medical condition falling outside of the standard DRG (reimbursement) because of co-morbidities, and that affords increased reimbursement. DRG have "modifiers" or codes that allow for more reimbursements on sicker patients.
Outliers refer to all types of populations and "insurance" conditions.
https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-09-mlnc#_Toc37220540 Outpatient Prospective Payment System (OOPS)See: Price Transparancy. One of two Trump HHS rules forcing hospitals to divulge secret rates they charge different insurers or patients. A "separate" "final rule" termed, 2020 OOPS & Ambulatory Surgical Center (ASC) Price Transparency Requirement for Hospital to Make Standard Charges Public Final Rule confirmed that HHS will move forward to publish publicly facing ("machine readable" - whatever that means?) "best prices" they contract with their insurers. Be sure this will cause major league problems for hospitals who routinely charge 200%-100% more for the same procedure to a person over 65 as a person under 65. Even more difficult is calculating accurate MOOP, which is a requirement of one of the rules. Hospitals will need to comply by 1/1/21. Source: Revcycle Intelligence. See Shared Savings, and MLR, and bring aspirin. Overloan Provision Prevents an outstanding policy loan from terminating life insurance policy, even if the accumulation value
is insufficient to cover policy charges. There is no charge for this agreement until exercised. Remember, IRS compliant Life insurance policies allow for loans against AV ( not cash value) that are not taxed as income. Most people fail to appreciate how paying 25%-35% of investment gains radically effective returns in the 10-40 years of investment term (and paying the about 1% financial management fee). Its big! Do the numbers, and look at carrying income tax liability (i.e. 25%), and market-crash risk in old age - against contractually promised interest crediting (i.e. from 0% - 17% blended index). See: IUL Overpayment A term generally considered to be a type of claims denial (amount).
P Pallative Care (Costodial or Hospice care)
Its estimated that 4% of the Medicare population (age over 65) accounts for 25% of the entire Mecicare spending budget. Many advocates for reducing these costs recommend end of life planning BEFORE people are at the end of life.
Other estimates put the estimate of LIFETIME costs of medical care being 80% incurred in the last weeks or months of life.
Herein lies a delicate balance of merging a multidiciplanary approach to "end-of-life" counseling patients to seek, or not seek heroic (expensive) medical care measures (like resussitation of a person whose brain is no longer functioning, or living wills, etc.), where physicial/mental recovery is unlikely, and further care causes even more pain and suffering to themselves, and their familys.
Waiting until the patient is too sick to render competent decision to refuse care without a sighed living Will typically means that hospitals will MANDATE all heroic medical care - even contrary to family members demanding care be terminated.
See: Living wills, and Advance Directives. Be responsible for making these decisions, or force the burden upon your children at an extreme time of sadness. Do the work.
"As stakeholders call for a dedicated Medicare benefit for the growing field of community-based palliative care, one government-led payment model is going strong in California through Medi-Cal, the state’s Medicaid program.
Effective Jan. 2018, the state’s Senate Bill 1004 (SB 1004), requires Medi-Cal managed care plans to cover palliative care for patients suffering from cancer, end-stage liver disease, chronic obstructive pulmonary disease, or congestive heart failure. Patients may continue curative treatments while receiving palliative care." According to the article, only California Medicaid covers hospice care. Source: Hospice News - Dec 2019
https://hospicenews.com/2019/12/09/california-palliative-care-rule-could-serve-as-national-model/ Paper An informal term used to describe a licensed or Certificate holding “admitted” carrier in a particular state or country. These carriers are both eligible and authorized in states. Surplus lines carriers are eligible, but not authorized to conduct insurance business in a state.
Paremetric Insurance A term describing types of catastrophic coverage triggered by complex causes of loss. See: Proximate causes of loss. These polices make it easier to claim insured losses caused by wide ranging causes (earthquake, floods, your critical commodity supply ship sinking, etc) that may not be directly defined in a policy. See BI in GL, etc. Participating (Contracted)A term generally referred to as a contracted medical provider who has elected to accept as full payment what the contract says, and not what they may decide to charge at the time of service. See; Balance Billing, RBP. Participating Provider (In network provider)Contracted Provider, PPO/HMO network provider of medical services, supplies or hospital care. See: OON Members receiving care from contracted providers are protected from unlimited out of pocket costs, whereas care from non-contracted providers affords no limit to OOP under ACA. (where the feds enforce it...) Participation A group medical insurance term expressing the minimum percentage (70%) of employees required to quality for a QHP.
See: simultaneous Contribution rules. See: SHOP. It can be confusing, especially with what qualifies for QHP. Talk to an experienced agent. Pathways to Success See: Next Generation ACO Patient Activation Measure (PAM)A term used to describe a method of gathering more individual medical history to augment better care. Patient Assistance Program (PAP)Term used to describe a direct from manufacturer copay card that actually makes the patient choose the more expensive drug. See: Specialty Drug Patient Centered Medical Home (PCMH)A term used to describe a primary care physician lead team approach that coordinates Specialist care to achieve preferred EBM outcome. See: CMO, Episode Based Care (EBC), and Clinical Integrated Networks (CINs). Patient Centered Outcomes Research (PCQOR)Patient Centered Outcomes Research
The Patient-Centered Outcomes Research Institute (PCORI) fee is $2.39 per covered life for 2018. Self-funded employers are responsible for paying the fee.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/OutcomeMeasures.html Patient Protection and Affordable Care Act (ACA / Affordable Care Act/ Obama Care)The Patient Protection Affordable Care Act, or the Affordable Care Act/ACA/PPACA or Obama Care is the law of the land. The ACA (Affordable Care Act) is a 900+ page law encompassing all medical care in the US, but with very limited application to Veterans affairs, approved Limited Medical Plans and underwritten Medicare Supplemental plans. ACA compliant plans mandate: 10 Essential Healthcare Benefits (EHB) without annual benefit limits, tax credits for individuals earning between 100% - 400% of Federal Poverty Level (FPL), and Cost Sharing for people earning between 100%-250% FPL. Under the Trump administration, Federal Cost Sharing Reductions (CSR) have been retroactively denied to carriers already committed, and are in litigation today to resolve, with the Supreme Court saying they will decide it. Cost sharing reductions (CSR) lower deductibles and max-out-of-pocket member costs, thereby limiting total annual member health spend from (about) 2% to 9.66% AGI/MAGI. January 2017, the Trump administration denied "risk corridor" (reinsurance recovery safety-net payments to carriers) retroactively as well, thereby causing immediate (alledged $8-$12 BILLION damages) suit by affected carriers against the federal government. HR1 (Tax Reform law) was passed December 2017, and eliminates the Individual ACA law mandate (2.5% tax penalty), effective plan year 2019. ACA law is not repealed, however recent Federal Appeals court ruling holds that APTC (tax credits) absent recently repealed "individual mandate penalty" renders ACA "individual tax credit" void, but stopped short of declaring ACA law void.
(Where limited plans are offered by commercial carriers) Small employers (see ALE) are now offered tax credited plans through SHOP with employer available tax credits for years 1 and 2 of the plan offering. (Florida never offered any plans by any commercial carriers) Similar to Medicare Advantage plans, Individual and Small Group Insurance is provided by commercial carriers, not the government. As a rule the SHOP program has failed, and few plans are even offered by carriers in 2018. (There is very long history of carriers doing everything legal to not write groups under 4 lives - like paying commissions of $0 to $3.50 (FL) per employee/m to the agents, etc.) Several carriers have recently won there cases upholding CSR against the Federal Government. However, a couple of federal courts have found the payments are properly denied. Appeals are likely... See: H.R. 1, Public Law 111-148, as amended by Public law 111-152. Dot forget to throw in Trump's Executive Orders conflicting with the law. (I.e. PreX exclusion being allowed, and violation of EHB-QHP, etc.)==================================
"The House passed a year-end (2019) spending bill implementing the deal it made with the Senate, appropriating $1.4 trillion to keep the US government open, raising the age to buy tobacco products to 21, and repealing several Affordable Care Act taxes including the health insurance tax, the so-called Cadillac tax and the medical device tax. Senate leaders hope to pass the measure in time to head off a partial government shutdown on Saturday, when the current funding runs out." Source: AHA News
https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-03027.pdf?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery PDM (Periodic Data Matching )See Advance Payment Tax Credit PEO Guidelines (NAIC PEO Guidelines)NAIC adopted Guidelines, Regulations and Legislation on Workers’ Compensation Coverage for Professional Employer Organization Arrangements. Per Admission Deductible (PAD)An out of pocket cost to an insured member admitted to a hospital for an inpatient stay. These costs are typically in addition to annual plan deductibles, and are subject to maximum out of pocket maximums stated in the policy, and / or "statutorily" guided. Per Diem Contracts Per Diem Contracts are contracts reimbursing hospitals a flat amount per day for specified hospital services. Per Diems are common stop loss and reinsurance coverage limitations consisting of average daily maximum allowable amount per day. Per diem contracts can also be vender related pricing sold to various self funded employers or carriers offering insurance in an area.
Per Diem Maximum A Per Diem Maximum is typically an in-patient hospital coverage in a stop loss or reinsurance contract limiting the carrier's exposure per day for eligible charges. It is generally required in all Provider Excess and HMO reinsurance policies. Special care should be taken to understand how large claims incurred within a small number of days are affected. Expressed as either a Maximum Daily Limit or Average Maximum Daily Limit, this coverage usually reduces the total eligible hospital charges reimbursable in the policy. The Average Daily Maximum Limit is richer coverage and should be sought. Per Visit Deductible (PVD)A term used to describe an out of pocket cost to the insured member receiving care at an outpatient medical facility. Performance Year (PY)A term CMMI uses in Direct Contracting indicating surplus or deficit from year 1, or "PY1", year 2, or "PY2", etc These contracting option include non risk, and risk based where "Participants" (providers) choosing capitation (etc), participate in surplus or deficit year end reconciliation against a FFS services charged in excess to the capitation. Its complicated. See: Direct Contracting Personal Auto Policy (PAP) Personal Injury Protection (Auto) (PIP, No Fault insurance, PPI)A complex law governing auto insurance liability, and providing PRIMARY coverage response for property or medical claims without assignment of fault. I.e. each party gets paid by his own policy up to $10,000 per person, and $20,000 per accident. i.e. "No-Fault insurance". Legal remedy may also be available at higher limits where damages are severe or permanent, and/or excess of the $10,000 per person limit. No-Fault insurance is designed to reduce court congestion on low dollar claims. Statutory rules apply to medical billing.
In MI its PPI, Personal Protection Insurance - that has recently been changed to allow people to elect other options less than unlimited coverage. Personal Representative A term defined by HIPAA related to handling PHI with prudent confidentiality defined under the law. Personally Identifiable Information (PII)See: HIPPA
PII Data as defined by CMS, and Marketplace agent training
APTC percentage and amount applied
Auto disenrollment information
Applicant Telephone number
Applicant Social Security number
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant CHIP eligibility indicator, start and end dates
Applicant QHP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end dates
Applicant household income
Applicant Maximum APTC amount
Applicant CSRs eligibility indicator, start and end dates
Applicant CSRs level
Applicant QHP eligibility status change
Applicant APTC eligibility status change
Applicant CSRs eligibility status change
Applicant Initial or Annual Open Enrollment Indicator, start and end dates
Applicant special enrollment period eligibility indicator and reason code
Contact Telephone number
Contact Email address
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FFE Applicant ID
FFE Member ID
Issuer Member ID
Net premium amount
Premium Amount, start and end dates
Credit or Debit Card Number, Name on Card
Checking account and routing number
Special enrollment period reason
Subscriber Indicator and relationship to subscriber
Tobacco use indicator and last date of tobacco use
American Indian/Alaska Native status and name of tribe
Requesting financial assistance
Applicant/Employee/dependent sex and name
Subscriber indicator and relationship to subscriber
Total individual responsibility amount
Employee Applicant Name
Employee Unique Employer Code
Employee Home Address
Employee Applicant Mailing Address
Employee Applicant Birthdate
Employee Social Security Number
Employee Applicant Telephone Number (and type)
Employee Applicant Email Address
Employee Applicant Spoken and Written Language Preference
Employee Tobacco Use Indicator and Last Date of Tobacco Use
Employee Race and Ethnicity
Employer Business Name
If American Indian/Alaska Native: Name and Location of Tribe
Health Coverage Type (Individual or Family, if offered)
Health Plan Name and ID Number
Dental Plan Name and ID Number
Other Sources of Coverage
Accepting or Waiving Coverage
Dependent information, if applicable, including
• Dependent Name
• Dependent Date of Birth
• Dependent Social Security Number
• Dependent Relationship to Employee
• Dependent Sex
• Dependent Spoken and Written Language Preference
• Dependent Race and Ethnicity
• If American Indian/Alaska Native: Name and Location of Tribe
• Dependent Tobacco Use Indicator and Last Date of Tobacco Use
• If individual is living outside of home; name of individual, address, phone, e-mail address
• Dependent Other Sources of Coverage
• Dependent Accepting or Waiving Coverage
• Special Circumstances for Employees and Dependents, i.e., marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth
Employer Name/"Doing Business As”
Employer Federal Tax ID Number
https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html?language=es Pharmacy Benefit Manager (PBM)A Pharmacy Benefit Manager is a company specializing in the administration of commercial, Medicare, Medicaid and/or Workers Compensation pharmacy benefits. A PBM may also be a specialized entity in high dollar Rx such as factor agents for hemophiliacs, cancer infusion, dietary feeding, and an array of infusion therapies. Pharmacy Superspender A patient incurring pharmacy and medical drug therapy expenses of $250,000 or more annually. For many years, the fastest growing part of the health care cost dollar has been pharmacy spending, and especially for "Specialty Drugs". Many plans will simply exclude them, regardless of plan language. Physician Compare Downloadable Database CMS downloadable database for individual eligible professionals (EPs) - means everyone does not have access to it.
In addition to the recently released quality data, the Physician Compare Downloadable Database also includes demographic information and Medicare quality program participation for individual EPs, which is updated every two weeks.
https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/physician-compare-initiative/ Physician Compensation 2017 Source: Medscape
Medscape report Physician Fee Schedule (PFS)CMS term used by CMS when discussing proposed Medicare Part B QPP related matters.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12-2.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending Physician Hospital Organizations (PHO)Physician Hospital Organizations (PHO) are physician and hospital joint ventures typically organized to attract members from HMOs and self-insured employers. Many PHO’s become employed doctor practices acquired by hospitals or larger multispecialty groups.
Physician Incentive Plan Guidelines These are federal mandates requiring physician groups with less than 25,000 capitated members to purchase (PEL) stop loss.
Physician Quality Reporting System (PQRS)See QPP, MIPS, etc
2018 Physician Quality Reporting System (PQRS) Downward Payment Adjustment Notification
The Centers for Medicare & Medicaid Services (CMS) will soon begin distributing letters to Physician Quality Reporting System (PQRS) individual eligible professionals (EPs), EPs providing services at a Critical Access Hospital (CAH) billing under method II, and group practices regarding the 2018 PQRS downward payment adjustment. The letter indicates that the recipient did not satisfactorily report 2016 PQRS quality measures in order to avoid the 2018 PQRS downward payment adjustment and, therefore, all of their 2018 Medicare Part B Physician Fee Schedule (PFS) payments will be subject to a 2.0% reduction.
The 2018 PQRS payment adjustment letter being sent to individual EPs includes a Tax Identification Number (TIN)/National Provider Identifier (NPI) combination; the adjustment applies only to the individual EP associated with the TIN/NPI noted within the letter and not the clinic or facility.
The 2018 PQRS payment adjustment letters being sent to PQRS group practices include a TIN only and applies to all EPs who have reassigned their billing rights to the TIN. Please check your letter in the upper left-hand corner to determine if it contains your TIN or TIN/NPI.
For the 2016 reporting period, the majority of EPs successfully reported to PQRS and avoided the downward payment adjustment CMS anticipates that successful trend to continue under the new Quality Payment Program. The Quality Payment Program began January 2017 and replaces PQRS, the Value Modifier program, as well as the separate payment adjustments under the Medicare Electronic Health Record (EHR) Incentive Program. The Quality Payment Program streamlines these legacy programs, reduces quality reporting requirements and has many flexibilities that allow eligible clinicians to pick their pace for participating in the first year. To prepare for success in the Quality Payment Program we encourage EPs to review your PQRS feedback report, Annual Quality and Resource Use Report (QRUR) and visit qpp.cms.gov to learn about the Quality Payment Program.
If I received the payment adjustment letter, what are my options?
If you believe that the 2018 PQRS downward payment adjustment is being applied in error, you can submit an informal review request within 60 days of the September release date of the 2016 PQRS feedback reports. Informal review closes on at 8:00 p.m. Eastern Standard Time on the 60th day from report release. We will notify EPs of the report release via listserv including information on how, where and by what date they need to submit an informal review, if they so choose. CMS will investigate the merits of your informal review request and issue a decision within 90 days of receipt. All informal review requests must be submitted via a web-based tool on the Quality Reporting Communication Support Page. PQRS informal review decisions which result in the removal of groups or individual EPs from the PQRS downward payment adjustment file may also result in a change to their automatic downward payment adjustments under the Value Modifier program. For PQRS decisions that result in changes to the Value Modifier payment adjustments, groups and solo practitioners will automatically have their 2018 Value Modifier automatic downward payment adjustments adjusted. For more information about the 2018 Value Modifier and how to submit an informal review request for it, please visit 2016 QRUR and 2018 Value Modifier website.
EPs are encouraged to access and review their 2016 PQRS feedback reports and 2016 Annual QRURs prior to submitting an informal review request. The 2016 Annual QRUR provides information about the 2018 Value Modifier payment adjustment for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists billing under your TIN. CMS will announce the availability of the 2016 PQRS feedback reports and 2016 Annual QRURs via the Medicare Learning Network (MLN) Connects Provider eNews, PQRS listserv, and other CMS-related listservs.
CMS would also like you to know that there are no hardship exemptions for the PQRS downward payment adjustment.
The 2016 PQRS program year began January 1, 2016. Reporting during 2016 impacts any 2018 PQRS payment adjustment you may receive. Please visit the PQRS webpage for complete information on how you could have participated in 2016 to avoid the 2018 downward payment adjustment.
• For details regarding the 2018 PQRS downward payment adjustment, please see the PQRS Payment Adjustment Information webpage.
• For more information regarding the Quality Payment program, please visit the Quality Payment Program website.
• For information regarding other Medicare physician quality programs that apply payment adjustments, please see the 2016 QRUR and 2018 Value Modifier website and/or the EHR Incentive Program web
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html Plan Star Documents (PRDs)See Plan Star Ratings Point Of Service Plan (POS)A Point Of Service (POS) Plan is a program of commercial or Medicare health insurance which offers the customer two options of how they can receive care-in-network and/or out-of- network plan care. In-plan care allows members to save 30-40 percent of out-of-pocket expenses when they receive care from a provider within the panel of contracted providers. Point of service plans are designed to provide members greater choice of medical provider selection. POS plans typically insure out of network care, and are not the same as HMO, EPO, or “National Network” offered plans.
Policy Cancelation A term that can mean different things in different situations. See: Policy Rescission, Policy Termination. Policy Rescission A carrier action completely canceling an existing policy, as if it existed. See: Policy Cancelation, Policy Termination. Policy Termination A carrier action stopping coverage at a date prescribed by the carrier. Populate (Pre-populate)An on line or real time computer automated function inserting information into a field on an insurance form, or computer query to a user. A user is the person using the computer. Population Health Management (PHM)
A term with roots in disease management (DM) related historically to managing hospital admissions and readmissions from the same diagnosis or DRG. Population Health today typically refers to medical encounter data screened by medical diagnosis with a goal to improving medical outcomes at lower cost. Contentious debate surrounds what is effective medical care versus revenue maximizing medical provider behavior. Despite the rhetoric, many useful desease state managemetn medical protocols have, or are being established. Getting rank and file physicians to donate time to established refereed EBM care remains extremely challenged where the outcomes compete with revenue generation, or a perception of "cookbook" medicine.
Commonly sited population health measures include management of: Cardiac conditions, Hyper tension, Diabeties, prenatal care, Asthma, obesity, knee replacements, lower back pain, etc...
ACA structures federal position and referee to mandate clinical data submission (HIPPA compliant). 2018 is designated first year of penalizing non compliant physicians who choose not to participate, thereby resulting in Medicare Part B reimbursement reductions.
Portfolio Aggregate Reinsurance Portfolio Aggregate Reinsurance is coverage that responds when the expected claims value on a book or "portfolio" of coverage exceeds a specified percentage above the Expected claim value, typically between15%-25%. It is a layer of protection to the primary insurer for a catastrophic year on a specific block of business intended to cap the maximum probable loss on a book of business. Coverage typically responds at 115%-125% of the expected claims value.
Post Acute Care (PCC) Post Acute Providers (PAC)A CMS term used to describe QRP to the QIES-ASAP quality reporting measures related to after hospital discharge data (and multiple system problems related to uploading performance data from PAC). Potentially Avoidable Utilization (PAU)See: Maryland Health Care Commission Practice Improvement and Measures Management Support (PIMMS)See: MIPS, TEP Preauthorization (PA)What physicians and hospitals have to verify at the insurance company to assure they get paid. Can also refer to a Physicians Assistant degree Predictive Modeling A statistical method used to analyze data sets of targeted high cost medical procedures and/or conditions, and whose goal is to identify and treat conditions prior to onset of severe illness attack. Many "population based management" (i.e. Disease Management) approaches have been used over the years - with many falling short of accurately producing cost savings or better medical outcomes. Preexisting Medical Condition Medical Plan (PCIP Plan)A now defunct GOVERNMENT plan that was created in the first days of ACA that allowed sick people to enroll in insurance prior to federal exchange and state marketplace enrollment availability. The plan was eliminated with the Federal marketplace was established. Key is its cost data derived whish is cited with ambiguous new Trump ACA replacement initiatives centered on giving block grants to states to prevent the un-insurability problem (at any price of premium) public protections fixed by ACA passage. ($32,108 PMPY plus administrative/sales costs per CCIIO in 2013)
http://www.lifehealthpro.com/2013/02/26/average-pcip-enrollee-cost-32108-per-year?slreturn=1487602895 Prepaid Health Plans (PHP)Prepaid Health Plans (PHP) sometimes referred to as MPHP's (Medicaid Prepaid Health Plans) or LHSO's (Limited Health Services Organizations), are state-approved organizations which accept a capitation for services rendered to Medicaid members. An LHSO can be just about any special state-authorized entity approved to insure a limited risk, i.e., psychiatry HMO, dental HMO, etc. It is possible to include commercial and or Medicare lives as permitted by law/regulation. Prescription Drug Monitoring Program (PDMP)See: Maryland Health Care Commission. Prescription drug Monitoring Programs (PDMP)Means many things Presentism A term typically used by Human Resources to describe a reduction in employee productivity as measured by their distraction from many voluntary and involuntary causes. The point is that management is wise to recognize "some" personal, physical, and emotional causes of distraction that can dramatically increase or decrease (team) productivity which directly translates to earnings. The most inspired companies recognize employees are their business. Many have written about it. Prevention Care (Wellness care)Different carriers call it by different terms. In general, it means ACA defined preventative services INSURED without any out-of-pocket costs to the insured. newer services may include HIB prevention, and expanded women's health prevention - expanded coding for lactation counseling, breast cancer prevention medications, and postpartum depression counseling. See: Coverage Determination Guidelines (DCG) These are typically detailed by carriers in their policies, etc. See: ACA QHP
https://www.uhc.com/employer/news/brokers/2020-preventive-updates-to-coverage-determination-guideline Prevention Quality Indicator (PQI)See Maryland Health Care Commission Preventive Health Management (PHM)A term used o describe concurrent "large group" medical plan case management, and incentive payment to patients achieving improved medical outcomes (and typically lower comorbidity costs) in context to 5 chronic (expensive) conditions: BMI, Blood Pressure, Blood Glucose, Cholesterol and tobacco use. Price Transparancy (Healthcare Transparancy)Jargon not agreed upon that is typically used to describe some type of publicly facing "hospital best prices charged list". Sherman and Clayton antitrust prohibits price fixing, but public healthcare "policy" (benign negligence) "practically insulates" (most) hospitals from prosecution - thus the public law to show people what it costs. President Trump's HHS issued Memos directing CMS requirement of making hospitals divulge secret prices. Hospitals are fighting it, and want to keep cost-shifted (commercial) higher charged prices secret from those that have to pay them.
The rule also requires accurate MOOP estimation!
The problem is that the cost of insurance is past the tipping point with millions more uninsured in just the last few years - under President Trump's destabilizing: CSR withhold (going to the Supreme court), Medicaid work requirements (injuncted by a federal judge), federal Marketplace reinsurance program uncertainty, immigrant health insurance requirement (injuncted by a federal judge), etc, measures. Very contentious issue. Hospitals better figure out a way to live on 150% of Medicare allowable (instead of 150%-240% average, but it can be 1000% more) because that cost-shifted "cash cow" is getting too old to milk.
"Under one rule resisted for months by a broad swath of the health-care industry, hospitals must for the first time reveal the discounted rates they negotiate privately with insurers for a list of 300 services patients can schedule in advance, including X-rays and cesarean deliveries. That is slated to go into effect in January, 2021.
In new twist, the administration is also proposing to require most health plans that Americans get through their jobs to disclose the rates they negotiate with hospitals and doctors in their insurance networks, as well as the amounts they pay to doctors out-of-network." Source Washington Post
Most recently, hospitals are suing to stop the requirement under some kind of constitutional 1st amendment violation of "compelled speech"...? Its an obvious legal maneuver to compel the issue to the supreme court when they lose in court - and delay implementation until Trump is gone.
https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf Principal Based Reserving (PBR)No, not the beer!
A calculation some carriers may use to reserve revenue for future expected claims. See: State Compliance and licensure guidelines by state, and authorized product filing. Principle-Based Reserving (PBR)The 2017 Principle-Based Reserving (PBR) — a new way of calculating (life insurance, etc) reserves to pay future claims.
See: CSO Privacy Impact Assessment (PIA)See: HIPPA Privacy Notice: Provider Risk, LLC. PUBLICALLY FACING PRIVACY NOTICE: Provider Risk, LLC. collects Personally Identifiable Information (PII), and distributes it only to entities authorized and licensed Carriers, Agents or Brokers offering insurance coverage services. All customers have right to forbid transaction of PII at any time. By sending us, or telling us personally Identifiable Information - you grant us the right to distribute it to carriers requiring it for potential policy bid, program enrollment, or policy servicing issues. Call Stephen George at 305-546-2073, or HealthSherpa if you have any questions, or concerns about how your PII is managed in your best interests. Private Fee For Service (PFFS)See: Medicare PFFS Private Label (Fronted and Reinsured assignment)A sophisticated program of leasing an already licensed (usually A rated) carrier paper in a particular state (or many states) to field an "authorized" and/or "eligible" insurance product. See: Risk Bearing entities. These can take many forms of risk transfer, capital surplus, SIR, and claims liability, etc. These are a negotiated placement subject to ongoing negotiation. See: Finite and Facultative reinsurance. Professional Employer Organizations ( PEO, Employee Leasing)A corporation that derives its income from providing traditional Human Resource services (i.e., Group benefits, HR payroll tax filings, payroll, ancillary benefits, and typically discounted workers compensation coverage) to client employers on an "outsourced" basis. The PEO corporation may be the same employer, and lease the employees back to itself. The PEO can be a completely separate corporation selling their outsourced HR services to multiple employers in "similar" classes of industry. The "similar classes" method my comply with state MEWA requirements. Less expensive liability and health insurance are typically attributes of "leasing" one's own employees, if offset by the payroll fees PEO's charge. PEO's have a long colorful history of workers compensation employee class rating methodology and challenge. PEOs are not one size fits all, and come with colder approach to employee recruitment. PEOs do not all have top rated on-line capabilities. EPLI issues get squirrelly. Short story is that PEOs make economic sense where the workers compensation cost savings justify added payroll/HR processing charges, payroll filing benefits, and (in some cases) cross state workers compensation rating/administration, and fees. We recommend conservative approach, and rated paper if possible. See: MEWA and know if the PEO gets their MOD challenged by appropriate authority, then everyone in the same Comp rating gets hit, and the hit might be retroactive. Same goes for catastrophic claims (risk pooling) events of one member affecting the group. See: re-establishing MOD. Profit Sharing (Profit Commission, Premium Refund)A term used typically conveying a "premium rebate" contingent upon favorable (claims less than targeted loss ratio) claims history. These only happen under clearly defined contractual contingencies. Done well, profit sharing creates strategic advantage and co-dependent benefit. There are many kinds of profit sharing arrangements that can span into areas of contingency fees, and incentive programs, See: Dividend plan. Programs of All-Inclusive Care for the Elderly (PACE)Programs of All-Inclusive Care for the Elderly (PACE) for new populations, including individuals with physical disabilities, under the authority provided by the PACE Innovation Act. The PACE Innovation Act of 2015 (PIA) provides authority to test application of PACE-like models for additional populations, including populations under the age of 55 and those who do not qualify for a nursing home level of care, under Section 1115A of the Social Security Act.
https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/PACEInnovationAct.html ProPublica Treatment Tracker A report made available by CMS of transactional frequencies between fee-for-service Medicare Providers. Protected Health Information (PHI)A HIPPA term used to denote confidential medical information. see: PII Protecting Access to Medicare Act (PAMA)See: QPP, APM, MIPS, MACRA, AUC
Practice and reporting standards directed by CMS and related to Medicare eligible treatments. Provider Excess Loss (Provider Stop Loss)A coverage that does have federally issued mandates, but that typically does not always follow the guidelines. Coverages are typically issues by Physician and Hospital (specific")separated deductibles and rated premiums. Aggregate coverages are typically rare, but are not more common because of recent ACO initiatives sponsored by CMS.
See Physician incentive plan guidelines and ACO shared savings contracting. Provider Maintenance Organization (PMO)A Provider Maintenance Organization is a state or federally authorized physician and/or hospital owned entity that owns an HMO. These entities typically enjoy a three year period of not having to come up with the minimum state mandated solvency capitalization required of traditionally licensed HMO's. They may also enjoy a start up period requiring lower reserve requirements (i.e. In GA a PHSCC, Federally a PSO). Provider Reimbursement Review Board (PRRB)HHS board assigned to regulate and decide issues of medical provider billing rules and regulations. See 73 Fed. Reg. 30190. Recent procedural victory for hospitals alleging underpayment for Medicare outliers. (Meaning they do not have to file a cost report at the time of billing to get more money from the feds for what Medicare defines as outliers.
http://www.squirepattonboggs.com/~/media/files/insights/publications/2016/08/firm-wins-victory-in-overturning-key-parts-of-hhs-s Provider Sponsored Organization (PSO)A Provider Sponsored Organization (PSO) is a federal designation under Medicare Part C - given to physician and/or hospital groups which accept capitation for services rendered to enrolled Medicare members.
Public Health Services Act (PHS)The Affordable Care Act reorganizes, amends, and adds to the provisions of title XXVII
of the Public Health Service Act (PHS Act) relating to group health plans and health insurance
issuers in the group and individual markets. Public Option The public option is an ongoing movement gaining strength to create a voluntary government health plan "buy-in" that competes directly with commercially offered major medical plans, and that would be available to both individuals and small businesses. It is not free national health insurance to all, or any plan to eliminate Medicare, Medicaid, the VA or Tricare, or the large group market. It would not likely be available to larger employers. Central to the debate is how much less any plan using Medicare maximum allowable charges to rate the premium is way less than non-RBP rated plans, that currently charge much more. Physicians and hospitals are fighting it. Any plan whose underwritten claims are (I.e. 50% - 1,000%+) less costly, will price premiums that (render non-RBP plans) beat competing plans. plans. In other words, most people would pick a less expensive QHP with a bigger PPO network, over a plan priced to pay doctors and hospitals a lot more than Medicare allows - and not being exposed to unlimited OON MOOP, surprise billings, balance billings, etc. Be clear that doing it is almost turn key (network and network pricing is already accepted and established, and so is ACA QHP, and even Medicaid claims process units, reinsurance, CSR, CMMI, LAN, ACO hybrid, FFM, Community health center interface, AARP support, etc) where the pollical will to keep people insured, and so hospitals don't go bankrupt treating poor/uninsured people. Its coming simply because the premium costs have escalated beyond what millions of American can no longer afford, and the Feds (and states) will have to keep hospitals from going bankrupt.
Q Qnet (QNet)CMS hospital quality reporting program. Federal reporting of hospital quality that will eventually be publically available in meaningful assessable measures people can use to guide their care.
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetHomepage&cid=1120143435383 QPP Library
https://qpp.cms.gov/about/resource-library Qualifed Disabled & Working Insividuals (QDWI)A category of Medicare beneficiary getting help paying for Part A premiums where the individual did not pay tax or work 40 qualifying quarters to get Part A benefits. (i.e. $345) Qualifed Employer See: 45 CFR 155.20 Qualified Employee See: 45 CFR 155.20 Qualified Health Plan (QHP)A medical plan meeting ACA EHB for individual and Group coverage. See: ACA final rules. See: 45 CFR 155.20 Qualified Independent Provider (QIP)A term used by CMS related to Part A covered services and being eligible or participating as a Medicare provider, or supplier. Qualified Medicare Beneficiary (QMB) Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)Federal law H.R. 34, the 21st Century Cures law - allowing (qualified small) employers to give individual employees up to $4,950 (pretax - like a section 125 plan HRA group medical and/or ancillary benefit employer paid funding) in reimbursement for INDIVIDUAL (not Group medical) major medical premiums for 2017, and up to $10,000 in reimbursement for family coverage premiums. The intent of the law is to allow employers provide pretax funds to employees to buy INDIVIDUAL insurance on the Marketplace. The problem is that Group plans allow EMPLOYEE enrollment (without Preexisting medical condition exclusion) within 60 days of employee eligibility, and the Marketplace Rules apply to INDIVIDUALS applying during OEP and SEP.
https://www.congress.gov/bill/114th-congress/house-bill/34 Quality and Resource Use Reports (QRUR)See MACRA, MIPS, PQRS Quality Clinical Data Registries (QCRD)See MIPS, MACRA Quality Data Model (QDM)The Centers for Medicare & Medicaid Services has published the Quality Data Model (QDM) standard, version 5.4. The standard has been updated to align with the emerging standard, Health Level Seven International (HL7) Fast Healthcare Interoperability Resources (FHIR) and add increased explicit capabilities. Support for these features and modifications will be implemented in the production version of the Measure Authoring Tool (MAT) to be released in Fall 2018 (MAT v5.6). Measures produced using QDM v5.4 are anticipated for implementation in calendar year 2020, whereas QDM v5.3 is for calendar year 2019.
https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf Quality Data Reporting Architecture III (QRDA reporting)
https://ecqi.healthit.gov/sites/default/files/2020-CMS-QRDA-III-Eligible-Clinicians-and-EP-IG-v1.2-508.pdf Quality Improvement Organization (QIO)The QIO Program is the largest federal program dedicated to improving health and healthcare quality at the local level for
Quality Medical Care The least expensive legally defensible care supported by EBM. Quality Payment Program (QPP)The Quality Payment Program is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and includes two tracks — Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).
MIPS has replaced three Medicare reporting programs:
• EHR Incentive Program (Meaningful Use)
• Physician Quality Reporting System
• Value-Based Payment Modifier
The Quality Payment Program listserv will provide news and updates on:
• New resources and website updates
• Upcoming milestones and deadlines
• CMS trainings and webinars
2018 Performance Highlights
The final 2018 performance feedback data revealed:
• 98% of eligible clinicians participated in MIPS in 2018— up from 95% in 2017
• 98% of eligible clinicians exceeded the performance threshold score of 15 points to receive a positive payment adjustment— up from 93% in 2017
• 356,353 clinicians participated in MIPS through APMs— up from 341,220 in 2017
Moving Forward =================================
CMS Finalizes Quality Payment Program Rule for Year 2 to Increase Flexibility and Reduce Burdens
Quality Payment Program Year 2 Policies are Gradually Preparing Clinicians for Full Implementation
On November 2nd, the Centers for Medicare & Medicaid Services (CMS) issued the final rule with comment for the second year of the Quality Payment Program (calendar year 2018), as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as well as an interim final rule with comment.
CMS listened to feedback from the health care community and used it to inform policy making. As a result, the Year 2 final rule continues many of the flexibilities included in the transition year, while also preparing clinicians for a more robust program in Year 3 CMS wants to ensure that the program consists of meaningful measurement while minimizing burden, improving coordination of care, and supporting a pathway to participation in Advanced Alternative Payment Models (APMs).
Year 2 Final Rule Highlights
We’ve finalized policies for Year 2 of the Quality Payment Program to further reduce your burden and give you more ways to participate successfully. We are keeping many of our transition year policies and making some minor changes. Major highlights include:
• Weighting the MIPS Cost performance category to 10% of your total MIPS final score, and the Quality performance category to 50%.
• Raising the MIPS performance threshold to 15 points in Year 2 (from 3 points in the transition year).
• Allowing the use of 2014 Edition and/or 2015 Certified Electronic Health Record Technology (CEHRT) in Year 2 for the Advancing Care Information performance category, and giving a bonus for using only 2015 CEHRT.
• Awarding up to 5 bonus points on your MIPS final score for treatment of complex patients.
• Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the MIPS final score for clinicians impacted by Hurricanes Irma, Harvey and Maria and other natural disasters.
• Adding 5 bonus points to the MIPS final scores of small practices.
• Adding Virtual Groups as a participation option for MIPS.
• Issuing an interim final rule with comment for extreme and uncontrollable circumstances where clinicians can be automatically exempt from these categories in the transition year without submitting a hardship exception application (note that Cost has a 0% weight in the transition year) if they were have been affected by Hurricanes Harvey, Irma, and Maria, which occurred during the 2017 MIPS performance period.
• Decreasing the number of doctors and clinicians required to participate as a way to provide further flexibility by excluding individual MIPS eligible clinicians or groups with ≤$90,000 in Part B allowed charges or ≤200 Medicare Part B beneficiaries.
• Providing more detail on how eligible clinicians participating in selected APMs (known as MIPS APMs) will be assessed under the APM scoring standard.
• Creating additional flexibilities and pathways to allow clinicians to be successful under the All Payer Combination Option. This option will be available beginning in performance year 2019.
The final rule with comment further advances the agency’s goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery.
See MACRA, MIPS, PQRS, HCTTF
See: CMS 2019 Annual Report Appendices
https://www.cms.gov/blog/quality-payment-program-qpp-year- Quality Reporting Program (QRP)HHS and IRS mandated medical cost, and detail reporting aka Patient Centered Outcomes Research (PCORI). The $2.17 Tax per enrollee for this federal “umpire on efficacy of care” are charged to Carriers and self funded employers, and set to expire Sept 30,2019.
QRP and QRUR are part of the reporting function related to MIPS, and whose goal is to get physicians reviewing each other by GPCI to affect competition and or better cost to outcomes improvements. There is little question, these measures will cost lots to implement, and affect increasing percentages of the Medicare reimbursement dollar.
Quantitative Easing (QE)A term used usually to describe the Fed's behavior in making money less expensive by dropping the fed funds rate. It can be used to describe underwriter agenda to lower premium rates based on better than expected losses. Quota Share or (Pro Rata) Quota Share reinsurance sometimes referred to as "Proportional" or "Pro Rata" is coverage providing a specified percentage of premiums, expenses and claims losses between the primary insurer (ceding company) and the Reinsurer. Risk transfer can assume up to 100% of the total premium risk. It is typically a first dollar coverage, where the reinsurer receives the same percentage of premium as it funds claims.
R RAISE Recognize, Assist, Include, Support and Engage (RAISE) Family Caregivers Act — had passed the House late last year. It directs the Department of Health and Human Services (HHS) to create an advisory council charged with making recommendations on the strategy to support family caregivers.
https://www.aarp.org/politics-society/advocacy/caregiving-advocacy/info-2015/raise-family-caregivers-act.html Rated or Ratings (FSR - Financial Sequrity Ratings)A term used to convey a compan'y financial strength and / or reputation for paying claims timely. i.e. Standard and Poors, Moodies, AM Best, Fitch, etc. Ex: AM best specifically includes reputation for paying claims promptly, whereas other agencies my not keep track of customer complaints at the state level. Be cautious.
Demotech and D&B ratings are not typically accepted by underwriting. Demotech offers Agents an E&O coverage (extension) that triggers if an insolvent carrier is actually liquidated. Be cautious. Re-establishing MOD The process of NCCI establishing a new employer MOD (typically higher). See: PEO, and know that leaving a PEO is a time consuming and sometimes expensive process. Reasonable and Customary Charge (R&C or UCR)Reasonable and Customary charges are sometimes referred to as Usual Customary and Reasonable charges (UCR). R&C is not a fee schedule with precise amounts by medical procedure, device, service or hospital charge. Determining R&C can be guided by reasonable location, and relative comparison to various statutory, and/or regulatory fee schedules used to establish reimbursement for purposes of insurance subject to the policy language, policy type, and general convention(s). Reasonable and customary and medical necessity are two separate issues. Many if not all states have at least two statutes guiding two, if not three medical billing limits. Federal regulations can also guide nationally recognized maximum allowable charge limits standard(s). The vast majority of medical insurance plan documents, and medical stop loss policies detail R&C language and/or direct fee schedule reference to avoid ambiguity when it comes time to pay claims.
As a general rule, it is not uncommon to see medical billings invoiced at about 4 times (400%+)what most physicians and or hospitals "expect and accept" (after managed care contractual adjustments subject to stated policy coverage limits, exclusions, and/or legislated limits). Coverage for out of network care can be materially reduced posing real problems to members who thought they were protected against unlimited and uninsured medical charges. This is a growing problem - especially in ACA compliant unlimited EHB coverage(s). Balancing the primary promise of reasonable insurance against ACA compliant policy language excluding care, or care received "out of network" can be complicated and contentious.
The attached link references a Johns Hopkins study showing median physician charges to "Medicare Allowable" billed was at 2.5 times more. The future looks even more interesting - see QPP and MACRA
see bill H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015
http://www.medscape.com/viewarticle/874584?src=wnl_mdplsnews_170120_mscpedit_wir&uac=166293CV&impID=1275798&faf=1 Reciprocal A state authorized risk bearing entity that is typically not assessable to it's capitalizing 'association" membership. Referenced Based Pricing (RBP)A term used to define Plans insuring, or "reimbursing" members up to an established fee schedule. RBP plans may not be insurance. See: Risk Bearing entities, STM, Ministry health share plans, Health Sharing plans, Limited Medical plans, scheduled medical, medical discount plans, ACA compliant QHP. Medical billing disputes litigated in many states are increasing.
Prompt payment: ERISA (each state) policy language and medical provider "not-for-profit" organizational type, etc - obligations help guide the process.
This from a major carrier published December 2019... "All Savers® Alternate Funding will no longer access the Shared Savings Program (SSP), effective Jan. 1, 2020, for all new and existing business.
Note: This change was implemented on Sept. 1, 2019, in Florida, Georgia, Illinois, Missouri, North Carolina, South Carolina and Texas.
Claims from out-of-network providers will be paid using Extended Non-Network Reimbursement Program (ENRP) or Maximum Non-network Reimbursement Program (MNRP). Processing claims at ENRP or MNRP rates rather than discounted Shared Savings Program rates will help decrease the All Savers out-of-network spend, provide a greater financial incentive for members to use network providers and further align All Savers with fully insured reimbursement policies.
Were members notified of the program changes?
Yes, members with 5 or more out-of-network visits in the last 6 months of shared savings providers have been notified.
Were ID cards reissued to members who no longer have access to SSP?
Yes, all members in the impacted states received updated ID cards without the Multiplan logo.
Does the change to SSP access constitute a change (reduction) in benefits?
No, this does not constitute a reduction in benefits. We are still covering out-of-network (OON) services according to the member benefit plans, but if a member continues to utilize OON providers, they may have additional financial responsibility.
Can members be balance billed?
Yes, when non-network claims are paid at the ENRP or MNRP rate, the provider can balance bill the member for the difference between billed charges and the ENRP or MNRP rate."
THis from Benefits Pro 2/14/20, in context to pharmacy. "The cost savings the tactic provides are not only significant, but also grow over time for both plan sponsor and employee—a finding that was borne out by previous research published in the New England Journal of Medicine in 2017 that used the same employee population. The addition of the second study added another two and a half years of data and brought the total research period to five years.
While the 2017 study had found that use of reference pricing resulted in drug spending for employers that was nearly 20 percent lower, it also resulted in a 10 percent increase in cost-sharing for patients. However, the new study found that cost-sharing fell by more than 20 percent as both physicians and patients adjusted to the use of reference pricing.
By five years after implementation, according to ActiveRADAR,..." Source: Benefits Pro Feb 2020 Registered Health Information Technicians (RHITs) (RHITS) Registration Completion list (RCL)CMS published list of certified Marketplace agents/brokers/navigators. Regulation Best Interest (Reg BI)A DOL regulation affecting licensed securities brokers providing advice on retirement account roll-overs - requiring certain types of disclosures (declaration of compensation, conflicts of interest and any disciplinary actions on the broker dealer or financial advisor) on investments. Reg BI mandates greater disclosure than standard "suitability". See form CRS filing, See: BIC
See: Form CRS Relationship Summary, the Standard of Conduct for Investment Advisers, and a new Interpretation of “Solely Incidental.”
"Reg BI also requires the following:
Disclosure obligation: Broker-dealers must disclose material facts about the relationship and recommendations, including specific disclosures about the capacity in which the broker is acting, fees, the type and scope of services provided, conflicts, limitations on services and products, and whether the broker-dealer provides "investment monitoring" services
Care obligation: The broker-dealer must establish, maintain and enforce written policies and procedures reasonably designed to identify and at a minimum disclose or eliminate avoidable conflicts of interest. The obligation, which is an enhancement from the proposal, specifically requires policies and procedures to:
Mitigate conflicts that create an incentive for the firm’s financial professionals to place their interest or the interests of the firm ahead of the retail customer’s interest;
Prevent material limitations on offerings, such as limited product menu offering only proprietary products, from causing the firm or its financial professionals to place his or her interest or interests of the firm ahead of the retail customer’s interest; and
Eliminate sales contests, sales quotas, bonuses and non-cash compensation that are based on the sale of specific securities or specific types of securities within a limited period of time.
Compliance obligation: In an enhancement from the proposal, broker-dealers must establish, maintain and enforce policies and procedures reasonably designed to achieve compliance with Regulation Best Interest." Source: Think Advisor June 2019
CEO Ron Kruszeswki states, "It’s very important to note that Reg BI applies the same fiduciary principles to the brokerage model: a duty of loyalty — a duty to act in the best interest of the customer, to not place a broker’s interest ahead of the customer. Likewise, Reg BI has a duty of care — to act with diligence, care and skill in making an investment recommendation." June 2019 Stifel CEO Praises CEC Reg Bi, Blasts House Vote as Partisan" ThinkAdvisor June 2019 Rehabilitation Facilities (IRF)See CMS or HHS quality reporting Reinsurance Reinsurance is an insurance which provides coverage for catastrophic medical charges incurred by a plan member. Generally, the types of medical reinsurance are HMO reinsurance, Employer Stop Loss, Provider Excess loss, Workers Compensation reinsurance, and CHAMPUS/Tricare reinsurance. Reinsurance applies to insuring an authorized insurance plan, or re-insurance. The ACA authorized (by regulation) coverage insured between $45,000 to $250,000, and is in its own class. There are thousands of kinds of reinsurance. See Aggregate and Specific insurance.
As it relates to ACA offered GROUP and self-funded ERISA participants - reinsurance charge 2016-2017 program - per United Healthcare Agent Advisory October 2017
"Final Reinsurance Fee Payment Due Nov. 15 for Self-Funded Employers
October 5, 2017
The final installment of the Transitional Reinsurance fee is due by Nov. 15 for those employers who selected to pay the 2016 fee in two installments.
For the final year payment, self-funded employers who selected to pay in one installment paid the $27.00 per covered life Jan. 17. Those self-funded employers have no further payment obligations.
For those employers who selected two installments, the payment schedule is:
•$21.60 per covered life – payment made Jan. 17
•$5.40 per covered life – due Nov. 15
Under the Affordable Care Act (ACA), the Transitional Reinsurance fee has been paid by health insurance issuers and self-funded group health plans to fund a Transitional Reinsurance Program in place from 2014 to 2016.
•For fully insured clients, UnitedHealthcare pays the fee.
•For self-funded employers, the employer is required to pay the fee.
For the final year, the fee was determined to be $27 per covered life and was based on enrollment in major medical coverage for the first nine months of 2016, regardless of the plan’s renewal date.
Employers were responsible for submitting their enrollment count and selecting their payment date(s) on the government portal (pay.gov) last fall.
https://www.benefitspro.com/2016/09/30/gao-reinsurance-ruling-could-cost-health-insurers/ Relative Value Unit (RVU)See: RUC Republican Agenda — Healthcare Reform (A Better Way)Trump Executive Order allowing similar occupational business to purchase "Association" medical insurance across state lines (where state funding standards allow it). Executive order allows carriers to exclude preexisting medical exclusions, and not offer 10 UNLIMITED "essential medical benefits" mandated under ACA to avoid tax penalties. Individual's 2.5% tax penalty is eliminated, but employer tax penalties still apply. Available plans are available only where carriers offer them, or business associations are able to fund plan designs to state insurance compliance standard - meaning association medical plans are an old idea that has been crushed for years by states. See MEWA Note: This is not tax advice. Recommend specialized CPA tax advice before acting. In Short: Major Medical Association plans typically require a funded high deductible shared by Association employer-members. Getting reliable employee participation numbers, and up-front deductible (capital) funding among small employers is next to impossible. Short term plans cost way less, because they are not true (ACA compliant - i.e. unlimited) catastrophic (Major Medical) plans. Several "new breed" plan are available including "referenced based pricing", and "faith-based" plans that insured only a maximum fee schedule reimbursement, and may expose the insured to a "balance-billing" liability. Some are promoted as a plan, but that is NOT insurance. Many are available - including plans offering 12 months of guaranteed renewable coverage, but with sub-standard annual benefit limits that include: maximum fee schedule limitation, preexisting medical condition exclusion, and no pharmacy coverage, etc. See: Final Rules, CSR, MACRA, corridor risk.
Read ACA Law, and figure out for yourself what is being ignored and what is being enforced.
Latest bill Request For Application (RFA)Term CMMI uses to announce next demonstration initiative to lower costs and improve quality. Request For Proposal (RFP) Required Minim Distributions (RMD)A statutory minimum amount that must be taken out (distributed) of retirement accounts, and that gets taxed - usually as income. The amount is typically 5%. Many rules apply. Required Minimum Distribution (RMD)See federal law requiring IRA (and mandated at 5%) distributions from age 70.5. See: IUL (that does not have the mandate, and whose "pension" distributions are not taxed as income. Reservation of Rights (ROR letter)A letter typically from and insurance carrier agreeing to something, but reserving their right to amend what they have agreed to... Responsible Official See: HIPPA, ACA law, and good luck. Responsible Reporting Entities (RREs)See: CMS NGHP, MBI, GHP
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/GHP-User-Guide/GHP-User-Guide Responsible Reporting Entity (RRP)See: QPP
i.e. "CMS will be hosting a second webinar on to discuss the impact of the SUPPORT for Patients and Communities Act on Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 reporting for GHP Responsible Reporting Entities (RREs). The intention of this webinar is to further clarify who should report as an RRE and provide additional information on how to appropriately submit primary prescription drug coverage information. Complete webinar information is available in the Downloads section of the Mandatory Insurer Reporting for Group Health Plans (GHP)" Source CMS (your government in action.) Retiree Drug Subsodie (RDS)A tax subsidy program available to fully insured and self funded employers. Audits are required that offset costs savings. Retirement Account 401(k), ect *Source Benefits Pro - 10/18
Participants in 401(k) and other defined contribution retirement accounts will see their annual contribution cap raised from $18,500 to $19,000 in 2019, according to the Internal Revenue Service.
The catch-up contribution limit on defined contribution plans remains unchanged at $6,000.
Savers with IRAs will see the annual contribution cap raised from $5,500 to $6,000 — the first time the cap on IRA deferrals has been raised since 2013. The annual catch-up contribution for savers age 50 and over will remain at $1,000.
COLA increases will also be applied to the deduction phase-out scale for IRA owners who are also covered by a workplace retirement plan:
for single filers the scale will be $64,000 to $74,000, up $1,000
for joint filers where the spouse contributing to an IRA is also covered by a workplace plan, the phase-out slot increase to $103,000 to $123,000
for an IRA contributor whose spouse is covered by a plan, the income phase out is $193,000 to $2003,000
Single contributors to Roth IRAs will see the income phase out range increase to $122,000 to $137,000, up $2,000 from last year. For married couples filing jointly the range will increase to $193,000 to $203,000, up $4,000 from last year.
More low and moderate-income families may be able to claim the Saver’s Credit on their tax returns for contributions to retirement savings plans. The threshold increases $1,000 for married couples, to $64,000; $48,000 for head of households, up $750; and $32,000 for singles and single filers, up $500 from last year.
The deferred compensation limit in defined contribution plans for pre-tax and after-tax dollars will increase $1,000, to $56,000. And the maximum defined benefit annual pension will increase $5,000, to $225,000.
http://www.401khelpcenter.com/2017_401k_plan_limits.html#.W4RPV_Hrvcc Retirement plan for public schools and NFP employers (403(b))Similar to 401(k) plans, that employers can match employee contributions with pre-tax dollars.
https://www.irs.gov/retirement-plans/irc-403b-tax-sheltered-annuity-plans Retirement Plans (employer sponsored) (Golden Handcuffs)Employers can initiate Defined Benefit and Defined Contribution plans that "vest" to the employee over period of time, thereby retaining valuable key employees. IRS regulations mandate a minimum of 5 years funding, however the intent is permanent sponsorship being funded indefinitely. … Defined Benefit Plans use life and annuity products, with the life products allowing efficient "borrowing" against "cash value", in addition to the life insurance benefit. … Defined Contribution plans offer cash that can be invested in risk bearing marketable securities, (managed by properly licensed brokers), and that vest over a period of time. Funding of these benefits is pre-tax. Many regulations affect such transactions.
… "Retirement Plan Types
Defined Benefit Plans Defined Benefit Plan A Defined Benefit Plan is a retirement plan that provides guaranteed retirement benefits to the owners and employees of a company, provided annual premium contributions have been funded. The plan may be funded with, but not limited to, life insurance and annuity contracts.
Fully Insured Defined Benefit Plan A 412(e)(3) Fully Insured Defined Benefit Plan is a retirement plan that provides guaranteed retirement benefits to the owners and employees of a company, provided annual premium contributions have been funded. The plan is funded solely with life insurance and annuities, or annuity-only contracts, offering minimum guaranteed interest rates.
Cash Balance Plan A Cash Balance Plan is a defined benefit plan that provides benefits to participants in the form of hypothetical account balances normally stated as a dollar amount or a percentage of compensation. Each year, eligible participants receive their benefit in the form of a pay credit and an interest credit that is added to their hypothetical account. However, the plan is still funded like a traditional defined benefit plan with funds going into a pooled account.
Defined Contribution Plans Profit Sharing Plan A Profit Sharing Plan is a defined contribution plan in which the employer makes discretionary contributions. A key advantage is flexibility in determining the annual contribution. The maximum annual employer deduction for contribution is 25% of eligible compensation. There is also a maximum individual contribution limit. The individual limits are adjusted annually for cost-of-living increases.
401(k) Profit Sharing Plan A 401(k) Profit Sharing Plan allows employees to defer a portion of their income (tax deferred) to the plan while also allowing the employer to fund a matching and/or discretionary contribution.
Lafayette Life Retirement Services Pension Guide > 5/ 16
The salary deferrals are always 100% vested. They are limited to the lesser of 100% of the employee’s compensation or the current year’s dollar limit. Participants age 50 or older may make an additional “catch-up” deferral. These thresholds are adjusted annually for cost-of-living increases. A matching contribution by the employer may be included based on the salary deferrals. The matching allocation formula varies according to the employer’s funding objectives and may be discretionary. Highly compensated employees’ deferrals may be limited, and retirement benefits are impacted by investment returns. 401(k) Plans also must satisfy nondiscrimination testing requirements.
Safe Harbor 401(k) Profit Sharing Plan The Safe Harbor 401(k) Profit Sharing Plan is designed to eliminate the nondiscrimination testing imposed by traditional 401(k) Plans and allow every participant, including the owners, to defer up to the maximum limits. In order to maintain the “safe harbor” status, the employer must make a 100% vested “safe harbor” contribution with one of the following two options: a 3% of compensation contribution to all eligible employees; or a matching formula equal to 100% of salary deferrals up to 3% of compensation and 50% of salary deferrals between 3% and 5% of compensation. Retirement benefits are impacted by investment returns." Source: Lafayette Life insurance company 2019:
We recommend experienced agency for these products and services. …
This is not tax advice. Retrocessional Reinsurance (Retro)Coverage bound by insurance companies insuring insurance companies following the 1st rule of managing catastrophic risk - "spread it out", or "don't take all of it". Return of Premium (RoP)Many Meanings. In life insurance it can mean, return of all premiums PLUS the death benefit. For other policies: An insurance policy provision allowing for all or part of premiums being refunded where the policy coverage was never accessed by the insured. These are not uncommon in Long Term Care policies. Sometimes the provision is combined with a term life insurance death benefit payout offering both LTC payout to the insured, with up to 20% of death benefit inuring to the beneficiaries. Read the policy carefully.See: Policy rescission, policy termination, policy replacement, policy cancelation. Revenue Cycle Management (RCM) RISK The probability of gain or loss associated with a choice or investment. Contrary to Merriam Webster's definition (an obvious pessimist!) ... it implies both gain or loss.
Risk, like beauty, is in the eye of the beholder. Unpredictable risk (to a policy holder) is generally considered SIR excess of $50,000. Appropriate SIR is a function of risk appetite, liquid assets (defined by its jurisdiction), underwriter opinion, available instant / long term credit and/or finite treaty, etc. In context to stop loss / reinsurance premium performance (rating), its what the underwriter is willing to accept to transfer the risk (at various SIR, limits, terms). All underwriting units have their sweet spot. Risk Adjustment - ACA
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-17142.pdf Risk Adjustment Data Validation (RADV)A CMS audit to discover over-reported (or fraudulently) reported medical severity scores by hospitals resulting in overpayments from CMS, and to recover overpayments by CMS on MA beneficiaries. Risk Adjustment Factor (RAF)Each HCC is weighted by RAF to reflect relative weight (to DRG), age, gender, comorbidities, etc. Its a work in process whose goal is part of the transformation by CMS to structure reimbursements (and shared savings derived by beating the assigned budget for care) to better outcomes at lower cost.
The transition is from Hospitals managing "beds not heads", to "heads not beds" (filled with FFS patients).
See: DRG Outlier Risk Bearing Entities As a general description of "options" available to companies seeking to assume their personal risk, or group's risk(s): Admitted carrier, Non-Admitted carrier (Surplus Lines), Cover Holder, Risk Retention Group (RRG), Reciprocal, Captives, Captive cell(s), VEBA, MEWA, ERISA plan, PSO, AHP, ACO, HMO, PPO, IPA, COOP, off-shore X, Fronted & Reinsured Assignments, etc. Selection of risk bearing structure starts with liability considerations, and insolvency accountability against its corporate and / or capital contributing participants. Fronted and reinsured assignments can be substantially better alternative to managing risk at much lower costs than captives. We recommend experienced legal, accounting and brokerage agency when considering the risks and costs of fielding one's own product, and/or risk transfer. See: ERISA obligations Risk Corridor (ACA risk corridor)In context to ACA law and reinsurance payments already made to participating major medical Marketplace carriers over several years of Obama administration - it means federal payments to carriers who paid much higher claims amounts (by lowering deductibles and MOOP of their insureds) for INDIVIDUAL and SMALL GROUP (SHOP) members whose income fell between 100% - 250% FPL. The deductible and MOOP limit reductions are the CSR federal help to the poor (along with APTC). … ACA law did not spedify federal reinsurance set rates, or detail specific payments to carriers. The reinsurance was to have come from a 2.5% - 3% premium tax that purchased a $45,000- $250,000 stop loss recovery "safety net".
Additional restriction on carriers, above the already stringent MLR (80%-85%) mandated any "profits" greater than 3% would be forfeited to the fund to pay carriers getting hit with adverse selection.
… So far several Federal Courts have agreed with the Trump administration that the government does not owe carriers what the law does not explicitly stipulate (ignoring about seven years of HHS payments) payable. Carriers are looking to the Supreme Court to settle it. Current estimates of the payments are over $12 BILLION, and significantly expose many large carriers (especially Blue Cross alleging $5 BILLLION owed), to insolvency. Also very exposed are hospitals exposed to large uninsured populations. … Chief Judge Sharon Prost filed the majority opinion on Moda Health’s claim that HHS is contractually obligated to reimburse risk corridor payments in full. The judges stated that there was no official contractual agreement between HHS and health insurers for the timing of risk corridor payments, which makes Moda’s claim to the payments invalid.
“Although section 1342 [of the ACA] obligated the government to pay participants in the exchanges the full amount indicated by the formula for risk corridor payments, we hold that Congress suspended the government’s obligation in each year of the program through clear intent manifested in appropriations riders,” Prost said.
“We also hold that the circumstances of this legislation and subsequent regulation did not create a contract promising the full amount of risk corridors payments.”
The judges also contended that the risk corridor payments were not budget-neutral, and that risk corridor payments were not obligatory, since the government did not provide budgetary authority to HHS to administer the payments. (Source: Healthpayerintellegence 6/18)
Carriers like Blue Cross who are allegedly is owed over $5 BILLION argue, federal "performance" payment history clearly show congress' intended to fund it, without it being specifically detailed in the ACA law over many years (its called regulation). DOJ contends congress is not obligated to pay what the "law" (DOJ loosely honors on other very important items like preexisting medical conditions plan sales being illegal) stipulated, and that congress separately intended to fund each year (if HHS felt like it "this" year). Result: Destabilized individual, small group and even large group health care Marketplace with millions more people uninsured. Many carriers - Cigna, United, Coventry, Aetna, Humana) carriers abandoned the individual and small group market offerings. Result: REAL insolvency risks to any carrier carrying debt for (Deductible and MOOP higher) claims they already paid, and long term insolvency risks especially to small hospitals, and even large hospital oligopolies (because people abandon insurance, incur giant bills when they show up in the ER).
Risk Corridor is very different (Stop Loss and or Professional coverages offered by CMMI under Direct Contracting with 0% to 90% "shared savings" potential bonus on Medicare lives. Its complicated. Risk Pooling A term typically used to describe a grouping of risk involving an manuscripted coverage. Many types of risk pooling exist on the private and public fronts like HO3, General Liability, Workers Compensation, MEWA, Trusts, OBGYN Professional Liability, PEO, various surplus lines initiatives (on-shore & Off-shore), etc. Risk Retention Grop (RRG)A state authorized risk bearing entity that, depending on the advising attorney advice, is not assessable to hits capitalizing membership or holding company.
Assessable liability may change depending on RRG meeting minimum and ongoing capital surplus state requirements. Its complicated, so rely on licensed legal advice. Roll Out The termination of the split dollar (life insurance plan paid for by the employer - SERRP)plan and the resulting transfer of sole ownership to the insured employee is called a rollout. Not the same as roll-up, which is typically a term used when describing interest rate performance in an annuity. Rule 8424 fiduciary exemptioin A Dept of Labor issued exemption from a fiduciary standard disclosure requirement related to facts and circumstances surrounding investment advice or recommendations involving qualified money. (untaxed income, or funds used from retirement accounts - i.e. some IRAs, 401, etc.).
Investment recommendations involving qualified accounts DOES require separate sign off and management from a registered financial advisor or institution.
Many Federal cases are in litigation now, and the compliance targeted for Jan 2017 has been delayed. See current DOL advisory.
Rule of 72 A rule allowing people under 59 1/2 to take money out of their 401's without the 10% penalty It is called a Section 72(t) distribution. In a 72(t) withdrawal, the distributions must be "substantially equal" payments based upon your life expectancy. Once the distributions begin, they must continue for a period of five years or until you reach age 59½, whichever is longest.
https://www.irs.gov/forms-pubs/about-publication-590-b Run Out A Run Out is typically used to define the length of time claims are adjudicated and paid when carriers decide to end an insurance plan. Typical lengths of time may be statutorily defined, and are contingent upon carrier solvency, and/or court receivership assignment/management. Rural Health Clinic (RHC) Rural Health Clinics (RHC)See Federally-Qualified Health Centers Rural-Urban Continuum Codes (RUCC)See: Maryland Health Care Commission RVS Update Committee (RUC)See: RBRVS
S Safety Net Providers (ODF )CMS term for Safety Net Providers. The “Low-Income Health Access” Open Door Forum (ODF) has been renamed as the “Safety-Net Providers” ODF. A forum for issues of concern to Medicare and Medicaid providers and suppliers who furnish services to low-income and vulnerable populations. Federally-Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Tribal Clinics, Hospitals, and others are encouraged to participate on the calls. SBM-FP - State-based Marketplace on the Federal platform (SBM-FP )While the PPACA allowed each State
to operate its own State Exchange,
currently 11 States and the District of
Columbia operate their own Exchanges,
five States utilize the SBE–FP model,
and FFEs operate in the remaining 34
States. CMS seeks to support innovation
by States operating State Exchanges by
providing opportunities .... Script Jargon used to describe a medical prescription for drugs. See AWP See DTC. Second Dollar Risk Relative to "specific" medical stop loss coverages, it can be the amount of eligible claims excess of $50,000 per person per year. The amount is subjective by type and line of insurance. Section 125 Plans (125 Plans)
Medical benefit plans employers can establish to pay for eligible insurances with pretax funds, and thereby save approximately 7.65% of payroll taxes. Many eligibility rules and regulations apply to maintaining tax preferred funding of employee benefits. Section 125 plans are different from HRA accounts. Section 125 account balances NOT spent on eligibile medical expenses during the policy year DO roll over to subsequent years, and can be used in retirement too. Tax considerations and regulations are many, and must be confirmed with Licensed CPA’s or attorneys.
Sector In context to the S&P 500 Index (Standard and Poors): A term describing one of eleven industries representing 500 stocks included in the index. See: SPY Security Contral See: HIPPA, etc. Security Incident See: Glossary of Office of Management and Budget. A ambiguous category of unauthorized or perhaps even criminal hacking/release of PII. See HIPPA, and good luck figuring out who is guiding what standard, and when it becomes whose responsibility to inform who that their data "may" have been hacked? See: Security Control, Responsible Official, Self Funded Plan A plan typically operating under ERISA that offers medical insurance to employees. Sometimes referred to as "Self Insured", a Self Funded insurance is a statutorily compliant plan of insurance characterized by high deductible. These plans are typically less expensive and more flexible than buying "Fully-Insured" medical plans with lower deductibles. Self funded plans take many forms, and contractual structure. Self Funded Plans are typically characterized by deductibles (to the employer, not the individual employees) over $35,000. Most common are ERISA (employer) Group plans, General Liability, Professional Liability and Workers Compensation self funded plans, etc. Many payment rules, statutes, regulations and standards apply to claims settlements. See Fronted and Reinsured Assignments. Self Insurance Political Action Committee (SIPAC)A republican lead committee whose goal is protection of ERISA self funded plan interests. Self Insured Plan See Self Funded Senate Health, Education labor and Pensions Committee (HELP (Senate Committee))Republican lead committee vetting various healthcare bills, and that passed (November 2019 - vote of 20-3) the "Lower HealthCare Costs Act" aimed at eliminating surprise (in-network) billings, and allows the federal government to directly negotiate pharmacy (entitlement programs: Medicare, Medicaid, Tricare, etc.), instead of the health plans directly negotiating them at smaller scale, authority and effect. Source: Squire Patton Boggs Senate Health, Education, Labor, and Pensions Committee (HELP)A Senate committee that passed the Lower Healthcare Costs Act (i.e. Surprise Billings prohibition on IN NETWORK care) You are still out of luck with unlimited MOOP on OUT OF NETWORK care. See: Balance Billing Seriously Ill Population (SIP)See Primary care first webpage at CMS.
"Primary Care First Model Options
Select link to open options for Share
Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First is based on the underlying principles of the existing CPC+ model design: prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and high need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes.
Primary Care First Model Options will be offered in 26 regions for a 2020 start date: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide)."
https://innovation.cms.gov/initiatives/primary-care-first-model-options/. Service Area (Blue Cross Blue Shield defined) Blue Cross defines, " service area means 1) the geographic area certified by the Marketplace through QHP; or 2. if not a QHP, the geographic area approved by the Agency for Health Care Adminstration (AHCA); and in which rates have been approved by the Florida Office of Insurance Regulation (OIR)."
https://consumer.websales.floridablue.com/cws/plan-counties Shared Accountability See: Value Based Pricing. "The new goals for adoption of shared accountability alternative payment models include increasing the percentage of payments tied to quality and value to 50% for Medicaid and commercial health care expenses, and to 100% for Medicare Advantage and traditional Medicare expenses — all by 2025." Source: Think Advisor Jan 2020 Shared Decision Support (SDS)A CMMI program
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-12-08-2.html Shared Risk Federal Report of how the reinsurance provided to commercial carriers by the federal government for Marketplace INDIVIDUAL plans responded.
I. Highlights of the Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2016 Benefit Year
The transitional reinsurance and permanent risk adjustment programs functioned smoothly for the 2016 benefit year, as the Patient Protection and Affordable Care Act-compliant market continued to grow.
• The reinsurance program provides payments to issuers of non-grandfathered, individual market plans subject to the federal market reforms established under the Patient Protection and Affordable Care Act.
• The risk adjustment program applies to any health insurance issuer offering plans in the individual or small group market, with the exception of grandfathered health plans, group health insurance coverage described in 45 C.F.R. § 146.145(c), individual health insurance coverage described in 45 C.F.R. § 148.220, and any plan determined not to be a risk adjustment-covered plan in the applicable Federally certified risk adjustment methodology.
• A total of 767 issuers participated in the reinsurance and risk adjustment programs for the 2016 benefit year, of which 726 established EDGE servers.
• Of 496 issuers participating in the reinsurance program, all issuers successfully submitted the EDGE server data necessary to calculate reinsurance payments.
• Of 751 issuers participating in the risk adjustment program, 710 submitted EDGE server data to calculate risk adjustment transfers. The default risk adjustment charge was assessed to 1 of these issuers for failure to provide HHS with access to the required data and to an additional 41 issuers that did not submit EDGE server data.
The transitional reinsurance program continues to provide significant protection to individual market issuers with exceptionally high-cost enrollees.
• The initial, estimated reinsurance coinsurance rate for the 2016 benefit year is 52.9 percent.1
• For the 2016 benefit year, as of the date of this report, an estimated $4 billion in reinsurance payments will be made to 496 issuers nationwide.
Both the transitional reinsurance program and the permanent risk adjustment program are working as intended in compensating plans that enrolled higher-risk individuals, thereby protecting issuers against adverse selection within a market within a state and supporting them in offering products that serve all types of consumers.
1 As stated in 45 C.F.R. § 153.230(d), “if HHS determines that all reinsurance payments requested…for a benefit year will not be equal to the amount of contributions collected, HHS will determine a uniform pro rata adjustment.” As such, CMS can update the coinsurance rate after HHS determines the total amount of reinsurance payments requested. The initial, estimated reinsurance coinsurance rate for the 2016 benefit year is subject to change -- and may increase or decrease – in light of differences between projected and actual reinsurance contribution collections, discrepancies and appeals
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/Downloads/Summary-Reinsurance-Payments-Risk-2016.pdf Shared Risk (Medicare Risk Contract)A term usually applied to a Medicare risk bearing contracts offering downside financial risk, and upside splitting of surplus(es) achieved during a contracted period of time - typically 3 years in duration.
"Direct Contracting Risk-Sharing Options - Direct Contracting Risk-Sharing Options: Submit Letter of Intent by December 10, 2019.
Direct Contracting creates a variety of pathways for health care providers and suppliers to take on financial risk supported by enhanced flexibilities. Because the model reduces burden, supports a focus on complex, chronically and seriously ill patients, and aims to encourage organizations to participate that have not typically participated in Medicare fee-for-service, Innovation Center models, or both, CMS anticipates that this model will appeal to a broad range of physician and other types of health organizations.
CMS is testing two voluntary risk-sharing options:
Professional: Lower-risk option (50% shared savings/shared losses) and primary care capitation equal to 7% of the total cost of care benchmark for enhanced primary care services
Global: Full risk option (100% shared savings/shared losses) and either primary care capitation or total care capitation" Source: CMS Shared Savings Program See QPP, CSR, MSSP, Direct Contracting Risk-sharing
Shared savings is a term typically used to describe the ACA rules and payments to carriers to help people earning between 100%-250% FPL, that lowers individual deductible and max out of pocket member costs from what is stated on each persons plan. Does not apply to Medicare.
Shared Savings does apply to ACO's entering track 2 or 3 of available at risk contracting with CMS for targeted ACO accepting risk. Savings below target are "shared" with the providers. Per Medical Intelligence update September 2018, "MSSP ACOs with just one to two years of experience in the program actually increased Medicare spending, researchers reported.
"Direct Contracting Risk-Sharing Options - Direct Contracting Risk-Sharing Options: Submit Letter of Intent by December 10
Direct Contracting creates a variety of pathways for health care providers and suppliers to take on financial risk supported by enhanced flexibilities. Because the model reduces burden, supports a focus on complex, chronically and seriously ill patients, and aims to encourage organizations to participate that have not typically participated in Medicare fee-for-service, Innovation Center models, or both, CMS anticipates that this model will appeal to a broad range of physician and other types of health organizations.
We will test two voluntary risk-sharing options:
Professional: Lower-risk option (50% shared savings/shared losses) and primary care capitation equal to 7% of the total cost of care benchmark for enhanced primary care services
Global: Full risk option (100% shared savings/shared losses) and either primary care capitation or total care capitation" Source: CMS
https://qpp.cms.gov/docs/QPP_MSSP_and_QPP.pdf Short Term Limited Duration Insurance (STLDI)See: STM
Its what United Healthcare typically calls STM Short Term Medical Plan (STM, STCI, Scheduled Medical, Limited Medical, Min)A medical plan available to people both inside and outside of Open Enrollment, and whose term of coverage is typically less than 364 days.
Trump EO and ACA non-enforcement of ACA law prohibition against preexisting medical conditions, and QHP allows plans to exist in the US now. Plans cost about 10%-60% of ACA compliant insurance.
Do the work to understand what you are buying, or don't buy the plan. Beware exclusions, and balance billing liability.
See: Balance Billing, QHB, EHB, coverage denials, policy rescission, etc. Most important in the current status is that STM can exclude preexisting medical conditions (apparently during both Open Enrollment and Special Enrollment Periods).
Most STM's are not "faith based" plans.
Many other types of medical plans are available, that may also be a type of short term plan inclusive of: Limited Medical Plans, or Cancer-Cardiac-Critical care plans, Hospital indemnity (gap) plans, Travel Accident plans, Accident only plans, etc.
Most STM provide little or no Rx insurance.
AARP plans to roll out a STM in 2020 to members, and is expected to exclude several medical conditions and underwrite both height and weight - a practice that is prohibited on ACA compliant plans.
https://www.cms.gov/CCIIO/Resources/Files/Downloads/dwnlds/CMS-9924-F-STLDI-Final-Rule.pdf?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery SIC codes (Class codes)See NCCI who issues about 700 work type codes for purposes of assigning workers compensation premium (risk) assignment. Means, dangerous jobs cost more than white collar jobs. See: MOD's. Silver Loading A carrier practice of disproportionately increasing the premiums of "silver" (metallic) ACA QHP offered plans. I.e. Blue Cross Plan increased my Silver Plan 45% on 2018 in my renewal. The term can also mean republican administrative "actions" to disrupt ACA law. Silver Tsunami Term used to warn everyone about (baby-boomers) 10,000-11,000 people a day turning 65, and federal/state/municipal/employer/individual preparation needed to fund and treat a much older population. Just know that Medicare medical utilization is about 3 times greater than for under 65 years old cost of care. Simple or SEP Retirement Plan (SEP)A retirements plan used by some smaller corporations or sole proprietors.
https://www.irs.gov/retirement-plans/plan-sponsor/simplified-employee-pension-plan-sep Simultaneous Funidng A stop loss policy feature that if offered, and/or requested, allows for simultaneous processing of a specific and aggregate claims, even 7-10 days after the end of the policy (well before three month policy term). These get a bit squirrely to manage where aggregated claims are not well above aggregate attachment stipulated in the policy. Single Employer Trust or Association Health Plan The association health plan is a self funded ERISA major medical group insurance that is exempt from community rating, and operates under ERISA. Advantages include an advanced aggregate reinsurance coverage, lower agent & TPA fees, favorable experience discounts and other significant savings. Typical minimum program requirements include 1,000 lives and retention at $50,000. Pooling of first dollar risk among multiple employers is prohibited (except for possible MEWA where permissible). Favorable experience is rewarded by refunding unused premium and discounting future premium. A single employer trust offers a middle ground between the higher risk of traditional self funding, and the higher cost of a fully insured benefit while providing a fixed monthly premium easily budgeted by the employer. They are different from Level Funded plans by offering higher retention levels which means managing more risk.
Single Payor System A make believe term used by conservatives to describe a government offered major medical plan for everyone. See Medicare for all, Medicaid for all, Medicare supplemental plans, SHOP plans, Marketplace offered plans, off marketplace offered plans, Commercially offered group/small group/ERISA self-funded etc. Skilled Nursing Facility Quality Reporting Measures (SNF QRP)
The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Review and Correct reports are now available on demand in the CMS Certification and Survey Provider Enhanced Reporting (CASPER) application. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage. NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.
• Contain quality measure information at the facility level
• Allow providers to obtain aggregate performance for the past four full quarters (when data is available)
• Include data submitted prior to the applicable quarterly data submission deadlines
• Display whether the data correction period for a given CY quarter is “open” or “closed”
Small Business Health (Insurance) Options Program (SHOP)A failed federal medical insurance program generally available to small business under 50 FTE's (whose employee average income is under $50K), that offers potential BUSINESS tax credit up to 50% (year one) and 35% (year two, and nothing for years 3+) of what the employer contributes towards an employee’s premium. Tax credits are offered up to two years. Enrollment is 100% electronic, and premium payments must be in no later than the 15th of each month. Carriers like Coventry/Aetna pay about 1.5% commission to agents which means a loss to any agent for small group enrollments. Federal and commercial efforts to enroll small employers has essentially failed under the current non-commissioned agency structure. Carriers have for many years done their best to not write small group, with Aetna and United leading the way. Most carriers do not offer any SHOP plans. Eligibility rules are complicated - employers generally must be "small employers" and have at least one employee on the first day of the plan year. Group "participation" rules are waived. ACA defines ALE. Estimating employer size can be complex and agents and brokers should refer to official Department of Health & Human Services and Internal Revenue Service (IRS) guidance on this topic before advising employers regarding their size. Generally, an employer is a "small employer" if it had one to 50 full-time and full-time-equivalent (FTE) employees (one to 100 in some states) on average, on business days during the preceding calendar year. When counting FTE and full-time employees, do not include the following. PEO is complicated.
Under this methodology, a full-time employee is one who is employed for, on average, 30 hours or more per week. A FTE employee is a combination of multiple part-time employees whose combined hours total 120 hours per month. If an employer was not in existence throughout the preceding calendar year, the count of full-time and FTE employees is based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year. The SHOP coverage must be offered to all full-time employees (full-time employees are those employed for an average of 30 hours or more per week). Employers may offer coverage in a combination of Federally-facilitated SHOP Marketplace states and State-based SHOP Marketplace states, including State-based SHOP Marketplaces not using the federal platform.
For an employer group to enroll in SHOP coverage, a certain percentage of employees must enroll, unless the enrollment occurs between November 15 and December 15 of each year. This is called the minimum participation rate (MPR). In most states, during the months when the MPR applies, at least 70% of the business' or group's full-time employees must accept the employer's offer of SHOP coverage or be enrolled in certain other coverage before the group can enroll. A few states with a SHOP Marketplace have set a different MPR, which can be found at HealthCare.gov. The MPR is determined by first adding the number of full-time employees accepting coverage offered by a qualified employer to the number of full-time employees who, at the time the employer submits the SHOP group enrollment, are enrolled in coverage through another group health plan, government-sponsored coverage (such as Medicare, Medicaid, or TRICARE), the individual market, or other minimum essential coverage. This number is then divided by the number of full-time employees offered coverage to calculate the participation rate.
The MPR is only calculated at the time of initial enrollment and upon renewal. From November 15 to December 15 of each year, eligible small employers can enroll in SHOP coverage without meeting the MPR requirement.
Levels of Coverage and Choice
The QHP levels of coverage correspond to different levels of actuarial value (AV) based on how enrollees and the plan can expect to share the costs for health care. For purposes of establishing a “employer GROUP” standard, the lowest cost Bronze level plan by zip code region is used.
The category an employer chooses affects, on average, how much enrollees pay for things like premiums, deductibles, and copayments, and the total amount they have to spend out-of-pocket for the year if they need a lot of care
Bronze. The health plan covers about 60% of the total costs of care on average. An average enrollee can expect to pay about 40%
Silver. The health plan covers about 70% of the total costs of care on average. An average enrollee can expect to pay about 30%
Gold. The health plan covers about 80% of the total costs of care on average. An average enrollee can expect to pay about 20%.
Platinum. The health plan covers about 90% of the total costs of care on average. An average enrollee can expect to pay about 10%.
Very few carriers offer SHOP plans making it almost impossible for employers to consider them. Existing Agent Commissions on groups under 4 lives have been reduced or eliminated completely, thereby eliminating the line of business for many agents.
*Definition from Marketplace Agent training:
Small employers (generally those with 1-50 employees) may be able to enroll in SHOP plans through an insurance company or with the assistance of a SHOP-registered agent or broker. For more information on how to assist employers in the SHOP, please complete the SHOP course included in this training. Remember, if you intend to only help clients purchase SHOP plans, this training is recommended, but not required.
However, all agents and brokers who wish to participate in the SHOP in the FFM and SBM-FPs must read and accept the “Agreement Between Agent or Broker and CMS for the Small Business Health Options Programs of the Federally-facilitated Exchanges and State-based Exchanges on the Federal Platform” (SHOP Privacy and Security Agreement) annually prior to assisting employers with selecting and enrolling in SHOP coverage. You can access this Agreement via the Marketplace Learning Management System (MLMS).
Employer-sponsored insurance is considered unaffordable for an employee, and the employee’s family members if they are also allowed to enroll in the coverage if the amount the employee must pay for the lowest-cost self-only plan that meets the minimum value standard is more than a percentage of the worker’s projected annual household income. The percentage is 9.86% for plan years beginning in 2019. The percentage for plan years beginning in 2020 is not available as of the publication date of this training.
A health plan meets the minimum value standard if both of the following apply:
It is designed to pay at least 60% of the total cost of medical services for a standard population.
Its benefits include substantial coverage of physician and inpatient hospital services.
If the employee and his or her family members actually enroll in the employer-sponsored insurance, the employee and family members are eligible for Marketplace coverage (and not allowed APTC) regardless of whether the employer plan is affordable or provides minimum value.
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Source Agent Marketplace Exam
See: Contribution, participation
https://www.healthcare.gov/small-businesses/choose-and-enroll/shop-marketplace-overview/?utm_campaign=hcgov_hra&utm_content=enroll2020&utm_medium=email&utm_source=govdelivery Small Employer Tax Credit Small Employer Tax Credit
Small employers (those with fewer than 25 full-time employees) may be eligible to receive a tax credit for premiums paid for employee health insurance coverage. The credit may be carried back one year and forward 20 years.
The available credit is subject to limitations based on:
- the number of employees
- the average annual wages paid to employees
The maximum small employer health insurance premium credit available to eligible small (For Profit)employers is 50 percent of workers’ health care premiums paid by small employers and 35 percent of such premiums paid by small tax-exempt (Not for profit) employers, such as charities. It is only available if an employer obtains coverage through a Small Business Health Options Program (SHOP) in the ACA Healthcare Marketplace.
Source: Florida Agent Licensing Exam Course SNF Quality Reporting Measures see SNF QRP Social Determinants of Health (SDOH)Measured and tracked behaviors (i.e. drinking, smoking, access to care, etc) studied to determine: financial, co-morbidity and mortality causality.
SDOH purpose is to effect healthier behaviors resulting in better health, and lower costs. One of the latest terms used to focus on what matters in "value Based reimbursements" (or treatments of highest efficacy to EBM outcome). Its direction today is to place monetary benefits for members making healthy lifestyle choices, and/or complying with medication and treatment regimens. Plainly, SODH looks to derive practical monetary incentives to "members" (under a stakeholders financial responsibility) smoking cessation, hypertension, diabetes, eating high salt/fat/sugar foods, drinking, resting, etc.
See: Aetna's "Resources for Living" program that draws on information from the social isolation index to recommend social interaction opportunities that are tailored to the member's independence, mobility and health.
See: Humana's community relationships and social determinants of health focus to pursue grocery benefits and home improvements for patients at risk for falls.
See: Blue Cross' grocery, home finance and patient transportation program. Social Justice A phrase used to denote a juries holding larger corporations responsible for larger awards for punitive damages. Social Security A federal entitlement program offering many benefits, among which are monthly pension payments to qualified people over 66 (now 66) who have worked and paid taxes for 40 quarters into the system. Social Security pension payments are typically accompanied by Medicare major medical insurance coverage entitlement too.
*2020 earning limit for people UNDER full retirement age (65) all year is $18,240. Social Security Administration deducts $1.00 from you benefits for each $2.00 earned over $18,240.
*The 2020 earnings limit for people turning FULL RETIREMENT age (66) is $48,600. Social Security deducts $1.00 for every $3.00 earning over $48,600 until the month you reach full retirement.
Social Security is not Medicare, but does deduct Medicare Part B premiums (about $135/m depending on income and age) each month on people qualifying for coverage.
Social Security Social Security eligibility An individual 62 years of age or greater, who has contributed FICA taxes himself or by his employer for a minimum of 40 quarters (10 years). Filing an application with Social Security is required. Special Enrollment Period (SEP)Under ACA, (in context to commercial, and not Medicare, Group, or Medicaid lives) a special enrollment period is a 60-day period following a qualifying event where individuals may enroll in permanent (QHP) major medical insurance coverage through the health insurance marketplace, and/or other allowed sites. A special enrollment period must be triggered by certain qualifying life events or extraordinary circumstances.
SEPs that require pre-enrollment verification include:
• Loss of qualifying coverage
• Gaining or becoming a dependent through birth, adoption, placement for adoption, placement in foster care, or a child support or other court order
• Medicaid or Children’s Health Insurance Program (CHIP) denial after applying for Medicaid/CHIP during Open Enrollment, or after applying for Marketplace coverage during Open Enrollment or following another SEP-qualifying event.
Individuals who miss Open Enrollment generally cannot sign up for coverage until the next open enrollment period begins, unless they qualify for a special enrollment period due to a qualifying life even.t such as:
• getting married
• having or adopting a child
• placing a child in adoption or foster care
• involuntary loss of other health coverage due to:
o turning age 26 under a parent’s coverage
o termination of employment
o expiration of COBRA coverage
o loss of Medicaid or CHIP eligibility
o closing of a plan year
o decertification of a health plan
• moving one’s residence out of the area served by an existing plan
• becoming newly eligible to sign up due to:
o gaining citizenship
o gaining status as a member of an Indian tribe
o leaving incarceration
• if already enrolled, having a change in household status or income that affects eligibility for subsidies
However, individuals who qualify for Medicaid or for the Children’s Health Insurance Program (CHIP) can enroll at any time of the year. Also, small business owners (those with 50 or fewer full-time employees) can obtain employee coverage through the Small Business Health Options Program (SHOP) Web site (www.healthcare.gov/small-businesses) at any time of the year.
https://www.agentbrokerfaq.cms.gov/s/article/What-is-a-special-enrollment-period-SEP-and-what-qualifies-a-consumer-for-an-SEP?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery Special Enrollment Period (SEP)See: Open Enrollment, Marketplace plans, Medicare Plans, and Employer group medical plan designated periods. SPecial Enrollment Period Pre-Enrollment Verification (SPEV)See: Marketplace eligibility SEP. Specialty Drug (Tier 4 or 5 drugs )A super expensive "brand name" drug that is typically protected by patent and much higher pricing that may, or may not be insured, depending on the plan. Very contentious situation where the FDA approves the drug, and the carrier denies coverage.
A specialty drug can also be called an Orphan Drug, even though an orphan drug term is used to denote a drug whose high manufacturing cost and low demand prevents active commercial sale due to no profits. The federal government has some programs for some orphaned drugs.
" Drug makers have built a lucrative business around drugs developed to treat rare diseases, according to an AHIP study that found prices for orphan drugs are 25 times higher than prices for traditional drugs. Average annual orphan drug prices increased from $7,136 in 1997 to $186,758 in 2017, 88% of them cost more than $10,000 per patient each year, and drug makers are increasingly focused on rare diseases." (Source: AHIP update September 2019)
These drugs can cost $30,000 to over a million a year to buy. There is no one definition. Specific Stop Loss/Reinsurance A stop loss or reinsurance coverage that triggers after a deductible. Specific coverage is a per person per year coverage that can reimburse: employers, HMO's, ACO's, and ERISA entities' catastrophic claims excess of (typically) $50,000. Higher deductibles are common. Specified Low-Income Medicare Beneficiary (SLMB)Help pay for Part B premiums. See SLMB+ (that some people are eligible for full Medicaid Benefits. Stage 3 Meaningful Use (Meaningful use)See CMS on Meaningful use. Stage 3 refers to requirements under QPP related to Hospitals inclusive of avoiding Medicare Part A & B (physicians charges for hospitals based doctors) reimbursement reductions that will require certified EHR technology (CEHRT) in the ONC Health IT Certification program for Stage 3 Meaningful Use. Stand Alone Dental Plans (SADPs)Dental plans added to individual major medical plans. These are dental plans enrolling one at a time, even for individual employees each electing a voluntary benefit offered or not offered by their employer. Star Ratings A CMS - one to five star rating of Medicare Advantage and their pharmacy plans that includes beneficiary feedback. (including dual eligible erollees)
"Each year, CMS publishes the Medicare Advantage and Part D star ratings that include measures on the experiences of beneficiaries.
Medicare Advantage with prescription drug coverage contracts are rated on up to 45 unique quality and performance measures; MA-only contracts (without prescription drug coverage) are rated on up to 33 measures; and stand-alone PDP contracts are rated on up to 14 measures." Source Healthcare Finance Oct 1090. Stare decisis Under the principle of stare decisis, all other state and federal courts will follow state supreme courts decisions in insurance coverage matters.
US Supreme Court MUST apply each state's Circuit Court (federal Court) INSURANCE law precedent, and establish its own law without consideration of each state's insurance laws judgements. Stark (Anti-Kickback law)A federal law making illegal self referrals from doctors to entities they have a financial interest. State Based Marketplace (SBM)A term referring to states that operate their own separate INDIVIDUAL and / or SHOP health insurance on line exchange charged with selling ACA compliant medical plans. See: SBM-FP, FFM. ect State Based Marketplace on the Federal Platform (SBM - FP)On online site that is similar or identical to the Federal Marketplace platform offering individual and SHOP (employer small group) medical plans. See: FFM, COOP, etc. State Data Resource Center (SDRC)
http://www.statedataresourcecenter.com/announcements.html State Health Insurance Assistance Program (SHIP)See: Medicaid, Dual Eligible, SSI State Laws Impacting Healthcare Cost and Quality (SLIHCQ Database)A 116 page report detailing state (not federal) laws impacting price, cost and quality. Reports that two similarly sized same region hospitals merging likely to increase hospital prices by 9%.
"Studies like the RAND Hospital Price Transparency Study show that prices in some
markets have reached extraordinarily high levels -- at the highest end of the
spectrum, some health systems can command over 400% of what Medicare pays on
average. Nationally, the chasm between Medicare and commercial prices grew
significantly over the past two decades: in the 1990s, the average hospital received
110% of Medicare’s rates for inpatient care; by 2017 the gap widened to 204% of
Medicare's rates for inpatient care, and almost 300% of Medicare for outpatient care.i" Source: the catalyst for Payment reform, and The Source on Healthcare Price & Competition (project of the University of California) March 2020
https://www.catalyze.org/product/state-policies-market-power/ State Partnership Exchange Means a type of FFE in which a State assumes responsibility for carrying out certain activities related to (ACA QHP) plan management, consumer assistance or both. (Source: CMS Marketplace Exam study material. Steerage Steerage refers to managed care procedures that direct members inside a contracted network of providers. Sometimes referred to as repatriation, Steerage also refers to the effectiveness of utilization review functions to get out-of-area members back into the local contracted network. This is especially important to the management of transplant, burn, rehabilitation and neonatal patients. Stop Loss Stop loss is an insurance which provides reimbursement for catastrophic medical claims incurred by a self-funded employer's employee or by a capitated HMO member. There are two primary types of medical stop loss - employer stop loss and provider stop loss (provider excess loss).
Stranger Owned Life Insurance Policy (STOLI)Depending on the state and Agent Appointment contract, there may be a prohibition against financing, or paying premium (on a new policy) by an unrelated third party without a "insurable interest" beyond an investment return. These policies have historically been used by investor groups with no insurable interest to the insured. As always, fraud in any application is fraud. Most carriers will not knowingly issue STOLI's. Many states prohibit them as violating life insurance public interest value. NJ Supreme Court upheld that these policies are not enforceable, with premium refund being potential remedy. See: Life Settlements Subhealth Plan (SHP)Meaning set forth in 45 CFR 162.103 Subhealth Plan (SHP)See: ACA : 45 CFR 162.103 Subrogation (Primary, secondary and/or tertiary payer)Subrogation is the right of recovery of one party against another party. It may also be defined as the order of insurance company liability and payment sequence. This can refer to the rights of the (Commercial not Medicare) HMO, or provider group (or carrier) to recover additional monies from a second insurance policy. In managed care, it can refer to an obligation of a provider group to use all legal remedies to repay the (stop loss) insurer for any claims paid, and whatever else they can collect.
Medicare and Medicaid Subrogation rules are different from Commercial (individual and "group" employer plans) rules. I.e. These types of coverage usually pay first - for services related to each type services also insured by: No Fault insurance (PIP) including Auto Liability insurance, Black Lung Benefits, workers compensation (which is always first). Medicaid and TRICARE never pay first for Medicare- covered services. They only pay after Medicare, employer group health plans, and/or MediGap (Supplemental) have paid. Source: 2020 Medicare Handbook Suitability (Senior Suitability)In context to a recommended financial transactions inclusive of insurance need(s), suitability means putting the client's interests first. In context to Senior Suitability, it means completion of a state designated Senior Suitability application by the potential annuity buyer, and carrier approval to sell the annuity. Suitability relates to the buyers financial ability to sustain a loss, or invest for appropriate periods subject to their age, investment's Principal safety, and expectation of interest returns over time.
See: NAIC / DOL mandates and guidelines and BIC and/or fiduciary requirements. Risk, like beauty, it is in the eye of the beholder. But, when it comes to funds moved from retirement funds, there is a higher standard to vet for suitability in annuity sales. Suitability can mean several things in context to what person is buying something with funds from (qualified or unqualified) retirement accounts, or taxed funds invested with safety and/or interest guarantees. Investments, like annuities that do not crash when the stock market crashes, and that enjoy contractually (stated) promised interest crediting and safety are not the same as investments that do crash when the stock market crashes, and that offer no interest crediting or safety guarantees.
https://content.naic.org/cmte_ex.htm Summary Plan Document (SPD)An ERISA mandated description of medical benefits that gets distributed to employees of self funded plans. Supplemental Executive Retirement Plan (SERP)A retirement/disability/life insurance plan paid by taxed (non qualified)employer funding, that may also allow complete employer reimbursement of the benefit (deferred compensation) at death of a key executive. Supplemental Security Income (SSI)See: Social Security. SSI is what disabled people get each month from the federal government. See: Medicaid, and Medicare dual eligible - and good-luck trying to figure it out. SUPPORT Group Health Plan (GHP) Reporting forSubstance Use-Disorder Prevention that
Promotes Opioid Recovery and Treatment (SUPPORT). Source: CMS
See: GHP Suprise Balance Bills (Balance Bills)See: Balance Billing
Bills from non-contracted (PPO) physicians (technically out of network doctors) received at in network facilities. It can also be a balance bill to the patient calculated at the difference between what the carrier pays (their allowable reasonable and customary charge) and the (non-contracted provider) bill. Ex. ER doctor, Anesthesiologists, infectious disease specialists, surgeons in emergency surgery... See: Surprise billing, and know there are several contentious proposed "bills" in congress in process.
Surplus Lines Carrier (Non Admitted Carrier)Typically refers to an insurance company that is Eligible but not Authorized to write policies in a given state. Surplus lines carriers are usually referred to as "non-Admitted" markets/carriers. Surplus Lines policies do not enjoy State Insurance Guarantee Association support in the event of insolvency. States mandate special disclosure to policy holders of Surplus Lines carrier status. Surplus Lines carriers can be extremely large, and extremely well funded. As a general rule, surplus lines coverage is attractive when the carrier rating is A or better and used when desired coverage terms are unavailable in the "admitted carrier" market. There are entities like Citizens JUA (joint underwriting association) that insures windstorm risk in Florida. Citizens is not a surplus lines carrier, and does not enjoy State Guarantee Association. Citizens is an UNRATED insurer. Surplus Relief or Finite Reinsurance Surplus Reinsurance is coverage that effectively transfers premium from the primary insurer to the Reinsurer thereby improving capital reserve ratios and financial ratings. Typically, these reinsurance agreements are in the form of a Quota Share arrangement with profit sharing reverting back to the primary insurance carrier for a risk charge. Coverage typically responds at 125%+ of the expected claims value. See Finite Reinsurance Surprise Billings See: Balance BIlling Surprise Bills Generally used - means balance billing to patients entering in network facilities, but who get treated by out of network physicians. Several states have laws prohibiting such billing. It can also mean, high deductible, MOOP, or excluded medical treatments, etc, patients ignored, failed to consider, or hoped would never happen from a sickness or accident event. See: QHP, STM, Critical care plans, Gap, etc. Sustainable Growth Formula (SGF)Medicare formula for calculating maximum allowable charges that is now replaced with Quality Payment Program (QPP). System of Record Notice (SORN) System of Record Notice (SORN)"record" means a notice published in the Federal Register notifying the public of a System of Records maintained by Federal agency. The notice describes privacy considerations that have been addressed in implementing the system (as a result of extreme security issues caused by federal errors allowing unlicensed people collecting PII for Marketplace plan enrollments without adequate security controls) Note: Marketplace Agent Exam material for "SORN" has two definitions.... What? System Record Notice (SORN)Good luck with this one.
Means: any item, collection or grouping of information about an individual that is maintained by an agency including but not limited to that individual's PII, and transactions...and can also include voice/fingerprint or photo. See: System of Records
T Tax Tables IRS 2018
http://providerrisk.com/n1036.pdf TEchnical Expert Panel (TEP)CMS panel of experts relied upon by CMS to make and update targeted clinical and administrative standards and systems designed to reduce cost and increase medical quality.
Technical Expert Panel (TEP)What CMS calls clinical experts working on MIPS Telehealth Jargon used to describe professional care delivered over the phone or internet, and eligible for (Medicare or Commercial) insurance coverage. TeleMedicine or TeleHealth Healthcare advice delivered over electronic media and not in person. Technology is causing real savings in chronic care treatments in many areas like Cardiovascular Disease, Diabetes, COPD/smoking, etc. "Currently chronic illnesses account for roughly 75 percent of all physician visits, 80% of all hospital admissions, and 90 percent of all prescriptions." Source: BenefitsPRO Magazine March 2020 Jon Wiesen, MD.
Bottom line: Avoiding the super expensive ER or ICU visit means far better health (EBM), and lower costs. See: QPP
Twenty-eight states now require insurers to cover care provided through video calls the same way they would cover comparable care delivered in-person, the telehealth report team found.
Only 17 states' Medicaid programs cover remote patient monitoring services." Source LifeHealthpro Daily)
Multiple new products and services are being used now, with more being developed. Telemetry is not necessarily telehealth - but does use wireless reporting to advise disease and therapy real-time condition(s).
March 2019, Medicare final rules allow Medicare Advantage plan members to more aggressively use telehealth. See: CMS. Term Sometimes referred to as a Contract Basis, or Contract Period - Term refers to the policy year and claims submission period deadline. A typical stop loss term is for a 12/18 period. Here the policyholder's claimant has 12 months to accrue the claim, and 6 months after the policy year to report it to the carrier. Policies can be written on either a "Reported" or "Paid" bases. The Reported bases is richer coverage. Other Terms are 12/12, 12/15 and 12/24. Terminal Reserve Option Rider (Level Funded stop loss)A type of level-funded plan stop loss that triggers when a catastrophic claim happens (early in the plan year) before enough (fully funded) premium is there to cover stop loss deductibles and/or aggregated SIR. Call for details. Coverages are manuscripted, and not all the same. See: Terminal Aggregate Liability The Medicare Access and CHIP Reauthorization Act (MACRA)The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) changes the way Medicare rewards clinicians for providing quality care by streamlining multiple quality programs into a new Quality Payment Program tied to Part B Fee-For-Service payments. With the implementation of MACRA and the replacement of the Sustainable Growth Rate, we will pay clinicians participating in the Merit-based Incentive Payment System or Advanced Alternative Payment Models of the Quality Payment Program beginning in 2019 The Patient Driven Payment Model (PDPM)A developing model of payment for SKF patients based on the individual patients needs. See Value Based Pricing Thrift Savings Plan (TSP)Similar to 401(k) plans, but for federal employees.
https://www.tsp.gov/index.html Tortfeasor The "Defendant" being sued in a civil dispute. The person suing is the Plaintiff. Total Quality Improvement (TQM aka QA aka TQI aka Critical Pathways)A quality insurance vernacular which is the same or similar to Total Quality Improvement, Medical Pathways, Critical pathways, Total Quality Improvement, etc, and whose goal is to lower costs, and improve outcome of medical care delivery. Treatement, Payment Health Plan Operations (TPO)A contractual term used in Plan Documents to denote how HIPPA protected medical information is used for patient care and plan administration. Treaty Reinsurance (Automatic reinsurance) Treaty reinsurance is reinsurance of specified types or classes of insured exposures that are automatically "ceded” or accepted by the Reinsurer within the terms of the reinsurance contract or "treaty" without evaluation of each individual exposure. The reinsurance takes effect as soon as the primary insurance is sold. Treaty reinsurance is a general term used to discuss several types of coverages that can include profit sharing features. Trend A percentage increase for medical cost inflation and or utilization estimated for the following year's premium rate. Typical trend increases for large group are 4%-7%. Trend for second dollar risk is typically double first dollar risk. See: Wear Off TRICARE (DoD Tricare)A civilian component to military insurance, that is typically used when militarily staffed physician and hospital care is unavailable to an actively serving personnel, and/or some active reserve personnel. It typically pays prevailing rates to local doctors in underserved areas who agree to accept what TRICARE pays. Trigger Threashold An insured cause (peril) and/or amount of loss creating (triggering) an eligible claim. Trusted Data Sources A term the federal Marketplace uses to define reliable income data to verify accurate APTC. i.e. SSA, SSI, IRS, etc. See: MAGI, AGI.
U Uncollateralized Surety Bonds This type of financial guarantee bond is placed between the capitating HMO and the provider group as a safeguard against insolvency or bankruptcy. Different from the standard types of surety bonds which require 75% collateral, approved provider groups do not have to freeze their assets through an ILC. It is priced at 2% of face. Uncompensated Care (UCC)See: Bad Dept, up-coding Underwriting In context to insurance: A process of building a premium and assigning it to a particular risk. Premium setting (building) process exclusive to each risk seeker's willingness to accept a transferred risk. A forecasting process projecting future costs from historical data typically inclusive of: claims costs, carrier profit margin, carrier overhead, commission, reinsurance, premium tax, and fudge factor. See: Insurance professional designations Underwriting Death Spiral Jargon used to describe adverse selection caused by sick (high medical claims) members staying on a plan, and/or healthy people leaving a plan. Generally, most plans will not survive more than 1-3 years in such circumstances. Unearned Premium A carrier liability Uninsured Motorist (UM)Coverage triggering upon an auto accident caused by another driver (not the driver) that payd medical benefits to persons in the drivers car. Florida statute appears to detail that coverage applies to family members residing in the named insured's home at time of accident. UIM is underinsured motorists auto coverage triggering when liability limits purchased by the other driver are not sufficient to indemnify the injured party 's damage in accidents caused by the other driver (not the driver). Different states have different requirements. Uninsured Rates Report used by CD to estimate uninsured US population rates.
http://media.thinkadvisor.com/thinkadvisor/article/2017/08/30/cdc-health-insur201708.pdf US Core Date for Interoperability (USCDI)A term related to interoperability of data set reporting CMS uses primarily for Medicare. See: API, Interoperability 2021 in context to getting date (information) to patients and higher engagement that is expected to reduce costs and improve EBM outcomes. US Department of Heatlh and Human Resources (HHS)See: CMS
V Value Based insurance Design (VBID)According to CMS, the seamless test of carving in the Medicare hospice benefit into Medicare Advantage (that's Medicare HMO/PPO, not supplemental), as part of the Value-Based Insurance Design focused on Hospice care. Just know that palliative care costs massive.
See related (not just Hospice care: MACRA, QPP, PQRS
http://email-archive/2020-04-09-mlnc#_Toc37220540 Value Based Payment Modifier (VM)See: MACRA, MU, PQRS, VM, CPC+, QPP, APM, & Bundled Payment
KEY TAKEAWAYS (Source Healthcare Leaders Dec 2018)
More than 1,550 hospitals (over 55%) will share higher Medicare payments totaling about $1.9 billion in fiscal year 2019.
The average net increase in payment adjustments is 0.61%, and the average net decrease is -0.39%.
For 2019, average Total Performance Score across all participating hospitals increased.
Value Based Reimbursement (see RBP)See Bundled Payments.
VBR is an amorphous term used to define various types of "bundled", DRG, per diem, cost per confinement, or fixed budget outcome based chronic care Medicare provider contract - priced "valuable" by whatever criteria the buyer / seller finds valuable. Its implied goal is to improve medical outcomes at a lower cost, improve medical outcomes, and prevent up-coding single procedures into multiple procedures/charges. See: Bundled Payments
About 55% of hospitals earned Medicare incentive payments in 2019 under the Hospital Value-based Purchasing Program, slightly fewer than in fiscal 2018 when 57% of the hospitals did, or just under 1,600. Source: Feb 2019 Modern healthcare
"The Scorecard showed early investments in pay-for-performance, with 12.8 percent of payments stemming from one of these models in 2014. That percentage increased to 16.6 percent of payments by 2017. However, shared savings arrangements outpaced the models by that time.
Most value-based payments (29.7 percent) made in the commercial sector in 2017 were part of a shared savings arrangement, the Scorecard found. Shared savings arrangements were also the most popular form of value-based payment in 2016, with 23.7 percent of payments.
Notably, the proportion of payments made through a bundled payments model has remained flat since 2012 when 1.6 percent of dollars paid to providers in the commercial sector came from a bundle. By 2017, only two percent of dollars stemmed from these models.
READ MORE: More States Require Value-Based Reimbursement in Medicaid
CPR pointed out that the rate of growth in payment reform was largest at the beginning of the period in 2012 but has since tapered off. From 2012 to 2013, the proportion of commercial dollars coming from a value-based payment model more than doubled from 10.9 percent to 27.1 percent. From 2016 to 2017, however, the percentage of value-based payments only increased from 48.5 percent to 53.0 percent." Source RevCycle Intelligence 12/2019
https://healthpayerintelligence.com/news/value-based-payment-adoption-drives-5.6-reduction-in-care-costs?eid=CXTEL000000294213&elqCampaignId=5529&elqTrackId=6491f2c5ec404693828dbabbc4948816&elq=fdd36f97eb0b4227918984cebb59f25c&elqaid=5931&elqat=1&elqCampa Value St Authority Center (VSAC)See: eCQM
https://vsac.nlm.nih.gov/ Value-Based Care (VBC)Term Cigna uses to describe provider payments that are not FFS. Verification Carrier acknowledgement of a claim. See: Verification Vesting In contexts to Defined Benefit and Contribution plans sponsored by employers. … The period of time required to transfer ownership of plan or policy assets. The idea is to create a big asset, like in a overfunded life insurance policy, but keep these assets from being accessed until fully "owned" by the insured. These get complicated, and have all sorts of compliance issues involved.
See: Retirement Plans - Golden Handcuffs, Cadillac tax Veterans Health Administration (VHA) Viatical A life insurance policy that is typically sold to investors by an insured with less than two years to live. Viaticals offer a terminally ill persons access to funds prior to death. There are primary, secondary and tertiary markets for Viaticals. (See LE)
Viaticals are sold for ore than their "cash value", but less then the policy death benefit.
Voluntary Benefits Benefit offerings paid for by employer and/or employees. Sometimes referred to as “Ancillary Benefits” these insurances typically insure: Life, Dental, Short term Dissability, Long term care, Critical Illness, Accident only, Cancer, Cardiac/stroke/transplant, Short term disability, LTC, Hospital lump sum per diem GAP, AFLAC, etc.
W Wage index Formula A Medicare formula based on MAGI / AGI that establishes the premium rates charged for Medicare Part B, (and Part A for qualifying people over age 65). Waiver of Premium Typically, its a policy provision meaning premium payments stop when the policy coverage triggers. Wear Off An underwriting term expressed as a percentage increase used by Aetna - that is not a standard term. The percentage reflects expected claims inflation increase and individual employer's high dollar known (diagnosis) employee's claims expected in the coming year. See: fudge factor Web Broker See: ACA law - 45 CFR 155.22(s)(3) and 155.21, IMO, FMO, etc. Wellness Care A term whose meaning is tied to "participation" of insured people in "social determinants of health" and medical programs designed to manage chronic high cost medical conditions (i.e. hypertension, diabetes, drinking, obesity, etc.) in return for customer financial incentives that can stretch into concierge primary care privileges. See: Prevention care Wokers Compensation (Comp)A state mandated insurance coverage offering four primary coverages, and liability immunity to employers: Unlimited Medical insurance, Life insurance, disability income, and liability cover. Maritime standards are not the same as state requirements. Each state defines "statutory" coverage. Employers purchasing compliant comp enjoy some liability immunity. Employers not purchasing statutory cover may be guilty of a third degree felony.
Florida Worker Compensation Requirements Construction businesses with one or more employees and non-construction industry employers with four or more employees (full-time or part-time, including corporate officers and LLC members) must carry coverage. Agricultural businesses with six or more regular employees and/or 12 or more seasonal employees who work for more than 30 days must carry coverage. Sub-contractors are responsible for providing coverage for their workers, but primary contractors are responsible for ensuring that the sub-contractor has it. Out-of-state employers must immediately notify their carrier that they have employees working in Florida, carry a Florida workers’ compensation policy, or have the out-of-state policy include Florida.
Corporate officers are considered employees, unless they choose to exempt themselves from coverage. Sole proprietors and partners in the non-construction industry are not considered to be employees unless they choose to be. Members of an LLC will be considered as corporate officers/employees, unless they choose to be exempt.
Purchased from a commercial provider. Approved businesses may self-insure. Source: NFIB
***These brief jargon definitions are not advice. We recommend speaking with a licensed agent, the state of Florida or a licensed attorney specializing in workers compensation. These definitions are provided as a layman's courtesy. ***
See MCC, IME, EMA, DWC25 form, MSA, MMI, IW, etc.
https://www.nfib.com/content/legal-compliance/legal/workers-compensation-laws-state-by-state-comparison-57181/ Workers Comp (NFIP)See link: NFIP can also mean National Flood Insurance Program Workers Compensation Set Aside See Medicare WCMSA Workforce In context to people using/working/enrolling members on the Federal Marketplace that are not employees of the FFM::: A Non-Exchange Entity's FFE's, SBE-FP's employees, agents contractors, subcontractors, officers, directors, agents, representatives, etc. Wrap plan A term used many ways. It can be an umbrella plan, a gap plan or a plan over an EGWP. Write Your Own (WYO)An expression used in Flood policies sponsored by commercial carriers (with risk assumed by the federal government).
Y Year To Date (YTD)A common reporting measurement period.