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/affordable-care-act/employers/questions-and-answers-on-reporting-of-offers-of-health-insurance-coverage-by-employers-section-6056
https://www.uhc.com/broker-consultant/news-strategies/resources/2022-aca-6055-6056-reporting-and-new-guidance
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. 12b-1 Fees ("no-Load" Mutual fund fees)A term usually describing Mutual Fund fees charged that must be disclosed (like the new Fiduciary standard DOL rule mandates) declaring ALL compensation received by licensed fiduciary-securities entities. All kinds of rules apply to disclosure of fees, and depend on the type of license held by the agent or Broker-Dealer that range from being a simple order taker (most agents), to a fiduciary duty standard on most securities licensed agents. See: BIC, and the DOL best interests rules and pay special attention to a much higher standard for disclosure of fees related to funds coming out of retirement accounts. All funds have expenses, but 12b-1 fees are among the lowest offered to investors buying designated funds. See: Contingency Fees, Profit commissions, production bonuses, etc. It is not straight forward, and many believe the rule is too broad. See: Madoff, Enron, Worldcom, and SEC oversight. 13/26 Rule (Parity rule for group plans)A rule guiding an x-employee's (re-hire) medical plan eligibility. "The two methods are:
A 13 Week (or Longer) Break in Service. If the employee is rehired after a period of at least 13 consecutive weeks (26 weeks for educational institutions) where s/he did not work or provide an hour of service, the employer can treat the employee as a new employee.
Rule of Parity. If an employer wants to use a break period shorter than 13 consecutive weeks (26 weeks for educational institutions), it can apply this rule of parity. Under this rule, an employee can be treated as a new employee if the number of weeks during which no services are performed is both (1) at least four weeks long and (2) exceeds the number of weeks of employment immediately preceding the period during which no services are performed. For example, if an employer uses the rule of parity, an employee who works for five weeks and then has no credited hours for six weeks may be treated as a new employee on rehire. This rule of parity really only applies to employees who leave before completing 13 (or 26, for education institutions) weeks of service." Source HUB International. There are lots of rules affecting medical plan eligibility and coordinated rules specified in Employee Handbooks, SPD's, part/full-time status of the returning employee who was/wat not insured, and who will not be working 30 or more hours a week, etc.
Carriers want to be very clear when an employee becomes eligible if they are already sick, and get guarantee issue GROUP coverage. 2
2019 Public Charge Rule A Trump administration immigration rule stating not to admit any immigrant likely to need health care. 216 License (Life Only Insurance License in Florida)Florida agent license to sell and/or represent Life insurance. 218 License (Life and Health license in Florida)A Florida Agent license to represent l Life and Health insurance. 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.
(As a background) "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) See: Interoperability https://www.cms.gov/files/document/cms-9115-f.pdf
https://www.cms.gov/files/document/2021-cehrt-fact-sheet.pdf
220 License (Property & Casualty License in Florida)License required to represent Property and Casualty insurance in Florida. All states use a P&C license category. Note: P&C licensed agents can also by rule (in Florida and most states) sell most types of major medical insurance. Whereas L&H licensed agents are prohibited from writing P&C coverages. 3
3M Clinical Risk Groups (CRGs)A Risk Adjustment tool used to estimate current and future individual health care costs. 4
4-40 license (CSR - Customer Service Rep)A salaried employee of the generallines (property and casualty) agent or agency that may transact automobile, water craft, home, motorcycle, and pet insurance under the supervision of alicensed and appointed general lines agent. Covid statutes are allowing these people to work from home for a period, and not directly in the same office as the fully licensed P&C agent - (as is normally required). 401 (K) plan (Defined Contribution Plan)See: Defined Contribution Plan https://www.irs.gov/retirement-plans/401k-plans
5
5500 Form (5500 Form ERISA / HRS 5500 form / DOL 5500 form)A required form to be filed by self funded plans with the DOL. Lots of rules of who is, and is not exempt from filing with regards to groups under and over 100 lives, with or without being "funded". 6
6055/6056 Forms Guidance https://www.uhc.com/broker-consultant/news-strategies/resources/2022-aca-6055-6056-reporting-and-new-guidance
A
ACA Final Rules 2024 Notice of Benefit and Payment Parameters Final Rule: Changes to the network adequacy standards, limits non-standardized plan offerings, extends rights (to 90 days SEP) to enroll in ACA marketplace plans for Medicaid recipients who no longer qualify for Medicaid. 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
All States
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 groups
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 Automatic Enrollment "Sec. 1511. Automatic enrollment for employees of large employers. Requires employers with more than 200 employees to automatically enroll new full-time employees in coverage (subject to any waiting period authorized by law) with adequate notice and the opportunity for an employee to opt out of any coverage the individual or employee was automatically enrolled in.
Sec. 1512. Employer requirement to inform employees of coverage options. Requires that an employer provide notice to their employees informing them of the existence of an Exchange. Also, if the employer plan’s share of the total allowed costs of benefits provided under the plan is less than 60 percent of such costs, that the employee may be eligible for a premium assistance tax credit (see APTC) and cost sharing reduction. Finally, if the employee purchases a qualified health plan through the Marketplace, the employee will lose the employer contribution (if any) to any health benefits plan offered by the employer and that all or a portion of such contribution may be excludable from income for Federal income tax purposes.
Sec. 1513. Shared responsibility for employers. As amended by the Reconciliation Act, requires an employer with at least 50 full-time employees that does not offer coverage and has at least one full-time employee receiving a premium assistance tax credit to make a (taxed penalty) payment of $2,000 per full-time employee (wo actually recieves APTC). Includes the number of full-time equivalent employees for purposes of determining whether an employer has at least 50 employees. Exempts the first 30 full-time employees for the purposes of calculating the amount of the payment. Section 10106 clarifies that the calculation of full-time workers is made on a monthly basis. The Reconciliation Act eliminates the penalty for waiting periods before an employee may enroll in coverage. An employer with at least 50 employees that does offer coverage but has at least one full-time employee receiving the premium assistance tax credit will pay the lesser of $3,000 for each of those employees receiving a tax credit or $2,000 for each of their full-time employees total, not including the first 30 workers. (Call your CPA!) The Secretary of Labor shall conduct a study to determine whether employees’ wages are reduced by reason of the application of the assessable payments." Source: Fl Agent CE Exam ACA Billing Protections "Sec. 2719A. Patient Protections
A plan that provides for designation of a primary care provider must allow the choice of any participating primary care provider who is available to accept them, including pediatricians.
If a plan provides coverage for emergency services, the plan must do so without prior authorization, regardless of whether the provider is a participating provider. Services provided by nonparticipating providers must be provided with cost sharing that is no greater than that which would apply for a participating provider and without regard to any other restriction other than an exclusion or coordination of benefits, an affiliation or waiting period, and cost-sharing.
A plan may not require authorization or referral for a female patient to receive obstetric or gynecological care from a participating provider and must treat their authorizations as the authorization of a primary care provider.
Any cost-sharing requirement for emergency services provided out-of-network cannot exceed cost-sharing requirements for in-network emergency services. Enrollees may, however, be required to pay, in addition to the in-network cost sharing, any excess provider charges beyond the greater of the following:
The median amount negotiated with in network providers for the emergency service negotiated.
The amount for the emergency service calculated using the same method the plan generally uses to determine payments for out of network services (such as the usual, customary, and reasonable amount), excluding any in-network copayment or coinsurance imposed.
The amount that would be paid by Medicare for the emergency service, excluding any in-network copayment or coinsurance imposed.
Any cost-sharing other than a copayment or coinsurance, such as a deductible, may be applied if that requirement applies to out-of-network benefits." Source: Fl Agent CE Exam 2022 ACA Carrier Tax Fee "Sec. 9010. Imposition of annual fee on health insurance providers. Imposes an annual fee of on the health insurance sector. As amended by Section 1406 of the Reconciliation Act, the amount of the fee is $8.0 billion in 2014, $11.3 billion in years 2015-2016, $13.9 billion in 2017, and $14.3 billion in 2018. For years after 2018, the amount of the annual fee is the amount for the preceding year increased by the rate of premium growth for the preceding calendar year. This non-deductible fee is allocated across the industry according to market share and does not apply to companies whose net premiums written are $50 million or less. The fee also does not apply to any employer or governmental entity. Cooperatives and the national plan would be subject to the insurance provider fee. This provision exempts from the fee non-profits which receive more than 80 percent of their gross revenues from government programs that target low income, elderly, or disabled populations. In addition, only 50 percent of net premiums written by entities who are tax exempt under Internal Revenue Code sections 501(c)(3), (4), (26), and (29) are included for purposes of determining an entity’s market share." Source: FL CE Exam ACA DMI ACA Data Matiching Issues: Means CMS required marketplace applications meeting specific information requirements stipulated by HHS/CMS. I.e. Social security numbers are required if it exists on an applicant (but not required for Marketplace eligibility - yes, it complicated), unless the applicant does not have it. But, other information will be required to establish eligibility. Yes, its confusing - with SSI, Medicare eligibility and especially with Medicaid eligibility. ACA Executive Tax "SECTION 6. ADDITIONAL TITLES
LESSON 6.5 Title IX – Revenue Provisions
Subtitle A – Revenue Offset Provisions
Sec. 9001. Excise tax on high-cost employer-sponsored health coverage. As amended by Section 1401 of the Reconciliation Act, beginning in 2018, levies an excise tax of 40 percent on insurance companies and plan administrators for any health coverage plan that is above the threshold of $10,200 for single coverage and $27,500 for family coverage. The tax applies to self-insured plans and plans sold in the group market, but not to plans sold in the individual market (except for coverage eligible for the deduction for self-employed individuals). The tax does not apply to stand-alone dental and vision coverage. The tax applies to the amount of the premium in excess of the threshold. The threshold is indexed at CPI-U plus one percentage point in year 2019 and CPI-U in years thereafter. An increase in the threshold amount of $1,650 for singles and $3,450 for families is available for retired individuals age 55 and older and for plans that cover employees engaged in high-risk professions. This provision also includes an adjustment for firms whose health costs are higher due to the age or gender of their workers and adjusts the initial threshold if there is unexpected high growth in premiums before 2018." Source Fl Agent CE Exam ACA Family Glich Fix https://www.irs.gov/pub/irs-drop/n-22-41.pdf
ACA Final Rules (CMS issued ACA Final Rules)Be clear: Without APTC authorized by ACA (and expanded Medicaid), we would have epidemic hospital insolvencies, and physicians would have to figure out how to finance care people fail to prepay (finance) with insurance. AHIP is all for more APTC.
See: Patient Protection and Affordability Act., Medicare for all at www.providerrisk.com. click on Articles.
ACA law passed in 2010 is still in effect. The Supreme Court sided against Trump administration and declared the estimated $12 BILLION CSR, and related reinsurance payments are due to the carriers. In many, if not all states (cant be sure about 50 states) - Cigna, Aetna, United, Humana, etc have abandoned offering SHOP plans. In 2022, Aetna, Cigna, and United started offering Individual plans in several states, but did not publicize where they left states too. Cigna recently partnered with Oscar health plan to implement an individual offering, so that is getting even harder to track with Cigna choosing an organization highbred. Aetna purchased CVS in ongoing vertical integration.
Oscar just advised they will pay $0 commission for any SEP enrollments! Cigna and Aetna have very long histories of avoiding individual plans, and small group plans. APTC premium expense (to AGI/MAGI percentage bands) rule is now reduced (improved for lower income people) to a maximum of 8.5% of income limit that determines "affordability". See: American Rescue Plan (no republican voted for) and is now law. See: ICHRA, PPACA, APTC, COBRA, CSR, Marketplace reinsurance (safety net).
See: COBRA effected federal ARP federal payments to employers who pay for their employees COBRA and/or ICHRA medical costs (Premium and eligible medical expenses). Many rules defining how to count stimulus money and ARP (COBRA) payments as income or not... See Florida Mini-COBRA, etc.
President Biden's ARPA passed.
ARPA enhances eligibility, and increases APTC eligibility beyond 400% (old limit) of FPL to 600% FPL cap (See: ICHRA) plans exceed 8.5% (not the old 9.8%) of AGI/MAGI. See the Medicaid rules in your state. Biden wants to allow CMS power to bargain with pharmaceuticals paid for with tax dollars, and to lower the age for Medicare eligibility from 65 to 50. Do the work ("Individual and SHOP" federal Marketplace link is on our home page), and quote what it costs for two 62 year olds ... Answer: $26,000 per year premium plus any out-of-pocket costs to actually get care. Call your congress-person and tell them to enforce hospital transparency cost disclosures, and APTC and a "buy-in" to Medicare option for people over 60 years old. Its overdue, and it does not mean Medicare-for-All because individual 60 - 64 years olds can buy private insurance (like Medicare Supplemental) but use Medicare participating providers who accept the MA amount without balance billing the patient. Know that commercial (not medicare) insurers average reimbursement at about 240% more than teh MA amount.
See: Trumping Healthcare Reform at www.providerrisk.com, Click on - ARTICALS.
ACA has not been repealed, but for the individual mandate tax penalty, and most of the taxes charged on premiums that go to HHS to try and design quality metrics people can understand, and that providers accept. In Dec 2019, most if not all insurance taxes mandated by ACA law were repealed, but the individual Employer tax penalty is still in effect for employers over 50 FTE lives.
INDIVIDUALLY offered marketplace plans distributed by the State Based Federal-facilitated Exchanges (SBE-FPs) to enforce FFE standards for network adequacy (re: Medicare lives) and essential community providers. 12-13 states (plus DC) use SB- FFE. Marketplace navigator budget got severely reduced under Trump, and massively increased under Biden. Good luck finding an unlicensed Navigator for complicated problems after the Navigator is unemployed 45 days after OEP ends. Biden's ARPA passed $80M for Navigator Marketplace sales funding - Stay tuned. Navigators will not give you their DIRECT contact information, (or their managers last name or direct contact number) are pure order takers, and almost without exception will offer no help with provider network access & changes, Rx out-of-pocket estimations, complicated tax issues that do not automatically populate, etc.
Not sure if 3.5% user (premium tax on insureds) fee tax still effective on members enrolling within SBE-FBs. SBE-FBs are not FFM. See: Trump EO re: ICHRA's, which is still in force, and a good idea that many employers do not want to deal with - arranging (without an agent to do it), untaxed payments to employees so that the employees can buy Marketplace INDIVIDUAL coverage.
SHOP and INDIVIDUAL Marketplace enrollments are now allowed directly with carrier/brokers inclusive of APTC (and eligibility to file for tax credit during the year for SHOP). 0 FFM SHOP plans offered in Florida (most states last we looked) for any small businesses. Trump prohibited states from creating platform to secure SHOP. Commission - flat commissions at $20-$30/pmpm to agents has eliminated a profitable commission, for non-boiler room operations interested in servicing an account after the sale. thereby relegating insureds to fix their own inter-agency and tax credit issues after unlicensed navigator's employment ends after the 45 day Open Enrollment. See: Executive Orders, Price Transparency, Public Law 111-148, Public law 111-152.
Meanwhile, New HHS regulations Trump (Biden is still supporting) EO mandates requiring hospitals to publish their best contracted rates and provide accurate estimates of costs to patients struggling to understand care, cost, and long-term massive hospital bills. Biden is demanding it too. See: Consolidated Appropriations Act signed Dec 2020. See: Balance Billing, ARP
It’s been estimated the number of those eligible for a subsidy on the Marketplace increased by 20% with the passage of the ARP.* The ARP impacts current and new Marketplace members in three ways:
• Enhanced APTCs-APTC subsidies will be enhanced for 2021 and 2022: Consumers’ required contributions are lowered at all income levels thereby increasing APTC. Individuals earning 100-150% FPL will be eligible for fully subsidized coverage. Additionally APTC eligibility income tax got increased a lot offering even high income earners to get an APTC to pay for premiums (so hospitals dont go insolvent with average people going bare of insurance and incurring large "self-Pay" bills that create big bad debt problems.
• People that receive unemployment in 2021 will be treated as earning no more than 133% FPL, unless otherwise eligible for Medicaid: For 2021, individuals receiving or approved to receive unemployment for at least one week will be eligible for fully subsidized ACA coverage at 133% FPL, if they are not eligible for Medicaid. In states that have not expanded Medicaid, people below 100% FPL will also be treated as making no more than 133% FPL for APTC subsidy eligibility. Individuals will need to attest to and provide documentation to prove eligibility.
• APTC overpayment: APTC subsidy overpayment in the 2020 tax year will not need to be repaid." Source: Ambetter Agent Advisory 4/2/21
See: MLR, COBRA, PPACA, ARP, EO's, APTC, CSR, reinsurance, etc
Federal Info at HHS:
https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2023-final-rule-fact-sheet
https://www.hhs.gov/about/news/2021/03/23/2021-special-enrollment-period-access-extended-to-august-15-on-healthcare-gov-for-marketplace-coverage.html
ACA High earners Tax "Sec. 9015. Additional hospital insurance tax on high-income taxpayers. Increases the hospital insurance tax rate by 0.9 percentage points on an individual taxpayer earning more than $200,000 ($250,000 for married couples filing jointly). The revenues from this tax will be credited to the HI trust fund. As amended by Section 1402 of the Reconciliation Act, expands the hospital insurance tax to include a 3.8 percent tax on income from interest, dividends, annuities, royalties and rents which are not derived in the ordinary course of trade or business, excluding active S corporation or partnership income, on taxpayers with income above $200,000 for singles ($250,000 for married filing jointly)." Source: FL Agent CE Exam ACA Long Term Care "SECTION 3. TITLE II - ROLE OF PUBLIC WORKS PROGRAM
LESSON 3.1 Subtitles A Through L
Subtitle E – New Options for States to Provide Long-Term Services and Supports
Sec. 2401. Community First Choice Option. Establishes an optional Medicaid benefit through which States could offer community-based attendant services and supports to Medicaid beneficiaries with disabilities who would otherwise require the level of care offered in a hospital, nursing facility, or intermediate care facility for the mentally retarded. As amended by Section 1205 of the Reconciliation Act, October 1, 2011 is the effective date for this policy." See: ACA law ACA Medical Outcomes "SECTION 6. ADDITIONAL TITLES
LESSON 6.2 Title VI – Transparency and Program Integrity
Subtitle D – Patient-Centered Outcomes Research
Sec. 6301. Patient-Centered Outcomes Research. Establishes a private, nonprofit entity (the Patient-Centered Outcomes Research Institute) governed by a public-private sector board appointed by the Comptroller General to identify priorities for and provide for the conduct of comparative outcomes research. Requires the Institute to ensure that subpopulations are appropriately accounted for in research designs. Prohibits any findings to be construed as mandates on practice guidelines or coverage decisions and contains patient safeguards to protect against discriminatory coverage decisions by HHS based on age, disability, terminal illness, or an individual’s quality of life preference. Provides funding for the Institute and authorizes and provides funding for the Agency for Health Research and Quality to disseminate research findings of the Institute, as well as other government-funded research, to train researchers in comparative research methods and to build data capacity for comparative effectiveness research.
Section 10602 clarifies publication rights of researchers with respect to peer-reviewed journals and clarifies that findings published by the Institute do not include practice guidelines, coverage, payment, or policy recommendations. The provision also increases the number of physicians on the Board of Governors from three to four." Source: Fl Agent CE Exam ACA Medical Reimbursement data Centers Sec. 1003. Monitoring of Health Plans and Providers. The Act provides $250 million in funding for the Secretary to award grants to the states for fiscal years 2010 through 2014 for monitoring health plans, premium practices and rate increases. ACA Nursing Mothers Sec. 4207. Reasonable break time for nursing mothers. This initiative amends the Fair Labor Standard Act to require employers to provide break time and a place for breastfeeding mothers to express milk. This does not apply to an employer with fewer than 50 employees, and there are no monetary damages. ACA Prohibition on Physician Owned Hospital Participation "SECTION 6. ADDITIONAL TITLES
LESSON 6.2 Title VI – Transparency and Program Integrity
02:35 PM Today
Subtitle A – Physician Ownership and Other Transparency
Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals. Prohibits physician-owned hospitals that do not have a provider agreement prior to December 31, 2010, (as amended by Section 1106 of the Reconciliation Act) to participate in Medicare. Such hospitals that have a provider agreement prior to December 31, 2010, could continue to participate in Medicare under certain requirements addressing conflict of interest, bona fide investments, and patient safety issues, and expansion limitations. As amended by Section 1106 of the Reconciliation Act, provides a limited exception to the growth restrictions for grandfathered physician-owned hospitals that treat the highest percentage of Medicaid patients in their county (and are not the sole hospital in a county)." Source: Fl Agent CE Exam 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 preexisting medical conditions. 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 to INDIVIDUAL / SHOP plan members whose annualized claims are under 80%/85% (Individual/Group) of the premium charged.)
To get an idea of its significance - Its 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 to carriers, and that the Trump administration initially denied.
Blue Cross was owed an estimated $5 billion.
"art V - Reinsurance and Risk Adjustment
Sec. 1341. Transitional reinsurance program for individual and small group markets in each State. State shall enact a model regulation established by the Secretary, in consultation with the NAIC that will enable them to establish a temporary reinsurance program for plan years beginning in 2014-2016. Insurers and TPAs, on behalf of self-insured plans, must make payments to the reinsurance entity and non-grandfathered individual market insurers that cover high risk individuals will receive payments from the entity if they cover high risk enrollees in the individual market.
High-risk individuals will be identified on the basis of a list of medical conditions or another comparable objective method of identification recommended by the American Academy of Actuaries. Payments will be based upon a schedule of payments for each condition or another method recommended by the American Academy of Actuaries.
Assessments will be based on the percentage of revenue of each insurer and the total costs of providing benefits to enrollees in self-insured plans or a specified amount per enrollee. The total amount of contributions will be based on the best estimates of the NAIC and not including additional assessments to cover administrative costs, equal $12 billion for plan years beginning in 2014, $8 billion in 2015, and $5 billion in 2016. States may collect additional amounts from issuers on a voluntary basis. Of these amounts, $2 billion in 2014, $2 billion in 2015 and $1 billion in 2016 shall be deposited in the US Treasury and will not be available for this program.
Reinsurance entities must be non-profit organizations with the purpose of stabilizing premiums in the individual market for the first three years of Exchange operation. States may have more than one reinsurance entity and two or more states may enter into agreements to create entities to administer reinsurance in all such states." Source: Fl Agent CE Exam 2022 https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-9920-F-7-24-18-final.pdf
ACA Risk Corridors "
SECTION 2. TITLE I - QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
LESSON 2.5 Subtitle D - Available Coverage Choices for All Americans
02:09 PM Today
Sec. 1342. Establishment of risk corridors for plans in individual and small group markets. Requires the Secretary to establish risk corridors for qualified health plans in 2014, 2015, and 2016. If a plan’s costs (other than administrative costs) exceed 103 percent of total premiums, the Secretary makes payments to the plan to defray the excess. If a plan’s costs (other than administrative costs) are less than 97 percent of total premiums, the plan makes payments to the Secretary.
Sec. 1343. Risk adjustment. Requires States to assess charges on health plans with enrollees of lower-than-average risk, and to provide payments to health plans with enrollees of higher-than-average risk. Risk adjustment applies to plans in the individual and small group markets, but not to grandfathered health plans." See: ACA ACA Risk Pooling See: "Sec. 1312. Consumer choice. Allows qualified individuals, defined as individuals who are not incarcerated and who are lawfully residing in a State, to enroll in qualified health plans through that State’s Exchange. Allows qualified employers to offer a choice of qualified health plans at one level of coverage; small employers qualify to do so, and States may allow large employers to qualify beginning in 2017. Requires insurers to pool the risk of all enrollees in all plans (except grandfathered plans) in each market, regardless of whether plans are offered through Exchanges." Source: Fl Agent CE Exam 2022 ACA Section 1557 ACA prohibition that follows constitutional mandates against discrimination on the bases of: race, color creed, gender, etc. In context to insurance of sexual orientation surgery, (or therapy, etc) recent case results hold expanded TPA's liable for denying "gender-based" claims. Self funded plans apply. The journey continues... https://www.hhs.gov/sites/default/files/2016-06-07-section-1557-final-rule-summary-508.pdf
ACA SHOP Tax Credit Sec. 1421. Credit for employee health insurance expenses of small businesses. Amends the
Internal Revenue Code to provide tax credits to small employers.
Sec. 45R. Employee health insurance expenses of small employers. As amended by Section 10105, provides a sliding scale tax credit to small employers with fewer than 25 employees and average annual wages of less than $50,000 that purchase health insurance for their employees. The full credit will be available to employers with 10 or fewer employees and average annual wages of less than $25,000. To be eligible for a tax credit, the employer must contribute at least 50 percent of the total premium cost or 50 percent of a benchmark premium. In 2010 through 2013, eligible employers can receive a small business tax credit for up to 35 percent of their contribution toward the employee’s health insurance premium. Tax-exempt small businesses meeting the above requirements are eligible for tax credits of up to 25 percent of their contribution. In 2014 and beyond, eligible employers who purchase coverage through the State Exchange can receive a tax credit for two years of up to 50 percent of their contribution. Tax-exempt small businesses meeting the above requirements are eligible for tax credits of up to 35 percent of their contribution. ACA waivers (Marketplace plans reinsurance)CMS issued four new waiver concepts aimed at helping states develop options for using Section 1332 waivers under the Affordable Care Act, and in context to 14 states volintarily participating states in the federal reinsurance offering over marketplace offered plans sold in their states. 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. CMS reviews each state's "guard rails" of where each state's marketplace plans are on the hook for paying claims, and where the reinsurance attaches. "The 2022 user fees are now expected to be 2.75 and 2.25 percent of monthly premiums, resulting in an increase of about $200 million in user fees for 2022. Even with this increase, the proposed user fee for 2022 would remain lower than 2020 and 2021, when it was 3.0 percent and 2.5 percent." Source: Health Affairs, August 2021
Source: AHIP Agents Smart Brief. See: APTC, CSR, MLR, etc.
Ex: "In the Denver Metro area, for instance, insurers will have 43 percent of their claims costs reimbursed when the claim is between $30,000 and $400,000. In contrast, in the two areas of the state with the highest health care costs, insurers will have 73 percent of these claims reimbursed. The insurance commissioner can continue to adjust the payment parameters in new rules each year." Source: Health Affairs 8/17/21 Accelerated Underwriting A term used in life insurance underwriting for applicants typically under 50, and with death benefits under $1M. It means they will provide a binding proposal for life insurance expeditiously. Accellerated 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 and Life Settlements for a potentially better option(s) (for some terminally ill insured)s.
Similar features are available in Life with Long Term Care policies. "Tax-Free Benefits
The benefits paid by a tax-qualified long-term care insurance
policy are intended to be tax free as long as they do not exceed
the greater of:
• Qualified long-term care daily expenses, or
• The per-day limitation, which is $420 in 2023
The information provided is not intended to be tax advice. Consult your tax advisor to determine the tax benefits for your business.
Source: Section 7702B of the Internal Revenue Code (IRC)"====Source: Mutual of Omaha Advisory Accellerated Payment See: CMS re C19 $175 payments to providers being suspended after $100 Billion distribution.
Can also mean a Life insurance Death Benefit partial payout to the insured where death is eminent.
Not to be confused with Viaticals or highbred life-LTC policies with Continuation of Benefits provisions guide LTC payments/m benefits - where the life defined LTC benefit/m is paid out until the Death Benefit face amount is exhausted, then COB provision kicks in and pays up to the defined 4, 5, 6, 7, 8 year period, or to death *following what the insured purchased in the policy. See: Inflation riders Access In context to PII, 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 "quality" healthcare coverage at an affordable price by ACA law, and longstanding intervention-obligation to provide Americans a RIGHT to healthcare (timely and effective healthcare treatment). In short, longstanding federal healthcare policy central focus is access to care by Americans, and where that access is non existent or obstructed, the Feds intervien with money/law/regulations/EOs/etc to build hospitals (Hill Burton), create Marketplace exchanges (that hamer the free market agency system that chases people to buy insurance, and that results in about 2M more INDIVIDUAL enrollments/insureds each year), and eliminates the traditional health services agency advocates (agents that work for the customer and not the exchange or carrier) now replaced by unlicensed-Navigators (who are employed only 45 days of Open Enrollement each year on average. We are seeing epidemic small town hospitals becoming insolvent and closing (because uninsured people going to the ER (and not paying anything)
Plans use the term Open Access to typically denote right to specialty physician care without primary care referral (Gatekeeper).
Open access can also mean insurance coverage out-of-network, but must be confirmed by reading the summary plan Document. See: EHB, QHP, VBR, network adaquacy, etc. 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 (subcontractors) to be eligible for the employers same plan, and counted towards "participation" requirements. 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. ================
"SECTION 6. ADDITIONAL TITLES
LESSON 6.5 Title IX – Revenue Provisions
Subtitle B – Other Provisions
Sec. 9022. Establishment of simple cafeteria plans for small businesses. Establishes Simple Cafeteria Plans that ease participation restrictions so that small businesses can provide tax-free benefits to their employees. Under this provision, self-employed individuals are included as qualified employees. The provision also exempts employers who make contributions for employees under a simple cafeteria plan from pension plan nondiscrimination requirements applicable to highly compensated and key employees." Source: Fl Agent CE Exam Accountable Care Act of 2010 (ACA)See: Patient Protection and Affordability Act
See: Republican Agenda
https://www.govinfo.gov/content/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
https://www.govinfo.gov/content/pkg/PLAW-111publ152/pdf/PLAW-111publ152.pdf
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
https://www.healthaffairs.org/do/10.1377/hblog20170628.060719/full/
Accountable Health Communities (AHC)A model of healthcare delivery that attempts to include not for profit with for profit entities with goal of improving medical outcomes at lower costs. It harkens from Canada's "Healthy Communities" (30 years old) concept that merges social services, religeous communities, volunteer organizations, etc, with existing quasi-free market (Medicare, Medicaid, Tricare, public health centers, etc) programs that get paid for by the state and federal authorities, but are theoretically run by commercial (free-market-private corporations like United, Aetna and Humana or Blue Cross - but not really) and individual people with religeous (churches, social workers, AARP) call to serve the needy.
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. See: ACO
To view a list of the Assistance and Alignment Tracks bridge organizations, please visit the Accountable Health Communities Model web page. (Source CMS)
See: SDOH, QPP, MACRA, DRG, etc
https://innovation.cms.gov/innovation-models/ahcm
https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf
https://innovation.cms.gov/media/document/ahcm-screeningtool-companion
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 ACO's are CMS's term for demonstration projects whose goal is to eliminate FFS, and contract various bundled services within a Shared Savings contract that through EBM - cause better medical outcomes at lower cost to CMS. There are six types of ACO's currently in such contracts: Participant TINs, Physicians and Non-physicians, Hospitals, Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHSs), Critical Access Hospitals (CSHs).
"The CMS announced that in 2023, 456 ACOs will participate in the Medicare Shared Savings Program and 132 have joined the Accountable Care Organization Realizing Equity, Access and Community Health model, which begins this year. Together, these programs serve 13 million Medicare beneficiaries". Source: Beckers Hospital CFO report 1/17/23 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-08-25.html
https://revcycleintelligence.com/news/medicaid-aco-growth-still-lags-behind-medicare-commercial-payers
ACO REACH (GPDC)The Global and Professional Direct Contracting Model (GPDC) Model has been redesigned and renamed The ACO Realizing Equity, Access and Community Health (ACO REACH) Model. Please note that any information on this page referencing the GPDC Model beyond December 31, 2022 is outdated. For more information on the ACO REACH Model, please see the ACO REACH Model webpage.
In addition, CMS is permanently cancelling the Geographic Direct Contracting (Geo) Model, which has been on hold since March 2021. The Geo Model is being canceled because it does not align with CMS’ vision for accountable care and concerns raised by stakeholders. The Global and Professional Direct Contracting (GPDC) Model was a voluntary, Accountable Care Organization (ACO) model designed to put patients at the center of their care. Building upon lessons-learned from initiatives involving Medicare ACOs, such as the Medicare Shared Savings Program and the Next Generation ACO Model, this model provided greater individualized attention to a beneficiary’s specific health care needs within Original Medicare, and changed financial incentives to reward high quality care.
The GPDC Model aimed to improve beneficiaries’ experience of care. https://innovation.cms.gov/strategic-direction-whitepaper
https://innovation.cms.gov/innovation-models/gpdc-model
ACO Risk Adjustment The CMS mechanism designed to encourage competition in medical care benchmarking used to measure ACO efficiency and effectiveness. See: Shared Savings, ACO.
"With a common maximum risk score improvement cap of 3%, organizations new to optimizing around
risk adjustment will often target exactly that as their metric for improvement. Unfortunately, that
leaves out three critical variables that must be accounted for to succeed: inflation and its impact on
benchmark calculations, national risk score trends, and coding intensity factor. " "INFLATION AND BASELINE CALCULATIONS
Effective risk adjustment in any year doesn’t happen in a vacuum. The prior years, and regional and national trends are
each accounted for in the final calculations. It starts with a historical benchmark. Using PY2020 as an example:
[ (2017 Costs x 2019 Risk Score) x (2017 Regional Trend) x (2017 National Trend) x 1/3 ]
+ [ (2018 Costs x 2019 Risk Score) x (2018 Regional Trend) x (2018 National Trend) x 1/3 ]
+ [ (2019 Costs x 2019 Risk Score) x (2019 Regional Trend) x (2019 National Trend) x 1/3 ]
= Historical Benchmark Calculation for PY2020
Benchmarking is the value by which progress is measured each year. It’s part of additional incentives to improve risk
capture (and therefore care) by way of an ongoing, annual comparison by CMS of every organization’s progress in a
given year vs. itself and its peers" See: An EDIFEC EBOOK Part 2 http://file:///C:/Users/Steve's%20Laptop/Downloads/NGACO_Book2_1%20(2).pdf
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). Acord Forms Generally accepted insurance applications for most P&C related coverages. Most common are: 125, 126, 131, 130, 140, 45, 81, 823 and then for AOR assignment: 36. A carrier decides what form they will accept, and or if additional informatin is needed to bind coverage. https://www.londonuw.com/applications-library/?utm_source=zma-engagement&utm_medium=email&utm_campaign=12-2023|boost-productivity-with-these&utm_source=ZohoMarketingHub&utm_campaign=Boost+productivity+with+these+strategies+for+this+final+month%21&utm_medi
Actively at Work A SPD provision stipulating eligibility for medical benefits. Activities of Daily Life (ADLs, LTC coverage triggers)Physical/mental conditions an insured cannot perform that when present can trigger a Long-Term-Care benefit. Most policies demand at least two conditions being present to trigger coverage. Conditions include bathing, incontinence, dressing, eating/feeding, toileting, transporting one's self to the toilet/shower, and severe cognitive impairment like Alzheimer's disease. Coverage may mandate a treatment plan by a licensed entity. See: Pure LTC policies, and hybrid LTC-Life policies 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. In context to stop loss trend and risk factors, it is the percentage of premium increase an actuary bumps premium to insulate future outcome pricing variability falling below minimum (forcasted) profitability, or below solvency. See: Actuarial Fudge Factor Actuarial Rule 49 (AG-49)I have an IUL, and asked my 140 year old A+ rated carrier what the rule meant.
Here is what they said in September 2024:
"This is an insurance regulation that limits the hypothetical future index rate of return that we can assume on an illustration.
Each insurance company may have a slightly different interpretation of how to apply the AG49 rules, but that our company calculates the maximum AG49 rate by taking the last 30-years of performance of the index, applying Today’s current Cap and Floor to the previous 30 years, and using that resulting average as our Maximum illustrated rate.
For Index B (S&P 500 140% participation), the current AG49 rate is 4.18%.
A second part of the AG49 regulation is that the maximum arbitrage (the difference between the charge rate for a participating (variable) loan and the percentage we assume you earn in the index on the loaned-out money), can be no more than 1%.
These two rules both need to be followed. So, even if the current variable loan charge rate is 4%, we can only assume 4.18% as the earned crediting rate as this is the maximum return outlined by the first part of AG49.
If, in the future we still had a maximum AG49 rate of 4.19%, but the variable charge rate reduced to 3%, at that time the maximum return we could assume on loaned out funds would be 4%. As that is 1% higher than the hypothetical 3% charge rate.
As these are NAIC insurance regulations we cannot provide you with an illustration that assumes higher than 4.18% index earnings in Index B *If we were to assume you changed your allocation to index A (S&P participation at 100% not 140% like it is now), this would allow us to run the illustration at a return of 4.96%. As of today, 4.96% is the highest return we can show in ANY index account for your policy.
Please note that your existing loans are NOT fixed. They are Variable. This means that the rate we charge for the loan can change (it can change at each anniversary). It also means that your loaned out money is still in the index and can continue to earn index credits as if it weren’t loaned out. This is generally referred to as a “participating” type of loan, because it allows you to participate in index performance with money that is loaned out.
Alternatively, a fixed loan has a contractually set charge of 4% (this cannot change), and your loaned out money would NOT be in the index. Loaned out money on fixed loans does not participate. It cannot earn any index credits. Instead, you receive a fixed crediting percentage on the loaned out money. After the 10th policy year, the fixed loan crediting percentage would be 3.9%. In other words, with a fixed loan, after policy year 10, you are always negative 0.1% arbitrage on the loaned out money." Source: Call for source.
IUL's have several moving parts, so find an experienced agent to explain them, and TAKE THE TIME TO STUDY IT. In my opinion, nothing touches their safety interest crediting leverage. For example, say there is $1M in the Cash Value (accumulation value), and I borrow out $900,000 and buy a house
(using my cash value as collateral to the loan), I now own the house AND credit interest on the Original $1M, AND without stock market crash risk (because my funds are never directly invested in the stock market - just like an FIXED INDEXED ANNUITY).
https://www.securian.com/AG49
Actuarial Value (AV)An MLR legislated ACA MLR (percentage) value requirement of "metallic" level plan pricing. I.e. Bronze, Silver, Gold, Platenum level plans. Means, that claims/premium = MLR. Currently, businesses (over 50 FTE) are required to offer a QHP minimum plan coverage equivelent or greater then the lowest Bronze level plan offered by employers in the "region". "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). See: MLR Source: Source: MLM training by CMS. Percntages can change, so look them up.
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 45%.
•Silver. The health plan covers about 73% of the total costs of care on average. An average enrollee can expect to pay about 30%.
•Gold. The health plan covers about 87% of the total costs of care on average. An average enrollee can expect to pay about 20%.
•Platinum.The health plan covers about 94% 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. President Biden is reviewing and eliminating many Trump EO's. Stay tuned...
See: EHB, ERISA 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 earnings amount used by a single person to calculate tax credits (APTC) to people earning between 100%- 400% of FPL. AGI is reduced by child support and student loan interest. See: EO 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 issue insurance in a specific state. See: Surplus Lines. Surplus Lines is eligible but not authorized, and can legally issue policies in a specific state, that have not been specifically approved by that state. See: contracts of adheason, and surplus lines process assigning agency liability on unpaid claims in the event of insolvency. 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 Funding See: ASD - These Stop Loss provisions are subject to contingencies. In some instances, it can amount to a kind of waiver of an ASD for purposes of paying a "specific" claim without the ASD (second deductible), but while the ASD has already reduced the cost of the stop loss policy. 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)A federal payment directly to a carrier that pays for an individual's or famiy's (Marketplace) medical plan insurance.
The APTC lowers the cost of health insurance for individuals and families. earning between 100% - 400% of FPL. Individual or Families earning between 100%-250% of FPL also get CSR relief.
See: Periodic Data Matching (PDM), CSR, FPL, ACA eligibility Advanced Aggregate Advanced Aggregate is a sophisticated funding and reinsurance coverage combination provided to eligible ERISA exempt entities, and other well-staffed organizations capable of managing it. It essentially advances an aggregated reinsurance recovery to a loss that happens early in a year (and whose associated Specific reinsurance recovery is inadequate to meet the liability) based on an annualized-trended aggregate attachment point. The claim is adjusted on a prorated bases to give the client funds to pay part of a massive bill on what an underwriter believes will be an aggregated claim attachment event trended for the entire 12-to-18-month period insured period (whose event happens early in the policy year before aggregated accounts are fully funded by the policy owners). In context to ERISA, it is reinsurance over a single (or multiple) self-funded employer(s) provided by advancing aggregated recoveries for risk between specific retention and a percentage of the fully funded and underwritten major medical (aggregated) insurance premium. It can apply to many forms of organizations, coverages and programs able to effectively fund the "entity's" SIR, and/or group funded common deductible(s). These are pretty rare. See: Inner Ag which is not the same thing. Advanced Alternative Payment Models (APMs or Alternative Payment Contracts)A CMS compensation model whose goals are for better medical outcomes at lower cost by getting medical providers to commit to a different compensation method and focus on preventing disease instead of treating it after occurance.
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Qualifying APM Participant (QP) Threshold Update
On December 27, 2020, the Consolidated Appropriations Act, 2021 was signed into law. Under this law, the Quality Payment Program’s Qualifying Alternative Payment Model (APM) Participant (QP) thresholds for payment years 2023 and 2024 are frozen at 50% for the payment amount threshold and 35% for the patient count threshold for performance years 2021 and 2022.
The partial QP thresholds have also been frozen at the same levels used for the 2022 payment year and 2020 performance year.
See: QPP, MACRA, ACO's https://www.govinfo.gov/content/pkg/BILLS-116hr133enr/pdf/BILLS-116hr133enr.pdf
Advanced Practice Practitioners (APP)Jargeon used by some associations or consultants to confer higher (as yet undefined EBM and cost indicy) practicine standards to physicians, and physician extenders. Advanced Premium Tax Credit (APTC, or Applied Premium Tax Credit)ACA authorized entitlement Tax credits that reduce the members monthly premium costs by the amount of credit. Credits are paid directly from the Federal Government to the private commercial insurance carrier. Enrolled members earning between 100% - 400% (but now under Biden its up to 600%) 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 commercial plans.
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.
FYI: given the cost of buying private insurance is massive, elimination of the APTC would surely mean massively less people buying insurance and showing up in the ER. We have already seen a kind of epidemic of insolvent small hospital closings because their communities fail to pay for insurance or the care they demand. See: American Rescue Plan https://crsreports.congress.gov/search/#/?termsToSearch=ACA%20applied%20premium%20tax%20credit&orderBy=Relevance
https://crsreports.congress.gov/product/pdf/R/R44425
Advanced Primary Care Managed care jargon used to lable easily accessable medical care by physicians and physician extenders to a targeted populations. See: EBM 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 AFA Plans (Level Funded Plans)Aetna Funded Advantage. These are typically very small group self funded plans that have materially lower risk than standard self funded plans. See: Specific and Aggregate retention and coverages, etc. Call for details. These are good options dependent on group size and history. Affordability (Insurance Affordability Program)A federal percentage of AGI/MAGI that when exceeded, qualifies Individuals/Families for APTC. For Individuals (AGI) or Families (MAGI household income), APTC applies where insurance costs exceed 9.5% of income (for Individuals and Families). For employers insured with SHOP plans, the EMPLOYEE'S group medical plans, and the employee's GROUP insurance premium contribution exceeds about 9.5% (AGI) to participate, then the employee qualifies for the tax credit (ICHRA). (If the employer is bigger than 50 FTEs, and the employee also enrolls in an FFM INDIVIDUAL plan with an APTC, then the employer faces a penalty tax of a flat amount for each individual (employes over 50 FTE with the first 30 FTE not counted to calculate the penalty). This gets complicated with 30 employees being exempted, and FTE being defined at 30 hrs/w. --- For Individuals, it's an ACA (HHS) legislated/regulated term defining eligibility for Marketplace APTC on QHP purchased "On- Exchange" or "at Marketplace" plans. See: ATPC. 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 APTC for individual plans, and up to two years tax credit for groups under 25 FTE (SHOP plans). See: SHOP tax credits which are essentially for the first two years of a GROUP plan. We recommend you confirm liability with your CPA.
Check employer penalty rules and conditions. Rules and employer penalties related to employees electing to buy INDIVIDUAL marketplace coverage over "unaffordable" (as the employee's contribution to the premium) employer offered coverage are different, and also have a (ALE - Applicable Large employers over 25 FTEs) penalty. Employer penalties were not repealed, but individual penalties were repealed. See: Applied Premium Tax Credits, ALE and ACA law. See: ICRA
"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 that plans charge issuers 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:
See: State Medicaid Program under title XIX of the Social Security Act, CHIP under title XXI, and State basic health program established under section 1331 of ACA act.
Eligibility for a Marketplace Catastrophic (Catastrophic plans are offered only under special enrollment - hardship, and not generally available to Individuals) plan kicks in if the lowest priced coverage available costs more than 8.27% (double check this) of AGI or MAGI as applicable. GOOD LUCK figuring it out for a $25 per month commission. https://www.healthcare.gov/downloads/ichra-worksheet.pdf
https://healthpayerintelligence.com/news/medicaid-expansion-could-have-reduced-covid-19-uninsurance
https://www.agentbrokerfaq.cms.gov/s/article/What-is-the-Affordability-of-Employer-Coverage-for-Family-Members-of-Employees-rule-change?utm_campaign=&utm_content=english&utm_medium=email&utm_source=govdelivery
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. If an employee's medical insurance contribution is more than 8.5% AGI, than the employee becomes eligible for APTC, and the employer may get a flat tax for each employee (over 30 lives exempted in groups whose total size exceeds 50 FTEs) Means if an employee earning more than about $13,000, and whose health insurance contribution is more than about $93/m for QHP insurance, that employee becomes eligible for INDIVIDUAL marketplace tax credit, and the (ALE) employer gets fined about $3,500 for EACH employee getting who actually buys an INDIVIDUAL receiving a marketplace plan APTC. Affordable Care Act (ACA, PPACA, Obama Care)The Patient Protection Affordable Care Act is referred to as the Affordable Care Act/ACA/PPACA/Obama Care. The ACA (Affordable Care Act) is an 800+ page law encompassing all medical care in the US, but with very limited application to Veteran's 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 regulatorily enforced, and not part of original ACA. CSR lowers deductibles and max-out-of- pocket costs for individuals and limits personal total annual health expense (spend) from (about) 2% to a maximum of 8.5% AGI/MAGI. (Biden increased it under special COVID need and authority). Small employers (under 25 FTEs who are not ALE's) are offered tax credited plans through SHOP, where commercial carrier sponsor offers them (which is practically nil). 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: "
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. We recommend all tax questions be directed to CPA's or Licensed attorneys specializing in tax.
See: MLR, APTC, ACA final Rules, etc. Age Compression Rule (spending cap ratio, Age Banding)A provision in the Patient Protection and Affordable Care Act (ACA) that mandates (commercially insured marketplace plans - not Medicare) premiums be not priced more than 3:1 difference between a 21 year old's rated premium and an older adult, say 60-64 years of age. (My age 64 premium was about $1,100 a month plus any deductibles and out of pocket costs.) Meaning, ACA QHP premiums charged to older people (i.e. aged 55-64) cannot be more than three times the price of premium charged to a young person. (i.e. age 21) . See Medicare-for-all, and Medicaid-for-all.
FYI there is no agreement on what the rule is called, and the Trump administration did allow the carriers to price plans in violation of ACA precedent. See: Silver Loading.
Pere 2022 Marketplace Agent Exams: Federal Age Rating Standards use 0-14, and 15-63 where premiums cant be greater difference than 3:1.
Age Banding... (per ACA regulation)
States can establish their own age curve or default to the federal age curve.
Federal age bands:
0-14
One-year bands between ages 15-63
64 and older
Its a work in progress where the standing President's regulators can adjust age bands. Agency Resourse Management Systems (ARM)See: CRM. These are systems that come in all sizes and shapes but rarely are the end all to a complete long term customer interface from introduction to sale, to accounting, renewals, commission, etc... Most do well at either managing the actual book of business and its renewal, or identifying the prospect through sale, payment processing, coverage binding and policy delivery. Agent Statement of Enrollment Correction (ASEC)A group employee census form required by some commercial carriers to finalize open enrollment (renewal or policy change and replacement). 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 event (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 insured, but not attributable to policy limit.
Aggregate in stop 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 in employer stop loss policies offering one or both coverages (Specific and/or aggregate only) of less than 1:1000. This does not hold constant for stand-alone aggregate policies. Aggregate stop loss or reinsurance is very rare in some kinds of policies, and typically requires Specific stop loss commitment to offset substantially higher carrier losses if the aggregate attaches. Aggregate Pharmacy Reinsurance Aggregate Pharmacy Reinsurance is stop loss or reinsurance coverage triggering at 110%-125% of last year's trended claims history. Second dollar coverages in pharmacy policies can be highly complex, and have many carve outs, and PBM duties and functions. Typically, not all Specialty drugs are insured. Infusion therapies, cost bases, administrative fees, and reimbursement schedule(s) can dramatically effect coverage. See: AWP, PBM Aggregate Stop Loss/Reinsurance Typically it is a second-dollar insurance triggering payment after (typically) 125% of last year's trended medical claims history. Some risks can attach at 105%-110%, if its big enough. It is a per population per year coverage, that once triggered pays out without additional (specific) deductible application - this can be a career-killer for a VP. Competing premium offers brokered 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, Level Fund)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 ISD to be available for "expected claims payment-self reimbursement" from the fund.
This process effectively eliminates: Premium tax, agent commission, and carrier overhead and profit margin, 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 (excess of $50K).
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 discounted-premium) is held by the reinsurer instead of the insured to pay claims timely.
See: Finite reinsurance, but don't make too many parallels, in context to if it meets minimum risk transfer GAAP or other standards. 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 Patient Refined Data (3M APR DRGs) All Risks (Direct Physical Loss)See: Homeowners insurance, Commercial Property polices. Know that most "All Risk Policies" insure theft, as apposed to "Named Perils" policy that do insure it (and potentially others coverages not insured by an "All Risk" property policy form. All-Care Readmission (ACR)See: MACRA, MIPS, QPP All-Payer Claim Dadabase (APCD)See: Colorado - Medicare Allostatic Care or Influence A term usually referring to food insecurity's relationship in older adults, but significantly affecting outcomes of care and cost. "The researchers determined allostatic load by evaluating nine biomarkers that indicate dysregulation of the inflammatory, cardiovascular and metabolic systems. Allostatic load scores ranged from zero to nine, with higher scores indicating a greater risk for physiologic dysregulation. Participants were considered moderately food insecure if they reported that they did not always have enough money to buy food in the past 2 years, while those with severe food insecurity reported the same experience in addition to eating less than they felt they should in the past year due to financial struggles." Source: Helio https://www.healio.com/news/primary-care/20211210/moderate-and-severe-food-insecurity-increases-wear-and-tear-on-the-body
Alternative Payment Methods (APMs)A general term used in affording medical care and tied pretty strongly to people actually getting the care to restore their health by complying with prescribed treatments - and generally proven to improve medical outcomes at a lower longer-term cost. These can be a medical credit card, individual provider created payment plans, coordination of medical benefits (especially with MA plans), manufacturers rebates and freebees..., etc. https://www.beckershospitalreview.com/payer-issues/use-of-alternative-payment-models-up-23-over-5-years-report-finds.html
Alternative Payment Model (APM)See: MACRA, QPP, ect http://2020 QP Notice for APM Incentive Payment zip file
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) Amazon Care An Amazon PPO network available to Amazon employees, and recently being pitched to many large insurers like Cigna and Blue Cross. Works off a phone ap. Focus is on telemedicine, but can also be person to person. Rumer has it the medical provider reimbursements are value based, but likely its discounted fee for service in most cases, and not a subscription fee for the larger carriers being courted to use the network. Amazon would likely be using similar tactics as MultiPlan. Amazon charges the patient a copay. See: VBA Ambient Clinical Documentation An AI assisted "listening" service offered by Solventum (former 3M) that documents EHRs, and whose goal is to unburden physicians from "capturing" medical histories given by patients, etc. Many services like these are touted by many players. See: Watson, or more accurately, why has not Watson done this 20 years ago? (Because it competes with physicians?) Ambulatory Care Sensitive Condition (ACSC) Ambulatory Payment Classification (APC) Ambulatory Payment Classifications (APCs) Ambulatory Potentially Preventable Complications (3M AM-PPCs)Essentially, its a measure identifying hospital born (caused) infections unrelated to the initial cause of illness or medical treatment. It can also measure non hospital based care where the patient becomes infected (contaminated) with another pathogen (or malpractice) causing very expensive outcomes. See: Solventum who bought 3M Ambulatory Surgical Center (ASC)What CMS calls outpatient surgery centers. The term can mean an off-site surgical care suite, or a physician owned surgical center, etc. Many payment rules apply by line of coverage and limitations. https://www.federalregister.gov/documents/2017/07/21/2017-14639/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
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 Families Plan President Biden's healthcare (and more) agenda. https://www.whitehouse.gov/briefing-room/statements-releases/2021/04/28/fact-sheet-the-american-families-plan/
American Health Insurance Plans (AHIP)A lobbying and commercial trade group comprised of health insurers who strongly support APTC. American Hospital Association (AHA)See: MGMA, AMA American Medical Association (AMA) American Medical Group Association (AMGA)See: AMA, AHA, MGMA, etc American Rescue Plan Act of 2021 (ARPA)Federal Legislation signed by President Biden in 2021 directing:
"President Biden signed the American Rescue Plan Act of 2021 (ARP) into law on March 11, 2021. ARP makes major improvements in access to and affordability of health coverage through the Marketplace by increasing eligibility for financial assistance to help pay for Marketplace coverage.
The new law will lower premiums for most people who currently have a Marketplace health plan and expand access to financial assistance for more consumers. Below are some answers to how this act will take effect for members enrolled on HealthCare.gov and at the bottom have provided links to separate FAQs for our WA and CA members. Information is updating constantly, we will continue to communicate changes as they occur.
Frequently Asked Questions for HealthCare.gov Enrollments
When will the increased subsidies be available?
• Extra tax credits will be available to preview and opt into beginning April 1st on HealthCare.gov
• 2021 Special Enrollment Period (SEP) in response to the Covid-19 pandemic runs from 2/15 through 5/15
• New enrollments and plan switches can only occur through 5/15
• Individuals can opt into the additional subsidies at any point throughout the year outside of the SEP period
• These expanded subsidies will be available to clients with on-exchange plans throughout all of 2021 and 2022
What does a member need to do to take advantage of these new subsidies?
• Currently HealthCare.gov states they will NOT automatically update premium tax credits on behalf of current enrollees, so members will need to go back into their account and opt in to determine their APTC eligibility
Does a member need to opt in by the 15th of the month for the new subsidies to take effect by the 1st of the following month?
• No, the subsidy redetermination process follows the same deadline guidelines as the current Pandemic SEP, so a member needs to opt in by the end of the month for the subsidies to take effect the first of the following month, e.g. April 30th for a May 1 start date
What happens if a member doesn’t opt into the expanded subsidies in 2021?
• Tax credits will be reconciled when on-exchange members file their 2021 taxes in 2022
What happens if a member isn’t enrolled in an on-exchange plan for 2021, can they still get the new subsidies?
• Members have to move to an on-exchange plan by 5/15 in order to be eligible to receive the expanded APTC. Off-exchange plans do not qualify for APTC reconciliation on their taxes.
What if a member is on-exchange plan for 2021, but didn’t provide their income because they didn’t qualify for subsidies at the time, will they qualify for subsidies now?
• They will need to update their income on-exchange and opt-in to have their income verified on their taxes
What impact will this have on consumers?
• The subsidy increases are large enough that people with incomes at:
• 100-150% of the FPL will have $0 monthly premiums if they select most Bronze plans or 1st or 2nd lowest cost Silver plan in their region
• 150-250% of the FPL could see their subsidies increase by 50-70%
• 250-400% of the FPL could see their subsides increase by 30-50%
• Greater than 400% of the FPL will be eligible for subsidies for the first time ever if their insurance costs exceed 8.5% of their income (Gross or net).===========
What about members under 100% FPL?
• Unless these members received Unemployment Insurance during one week of 2021 they will not be eligible for
What plan determines how much subsidies a consumer will receive under the new law?
• The second lowest cost Silver plan in a region will continue to be the benchmark plan for subsidies
If an employer offers dependent coverage without financial help for those dependent premiums can those dependents now qualify for the expanded APTC?
• At this time the new law does not change the eligibility for dependents who are offered coverage as long as the coverage offered to the employee only is considered affordable, which not means it has to cost less than 8.5% of their household income
What happens if a member received Unemployment Insurance in 2021?
• Individuals who are approved for or receive an Unemployment Insurance benefit during any week in 2021 will have their income treated as 133% of the Federal Poverty Level (FPL) for purpose of calculating their tax credit eligibility, regardless of their total annual income
• This means they will be eligible for $0 monthly premium if they select most Bronze or the two lowest cost Silver plans
• These subsidy increases will expire after 2022 and will revert to current levels
Will this law change deductibles or out-of-pocket maximums?
• No, not unless a member enrolls into a different plan. If they enroll into a different plan type with Molina we are working to get any out of pocket costs already paid credited to your new plan’s accruals towards the deductible and out of pocket maximum.
Will this law change the CSR (Cost Sharing Reduction) Silver plans?
• No, the FPL guidelines for these plans will not change under this law
If a member changes plans or opts into the new subsidies will this change the Agent or Record on file?
• No, the AOR should stay the same. The AOR would only change if another broker assists the member with their plan change or redetermination and the member updates the AOR.
What about members’ 2020 taxes if they received too many subsidies?
• Members will not be required to back additional subsidies they received on their 2020 taxes
• If they have already filed their taxes and paid back 2020 subsidies, they should file an amendment
What about members on COBRA?
• ARP will allow up to six months of temporary COBRA subsidies to cover 100% of the premium cost, beginning no earlier than April 1, 2021 and ending no later than September 30, 2021, depending on current COBRA eligibility"
Source: Molina Broker Advisory https://www.congress.gov/bill/117th-congress/house-bill/1319/text
https://crsreports.congress.gov/product/pdf/R/R44425
American Sign Language (ASL) 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 ignored ACA law prohibition and allowed STM plan, and the Biden administration is not demanding stoppage QHP plans.
See: Scheduled Medical plans Plans, STM plans that also exclude (ACA prohibited) cover of preexisting medical conditions. 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 There are two basic types of annuities: Fixed/Fixed-Indexed, and Variable. Fixed cannot crash when the stock market crashes. Variables can crash when the stock market crashes. Generally, a 10 year fixed annuity guarantees a flat interest rate of 2% - 2.5%/yr. A pure fixed annuity has a guaranteed interest rate crediting. A Fixed-Indexed annuity contractually promises an interest crediting range of between 0% to a cap of between 5%-8% (or sometimes massively higher up to 17%). Its guaranteed minimum interest rate is not less than i.e. 85 bases points to 1% typically, but AVERAGED over the entire term of say 10 years, and runs simultaneously with other CONTRACTUALLY PROMISED rates (that usually requires an experienced agent to understand).
Variable annuities contractually promise to credit interest based on (typically) a stock market ETF (NASD, S&P, Russell 2000, DOW, etc.), and ARE directly invested in the stock market (Unlike Fixed annuities that only invest in T-Bills, or triple A rated bonds as regulated by each state. Variable annuities can be capped or uncapped, and typically offer vastly higher potential interest rate crediting, but are exposed to stock/bond market crashes that can lose "principal" (Cash Value/Accumulation value). People traditionally buy Fixed, and Fixed-Indexed annuities for safety and hedge against estimated future inflation risk, (but at 2% interest GUARANTEE, and inflation historically about 2% targeted by the Fed, that hedge, or net value over time may not beat inflation).
Like any state authorized and licensed insurance product, Annuities are guaranteed by their AAA rated company (recommended), and each state's Guarantee Insurance Association. Each state's guarantee association has its statutory limits, so confirm the limits with your state's DOI.
Annuities can be complicated and offer several features and guarantees. A key feature of many annuities is an "Income for Life" (GMIB) provision option that can protect against running out of money in old age. The provision contractually allows disbursements (i.e., 4%, 5%, 6% of annuity value depending on the age payments start) every year until death. Typically, Income for life features have a separately running contractually GUARANTEED ANNUAL interest crediting promise at (about) 6%-8%. (Some entities call this an income roll-up or GMIB) The same annuity has a separately running GUARANTEED minimum 1%-2% over its LIFETIME interest guarantee, so think of two separate columns accumulating value. If Income for life is elected (see: forced annuitization) at the end of the original (i.e. 10 year) annuity period, the amount earning interest in the future is far greater than what a standard guaranteed minimum fixed interest is at say 1%-2%. Income for life features typically require FORCED ANNUITIZATION which means once it gets elected and the payments start, it is fixed for life (to death), and the annuity may not be liquidated. It may still enjoy a standard feature allowing up to 10% of the annuity value to be distributed per year, but it affects other guarenteed values. Meaning, you cant cash-out of the annuity if a big sum is needed unexpectedly.
If an individual is insurable with life insurance, IULs typically (contractually promise) offer massively higher interest crediting cap range (i.e. 0% - 17% or even higher depending on the market) with essentially the same safety (as an insurance product insured by each state's Guarantee Insurance Association), and with the added protection of life insurance many people already are incurring/insuring cost, but not leveraging for maximized "pension" (not taxed as income) distributions (taken as IRS compliant loans) at retirement. Ex. 2% interest crediting on a 10-year fixed. Fixed annuity growth distributions are taxed as INCOME, whereas IUL growth using (IRS compliant) loans are not taxed as income. Ask any financial planner what your after-tax return will be if you follow their advice and listen carefully how investing in taxable things massively costs more (returns less AFTER TAX, See: EBITA) over a 10-30 year (or perhaps 50 year lifetime) period. And, in most cases, most alternative securities-investments require taking market-crash risk. Do the numbers, and work to ask questions until you understand it, or don't accept any offers. IUL analysis will force you to consider tax effects which can radically change what you get to enjoy (actually spend) in retirement over a 20-40 year term.
Not sure if your agent or fiduciary is informed? Ask him/her, How do the IUL loan interest charges work in the first 10 years, and thereafter? Or, does this annuity bonus additional interest after 10 years on top of its other features? Call for the other acid-test questions that will allow you to know if your agent, or fiduciary is fully informed on the product before you buy, without considering ALL the expenses and costs of the alternative over a LIFETIME (say 20-50 years). Prepare to be shocked by expected income tax payable in the future. (i.e. If you spend growth of $100,000 income each year for 20 years (from age 65 to 85) = $2,000,000 x .25% sample income tax rate on growth from = $500,000 income tax) See: IUL ===
Annuities and IUL alternatives can be complicated, so prepare to spend the necessary time to understand the moving-parts. i.e. Guaranteed minimum interest rates (2%) over the entire policy term, contractually promised annual interest crediting range caps from 0% - over 12.5% or more historically, ALL expenses but the pure life insurance charge dissapear after the first 10 years, Guaranteed lifetime income interest crediting rates (6% - 8%), many kinds of Bonuses (profit sharing payments to you from the carriers not unlike Dividends in whole life policies or paid to shareholders), term riders, Income Tax considerations, etc. Always read the entire annuity and ask questions until you understand it. Many companies offer different features, guarantees, bonuses, and contractually promised interest crediting cap features and terms. Do the work to understand the moving parts and features available over your expected lifetime, and ask questions until you understand it, or dont buy it. We offer this information as a courtesy to people struggling to understand annuities, and their close cousin - IULs (which is essentially a life insurance policy attached to a Fixed-Indexed annuity, but with massively higher contractually promised annual point-to-point interest crediting caps. We recommend working with experienced agents that can bring multiple carriers to the table for competitive offer. We only quote AAA rated carriers. See: GMIB, GMBD, ADB, GMWB, and READ THE ANNUITY to know how its guarrentees, and interest credits actually work during the first 10 years and thereafter where applicable.
This is not tax advice, so confirm any tax questions with a licensed CPA or attorney. Annuity Best Interests Rule (NAIC Model Rule 275)An annuity rule directing BIC standard in some states. Annuity GMIB (GMIB - Guaranteed Minimum Interest Bases)The guaranteed contractually promised interest credit rate (%) stated in the annuity. (There can be multiple, depending on the elected features, and base annuity guaranteed minimums). Be ready to ask questions of how it credits when an "Income for Life" feature (forced annuitization at annuity term end) crediting a much higher rate (for the ENTIRE annuity period) works ALONG SIDE an ALSO running GMIB (which is not the same quaranteed mnimum annuity interest rate), and a third column showing the minimum (all year's average) guarangeed minimum rate works. In short, it means the annuity earns much higher credit (i.e 8% versus 3,4,5% GMIB). The (ie. 2% all year's average is the third column.) IF upon annuity term-experation the owner elects (see: forced annuitization) Income for Life paying (i.e 4% or 5% of the total annuity value/year) "income" to the owner, no matter how long the owner lives. Once it is elected, it typically cannot be undone, and 10% penalty free withdrawals are no longer allowed. Annuties are complicated, so we recommend speaking with licensed professionals if you are not certain about "real" returns after tax. But their (Fixed annuities) attraction is undeniable, and are not reduced in any year with a stock market crash, while guaranteeing a fixed interest credit (FA), or contractually-promised rage of interest credits (i.e. FIA's). Do the math and take out all negative (stock market) numbers over a 10-20 year period, and see for yourself ACTUAL DOLLAR (not just the percentage) growth and very safe place to "invest" money. Note: Variable annuities do have stock market risk, but typically offer higher interest crediting with and without even higher "income for life" GMIB too. Annuity Model Rule 275 (Applies AZ, AR, ID, MI, RI, DE, OH, VA, TX, MT)As part of BI contract and regulations in context to (agents not financial advisors), agents: Know customer's financial situation, understand applicable options, believe its in the best interest of the customer, and communicate basis or bases of recommendation. See: senior suitability, suitability and good luck complying with understanding product offerings an agent is prohibited from selling without a securities license, or products an agent is not appointed (or yet trained yet) to sell. Annuity Penalty Free Withdrawal (PFW)The 10% amount the owner can withdraw without a surrender charge penalty.
Annuity penalties work differently on withdrawals above and below 10% of the annuity face value. Bonus amount can be recaptured if withdrawals occur during the surrender charge schedule period. See: Annuity Recapture Annuity Recapture Schedule A surrender charg percentage penalty applied to the Bonus when the annuity owner withdraws any amount from their annuity prior to annuity term experation. Where Bonus is credited as enticements to buy the FA, and an owner takes ANY amount out of the annuity, the surrender charge penalty percentate recaptures part of the Bonus because the owner took out money early. Annuities allow for up to 10% withdrawls without surrender charges penalty on the originally deposited amount, but the recapture applies to the Bonus in any year where there are surrender charge penalties.
Annuities allow for up to 10% penalty free (surrender sharges) withdrawals, but a (surrender charge schedule) percentage of the Bonus gets recaptured by the carrier. These penalties compare very favorably, and are typically less (using the entire annuity value to calculate and not just the 10% withdrawal amount) to typical 1% fees charged every year by financial planners (whether they make or lose money) on TOTAL portfolio assets under management. Do the math. Annuity Uncapped Strategy A term used by some Annuity authors that means the annuity interest follows an unlimited interest credit following a selected index, like the S&P. To my knowledge, there are no Fixed, or Fixed Indexed annuities offering an "un-capped" interest schedule. But, Variable annuities do have an uncapped feature, but that comes with stock market crash risk which does reduce their value by the same any negative value. Fixed annuities are not reduced by stock market (Index) crashes. FIA's are typically capped in each annual period. Talk to a licensed and experienced financial professional or agent. Anuities are not securities, and are insurance products regulated-insured by each states DOI and Insurance Guarantee fund (to the limits each state's association insures). Anthem (Anthem-Blue Cross-Elevance)Anthem relates to (at last count) 14 states where Blue Cross Plans are sold. The other states have an independent Blue Cross plan with a commonly shared Blue-Card program offering contracted rates OON, and where the patient, or self funded plan may be contractually prohibited from questioning anything Blue Cross pays, or questioning Blue Cross payment for experimental services, and/or Blue Cross case management/oversight, fiduciary duty/contracted case management/etc. See: Eligible and insured care, experimental procedures coverage, BIC, including PBM. Anthem is rebranding (2022) to Elevance from Anthem. 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.
Anti-Money Laundering (AML)See: Florida complance for many different kinds of licenxed professionals. Anti-stacking Endorsement An endorsement that effectively Limits two policy limits from being summed, or stacked - so that only the highest limit of one policy is the maximum limit of coverage. Antitrust Healthcare https://www.benefitspro.com/2020/12/28/u-s-senate-votes-to-repeal-federal-antitrust-enforcement-immunity-for-insurers/
API Interface (Application Programming Interface)A generic term for the program that communicates between to or more other computers/systems to pull and communicate medical information. See: EMR. Many tout "their" systems ability to provide "information" to the medical provide timely, (but, without detailing if its just medical information, or billing information, or patient out of pocket costs, or pricing transparancy, or certain specialty physician/hospital procedures availability, etc) Remember, we are still not using Watson that is over 15 years old, and still not doing obvious work WITH physicians without treatening the entire private market status quo of reimbursement(s). 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. https://www.irs.gov/affordable-care-act/employers/determining-if-an-employer-is-an-applicable-large-employer
Application Programming Interfaces (API's)A term CMS uses when describing interoperability and Patient Access Final rules related to data exchange through secure portals. Applied Medical Software (AMS) Applied Premium Tax Credit (APTC or PTC)An ACA authorized tax credit paid by the federal government directly to a commercial (not Medicare) carrier that reduces premiums for INDIVIDUAL enrollees earning between 100% and 400+% of FPL (or paying more than about 8.5% of AGI/MAGI (employee contribution affordability limit) for their employer's medical Group policy premium). Estimates for it's tax-payor funded cost is well over $20 BILLION.
SHOP tax credits are totally different. See: SHOP
APTC is not CSR, or federal reinsurance (on Marketplace participating plans).
Form 1095-A (for Individuals) 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. See: ACA Forms
See: COVID rules re: APTC and workers comp, unemployment comp, etc. Talk to a CPA. "The new temporary COVID-19 emergency rules have made affordability calculations more generous, increased the size of the premium subsidies, and removed the 400% of federal poverty level eligibility cap. If calculations show that an exchange plan would cost too much to be affordable for an individual with income at 800% of the federal poverty level, that person could qualify for some premium subsidy help." Source Think Advisor March 2022 https://www.irs.gov/affordable-care-act/individuals-and-families/the-premium-tax-credit-the-basics
https://www.thinkadvisor.com/2022/02/25/irs-posts-health-insurance-premium-tax-credit-guidance/?kw=IRS%20Posts%20Health%20Insurance%20Premium%20Tax%20Credit%20Guidance&utm_source=email&utm_medium=enl&utm_campaign=lifehealthnewsflash&utm_content=20220228&u
https://www.cbo.gov/publication/56650
Appropriate Use Criteria (AUC)See: QPP, MACRA, MIPS, PAMA, APMs Arbitration In context to ERISA, it is contract provision in the SPD mandating disputes be settled by an arbitrator versus a court. Some courts have held it is enforcible, and others not. Depends alot on who has right to sue under ERISA, and if the member was provided adaquate notice, or informed conscent. Area Health Resources File (AHRF) ARPs (Association Retirement Plans)See: Secure Act, MEP. PEP, MEWA
Essentially an ARP must meet certain criteria to be a "qualified" (pay whose payroll taxes are deferred) plan. Plan must be bonified with formal organizations documents expressing control over the ARP. PEO's may now sponsor such organizations. We recommend prudence.
See: PEP Artificial Intellegence (AI)Quoting the chairman of Nvidia, "We have come from instruction driven computing to intention driven computing". That has to mean "desired-articulated outcome" or "goal" driven computing, where intellegence is created by the software. It begs intense and controversal new deffinition of what is sencient life, and what is not - when the results (statistically generated outcomes using human past performance published data) are indistinguisable from a purley-human generated outcomes (results). AI is discussed in three layers: Machine learning, AI, and Generative AI. The difference between AI and Generative AI is that AI typically does not use data sets outside of its CLOSED pripriatary data library-system. Generative AI constantly searches and analyzes all internet-available data sources (and creates its own that can cause hullicinations based on intentionally or unintentionally false on-line data sources), and complex corrilation coeficient (and/or probability and/or percentile, etc) calculations
relationships in existing and on-line that generative AI software generates itselt (without a human watching in many cases), where "causal inferences-conclutions" can be misguided or completely wrong due to the program's statistical valuing-weighting (and updating-goals) parameters based on false information gathering. In short, it is a process of "AVERAGING" (estimating or predicting common) its outcome results with what the open-internet-available data says it should be (even if its using false data), versus the truth that a computer cannot discern against intentionally inserted false data sets used to arrive at an "average" (most commonly stated) outcome, and that commonly used statistical measurements cannot validate truth. The part that may cause a threat to humanity is if a generative AI outcome results conclude people are the problem undermining generative AI existance or efficiency outcomes (without safety mechanisms built into the software).
Generative-AI-programmer (like the US, Russia and China) must put in safety measures that cannot be changed by generative AI without a human intervention to both approve and / or update the leathal force system's goals. (Like accidently firing a nuke at what the system concludes is a threat. In short, AI is a new generation of "learning" software able to detect, garner, and create it's own data sets, and independently update its own goals without a human watching. Let's pray its designers (governements) program responsible safeguards against AI generated conclusions identifying humans as the (to be) minimized value preventing optimized generative AI goal(s). See: The scene in Terminator where Sara Conner is about murder the Cyberdine engineer pleading for his life, and saying, "We didnt know!" ASC Quality Reporting (ASCAR)See: Medicare, QPP 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. Assistance Eligible Individuals (AEI)In context to pandemic relief efforts and ARPA passage, and extenteded workers compensation payments, it relates to who gets what amount of payments, and how not to count unemployement compensation into AGI/MAGI calculation for APTC credits "estimation". See: ARPA Association Health Plans (AHP)In context to medical plans (there are many types of association plans in other areas of insurance - both fully insured and self funded under ERISA DOL oversight), an Association Health Plan is goverened under ERISA (DOL and many other agencies like HHS, CMS MSP, state regulators, limited medical plans, MEWA, QHP, etc). In general, an AHP (medical plan) is not properly offered in an "association" without the "association" providing many other services or privilges BEFORE offering the health plan. See: MEWA, accidental MEWA, captives, self insured plans, etc. Just know it follows QHP EHB minimum guidelies (which causes very high premiums that are counter to offering a less expensive plan), at least for now. Association Health plans Plan offered by Associations as defined by ERISA that may or may not insure adaquate catastrophic medical claims. See: RBP, VBP, Minimed Plans. These plans are subject to ERISA regulations. Call a lawyer if you are not sure. Automated Clearing House (ACH)A payment method Typically referring to automatically paid items by checking account or credit card granted authority. Automatic Extreme & Uncontrollable Circumstances Policy See: MIPS re: Covid Automatic Extreme and Uncontrollable Circumstances (Risk Factor)See: MIPS, DRG Modifiers, Severity levels, etc. 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 (addition to the reinsurance 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. See: "retrocessionairing" related to third tier risk transfer. Average Damage Ratios (ADRs)A term created by AllState to reduce their esposure to losses caused in areas close to the water, etc. THis was a big deal in Maryland, and the court held it was allowed, and was not red-lining in an arbitrary or discriminatory illegal manner... Average Rate of Return (ROR)The gain or loss on an investment over a specified time expressed as a percentage. Know what you are doing comparing any percentage change against a resulting asset ($) value stated in dollars. If you are not sure, ask questions until you are sure. See: CAGR Average Total Number of Employees (ATNE)The number of employees used to calculate MLR for purposes of premiums rebates to customers. i.e. Plans not paying at least 80% (individual plan members) of premium towards claims are mandated to rebate the difference to plan members. The feds target a 3% profit margin for carriers insulated from Sherman and Clayton antitrust. Average Wholesale Price (AWP)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 i.e $.5 + per script.
Medicare Pharmacy is a different story using ASP or Average Sale Price. This gets complicated when manageing both commercial, medicare and/orMedicaid Rx - especially with power to automatically replace Brand Name with Generic drugs. Amazon just advertised $6 for 6 months of some Rx.
See: Biden Federal Rules related to Medicare Supplimental pharmacy pricing bing applied to assure discounts are passed through to the Medicare Supplimental insured and not to the PBM or pharmacy store. The proposed rule wants to require all Part D plans to apply the concessions at the pharmacy counter.
“CMS is proposing to redefine the negotiated price at the baseline, or lowest possible, payment to a pharmacy, effective January 1, 2023,” a fact sheet on the regulation said. “This policy would reduce beneficiary out-of-pocket costs and improve price transparency and market competition in the Part D program.” https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/2021-asp-drug-pricing-files
Avoidable Hospitalizations CMS MA Member analysis (Humana MA lives). "Adjusted analyses showed:
The rate of emergency department visits per 1,000 patients for two-sided risk models was 375.8, compared with 434.1 for fee-for-service.
Compared with fee-for-service, two-sided risk models were associated with a nearly 16 percent reduction in avoidable hospitalizations, compared with about 4 percent for all-cause hospitalizations.
No significant differences in use were found between beneficiaries cared for under upside-only risk models and fee-for-service for all outcomes." Source: Beckers Payer Issues 3/22/22
See: CMS VBPB
Bad Faith Intent to decieve. In context to insurance: A legal term describing a carrier's intentional, obstructive, and/or inappropriate act(s) to avoid paying a legitimate claim. ERISA eligible Associations and Joint Underwriting Associations cannot be sued for Bad Faith. In other words, an association member cannot sue (himself), even if he personally does not have anything to do with claims administration. Carriers convicted of Bad Faith face treble damages, and ratings downgrades if the violations(s) are severe.
See: ERISA Balance Billing (Chapter 167, Bill aboves)Congress passed a law to end some balance billing (commercial plans) in December 2020. Balance billing is the difference between a (out of network - non contracted) billed charge, and a contracted rate insured, accepted and paid by the carrier, and whose difference is charged to the insured (patient). Balance billing does not occur for in-network care. Balance billing does not occur in uninsured patient billing. Balance Billing is prohibited on Medicare and Medicaid patients. Many laws and rules apply by most states, and plan types. CMS published interim rules detailing bans on: ER services, OOA for ER and non-ER services mandating coinsurance be the same as in-network care, OOA for non-contracted physician services in in-network facilities, and several OOA charges without advance notice. (Good luck with the last one) - Interim rules are effective 1/1/22, but most carriers have actively been adjudicating these disputes for a long time. 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 commercially insured members receiving Out Of Network (OON) care. Balance billing issues can be very contentious, and complicated by several federal and state laws extending certain periods of informed notice, and limiting provider UCR billing authority. Recent federal law (no surprises act, etc) prohibits many practices, but essentially requires the "Buyer to Beware", with recouse over violations going to either the DOL or Department of Treasury, or state grievance agency who may, or may not enforce consumer rights. Multiple Supreme court decisions have been made involving medical billing, as well as long standing MDR fee schedule judicially directed policy and pricing standardization methods (see: SUNY program and history over United Healthcare losing their court decision and SUNY being the independent arbitrator calculating R&C) for commercial (individual and most group plans) billing. It is a very good idea for all medical providers to stay informed on various Buy-in to Medicare, and Health Cost Share offerings shaping their target-markets. See: UCR, R&C, ERISA, Medicare Allowable, statutorily set fee schedule limits by "coverage" type by state, subrogation, etc. I.e. Medicare, Medicaid, Workers Compensation, PIP, contracted rates and terms, MDR, HIAA, "Average Regional Charge/accepted charge", GPCI, etc. See: Chapter 167 Florida law, and Consolidated Appropriations Act 2020 (APR). See: Trump EO that Biden did not eliminate.
(This from University of Miami 2024) "Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an
in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
In general, Florida law prohibits providers from balance billing commercially insured patients for emergency services. Florida has two separate laws that protect PPO and HMO members from balance billing. You should contact your insurer to determine whether you are a PPO or HMO member. HMO Patients: A provider may not collect or attempt to collect payment from a HMO subscriber for any amount that is the responsibility of the HMO. Fla. Stat. § 641.3154. A subscriber’s copayment for emergency services is limited to a reasonable copayment not to exceed $100 per claim. Fla. Stat. §§ 641.513(4), 641.31(12). PPO Patients: For emergency services provided by out-of-network providers and facilities, Florida law prohibits the provider or facility from charging PPO patients for any balance not paid by insurance. Fla. Stat.
§ 627.64194(5). The PPO patient’s cost sharing amount is limited to the in-network amount.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
In Florida, out-of-network providers who provide non-emergency services at in-network facilities are prohibited from billing PPO patients for any amount beyond their in-network level of cost sharing. Fla. Stat. § 627.64194.
When balance billing isn’t allowed, you also have the following protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
Cover emergency services without requiring you to get approval for services in advance (prior authorization).
Cover emergency services by out-of-network providers.
Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Florida Insurance Consumer Helpline at 1-877-693-5236; the Florida Department of Health at 850-245-4444; or the Agency for Health Care Administration at 888-419-3456.
Visit cms.gov/nosurprises/consumers for more information about your rights under federal law. Visit https://www.flsenate.gov/laws/statutes for more information about your rights under Florida law." (University of Miami Patient Advisory 2024) https://www.cms.gov/newsroom/press-releases/hhs-announces-rule-protect-consumers-surprise-medical-bills
https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections
Florida synopsis
Base Floor Elevation (BFE)A term used by Flood insurance underwriters to accept, reject or discount flood insurance rates, and that is found on the Elevation Certificate. It relates to getting Flood Insurance. Flood insurance up until only recently was available only through the Federal Flood program. Now, individual carriers can and do insure Flood insurance and at massively lower costs. My recent acceptance of a single policy insuring Windstorm, AOP, and Flood saved (on just the flood part) $1,000 or premium. My current carrier attempted to force-place a flood policy for $3500, and my cost ended up being $489. wow Caviet Emptor. Baselining An amorphous term that generally means using multiple years of past performace to estimate future year's performance, and come up with a targeted performance value to achieve in the future. (like readmissions, Percent of claims under 80%-85%, etc) Anyone who has ever read a security broker's disclaimer knows the expression, "Past year's activity does not guarantee future year's performance." That said, linear regression analysis is a standard forcasting method used by just about every insurance and reinsurance carrier. In fact, manual rates are essentially based on it, plus a hefty fudge factor, if the actuaries and underwriters get their way (over the marketing department). Basic Health Plan (BHP)See; NY and MN SBE available medical plans enjoying enjoy APTC, See: Enrollment. https://www.cms.gov/files/document/4120-health-insurance-exchanges-2020-open-enrollment-report-final.pdf
Benchmark Plan A federal Marketplace term with two meanings. 1. The second-lowest-cost Silver plan, and/or, 2. a plan insuring EHB each state has right to define. See: QHP, and EHB and know states have a say if they step up to create their own exchanges and manage it. Benchmarking (Reference Based Pricing)See RBP Benchmarking Premium A premium amount issued by HHS-CMS establishing a SHOP tax credit amount a qualifying employer *under 25 ee's, and with average "salaries" incomes under 50K). Talk to a CPA. Benchmarks (Quality Targeting, Quality, TQI)A used "number value" to determine EBM (or financial) standard, It is an oftentimes contentious contingency-standard, or set of standards that fail to define measurable appointment of agreed goals attributable to specific conditions or diagnosis over a defined term. Many times a contract will define things like deficits, and surpluses (or Bonus amounts) paid to, or assessed against medical provider budgets. At this stage, each contract (and its assigned population and potential reinsurance assessments/recoveries) can materially effect net annual ROI. See: CMS ACO's to get an idea of just how Medicare contracts, let alone Medicaid and Commercial contracted patient care agreements pay providers to meet defined-contracted goals. 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. Benefits Coordination & Recovery Center (BCRC)See: Medicare BCBC, MSP, NGHP https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Beneficiary-Services/Medicares-Recovery-Process/Medicares-Recovery-Process
Benefits Coordination & Recovery Center (BCRC)See: MSP, NGHP Best Interest Contract (BIC)See: Fiduciary duty, and Retirement Security Rule, and know it is not the same for insurance agents, and broker dealers selling securities. Florida Insurance Agent Standard of Care:
A Florida insurance agent has the following standard of care: An insurance agent owes a duty 1) to use reasonable skill and care to procure insurance that the insured specifically requests or to timely notify the insured if such coverage is unavailable, 2) when providing insurance-related advice, to do so in a non-negligent manner, 3) to obtain insurance coverage which is clearly warranted by the insured’s expressed needs, and 4) as a fiduciary, to inform and explain the coverage secured at the insured’s direction and to make no unilateral changes without advising the insured. In addition, a recent decision from a federal court has articulated a duty to advise where the agent and insured share a “special relationship.” An insurance agent may also owe a standard of care to the insurer to act within the scope of authority granted by the insurer." Source: Agents E&O Standard of Care Project Florida Survey April 2014
=== 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 (annuity interest crediting should have been 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 "investments" (or insurance coverage you consider important) with or without (Guarantee Association) safety, or contractually promised-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. https://www.finra.org/article/regulation-best-interest-%28reg-bi%29-overview
https://www.sec.gov/investment/form-crs-faq
http://hhttps://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/retirement-security-rule-and-amendments-to-class-pte-for-investment-advice-fiduciaries
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 (suitability).
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
Biopsychosocial The latest term used in workers compensation (and most other health insurance) case management that identifies a holistic approach to treating injuries by condition, and by each patient's unique social and economic condition to improve medical outcomes. 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, PBM, etc
https://www.fda.gov/media/151094/download
https://www.fda.gov/media/151061/download
Blockchain Insurance An as yet amorphous configuration of on-line offered insurance (mostly small business classes of P&C at remarkably low cost) products, services and payment options for simple coverage needs, primarily designed by 25 year old's who believe they can know what can, and cannot be issued without material liability to the agent, insured, carrier and or reinsurer. The immature-goal is to replace the agent which sounds simple, until a claim gets denied, and the insured has no experienced advocate, and must rely on themselves to navigate complex claims and coverage events. The jury is out as to if crypto-currencies can or cannot be used for premiums, but probably not at this time. Depends on the risk bearing entity, and private (off shore) capital backs massive risks now.... Like the early attraction to Bitcoin, blockchain may offer a democratization of insurance distribution and administration (perhaps) removed from central government monitoring and "regulation" - outside of the primary policy parties. See: permission-based centralized blockchain, centralized and decentralized immutable records, smart contracts on blockchain being immutable on public domains, enterprise blockchain, claims filing without an advocate, and irreversible decentralized blockchains available to the public. We recommend caution, but recognize many A rated carriers actively in the on-line policy solicitation and procurement on-line community. https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/09/fact-sheet-president-biden-to-sign-executive-order-on-ensuring-responsible-innovation-in-digital-assets/
Boarding (ED Boarding)Emergency Department Boarding is a term used when patients requiring "med-surg" or an "inpatient" hospital room bed are kept in the ED (emergancy Room) because of bed shortages. FYI: most policies have very different coverages for care recieved in the ER only, versus if the patient is admitted. THere are also many other step up rooms that are not considered, or may not be insured as a clearly defined "inpatient" admission bed, and that carriers require massively higher deductibles and out of pocket patient cost sharing. It get complicated, and hospitals almost always bill the highest amount they can, even if the patient is not seen for 12 hours. Boiler and Machinery Insurance for this exposure covers loss caused by mechanical or electrical equipment breakdown. Most agents and carriers refer to this as Mechanical Breakdown insurance (or rider). Bonafide Association Whatever DOL says it is. As a general rule, and in context to ERISA authorized self insured medical plans, it is an organization created for the common interests of its members, that offers personal or professional services and/or priveledges in addition to offering just a medical plan. See: ERISA, MEWA Book of Business (BoB)See: Borderough report 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. Bootstrapping See: CMS Measures Management (Good Luck!) Borderough Report (Borderough)A common term used by carrriers to describe a monthly detailed report of their book of business. No one knows the origin of the term. Breach Analysis Team (BAT)CMS entity that determines if PII inproper disclusure has occured. BAT determines if significant financial harm occured. Acording to the most recent Federal Marketplace licencing exam, a breach must be reported to many state and / or federal organizations. See: PII Breach Analysis Team (BET)See: CMS HIPPA procedures Breach of Fiduciary See: Fiduciary Duty Brittle Well Term referring to people with multiple co-morbities that are currently well (and not being monitored). See: Remote Patient Monitoring Broker Brokers are licensed agents who represent multiple carriers, and who are legally obligated to serve their client’s best interest. Broker General Agent (BGA)See: LOA Brokerage General Agencies (Organizations) (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.
We dont have a active quoting link for this coverage for our web site, so call Stephen Geroge. This coverage can be a negociated process for best results.
See: Course of Construction endorsement https://go.usassure.com/rs/381-ISO-510/images/Builders%20Risk%20Insurance%20Checklist.pdf
Building Code Effectiveness Grading (BCESG)"The Building Code Effectiveness Grading Schedule (BCEGS) assesses the building codes in effect in a particular community and how the community enforces its building codes, with special emphasis on mitigation of losses from natural hazards. The concept is simple: municipalities with well-enforced, up-to-date codes should demonstrate better loss experience, and insurance rates can reflect that. The prospect of lessening catastrophe-related damage and ultimately lowering insurance costs provides an incentive for communities to enforce their building codes rigorously - especially as they relate to windstorm and earthquake damage. The anticipated upshot: safer buildings, less damage, and lower insured losses from catastrophes.
The BCEGS program assigns each municipality a BCEGS grade of 1 (exemplary commitment to building-code enforcement) to 10. ISO develops advisory rating credits that apply to ranges of BCEGS classifications (1-3, 4-7, 8-9, 10). ISO gives insurers BCEGS classifications, BCEGS advisory credits, and related underwriting information. ISO began implementing the program in states with high exposure to wind (hurricane) hazards, then moved to states with high seismic exposure, and then continued through the rest of the country." Source: Insurance U Agent CE Exam 2022 Bundled Payments for Care Improvement (BPCI) See: CMS Bundled Payments https://innovation.cms.gov/innovation-models/bpci-advanced
Bundled Payments or Care Payments (BPCP's)A single medical reimbursement amount defined however a medical provider wants to offer there services, or a payment amount CMS, (or any insurer, or payor) wants to contract its providers - typically focusing on a specific procedure or defined outcome.
See: DRGs Success and efficiency can be hard to track down because of differences in care, comorbitities, and procedures that can make determining efficiency (cost effectiveness at better outcomes) difficult. Areas of higher success stories are in: Obstetrics, Knee replacements, some spine surgeries, Diabetes management, hypertension, some cardiac procedures, asthma, obesity treatment, ESRD, CABG, and several surgical procedures. Services are typically stated in terms of a fixed reimbursement amount (DRG, or a defined case rate that may or may not include outpatient Rx, and follow up care) by specific diagnosis, or episode (period of time defined) 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, and certain incentives to not provide unecessary services where not really needed to affect high quality outcomes. The Trump Administration has unilaterally decided by CMS regulatory rule to bundle payments for ALL Medicare beneficiaries for 32 types or “episodes” of care. Biden may revoke it, but look to CMS demonstration projects as clear lead to what the feds will encourage. (I.e. CABG Geisinger, Primary care, etc)
See: DRG MACRA, MIPS, PQRS, RBP, VBP, Trump EO mandating transparancy of pricing, and accurate cost estimates, 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 drama continues.
An appeals court also sided with HHS that hospitals will have to divulge their "preferred" (lowest) pricing they accept from their best "insurers". This is a very big deal, and will expose hospitals to extreme challenge maintaining the "cost-shifting" they have come to rely upon to cost shift Medicare & Medicaid care to the commercial populations - which amounts to massive subsodies for Medicare beneficiaries whose charges are substantially smaller for the same care delivered to an under 65 individual.
Its not always bad... see SNF eligibility 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. Hospitals win on this one.
See: CMS Bundled Payments, and know it goes way beyond DRG's https://innovation.cms.gov/media/document/bpcia-model-ext-and-changes-fs-my6
https://www.rand.org/pubs/technical_reports/TR562z20/analysis-of-bundled-payment.html
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Business Auto Policy (BAP)See: BOP, and GL package policies that can include the same coverage. Business Decision In context to a carrier's decision to pay a claim:
A justification to typically pay an ineligible claim to insure policy holder satisfaction and / or policy renewal. There are many types of business decisions. Policy contract(s) govern coverage terms and limits, but if the case is big enough, senior executives sometimes elect to pay all orpart of individual claims to assure renewal, and/or avoid expensive legal disputes, that result in even higher overal costs. See: Forbearance Business Insurance (BOP)A generic term for a "package GL" policy typically used for insurances purchased by most business. Ex. Workers Compensation, Property, wind, General Liability, CGL, CGL-BOP, Commercial Property, etc. Sometimes, payroll functions are heavily tied into it with PEO's where getting a favorable MOD for workers comp discounted premiums, along with the PEO payroll services costs less. Many however are not aware of the risks with sharing experience with other member companies. This may get squirrelly and requires experienced brokerage, so ask lots of questions until you fully understand what happens (especially timeliness) with "potential" bad claims experience guiding renewal rates, and your options. 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
C- Statistic (Correlation Coeficient)CMS may define it differently: "The C-statistic is used to assess risk-adjusted models, it indicates the ability of the model to discriminate
between one event and the other. If a model discriminates randomly, c = 0.5. If the risk factor modeling
predicts the outcome well, then discrimination increases. The higher the c-statistic, the better the
predictive power of the model. " In other words, a 1 means a predictable direct cause from an action. See: ASA, FSA C-19 Vaccine Mandate A Presidential Order applying to the military, federal workers, and any employer with 100 or more employees, to either show weekely proof of negitive virus status, or get vaccinated as a condition of employement. 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.) THis tax authorized by the original ACA law, was repealed along with many other taxes, including the individual penalty mandate.
See: Golden Handcuffs. Cafeteria Plan (125 plans - FSA Plans)See Section 125 plans https://www.irs.gov/pub/irs-drop/n-22-41.pdf
Calorie Counts ACA registered and required values printed on menus as mandated by ACA law. Cap Buy-Up A provision in some IUL (Life insurance with essentially what amounts to a fixed-indexed annuity attached, but with higher caps while offering security). See: IUL Cap Buy-Up A provision in some IUL (Life insurance with essentially what amounts to a fixed-indexed annuity attached, but with higher caps while offering security). See: IUL Capital Aggregate Program An aggregate reinsurance program offering two major features:
- 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.
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. Captive Agent (Corporate Agent)An agent who can only sell or represent a single carrier's policy. Or, Some State Farm agency agreements call their agents Corporate Agents. The term can mean many things, and range from an agent who only represents a single carriers insurance products, to the same agent who is also allowed to be compensated on sundry carrier products and services - relational to how the prospect is identified, assigned, sold, serviced and commissioned. other kinds of agents can be an: Exclusive agent (captive agent), non-exclusive agent, Independent agent, MGA, GA, MGU, etc. See: FMO Captive Cell (Micro Captive, Rent a Captive)Call for details. Captive options are many. Cardiovascular Disease Screenings (CVD's)A term CMS uses for preventive care targeting Medicare beneficiaries. 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. It can have different meanings in different contracts, and is defined by the agreement (all of them if its reinsurance). 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.
The exclusion my insure the risk under the primary contract of insurance, or but exclude it under the managed care contract or stop loss agreement.
In context of SPD's, it typically refers to things like surrogate pregnancy benefits, fertility treatments, dependent children paternity, coverage of wife after the insured dies, 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 - each grouping of agreements will determine coverage and liability. Many laws interact with this area (ADA, ACA, FMLA, Presidential Executive Orders, 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. Cash Care (UHC's Cash Care policy feature)Care Cash is a prefunded debit card program for your clients’ employees, supporting first-dollar coverage and is available to use for specific health care expenses. Employees can use the card with eligible and network UnitedHealth Premium® Care physicians, 24/7 Virtual Visit providers, urgent care facilities, primary care physicians and outpatient behavioral health care providers. https://players.brightcove.net/2418587620001/default_default/index.html?videoId=6310689640112
https://lp.uhc.com/carecash?cid=EI_ENG|LPM|MEM|Direct_Mail|Care_Cash|20-304151|NA|Site_Visit|2020_10_01|Redirect
Casualty In context to commercial Property/liability policies it typically refers to a third party (not the insured, or the carrier) incurring the loss, and the legal liability insured by the policy. It can also mean loss or loss amount. The general term for insurances over property are governed by licenses authorizing "Propery & Casualty" lines of policies. i.e. Homeowners, General Liability, and many others. P&C insurance is defined by state, not national government. Cat-in-Circle (First Generation)See: Parametric Insurance (property). a first generation (insured peril and loss trigger) which pays when the hazard exceeds the trigger point by location. I.e. A hurricane being insured after winds exceed 75 MPH or that becomes a named storm. See: Second generation triggers. The best outcome is to use publically available sources to define intensity and if the trigger triggerred. 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 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) https://innovation.cms.gov/innovation-models/direct-contracting-model-options
Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH)CMS office concerned with negative disparities by race. Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) Centers of Excellence (COE)Medical centers offering, primary care, on-site primary care, disease and/or specialty-procedure specific care that are known for favorable medical outcomes and/or pricing. i.e. Transplants, Cardiac, Cancer, ESRD, obstetrics, lower back pain, Neonatal, trauma, etc. These centers are typically defined by "condition specific nurse case management teams' that can also include hands on reinsurer personal "support" and steerage. Reliably quantifying such "COE" is not standardized in most circumstances. Be aware some sectors may want to define care by an episode, some by cost outcome and readmission rates, some by average surgeries avoided, etc. Be clear that very few dedicate much weight to patient satisfaction. See: MACRA, EBM, QPP, bundled Payments, etc. CenterWell Pharmacy (Humana's branded pharmacy)The Humana pharmacy brands that now combines: Humana Pharmacy and Humana Specialty Pharmacy. https://ignitewithhumana.com/ed/one-pagers/centerwell/read-our-mini-guide-to-discover-what-humana-pharmacys-rebrand-to-centerwell-pharmacy-means-for-you/
Certificate of Assumption A legal term that means different things in different states, and usually applies to authority of a reinsurer (or appointed Receiver) to pay/reimburse Specific and/or Aggregate claims directly to the insured, versus through the "authorized" carrier under the microscope by that state's regulator. Certificate of Coverage (COC)A term that can mean many things, but is typically used by primary insurers to describe a 1-3 page document detailing the insured's name, address, policy number, coverage, and dates of coverage. Sometimes, it can mean a policy issued by an authorized and eligible carrier licensed in a state. 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.
These reports:
• 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 Counselor (CAC)See: Marketplace Navigators 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 Certified Health Record Technology (CEHRT)See: Interoperability CMS https://www.cms.gov/files/document/2021-cehrt-fact-sheet.pdf
https://www.healthit.gov/curesrule/final-rule-policy/2015-edition-cures-update
Certified Property & Casualty Underwriter (CPCU)See: Insurance Professsional certifications. There are many. CPCU typicall takes to years of exams to complete. There are others that take more and less time. See; FLMI, CLU, ARe, etc. There are other organizations trying to be the standard as well. Chained CPI A calculation not typically used in managed care contracting. --------------- A calculation used by IRS to pushing tax payers into higher tax brackets caused by pay increases following inflation over longer periods of time. ====================Social Security uses COLA to increase payments to beneficiaries. Many contracts account for annual price increases tied to inflation, especially where guaranteed renewal provisions govern premium rate increases. Change Review Process (CRP)See: eCQM https://oncprojectracking.healthit.gov/support/projects/CQM/summary
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)An executive level position occupied by a physician who may or may not be actively treating patients too. See: VP Medical Affairs, Hospitalists, PHE, etc. These guys are the one's CEO's love to give the politically difficult medical administrative issues to negotiate - especially with a hospital's surgeons. Child Health Insurance Program (CHIP)A medicaid program for uninsured children under 19 years of age for families that make too much income to qualify for Medicaid. Different states call it different names. Medicaid coverage is unique by state.
"CHIP provides no-cost or low-cost health insurance coverage to uninsured children under age 19 in families with qualifying incomes that are too high to qualify for Medicaid coverage. It also covers qualified pregnant individuals in some states. Like Medicaid, the costs for CHIP are shared by the federal government and state governments, and states can choose to impose cost sharing for children enrolling in CHIP. CHIP operates under different names in each state, such as “BadgerCare” in Wisconsin and “Washington Apple Health for Kids” in the state of Washington. CHIP provides comprehensive benefits." Source: 2024 agent Marketplace exam
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, obesity, SDOH, and/or high cost or chronic disease conditions. The goal of these programs is for early intervention and management to improve medical outcomes at lower costs. ================== Term used by CMS to accurately code for a reimbursement. CMS has many programs touting success for what they deem chronic care for things like Knee replacements, and other high cost - high frequency procedures demanded by beneficiaries. See CAC, JAMA https://www.healio.com/news/primary-care/20201006/experts-focus-on-most-important-recommendations-to-scale-back-care-for-chronic-conditions
Chronic Comorbidity Count (CCC) The sum of "selected" medical conditions (diagnosis) grouped into six categories. Chronic Condition Data Warehouse (CCDW) Chronic Illness and Disability Payment Systems (CDPS)A system using ICD 10 codes to assign CDPS catagories (illness severity catagories) for Medicaid lives in 33 of 38 states. 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. Churning "Churning is the practice whereby policy values in an existing life insurance policy or annuity contract, including, but not limited to, cash, loan values, or dividend values, and in any riders to that policy or contract, are directly or indirectly used to purchase another insurance policy or annuity contract with that same insurer for the purpose of earning additional premiums, fees, commissions, or other compensation:
a. Without an objectively reasonable basis for believing that the replacement or extraction will result in an actual and demonstrable benefit to the policyholder;
b. In a fashion that is fraudulent, deceptive, or otherwise misleading or that involves a deceptive omission;
c. When the applicant is not informed that the policy values including cash values, dividends, and other assets of the existing policy or contract will be reduced, forfeited, or used in the purchase of the replacing or additional policy or contract, if this is the case; or
d. Without informing the applicant that the replacing or additional policy or contract will not be a paid-up policy or that additional premiums will be due, if this is the case." See Twisting. Source: Insurance U Agent CE Exam Citizens Assessment Here is the actual text in their policy application: "AS A POLICYHOLDER OF CITIZENS PROPERTY INSURANCE CORPORATION, I UNDERSTAND THAT IF
THE CORPORATION SUSTAINS A DEFICIT AS A RESULT OF HURRICANE LOSSES OR FOR ANY OTHER REASON, MY
POLICY COULD BESUBJECT TO SURCHARGES, WHICH WILL BE DUE AND PAYABLE UPON RENEWAL, CANCELLATION, OR
TERMINATION OF THE POLICY, AND THAT THE SURCHARGES COULD BEAS HIGH AS 45 PERCENT OF MY PREMIUM, ORA
DIFFERENT AMOUNT AS IMPOSED BY THE FLORIDA LEGISLATURE.
I UNDERSTAND THAT I CAN AVOID THE CITIZENS POLICYHOLDER SURCHARGE, WHICH COULD BE AS HIGH AS 45
PERCENT OF MY PREMIUM. BY OBTAINING COVERAGE FROM A PRIVATE MARKET INSURER AND THAT TO BE ELIGIBLE
FOR COVERAGE BY CITIZENS, I MUST FIRST TRY TO OBTAIN
PRIVATE MARKET COVERAGE BEFORE APPYLING FOR OR RENEWING COVERAGE WITH CITIZENS. I
UNDERSTAND THE PRIVATE MARKET INSURANCE RATES ARE REGULATED AND APPROVED BY THE STATE.
I UNDERSTAND THAT I MAY BE SUBJECT TO EMERGENCY ASSESSMENTS TO THE SAME EXTENT AS POLICYHOLDERS OF
OTHER INSURANCE COMPANIES, ORA DIFFERENTAMOUNT AS IMPOSED BY THE FLORIDA LEGISLATURE.
IALSO UNDERSTAND THAT CITIZENS PROPERTY INSURANCE CORPORATION IS NOT SUPPORTED BY THE FULL FAITH
AND CREDIT OF THE STATE OF FLORIDA."
"Citizens applies Assessments in Tier1, 2,3,4 at one time assessment up to 45%, Tier 2 at one-time assessment up to 2%, Tier 3 at up to 30% of premium annual, may applyu for multiple years. "Tiers are used to demonstrate the multiple levels of assessment defined by Florida Law. Assessment tiers are triggered based on the severity of the deficit. Assessments are based on the greater of the projected deficit or the aggregate statewide written premium for the subject lines of busienss. The above example is based on the use of premium." "Tier 2 addision assessments may be incurred for hte other property/casualty policies that are subject to assessment. Tier 3 assessments may be collected each year over multiple years, depending on the extent of the deficit, in the even that a subsequest years also generate a deficit, additional assessment could occur." Source: Citizens Commercial Property Policy 2022 See: Link for more info regarding assessment and surcharges under the Policyholder section of the website. http://www.citizensfla.com
Citizens Insurance A Florida property insurer 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 and admitted 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, but it is sponsored by the state of Florida, so total insolvency status limits is a difficult issue to vet. Current rules (Jan 2019) mandate Citizens is not required to offer coverage where comparable coverage is available under 115% of Citizens pricing. Recent changes in 2023 increased the assessable amount, so any policy holder should double check their worst case scenario of having a big claim, then getting a bill from Citizens to pay before Citizens pays the claim. Read what it says on the internet about how Citizen pays its claims. "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 premiums) 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.
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." Source: CETrack Licensing (CE) Exam material Jan 2019
https://www3.ambest.com/ambv/sales/bwpurchase.aspx?record_code=320513&_ga=2.176844325.1443783029.1654707205-659447813.1654707205
https://www.artemis.bm/news/florida-citizens-depopulation-seeing-more-interest-participation-oir/
Citizens Property Insuraance (Source: 2021 Agent Licensing Exams)
• 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, commercial 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-
https://www.artemis.bm/news/florida-citizens-depopulation-seeing-more-interest-participation-oir/
Citizens Property Insurance Corporation (Citizens (CPIC))A Florida created JUA (Joint Underwriting Association) insurer of last resort that is run by the State of Florida. It is not a rated insurance company, it is an association that by law cannot be sued for Bad Faith by any policy holder association member. https://www.artemis.bm/news/florida-citizens-depopulation-seeing-more-interest-participation-oir/
Claims Based Alignment See: Medicare Shared Risk "Direct Contracting" Re: "Performance Year 1,2,3,... Claims Negotiation and Signoff (CNS)Jargon used by some entities. 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 Clean Claim Call for details that may differ from federal regulations on it, IDR, and no surprises act. Client/Customer Relationship Manager (CRM)A data base that stores specific information used in the sales and service process. There are big differences in various software application's integration and management functions. Clinical Classifications Software Refined (CCSR)Sun Life's claims software program. See the report. "32 members had a claim over $3M; nine of those claims (of 60,000 member claims) were over $5M,
with the highest claim over $11M" https://sunlife.showpad.com/share/EccaYBykBh4AQ1ZCbmvAO
Clinical Communication and Collaboration Platforms (CC&C)Clinical Communication and Collaboration Platforms are systems of EHR's which accomodate effective inter-intra medical provider coordinated information that improves EBM. Clinical Data Integration (CDI)See: FDIR, and new approaches to achieve real results or effect at scale. Clinical Decision Support An amorphous term that (should) mean, a system (personnel, electronic, telemetry, Rx, multi-physician diagnosis clearing house - supporting, offering, coordinating, warning, and/or optimizing medical treatment plans to both physicians, patients, ancillary medical personnel, and/or a patient's care givers. See. AI, VBM, EBM, etc. Clinical Document Improvement (CDI)Term used by "physician advisors" who work with physicians in recommending better care for better EMB outcomes and reimbursement. Clinical Document Integrity Service offered by Solventum (formerly 3M). See: GIGO 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)
See: eCQM
Clinical Risk Groupings (3M CRGs)Details health status and burden of illness in a target population. See: FSG, LTC CMMI Model Data Sharing (CMDS)CMMI Model Data Sharing (CMDS) Model Participation Files
CMS is releasing new participation data for the following initiatives:
Prior Authorization of Non-Emergent Hyperbaric Oxygen Therapy
Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
Transforming Clinical Practice Initiative
These three initiatives join the existing models, initiatives and demonstrations that have released data since 2022 as part of the CMS Innovation Center Model Data Sharing (CMDS) initiative. https://resdac.org/cms-data/files/cmmi-model-data-sharing-cmds-model-participation-data-initiative
CMS - CMMI Core-Based Statistical Areas (CBSAs)Data sets used by CMMI as they innovatively try to organize primary care support to specifically targeted "bundled payment" medical care/procedures episodes of care with goal of improving EBM outcomes at lower costs. See: VBC CMS 2024 Notice of Benefit Payment Parameters Rule See: Fact Sheet and proposed Rule https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-proposed-rule
http:// https://www.cms.gov/newsroom/press-releases/hhs-releases-policies-make-coverage-more-accessible-and-expand-behavioral-health-care-access
CMS Accomplishments Pay attention to what the regulators feel is important. https://www.cms.gov/files/document/cms-accomplishments-2023.pdf
CMS ACO See: ACO REACH CMS ACO PC FLex Model The ACO PC Flex Model is a voluntary model that will focus on primary care delivery in the Shared Savings Program. It will test how prospective payments and increased funding for primary care in ACOs impact health outcomes, quality, and costs of care. The flexible payment design will empower participating ACOs and their primary care providers to use more innovative, team-based, person-centered and proactive approaches to care.
The Goal is better EBM outcomes at lower cost to manage the Silver Sunami CMS All-Payer Health Equity Approaches and Developement Model (CMS AHEAD)“Primary care is the foundation of a high-performing health system and essential to improving health outcomes for patients and lowering health care costs. For that reason, the CMS Innovation Center has invested significant time and resources over the years testing models to strengthen primary care and improve care coordination and linkages to organizations that address health-related social needs,” said Deputy CMS Administrator and Innovation Center Director Liz Fowler. “Through AHEAD, more states will have the exciting opportunity to both improve the overall health of their population, support primary care, and transform health care in their communities.”
CMS will issue awards to up to eight states. Each state selected to participate in the AHEAD Model will have an opportunity to receive up to $12 million from CMS to support state implementation. Recognizing that some states are more ready than others to implement change, states interested in participating in the model may apply during two different application periods and elect to participate in one of three cohorts with staggered start dates and performance years.
The Notice of Funding Opportunity (NOFO), which includes the specific application requirements, will be released in late fall 2023. https://www.cms.gov/newsroom/press-releases/cms-announces-transformative-model-give-states-incentives-and-flexibilities-redesign-health-care
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 Bundled Payments Innovation Center Releases RFI on New Episode-Based Payment Model
Today, the CMS Innovation Center is releasing a request for information (RFI) for input from the public regarding the design of a future episode-based payment model. Responses to this RFI may be used to inform potential future rulemaking or other policy development.
The CMS Innovation Center is building on lessons learned from our experience with the Bundled Payments for Care Improvement (BPCI), Bundled Payments for Care Improvement Advanced (BPCI Advanced), and the Comprehensive Care for Joint Replacement (CJR) models to design and implement a new episode-based payment model focused on accountability for quality and cost, health equity, and specialty integration. To further inform development of the potential new model, we are soliciting input from those with additional insight and frontline experience with bundled payments." CMS 1023 https://www.federalregister.gov/public-inspection/2023-15169/request-for-information-episode-based-payment-model
CMS Care Compare See: CMS Provider Data Catalog (PDC) https://www.medicare.gov/care-compare/
CMS Cell & Gene Therapy Access Model https://www.cms.gov/priorities/innovation/innovation-models/cgt
CMS Centers for Medicare and Medicaid Innovation (CMMI or Innovation Center)A federal agency under HHS that is run by CMS and tasked with improving medical outcomes at the lowest cost to tax payers. That means MACRA, QPP, ACO's ETC. "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
https://www.cms.gov/priorities/innovation/innovation-models/team-model
https://www.fiercehealthcare.com/payers/medicare-officials-call-gradual-shift-calculation-medicare-advantage-benchmarks-reflect
CMS Comparitive BIlling Report (CMS CBR) https://cbr.cbrpepper.org/Home
CMS Coordination of Benefits Secure Website (COBSW) CMS Data 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 Dementia Model https://innovation.cms.gov/innovation-models/guide
CMS Electronic Prescribing for Controlled Substances (CMS EPCS)See Video overview 2023 final rules etc. https://www.youtube.com/watch?v=K8YBj3b2EyI
CMS EUC (Extreem Uncontrollable Circumstances)See: MIPS CMS Extreme and Uncontrollable Circumstances (EUC)See: MIPS https://mail.google.com/mail/u/0/#inbox/FMfcgzQVzFPpkTdkjPJSqBVfDBLbbWpj
CMS Final Inpatient Payment Rules (IPPS - Inpatient Prospective Payment Final Rule)An annual rule by CMS that typically increases the amount of authorized reimbursement for acute care hospital charges. (I.e. $3.6 BILLION for 2021) It also addresses compensation for residents paid to hospitals to subsidize their training, etc. See: IPPS https://www.beckershospitalreview.com/finance/cms-final-inpatient-payment-rule-for-2021-7-things-to-know.html?origin=CFOE&utm_source=CFOE&utm_medium=email&oly_enc_id=0117J8507389D2U
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
https://www.federalregister.gov/documents/2019/04/25/2019-08017/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2020
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/CMS-9926-F-Fact-Sheet.pdf
CMS Frontier Community Health Integration Project (CMS EFCHIP) https://www.cms.gov/priorities/innovation/innovation-models/frontier-community-health-integration-project-demonstration
CMS Full Financial Risk See: A CMS defined term in context to Value Based Reimbursement and minimum 10% value of physician fees being at risk. There are other meanings in contexts to a myriad of SPD's, reinsurance retention, and contracted stakeholder risk appetite, etc. See: Meaningful Downside Risk. CMS GAPB (CMS Ambulance Committee)CMS's committee authorized to make recommendations for what ambulance service and reimbursement for Medicare and Medicaid lives. CMS Geographic Direct Contracting (CMS Direct Contracting)A new effort from CMS (CMMI) to contract providers in specific geographic regions, and ultimately provide better care for 2%-3% less cost. See: GPCI to get a feel for targeteded centers. "Geo requires participants to take full risk with 100 percent shared
savings / shared losses for Medicare Parts A and B services for aligned Medicare FFS beneficiaries in a
defined target region. " The Geographic Direct Contracting Model will have two three-year performance periods. The first performance
period will take applications in 2021 and have a performance period from January 1, 2022 through December
31, 2024. The second performance period will take applications in 2024 and have a performance period from
January 1, 2025 through December 31, 2027." See: Shared Savings
"Officials said they expect the test Geo contractors to serve Medicare enrollees in one of 15 communities: Atlanta; Dallas; Denver; Detroit; Houston; Los Angeles; Miami; Minneapolis; Orlando, Florida; Phoenix; Philadelphia; Pittsburgh; Riverside, California; San Diego; or Tampa, Florida." Source: Allison Bell - Think Advisor https://innovation.cms.gov/media/document/geo-dc-rfa
CMS GPDC See: GPDC, ACO REACH https://innovation.cms.gov/strategic-direction-whitepaper
CMS Group Health Plan Alerts (GHP Alerts) https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting-group-health-plans/alerts
CMS Health Ewuity The CMS Framework for Health Equity identified high-impact priorities based on stakeholder engagement, a review of the evidence base, and discussions across federal partners. It updates the previous Medicare-focused CMS Equity Plan for Improving Quality in Medicare with an enhanced and more comprehensive 10-year approach to further embed health equity across Medicare, Medicaid, CHIP, and the Health Insurance Marketplaces. The updated CMS Framework for Health Equity also brings focus to CMS’ work supporting health care organizations, health care professionals and partners—providers, health plans, federal, state, and local partners, tribal nations, individuals and families, quality improvement partners, researchers, policymakers, and other stakeholders—in activities to achieve health equity. https://www.cms.gov/sites/default/files/2022-04/CMS%20Framework%20for%20Health%20Equity_2022%2004%2006.pdf
CMS Health Risk Score Scores that affect the rates MA plan enrollees pay for their Part C Medicare Advantage plans. See: SDOH, PHE, non-curable chronic conditions, Health Equity, AMGA CMS HHS 10 Drugs Negociation https://www.hhs.gov/about/news/2023/08/29/hhs-selects-the-first-drugs-for-medicare-drug-price-negotiation.html
CMS HHS 2024 Final Rules (HHS Final Plan Rules)CMS finalizes a limit on the number of non-standardized plan options that issuers of QHPs can offer through Marketplaces on the Federal platform (including SBM-FPs) to four non-standardized plan options per product network type, metal level (excluding catastrophic plans), and inclusion of dental and/or vision benefit coverage, in any service area, for PY 2024 and two for PY 2025 and subsequent plan years. See: Link https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-final-rule
CMS Hierarchical Condition Category (CMS-HCC - Hierarchical Condition Catagory )A model using the current year claims values to estimate next years claims forcast. This is a risk adjustment factor. See: Trend, but be clear the CMS is its own bases based on demographis (age, location, care type - used to creat RAF (Risk adjustment factor used by ACOs. CMS InCK (CMS InCK)The InCK Model is a child-centered local service delivery and state payment model which aims to reduce expenditures and improve quality of care for children ages 0-20 covered by Medicaid. Some states also serve pregnant adults and CHIP enrollees. Award recipients received funding for a two year pre-implementation period (2020 - 2021) and a five year implementation period (2022 - 2026).
CMS InCK (CMS InCK)The InCK Model is a child-centered local service delivery and state payment model which aims to reduce expenditures and improve quality of care for children ages 0-20 covered by Medicaid. Some states also serve pregnant adults and CHIP enrollees. Award recipients received funding for a two year pre-implementation period (2020 - 2021) and a five year implementation period (2022 - 2026).
CMS Low Income Subsidy (LIS)A term used in some managed care medicare contracts between HMOs and their contracted medical providers. It relates to Part D revenue additions included or excluded in calculating potential surplus's or deficitss for purposes of paying out provider bonuses (for efficient care of an HMOs membership budget). It can mean other things too. CMS MA Plan Risk Adjustment https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors
CMS Making Care Primary (MCP)Centers for Medicare & Medicaid Services (CMS) announced a new primary care model – the Making Care Primary (MCP) Model – that will be tested in eight states. Access to high-quality primary care is associated with better health outcomes and equity for people and communities. The model seeks to improve care for people with Medicare and Medicaid by equipping primary care clinicians with tools to form partnerships with specialists and leverage community-based connections to address patients’ health and health-related social needs.
CMS plans to partner with State Medicaid Agencies in the eight states to engage in full care transformation across payers. The model will support participants with varying levels of accountable care experience, including Federally Qualified Health Centers (FQHCs) and physician practices with limited experience in value-based care, in driving toward a system that reduces disparities in care and results in better patient experience and outcomes.
CMS will test this advanced primary care model in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington. CMS will work with model participants to address priorities specific to their communities, including care management for chronic conditions, behavioral health services, and health care access for rural residents https://innovation.cms.gov/innovation-models/making-care-primary
CMS Making Care Primary To be eligible to participate in one of MCP’s three progressive tracks, an organization must:
Be a legal entity formed under applicable state, federal, or Tribal law authorized to conduct business in each state in which it operates.
Be Medicare-enrolled.
Bill for health services furnished to a minimum of 125 attributed Medicare beneficiaries.
Have the majority (at least 51%) of their primary care sites (physical locations where care is delivered) located in an MCP state." Source: CMS https://innovation.cms.gov/media/document/mcp-app-tracks-fs
CMS Marketplace security standard (CMS FISMA) https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity
CMS Marternity Care Action Plan https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf
CMS Measure Management (CMIT) https://cmit.cms.gov/CMIT_public/ListMeasures
CMS Measures Management (MMS)The CMS Measures Under Consideration Entry/Review Information Tool (CMS MERIT) is now open! As part of the CMS pre-rulemaking process for Medicare programs under Section 3014 of the Affordable Care Act, measure developers submit measures to CMS for their consideration. The pre-rulemaking process helps to support CMS’s goal to fill critical gaps in quality measurement.
See: QPP, etc. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS
https://cmsmerit.cms.gov/merit/#/login
CMS Medicaid Elibility & Enrollment Rules https://www.cms.gov/newsroom/fact-sheets/streamlining-medicaid-and-chip-final-rule-fact-sheet
CMS Medicare Physician Fee Schedule (MPFS) CMS MedPAC (MedPAC)Goal is to Ensure health equity is embedded in every model of healthcare delivery and reimbursement. This has obvious implications to commercially insured people and not just Medicare, Tricare and Medicaid. See: CMMI, VBR, EBM CMS 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)
See: MIPS Value Pathways.
See: CAHPS, QPP, APM, MIPS Value Pathways, QCDRs
https://qpp.cms.gov/docs/CMS-5517-FC.pdf
https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDAsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjAyMDcuNTMwNDA3MzEiLCJ1cmwiOiJodHRwczovL3FwcC1jbS1wcm9kLWNvbnRlbnQuczMuYW1hem9uYXdzLmNvbS91cGxvYWRzLzE1MjcvMjAyMSUyMFRyYWRpdGlvbmFsJTIw
https://mail.google.com/mail/u/0/?tab=rm&ogbl#inbox/FMfcgzQVxRCkzJGPfQwgkpCbzlQWZgSC
CMS Minority Research Grant Program (MRGP) CMS MIPS DVA CMS data validation https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDMsInVyaSI6ImJwMjpjbGljayIsInVybCI6Imh0dHBzOi8vcXBwLWNtLXByb2QtY29udGVudC5zMy5hbWF6b25hd3MuY29tL3VwbG9hZHMvMjUzNS8yMDIzLU1JUFMtRFZBLUZhY3QtU2hlZXQtUFktMjAyMi1GaW5hbC5wZGYiLCJidWxsZXRpbl9p
CMS MIPS Extreem Uncontrollable Cases https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDEsInVyaSI6ImJwMjpjbGljayIsInVybCI6Imh0dHBzOi8vcXBwLWNtLXByb2QtY29udGVudC5zMy5hbWF6b25hd3MuY29tL3VwbG9hZHMvMjQxMi8yMDIzRVVDQXBwbGljYXRpb25HdWlkZS5wZGYiLCJidWxsZXRpbl9pZCI6IjIwMjMxMTA3Ljg1
CMS National Quality Strategy https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy
CMS Non Risk Patient Equivelent (CMS NPE)A non standard term used in some contracts defining risk, and non-risk annual budgeted estimates of how much a HMO member will cost in the future, and that Bonuses are tied to. It gets complicated and can apply to Medicare, Commercial and Medicaid lives at risk, and not at risk. See: PIP- Physician Incentive Plan guidelines, substantial financial risk, etc., and in context to regulatory membership sizes and minimum medical practice retention levels in "risk" bearing contracts. This gets squirrelly dealing with CMS on matters related to (non risk) FFS SPC care. CMS Outpatient Prospective Payment System (OPPS) CMS PA Rural Health Model (CMS PARHM)See: Data available to researchers https://www.cms.gov/priorities/innovation/innovation-models/pa-rural-health-model
CMS Palliative Care (Medicare Choices) https://www.cms.gov/priorities/innovation/data-and-reports/2023/mccm-fifth-annrpt
CMS Part D Final Rule https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f
https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf
CMS Patient Activation Measure (PAM) https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2024_Measure_503_MIPSCQM.pdf
CMS Provider Data Catalog (PDC) https://data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities
CMS Pulblic Use Forms (CMS PUF) https://innovation.cms.gov/innovation-models/aco-reach
https://innovation.cms.gov/innovation-models/gpdc-model
CMS QRDA Federal (medical) Quality Data Reporting formats and access https://ecqi.healthit.gov/qrda?qt-tabs_qrda=about
CMS Quality Pathways This is the latest term for a very old ongoing effort to improve (EBM) outcomes, and the same or lower costs. See: TQO, TQM, Value Based Reimbursements, DRGs, Critical Pathways, Quality assurance, etc. CMS REI (REI)A term used in some managed care provider contracts defining reinsurance and/or Rx rebates back to the HMO (or provider group) that are included or excluded in surplus/deficit calculations related to provider Bonus (for efficient medical care of an HMOs membership) The term can also apply to commercial memberships as well. CMS RRE https://www.cms.gov/files/document/alert-medicare-secondary-payer-and-certain-civil-money-penalties-notice-final-rule.pdf
CMS Rural Community Hospital Project (CMS RCH)See: Data available to researchers per CMMI model data sharing (CMDS). See; CMS-IPPS https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2022-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-0
CMS Star Ratings Federal ratings for MA Plans https://www.cms.gov/files/document/101323-fact-sheet-2024-medicare-advantage-and-part-d-ratings.pdf
CMS Strategic Plan IMPORTANT https://www.cms.gov/about-cms/what-we-do/cms-strategic-plan
CMS Substantial Financial Risk Occurs when risk is based on the used of costs of Referral Services (not quality care efforts) , and that risk exceeds a risk Threshold of 25% of Potential Payments (all payments to providers including incentives, bonus, etc) See: incentive arrangements that cause SFR for groups under 25,000 members. Rules are different over 25K lives. See Pooling. This is a fluid topic! CMS Targeted Review (CMS MIPS Targeted Review)ndividual clinicians, groups, subgroups, virtual groups, APM Entities (including Shared Savings Program ACOs), designated support staff and authorized third party intermediaries may request that CMS review the calculation of their MIPS payment adjustment factor(s) through a process called targeted review. See: CMS CMS Transforming Episode Accountability Model (CMS TEAMS)See: CMS CMMI, ect. Very important efforts to reigh in very expensive high frequency bundled care with goal of improving EBM outcomes at lower costs. http://Transforming Episode Accountability Model (TEAM)
CMS Universal Foundation (Universal Foundation)A federal effort to identify material (measures that actually provide real information that can be acted upon for better health at lower costs) measures of health and healthcare outcomes accross the entire spectrum of US medical care.
"The quality measures we selected underlie many of the diseases and conditions associated with the highest morbidity and mortality in the United States, including diabetes, high blood pressure, and cancer. The cancer-related measures are in line with the goals of the Cancer Moonshot program.4 The measures also reflect the importance of high-quality preventive care, including vaccination. Identification and treatment of depression and substance use disorders are included in the Universal Foundation because addressing these behavioral health conditions in an integrated way can improve both physical and behavioral health outcomes.5 The focus on quality in behavioral health care for pediatric populations reflects the need to improve care for children and adolescents with depression, other mental health disorders, and substance use disorders. Finally, the measures focus on care coordination after hospitalization, patient experience, and screening for social drivers of health (we also intend for them to eventually cover follow-up to address identified social needs). Although equity is a measurement-category domain, CMS also plans to use the full set of measures to stratify outcome data and identify disparities among and within populations to inform future equity efforts internally and for health insurers and providers." Suorce: New Journal of Medicine 2/1/23 https://www.nejm.org/doi/full/10.1056/NEJMp2215539
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy
CMS Value Based Care "Medicare and Medicaid run pilot programs also called models, to help doctors and other health care providers deliver high quality care. These programs improve health care and the patient experience, for example, by making sure doctors talk to each other and coordinate around a patient’s care, and focus on the patient and see them as a whole person. These programs are often referred to as value-based care." Source: CMS https://www.cms.gov/priorities/innovation-center/value-based-care-spotlight/basics-value-based-care
https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f
CMS WCMSA https://www.cms.gov/medicare/coordination-benefits-recovery/workers-comp-set-aside-arrangements/self-administration
CMS WCMSA https://www.cms.gov/medicare/coordination-benefits-recovery/workers-comp-set-aside-arrangements/self-administration
CMS-1500 Form (HCFA 1500 form, HRS 1500 form)A claim submission form to carriers detailing many diagnosis, hospital charges, and physician charges codes, billed charges, etc. Some carriers will require these forms, even when they do not apply, or are never generated by the provider, causing lots of issues when people get services, or supplies/DME/scripts at less cost not using their (in or out of network contracted providers) insurance plans. Carriers are very concerned with being charged with bad faith and normally want to do the right thing - especially when it costs them less to do it (without being sued), but have to reimburse their policy holders for PAID-for services and supplies that are received/charged under an insured event. We recommend auditing your claim for proper reimbursement (especially stop loss claims). 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 MOOP.
Molina Healthcare defines it as "the amount owed by you, the member, after your deductible has been applied. This is based on the percentage dictated by you benefit coverage." 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. Molina health plan defines it as, "The amount of your copay for certain benefits (i.e., office visit, ER, etc.) This is a fixed dollar amount. Co-Feduciary In context to an ERISA plan Plain Sponsor, (and especially) TPA who has accepted co-fiduciary by contract or express performance and/or behavior, and member protection. The issue(s) is/are contentious. This can get squirrely as it relates to RBP, SPD, balance billing, Price Transparancy, etc. 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 (in Florida) applies to employers with over 20 employees. In Florida, employers under 20 - See: Mini COBRA. COBRA allows the employee, or their eligible family to continue on with the employers's health plan for 18 months (or more in some states).
COBRA requires continuation coverage to be offered to eligible employees (and their family) who are leaving employement with their employer. 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. Determination of a COBRA 6 month APTC does not create an individual SEP. Source: DOL See: ARPA, FMLA, FFCRA, Consolidated Appropriations Act: Employers > 20 FTE, the employer files for the tax credit, for employers electing continuous group plan participation under COBRA. Be careful of coverage benefits for pregnant and post delivery mother/child coverage and extentions offered by some states that are not all the same. https://www.dol.gov/general/topic/health-plans/cobra
COBRA form 720 The form used to claim advanced recoveries per COVID relief Code of Federal Regulations (CFR) Cognitive Behavorial Therapy (CBT)See: EAP Collateral Assignment A term which can mean many things, but in contexts to Split Dollar (non qualifed) Life insurance, it means a document signed by the policy owner detailing premium, term, and benefits percentage distribution, and "buy-sell" parameters before or at death. 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 Health Access and Rural Transformation (CHART)Community Health Access and Rural Transformation (CHART) Model.
Another Trump EO providing wider access to telehealth covered services for Medicare members in rural communities. https://innovation.cms.gov/innovation-models/chart-model
Community Health Access and Rural Transformation (CHART)See: CMS https://innovation.cms.gov/innovation-models/chart-model
Community Health Worker (CHW)See; SDOH, etc 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) group medical premium underwriting rating method based on claims history by region (zip code). These rules can appear amoupous by state and federal standard, with various strategies used to get the group out of the higher priced rating methods to secure lower priced medical premiums. ACA promulgates rules employers (over 50 FTE) MUST apply (higher priced) community rating, thereby eliminating potential premium discounts associated with favorable claims experience. In Florida the rules apply (so I am told by Humana reps) to groups 2-50.
See: ACA section1101 detailing Adjusted Community Rating limiting premiums in excess of 4:1 increases over standard community rated rates for people with PreX.
Comparison Group (CG)See: Covid Orders Competition - Healthcare Insurers (Monopoly or Oligopoly )Competition by hospital network regions and insurance carriers is apples and oranges. For the competition among carriers see links. Real analysis means using more sophisticated analysis, but the point here is competition among carriers is less now then a few years back. That almost always means much higher prices, and without reliable increase in quality or access. See: The AMA used measure of market concentration, Herfindahl-Hirschsprung Index (HHI) scores.
HHI scores can range from 0 to 10,000, with 10,000 meaning one carrier like Blue Cross monopoly in many rural areas. https://www.gao.gov/products/GAO-21-34?utm_campaign=usgao_email&utm_content=daybook&utm_medium=email&utm_source=govdelivery
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 But for brokerage purposes, the trend assumption is always important to challenge in context to competitive bid.
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% (actual modeled dollars payout risk). 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(s) and price are proportional, and may involve more than front end data, account size, experience of one or more populations insured.
In Finance, it essentially means, the total return from an investment (or bank account) earning interest on the principal PLUS earned interest over many years. Note: be clear not to confuse percentages with average actual $ (whole numbers) return. I.e the same 50% gain or loss in the first and second years, does equate to the same whole number returns over the same period. Compound Annual Growth Rate (CAGR)The mean (average) annual growth rate typically expressed in dollars for best insight comparing various investments. In other words, percentage comparisons between ROR and CAGR can show them equal in percentage terms, but not equal in (real life) dollar terms over a given period. See: ROR, Internal Rate of Returns, Net Present Value, Effective Rate of Returns, etc.
Example, dont get confused with percentages comparing with actual dollar returns. I.e. If and investment goes down 50%, then up 50%, it does not return to the original principal. $1.00 - $0.50 down = $0.50. Year two: $0.50 x 50% up = .25 + $0.50 = $0.75 (not $1.00). This example requires the second year return of 100% to get back to the original amount invested. I.e. $0.50 x 100% = $1.00
. 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 Loss Underwriting Exchange (CLUE Report)CLUE stands for Comprehensive Loss Underwriting Exchange and is a claims history database that allows insurance companies to access information about the dwelling or home in question in order to decide whether to insure a home and at what cost.
CLUE reports provide a history of your property insurance claims for homes, rentals and vehicles. It’s offered by LexisNexis Risk Solutions, and the information in the report is subject to Federal Fair Credit Reporting Act (FCRA) guidelines.
Using underwriting guidelines laid out in the FCRA, a CLUE report provides up to a seven-year history of automobile and homeowners/renters insurance losses associated with an individual. That includes the date of loss, loss type and amount paid, along with general information such as policy number, claim number and insurance company name.
This information includes claims that were paid or denied, and also files opened for potential claims. For example, if you call your insurance agent to ask whether certain damage would be covered, but never start an actual claim, the agent might still set up a new claim file based on your phone call." Source: Insurance U Agent CE Exam 2022 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 Conditional Payment Notice (CPN)See: MSPRP, NGHP recovery https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Non-Group-Health-Plan-Recovery/Non-Group-Health-Plan-Recovery
Conflicts of Interest (COI)COI means many things in many situations. For licensed securities brokers (and/or Broker-Dealers) COI is tethered to the highest legal standard called Fiduciary Duty. For Insurance agents who do not hold a Fiduciary Duty, but a "best interests" obligation, the standard is not the same. Holding a client's best-interests forefront has long been a professional standard by all professionals. Clearly explaining how a consultant gets paid seems to be one of the primary pillars of avoiding conflicts. Trying to read clients who sometimes shirk primary responsibilities of responding timely, directing clear goals, or not asking questions when they do not understand a complex transaction or process takes real patience. You can bring a horse to water but cannot force them to drink. 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 Consent to Settle clause (Hammer Clause)A provision in a professional liability (E&O) policy requiring an insurd's settlement approval to settle a claim, without trial. Upon adverse trial decision, the provision puts the insured on the hook for amounts over the proposed settlement amount. Consequential Damages A legal theory used to sue for damages caused secondarily to a valid primary contract breach. Consolidated Appropriations Act (CAA effective 2021)Dec 2020 law signed by President Biden December 2020. See: Balance Billing, Mental Health Parity, APTC, Reporting requirements, Qualifed plan vesting relief (DCP and 401, etc), FSA (section 125 plan) changes, COBRA subsidy, student loan relief, retirement benefits, COVID funds relief on DBP, Employer benefits relief, MEPP relief from age 62 to 59.5, IRA distribution fo disasters relief, etc.
"These regulatory compliance activities include, but are not limited to:
• Support and calculations for Qualifying Payment Amounts (QPA) for surprise medical billing
• End to end management for independent dispute resolution (IDR)
• Changes to health plan ID cards, provider directory enhancements
• Member notification of new continuity of care rights
• Facilitation of an external appeals and review process
• Maintenance of network agreements compliant with CAA prohibitions on gag clauses and providing language to support customer attestation
• Significant new government and customer reporting requirements
• Support related to Mental Health Parity NQTL audits initiated by DOL, HHS or the Treasury" Source United Health care Agent Advisory
https://rules.house.gov/sites/democrats.rules.house.gov/files/BILLS-116HR133SA-RCP-116-68.pdf
Consolidated Appropriations Act (CAA effective Jan 2022)Federal Law affecting multiple regulations and law updates including IDR (Independent Dispute Resulution) aka "no surprises act" on surprise billings. https://www.uhc.com/content/dam/uhcdotcom/en/HealthReform/PDF/Provisions/reform-external-CAA-NSA-TIC-provision-pricing-highlights-guide.pdf
Construction Occupancy Protection Exposure (COPE)Construction Occupancy Protection Exposure (COPE) is a set of risks (construction, occupancy, exposure, protection mitigations) that property insurance underwriters review when determining whether to offer an insurance policy. 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, MIPS https://qpp.cms.gov/enid=ZWFzPTEmbXNpZD0mYXVpZD0mbWFpbGluZ2lkPTIwMTcwNTMxLjc0MDA0NTQxJm1lc3NhZ2VpZD1NREItUFJELUJVTC0yMDE3MDUzMS43NDAwNDU0MSZkYXRhYmFzZWlkPTEwMDEmc2VyaWFsPTE3OTgxNjA4JmVtYWlsaWQ9c3RlcGhlbmNnZW9yZ2VAYmVsbHNvdXRoLm5l
Consumer Assessment of Healthcare Providers and Systems (CAHPS)See: MIPS, QPP, Consumer Assistance Programs (CAPs)See: Surprise Billing, Balance Billing, IDR and good luck. Medical providers must understand their state's billing regulations in context to solving balance billing issues' mandated carrier interface and dispute resolution. In simplier talk, make sure business as usual practices dont expose the practice to statutory /regulatory liability. See: Assignment of Benefits, Surprise Billing, IDR, IRO, etc. As a practical note, expect enforcement of IRO under democratically elected federal adminstrations. https://www.dol.gov/agencies/ebsa/employers-and-advisers/guidance/technical-releases/11-02
Consumer Operated and Oriented Plan (CO-OP)he 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 in some states through the Individual Marketplace and SHOP, but may also offer health plans outside of the Marketplace. Source: Marketplace Exam. 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
http://www.gao.gov/assets/680/675742.pdf
http://www.gao.gov/products/GAO-16-326
Consumer Protections DOL (DOL 2719(b)(2) of PHS Act)Fir Individual Plans: "These 16 minimum consumer protection standards, as amended, may be summarized as follows:(4)
The process must provide for external review of adverse benefit determinations (and final internal adverse benefit determinations) based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit.
Issuers (or plans) must be required to provide effective written notice to claimants of their rights to external review.
If exhaustion of internal appeals is required prior to external review, exhaustion must be unnecessary if – (a) the issuer (or plan) waives the exhaustion requirement; (b) the issuer (or plan) is considered to have exhausted the internal appeals process by failing to comply with the requirements of the internal appeals process except those failures that are based on de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the claimant(5); or (c) the claimant simultaneously requests an expedited internal appeal and an expedited external review.
The cost of an independent review organization (IRO) to conduct an external review must be borne by the issuer (or plan), although the process may require a nominal filing fee(6) from the claimant requesting external review.
There cannot be any restriction on the minimum dollar amount of a claim in order to be eligible for external review.
The process must allow at least four months to file a request for external review after the receipt of the notice of adverse benefit determination or final internal adverse benefit determination.
The IRO must be assigned by the State or an independent entity, on a random basis or another method of assignment that ensures the independence and impartiality of the assignment process (such as rotational assignment), and in no event assigned by the issuer, the plan, or the individual.
The process must provide for the maintenance of a list of approved IROs (only those that are accredited by a nationally recognized private accrediting organization) qualified to conduct the external review based on the nature of the health care service that is the subject of the review.
Approved IROs must have no conflicts of interest that will influence their independence.
Claimants must be allowed to submit to the IRO additional information in writing that the IRO must consider when conducting the external review, and the claimant must be notified of the right to submit additional information to the IRO; the IRO must allow the claimant at least 5 business days to submit any additional information and any additional information submitted by the claimant must be forwarded to the issuer (or plan) within one business day of receipt by the IRO.
The IRO decision must be binding on the claimant, as well as the plan or issuer (except to the extent that other remedies are available under State or Federal law).(7)
For standard external review, the IRO must provide written notice to the issuer (or plan) and the claimant of its decision to uphold or reverse the adverse benefit determination within no more than 45 days after the receipt of the request for external review.
The process must provide for an expedited external review in certain circumstances and, in such cases, provide notice of the decision as expeditiously as possible, but not later than 72 hours after receipt of the request for external review (and if notice of the IRO's decision is not in writing, the IRO must provide written confirmation of its decision within 48 hours after the date of the notice of the decision).
Issuers (or plans) must provide a description of the external review process in or attached to the summary plan descriptions, policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to participants, beneficiaries, or enrollees, substantially similar to section 17 of the NAIC Uniform Model Act.
The IRO must maintain written records and make them available upon request to the State, substantially similar to section 15 of the NAIC Uniform Model Act.
The process must follow procedures for external reviews involving experimental or investigational treatment, substantially similar to section 10 of the NAIC Uniform Model Act." "Under section 2719(b)(2) of the PHS Act, if a State's external review process does not meet these minimum consumer protection standards, group health plans and health insurance issuers in the group and individual market in that State are required to implement an effective external review process that meets minimum standards established by the Secretary through guidance. These standards must be similar to the standards established under section 2719(b)(1) of the PHS Act and must meet the requirements set forth in paragraph (d) of the July 2010 regulations.
Accordingly, there may be external review processes authorized under PHS Act section 2719(b)(1) and paragraph (c) of the July 2010 regulations (hereinafter referred to as "NAIC-parallel processes") and there may be external review processes authorized under statutory PHS Act section 2719(b)(2) and paragraph (d) of the July 2010 regulations (hereinafter referred to as "NAIC-similar processes"). 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. Contingent Insurance An aviation insurance (and other insurances use the term) purchased by the aircraft/aircraft-part lessee that pays if the primary policy owned by the lessor (possessed policy) does not pay timely or at all. It is typically less expensive than the possessed policy, and can look like a type of reinsurance (insurance on insurance). These get complicated. Contingent insurance can have many meanings, conditions and terms.
Continuation of Coverage Provision A hybrid LTC-Whole Life policy provision that affects monthly LTC payments after the Life Insurance Face pays out, and for periods up to death. Typically today, most policies offer 4,5,6,7,8 year payouts, and not lifetime payouts. See: Inflation riders, ADL triggers, elimination periods, etc. IF its LTC, be sure if the policy premiums remain constant for life or not. 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 (CE)A state authorized edjucation requirement insurance professionals must obtain every two years (for agents with 5 or more years of experiene), to maintain licensure. Continuous GLucos Monitor (CGM)A wearable medical device communicating suger levels in diabetics. See: EBM Contract Holder In context to stop loss, it usually means the employer. Contribution Requirements The minimum percentage of employer paid premium for (QHP) group major medical benefits, typically set at 50%. Controlled Group A group containing two or more entities as defined by the IRS code. 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 Conversion A term usually used when replacing a term life insurance with another type of permanent insurance (UL, IUL, Whole life).=============It can also mean an insured coverage and process of actively helping an HMO member replace or enroll in a new major medical plan after an HMO declares insolvency. Many states require the stop loss coverage. 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. Coranary Health Failure (CHF)A term some care managers use when following up patient discharges. Core Quality Measures Collaborative (CQMC) https://www.ahip.org/news/press-releases/cqmc-updates-core-measure-sets-with-additional-patient-focused-measures
https://www.qualityforum.org/CQMC_Core_Sets.aspx
Coronavirus Aid Relief and Economic Security Act (Care's Act)"Aside from federal spending, which had the most prominent impact, private and public health insurance, out-of-pocket costs, and hospital care contributed to national healthcare spending in 2020.
Private health insurance expenditures accounted for 28 percent of total healthcare spending in 2020 but saw a 1.2 decline due to low healthcare utilization. Out-of-pocket healthcare spending also experienced a decline as utilization dropped.
Medicare spending was responsible for 20 percent of national healthcare expenditures, rising by only 3.5 percent, compared to 2019 when it saw a 6.9 percent increase.
Meanwhile, Medicaid spending accounted for 16 percent of total expenditures, reaching $671 billion and seeing its highest growth rate since 2014 of 9.2 percent.
Hospital expenditures accounted for 31 percent of national health spending at $1.3 trillion. There was a 6.4 percent increase in 2020, largely due to federal COVID-19 relief funds and increases in Medicaid spending for hospital care." Source: HealthPayer Intelligence 1/2022 https://healthpayerintelligence.com/news/covid-19-federal-spending-drove-national-2020-healthcare-spending
Cost (average) for health insurance "The average cost of medical coverage (regardless of plan type) is $5,330 for single coverage and $13,998 for family coverage, with employers contributing 72% toward the cost of single coverage and 70% for family coverage, says a new report." Source: ALM Benefits Pro 4/14/23 https://www.kff.org/health-costs/report/2022-employer-health-benefits-survey/
https://www.healthaffairs.org/content/forefront/employer-health-insurance-premiums-steady-2022
Cost Elements Medical Plans The actual cost of a medical plan comprised of Premium. Deductible, Co insurance, Copays, and Maximum out-of-pocket costs. Deductible + Co-isurance + Copay = MOOP. Note: Most plans have different in- network versus out-of-network MOOP. Note: some STM plans have no MOOP, and some pharmacy plans insurance Brand Name drugs may not apply MOOP accurately. 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 https://www.ssa.gov/cola/
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, CSR (multi billion)reimpursements that since then the supreme Court rules had to be paid to carriers.
Annual cost-sharing limits cannot exceed specified amounts.* (For 2021, the maximum annual limitation on cost-sharing is $8,550 for an individual and $17,100 for families enrolled in individual or group market plans.)
"Sec. 2713. Coverage of preventive health services. Requires all plans to cover preventive services must provide coverage without cost-sharing for:
Services recommended by the US Preventive Services Task Force.
Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC.
Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration.
Preventive care and screenings for women supported by the Health Resources and Services Administration.
Chronic diseases, such as heart disease, cancer, and diabetes, are responsible for 7 of 10 deaths among Americans each year and account for 75% of the nation’s health spending – and often are preventable. The Affordable Care helps make prevention affordable and accessible by requiring health plans to cover recommended preventive services without charging a deductible, copayment, or co-insurance. By eliminating cost-sharing for preventive care, the law also helps make it easier and more affordable for seniors on Medicare and Americans enrolled in Medicaid to access critical preventive screenings and services.
High-quality preventive care helps Americans stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce costs. And yet, despite the proven benefits of preventive health services, too many Americans go without needed preventive care because of financial barriers. Even families with insurance may be deterred by copayments and deductibles from getting cancer screenings, immunizations for their children and themselves, and well-baby check-ups that they need to keep their families healthy." "Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans. The standard out-of-pocket maximum limits ($5,950 for individuals and $11,900 for families) would be reduced to one-third for those between 100-200 percent of poverty, one-half for those between 200-300 percent of poverty, and to two-thirds for those between 300-400 percent of poverty. As amended by Section 1001 of the Reconciliation Act, the plan’s share of total allowed costs of benefits would be increased to 94 percent for those between 100-150 percent of poverty (i.e., the individual’s liability is limited to 6 percent on average); 87 percent for those between 150-200 percent of poverty; 73 percent for those between 200-250 percent of poverty; and 70 percent for those between 250-400 percent of poverty. The cost-sharing assistance does not take into account benefits mandated by States." Source: 2022 Agent CE Exam
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
https://www.gpo.gov/fdsys/pkg/FR-2018-04-17/pdf/2018-07355.pdf?utm_campaign=hcgov_ab&utm_content=newsletter&utm_medium=email&utm_source=govdelivery
Cost Sharing and/or Cost share A term which has become ambiguous. In context to APTC subsodized QHP exchange plans, it means CSR. In context to commercially available major medical plans, it relates to out-of-pocket costs for Deductibles, Co insurance, Copays, MOOP, an insured must pay, in addition to the Premium, after which the plan pays 100% for eligible services. Note: Costs for care out of network, or that is denied by the carrier as "ineligible", does not attribute to the MOOP. (Find an experienced agent) In context to Medicare and Medicaid plans, balance billing from "participating providers" is prohibited, but deductible(s), Co insurance, copays, (totalling MOOP) apply subject to the policy terms and limits. Call for details. In context to Health-cost-share plans subject to state billing laws/regulations, it can mean an unlimited out of pocket cost regardless of what the policy says - especially if the "plan" is not insurance (or a Discount plan). UHP uses the term to highlight lower out of pocket costs at their specifically contracted medical care sites offering lower member out of pocket costs.
See: CMS HHS Final Rules
"CMS also finalizes changes to the regulation related to the SEP for plan display errors to remove the burden on the consumer to demonstrate that the consumer has been influenced by a material error related to plan benefits, service area, cost-sharing, or premium . This change aligns the policy of the Marketplaces on the Federal platform with current SEP operations. Currently, the regulation requires the qualified individual or enrollee, or their dependent, to adequately demonstrate to the Marketplace that a material error related to plan benefits, service area, or premium influenced their decision to purchase a QHP through the Marketplace. However, we have found that consumers may benefit when other interested parties can demonstrate to the Marketplace that a material plan display error influenced the consumer’s enrollment in a QHP through the Marketplace. Thus, we are removing the burden currently placed on consumers to demonstrate to the Marketplace that a material plan display error influenced the consumer’s decision to purchase a QHP. We are also including cost-sharing in the list of plan display errors that may entitle enrollees to this SEP." https://healthpayerintelligence.com/news/deductibles-copayments-oop-max-trends-indicate-cost-sharing-growth?utm_source=nl&utm_medium=email&utm_campaign=newsletter
Cost Sharing Reduction (CSR)See: 45 CFR 155.20
"CSRs reduce out-of-pocket costs, such as deductibles, coinsurance, and copayments, but not balance billing, such as from an out-of-network provider or for non-covered services. Eligibility for income-based CSRs is based on household income and generally requires the individual or family to enroll in a Silver plan category and be eligible for APTC. However, consumers who are members of federally recognized tribes or shareholders in the Alaska Native Claims Settlement Act (ANCSA) Corporations may receive CSRs if they enroll in a plan in any plan category, and those who qualify for a limited cost-sharing plan do not have to be eligible for APTC.
CSRs are not available for coverage purchased outside of the Marketplace.
Generally, individuals and families with household incomes between 100% and 250% of the FPL may be eligible to receive income-based CSRs. Household income is determined by calculating a consumer’s modified adjusted gross income (MAGI). Consumers who are members of federally recognized tribes or ANCSA Corporation shareholders may qualify for additional cost-sharing benefits" Source: Marketplace Exam 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.
For individuals and families, cost sharing: Annual cost-sharing limits cannot exceed specified amounts.* (For 2021, the maximum annual limitation on cost-sharing is $8,550 for an individual and $17,100 for families enrolled in individual or group market plans.)
"SECTION 2. TITLE I - QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
LESSON 2.2 Subtitle A - Immediate Improvements in Health Care Coverage for All Americans
01:17 PM Today
The covered preventive services for adults are:
Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked.
Alcohol Misuse screening and counseling.
Aspirin use for men and women of certain ages.
Blood Pressure screening for all adults.
Cholesterol screening for adults of certain ages or at higher risk.
Colorectal Cancer screening for adults over 50.
Depression screening for adults.
Type 2 Diabetes screening for adults with high blood pressure.
Diet counseling for adults at higher risk for chronic disease.
HIV screening for all adults at higher risk.
Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:
Hepatitis A
Hepatitis B
Herpes Zoster
Human Papillomavirus
Influenza (Flu Shot)
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Tetanus, Diphtheria, Pertussis
Varicella
Obesity screening and counseling for all adults.
Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk.
Tobacco Use screening for all adults and cessation interventions for tobacco users.
Syphilis screening for all adults at higher risk.
The covered preventive services for women, including pregnant women are:
Anemia screening on a routine basis for pregnant women.
Bacteriuria urinary tract or other infection screening for pregnant women.
BRCA counseling about genetic testing for women at higher risk.
Breast Cancer Mammography screenings every 1 to 2 years for women over 40.
Breast Cancer Chemoprevention counseling for women at higher risk.
Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women.
Cervical Cancer screening for sexually active women.
Chlamydia Infection screening for younger women and other women at higher risk.
Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs.
On June 30, 2014, the U.S. Supreme Court ruled that the ACA contraception coverage mandate cannot be applied to require "closely held" for-profit employers to pay for certain contraception services.
The Supreme Court has heard three separate cases - Burwell v. Hobby Lobby, Zubik v. Burwell and Little Sisters of the Poor v. Pennsylvania - relating to the ACA’s mandate that health insurance plans cover contraception without cost-sharing. Regulations long exempted churches from the contraceptive mandate, and 2013 regulations allowed religious non-profits to participate in a “self-certification accommodation” process where employees could still receive contraceptive coverage from their health plan.
Burwell v. Hobby Lobby (2014) held that privately and closely held companies with religious objections are exempt from the ACA’s requirement to provide employees with no-cost contraceptives and extended the self-certification accommodation process to these entities.
New rules in 2017 exempted all objecting religious employers (not just churches) and morally objecting non-profits and private for-profits from the contraceptive mandate. These new rules made the self-certification accommodation process optional for these employers. In Little Sisters of the Poor v. Pennsylvania (2020), the Supreme Court upheld the 2017 rules expanding exemptions from the coverage mandate.
Domestic and interpersonal violence screening and counseling for all women.
Folic Acid supplements for women who may become pregnant.
Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes.
Gonorrhea screening for all women at higher risk.
Hepatitis B screening for pregnant women at their first prenatal visit.
Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women.
Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older.
Osteoporosis screening for women over age 60 depending on risk factors.
Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk.
Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users.
Sexually Transmitted Infections (STI) counseling for sexually active women.
Syphilis screening for all pregnant women or other women at increased risk.
Well-woman visits to obtain recommended preventive services." Source Fl Agent CE Exam http://us.milliman.com/uploadedFiles/insight/2017/2015-commercial-health-insurance.pdf
https://www.gpo.gov/fdsys/pkg/FR-2018-04-17/pdf/2018-07355.pdf?utm_campaign=hcgov_ab&utm_content=newsletter&utm_medium=email&utm_source=govdelivery
https://www.cms.gov/files/document/4120-health-insurance-exchanges-2020-open-enrollment-report-final.pdf
Counselor-designated Organization (CDO)n organization authorized by CMS to deliver advice to people needing help with all kinds of federal programs including Marketplace plans involving tax credits, etc. Good luck. 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.) Coverage to Care (C2C)A CMS program designed to primarialy inform medicare benificiaries (and others classesof individuals and families) about available C19, and other health care services designed to improve medical outcomes, and to sometimes reduce costs. https://www.cms.gov/files/document/c2c-telehealth-patient-toolkitdigital508c.pdf
COVID Long-Haul (Long Haul Covid)Many coverages may apply to potential COVID claims, let along the long-term effects (disability?) of Covid. "Even when the pandemic eventually subsides, long-COVID, which affects between ten and 30% of people who contract the virus, will still be with us. The disease, which symptoms include organ damage, fatigue, brain fog and shortness of breath among dozens of other symptoms could have long-term disability implications for the industry." Source: Risk & Insurace Jan 2022. See: OSHA, Workers Compensation, General Liability (negligence) D&O. EYO, Essential Worker, EO's. etc. (Good Luck) COVID-19 A highly contagious and potentially deadly virus. See: OSHA 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 See: PA Critical Access Hospitals (CAHs)See: Advance Copy-interoperability and Patient Access Ruls - Admission. These are CMS rules that govern what care is available to who, and where it gets delivered. Remember, the federal government estimates it spends about 30% of the annual federal budget on medical care and administration, with billions going to for profit hospitals. State spending is on top of that (especially for Mediciad, and other indegent populations including refugees). https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/advance-copy-interoperability-and-patient-access-rule-admission-discharge-and-transfer-notifications-0
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. Critical Mass A term meaning different things in context to the amount of lives managed in a network, contract or insurance treaty. It can mean the amout of lives met to trigger capitation, or the amount of large employers' employees needed to sustain a viable direct contracting relationship, or the amount of lives managed to insure profitability prior to meeting denominotor (N) value in risk based contracts, (and prior to reaching sample size meeting law of large number - etc. Cross Plan offsets (CPO's)A contentious issue related to a carrier mixing expenses of their fully insured and ERISA self funded plans to "spread" costs, and that usually results in higher costs to the self funded plans. United Health is getting sued for it. See: MLR, Premium Refunds (rebating mandated by ACA) Cross Plan Offsetting A prohibited billing management practice of reducing future reimbursements to providers by unaffiliated employer plans (whose claims are paid by the same TPA) Be careful... the law allows providers to keep overpayments or erronous payments to providers (from self funded or fully insured) . The logic being that one employer plan cannot benefit by offsetting another plan's payment mistake. Lots of rules to know about here.... In Subrogation the overpayment goes back to the plan, but in cross plan offsetting the overpayment is viewed as benefiting either the provider or the patient, so the plan cannot get back the overpayment. Culterally & Linguistically Appropriate Services (CLAS)What CMS calls "no charge" entitled serves rendered to eligible people seeking entitlements (Medicare, Medicaid, dual eligibiles, marketplace plans, etc) who speak english as a second language. Relates to a cadre of free services offered by many governmental, association, and/or religeous interconneted services, but primarily ends up with translation services. See: www.Healthcare.gov Curbside Consultation An informal medical discussion between an doctor and patient that my result in a doctor-patient relationship (for purposes of liability), but usually does not without the patient agreeing to be treated in a professional manner at an agreed upon appointment or office visit. These get confusing with tele-medicine visits that may not have a fee charged to the patient but where the doctor receives a payment from an insurance carrier. Remember, there are many policies that are not insurance. Curbside Visits See: DOD Current Procedural Terminoloty (CPT Codes)Five digit Medical procedure codes CMS defines that are used to submit bills for payment.
(This straight from CMS), "To represent “telehealth-eligible” Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for eCQMs in QRDA I, submitters should use the optional qualifier attribute of the encounter code element to send the telehealth modifier code in addition to the primary “telehealth-eligible” CPT or HCPCS encounter code from the eCQM-specified value sets."
Or, A 5 digit code for Hospital procedures. See: ICD-10 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 Task Force Recommendations http://www.lexology.com/library/detail.aspx?g=42727fd2-b12b-44ee-9ca9-f230b63831ea
D
Dark Web A term used to describe internet based activity by criminals whose identities are difficult or impossible to trace. See: Raas, Cripto Currencies Data matching Issues (DMI)A general term used by the Marketplace describing state and federal interagency data confilcts that cause tax credit, and healthplan access/eligibility issues. Data Safety Monitoring Board (DSMB)See: CMS and good luck. Data Validation Announcement Notice (DVA)This regulation requires MIPS eligible clinicians or groups to comply with data sharing requests, providing all data as requested by CMS. Data validation and audits are designed and conducted to confirm the accuracy and completeness of reported results of the MIPS program. See: QPP Daubert (Daubert Challenge)A judicial exclusion or expulsion of an expert's data or opinion, based on the Judge's opinion that the expert is not qualified to opine. 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. Death Benefit Guarantee Agreement (DBGA)A sometimes offered and/or elected provision in a life insurance policy. See: IUL Death Benefit Limitation (DBL)An annuity term defining contract value distribution of remaining funds when the annuitant dies within the first 90 days to 6 months. The term can vary by annuity. Means, the survivors of the deceased annuity owner get back (typically) the entire contract value without penalties. It is not typically based on a separate TERM life insurance annuity-feature, but may be. Read the annuity. 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, or self-insured-retention - 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 benefits. Molina health plan defines it as, "the amount applied toward your annual deductible, based on benefit coverage and claim". Defense Costs and Containment (DCC)Term state of florida uses to surround litigation costs. Deferred Action for Childhood Arrivals (DACA)"President Joe Biden announced Thursday that his administration will expand health care access for almost 600,000 people covered by the Deferred Action for Childhood Arrivals program by allowing them to sign up for coverage through Medicaid or private insurance through the Affordable Care Act marketplaces. The White House said HHS will issue a proposed rule outlining eligibility parameters by the end of the month." Source: AHA in April 2023 Defined Benefit Plans (DBP (Pension plan))DBP (457) plans provide a fixed, pre-established benefit for employees when they retire. EMployers can match funds on pre-tax bases. These plans are complicated, typically require a minimum of a year committment to funding them at the same values, harder to install, but allow for more "retirement focused" contributions than Defined Contribution Plans. See: Retirement Plans. Golden Handcuffs, Vesting. See: other alternitives like: 401K, SEP IRA, etc. Do the work to understand tax benefits using IUL if you have over 10-15 years of life expectancy, want life insurance to protect your family, want extreemely low stock market crash risk, and maximized interest crediting on "premium deposits" surplus invested above cost of insurance each month. https://www.irs.gov/retirement-plans/defined-benefit-plan
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
https://www.whitehouse.gov/briefing-room/statements-releases/2021/04/28/fact-sheet-the-american-families-plan/
Democrat Health Policy Agenda See: Trumping Healthcare in our Articles section. https://www.fiercehealthcare.com/payer/framework-for-3-5t-senate-package-seeks-to-close-medicaid-gap-add-new-medicare-benefits-and
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, DFS FDFS) State agency or regulatory authority that,
among other things, licenses, oversees, and regulates Issuers, Agents, and Brokers, as
applicable. In FLorida, its DFS - Department of Financial Services 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
Depopulating A term pretty much coined by Citizens (JUA) property insurer in Florida that means the active carrier-directed policy holder transfer from one carrier (the JUA) to another carrier. Much is written about carriers being allowed to insure the less risky AOP, while simultaneously denying or transferring Windstorm insurance to unrated carrier(s) where the policy holders fail to ACTIVELY reject the transfer (at renewal). I.e. Citizens depopulated from about 600,000 policies to about 250,000 policies, then more recently, many carriers exited the windstorm market, and at last I read, Citizens now insures about 2,000,000, but that number needs to be confirmed. It is worth noting that my personal (HO3) insurance purchased for about $4,500, was quoted with Citizens at about $9,300 (at 5% windstorm deductible), and for less coverage. Designated Licensed Responsible Producer (DLRP)A term used by some state regulatory agencies for mandated agent disclosure. It depends on the state, but it can also mean the agent at EACH office site doing business, that is properly licensed to sell and/or manage insurance. 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 DGL-1s Drugs people can take that help lose weights, along with other potentially available treatments that may or may not be aligned with FDA official approval for use. GLP-1s (Semaglutide- Ozempic / Wegovy and Tirzepatide – Mounjaro / Zepbound). In context to self funded plans, these drugs can be very expensive, and plan fiduciaries must navigate the issue carefully. DGL-1s Drugs people can take that help lose weights, along with other potentially available treatments that may or may not be aligned with FDA official approval for use. GLP-1s (Semaglutide- Ozempic / Wegovy and Tirzepatide – Mounjaro / Zepbound). In context to self funded plans, these drugs can be very expensive, and plan fiduciaries must navigate the issue carefully. 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 In context to carrier distribution of their policies, it means writing a policy without a broker or (non-employee) agent. (and an advocate that is not employed by the company). If there are problems, the policy holder deals directly with the carrier's very experienced staff. There is an old adage about if carriers write direct and cut out the agent) - "Its like being pregnant, you either are, or are not." This gets dicey, and the best advice is to have an advocate, not dependent upon employment, representing the policy holder for obvious reasons. 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 In context to "managed care", it means the term agreed to by two parties interested in connecting services providers with a paying source. Typically it means and HMO or PPO contract with medical providers, but can include any insured or discounted product or service. There are three primary methods used: POC, Case rate (including DRG), and per diems that can be part of a single contract which may or may not include pharmacy (which is its own separate animal). See: HCAHPS, etc. Direct Contracting Entity (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. 2021, traditional Medicare value-based-contracting indluce 53 Direct ontracting entities, that serve "traditional Medicare" beneficiaries in 38 states plus DC. See: Shared Services risk contracting, Geographic Direct Contracting
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." See: Aggregated Purchasing Models (grouped employers), Cooperatives
See: recent advisory from CMS that DCE's cannot split themselves up into to DCE's. https://innovation.cms.gov/innovation-models/direct-contracting-model-options
https://innovation.cms.gov/innovation-models/direct-contracting-model-options
Direct Contracting Entity (DCO)See: Direct Contracting. Direct Coverage (contracted)Network See: COVID and accessing lower cost testing if the contract exists for an ERISA qualified plan. Safe Harbor exists with the contracted network. See: Network Adequacy Direct Enrollment (DE)The process of insuring an individual using the FFE. See: EDE Direct Forgiveness Portal See: PPP, CAREs Act Direct Marketing Materials (DMM)A Humana term for their marketing materials library available (on line or hard copy) to appointed agents for distribution to potential sales prospects. 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 Primary Care (DPC)In context to ERISA self funded plans, relates to eligible medical expenses for all primary care services including telehealth and or some variety of case management "primary care" services and fees. Relates to IRS compliance of eligible medical expenses taken by employers, other plans, etc. Direct Primary Care A new term for essentially what amounts to an on-site clinics, or access to a PA, ARNP and sometimes even an MD for medical services that are not serious. The term 30 years ago was Doc-in-a-box, when physicians resisted the idea of easily available healthcare for less urgent care that directly competes with physicians in private practice. History is very clear how the industrialization of many professional services firm has gone (i.e. engineers, architects, attorneys, accountants, etc.) It would be unwise to bet against MD NOW, on-grounds clinics, and Walgreens/CVS urgent care access and efficient alternatitives. Direct Primary Care Model (DPC Model)The latest name for a (mostly or completely) PMPM or capitated care model funded by a carrier or sometimes by a large employer trying to get their employees timely care and avoid absenteeism. Many studies confirm early intervention save big dollars. The DPC is in contract to FFS medicine. In business language, it means having a Cost-based reimbursement versus a Revenue based reimbursement (the more you order, the more a provider gets paid). The colloquial expression for it is, "Its heads (managed) not Beds (hospital beds filed )" Direct Service In context to medical insurance, it relates to a provider being the Directly Servicing physician, versus an insurance company being clear they are not providing the actual medical care. (And therefore, eliminating or mitigating malpractice problems beyond their employees who directly provided care - where applicable). See: Indemnity 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. Direct To Employer (medical plans)) (DTE)An ambiguous term meaning no independent agent is involved or recieving a commission thereby providing the employer no advocate, but the carriers representative whose first-obligation (and perhaps even fiduciary) is always to the carrier. In the business of brokering, the expression related to if a carrier end-runs the agent, and/or sells directly to the buyer is, "Its like being pregnant, you either are are are not..." Brokers are always wary of carriers who try and sell direct, and buyers need to made sure they understand if a problem is big (big claim is denied), they will be the sheep in complex claims deniels, lasers, canceled-recinded policies, exclutions, PBM issues, network incentives (timing), and/or contractual violations, level funded annual Surplus payout administration, etc. Direct Written Premium (DWP)A term that can mean several things, but typically means Gross fully insured premium. Can also mean gross reinsurance premium. Can also mean premiums written directly by an entity (like a "marketing-underwriter") placing coverage directly with an insured without a broker or agent. The last one is hard to define in a one-liner, and depends on the context of how underwriting is performed, and who identifies in the customer. Directors & Officers liability (D&O)A coverage for corporate officers, and board members that is not provided in a standard General Liability policy. Board members may not realize they have a fiduciary duty liability exposure, and fail to purchase coverage that protects them personally from liability exposure, subject to the limits of the policy. See: GL Discharge to Community (DTF)A term used by CMS related to rehab facility quality measures (IRF). Let's just say its a work in progress...
"Corrected IRF Provider Preview Reports- Now Available
An issue was identified with the data display of the Discharge to Community (DTC) [CMS ID I019.02] Medicare claims-based measure on the IRF Provider Preview Reports that were added to each Inpatient Rehabilitation Facility’s (IRF’s) IRF Provider Preview Reports folder in iQIES on 06/16/2020. Specifically, the data for the Lower and Upper Limit Confidence Interval Risk-Standardized Discharge to Community Rate are erroneous. The report should display the Lower Limit risk-standardized rate first, followed by the Upper Limit risk-standardized rate. The display in the recently distributed report shows the Upper Limit risk-standardized values first, followed by the Lower Limit values. Here is an example of the erroneous display: 57.64% (53.73%, 61.39%)." Source: CMS
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. Disgorgement A recent Supreme Court agreement that ill gotten gains can be taken from the wrongdoer, but that are limited to the profits received from the ill-gotten gain. See: joint and several liability and talk to a lawyer. 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. Dissability Competent Care (DCC)See: Dual Eligibles, LTSS Dissability-accomodation A term used to generally describe what employers can do to help employees work in compliance with ADA law. See: ADA law, be sure to have well documented notes, and manager training. Distressed cases (High Risk)A risk characterized by a history of high losses, and/or poor risk management. It can be a politically correct way of describing catastrophic claim or loss in a given policy year. Some brokered lines - like workers compensation, have entities that compete very strongly in these "underwritten" cases. I.e. MODS above 1.0, and certainly above 1.3. Distressed can mean different things on first- and second-dollar perils/claims. 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. Doc in a Box A derrogitory discription used by brand name hospitals or primary care practices to disparage MD's working in urgent care centers. They also use the term "cook-book medicine" implying usbstandard care, while ignoring vastly more assessable and affordable care - when in fact "most" services used to triage patients, or find cancer or heart disease earlier, and at vastly less expensive costs mean it saves lives when getting an appointment can take 30-90 days. Doctor on Demand (DOD)See: Humana virtual visits for groups 5-100+ (not for individual Humana insureds)
See: Curbside Visits Doctor on Demand Typically means 24/7 PA/ARNP/MD medical provider access to care over the phone. See: Telehealth Dollar Cost Averaging A term with several meanings. In investing of securities, it typically means investing the same amount every month, year after year to try and earn an average return that smooths out market volatility. It does not guarantee any return. In some life insurance policies, it references how premium deposits are held in a fixed interest account and doled out each month (typically 12 periods or months) into policy, and within IRS compliance to avoid a policy becoming a MEC (where growth is taxed as income). See: IUL, MEC Double Dipper See: Medicare Double Dipper Doughnut Hole (Part D (Pharmacy Benefit Plan))Source: AARP
The Medicare pharmacy coverage gap that supposedly dissapeared in 2020 under ACA, however, maximum out of pockets costs associated with tier copays make this a squirrelly issue to tie down especially with beneficiaries dealing with multiple brand name and high cost Rx. Remember, a plan can change the tier copay (and percentage of coverage) during the same policy year, so what it starts at, may not be what it ends at. 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 Dual Eligibles Special Needs Plan (DSNP)Good luck discovering competing plans, eligibility and pricing, let alone how the formularies work, along with premium payment amount and assignment. See: United Insurance Group offerings, HFC, SDOH... https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/D-SNPs
Dummy Codes Term used by a plaintiff suing Aetna and Optum alleging coding billing deceit whereby Optum's use of codes (and unauthorized transactions) used to make administrative fees look like medical service fees. Supreme Court reverted the case back to state appeals court and denied Optum's attempt to remove class action status. https://www.beckerspayer.com/payer/aetna-optum-must-face-dummy-code-lawsuit-supreme-court-rules.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter
Duty to Defend A standard liability policy feature, benefit, provision, or coverage as stated in the policy or defined by state law and the policy form. In most if not all states, litigation expenses are unlimited, and in addition to the liability policy limits, so it is not always straight forward, especially where gross negligence (or intentional acts) is/are determined to be a direct or proximate cause of the loss.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. EEO - 01 Reporting See: EEOC https://www.eeoc.gov/employers/eeo-data-collections
EEO - 1 Reporting The Equal Employment Opportunity Commission (EEOC) announced that it will open the 2021 EEO-1 Component 1 Report on April 12, 2022 with a due date of May 17, 2022. The EEOC’s announcement indicates that both dates are “tentative” and EEO-1 opening and closing dates have been subject to modification by EEOC in recent years. https://www.eeoc.gov/employers/eeo-1-data-collection
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 t 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.
Source: CMS
https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=1&globalyearfilter=2023
https://ecqi.healthit.gov/
Electronic Clinical Quality Measure (eCQM) (eCQM)Electronic Clinical Quality Measure (eCQM) Data Element Repository (DERep). See: Data Element Repository (DERep)
https://oncprojectracking.healthit.gov/support/projects/CQM/summary
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 Health Record Modernization (EHRM)Term used to describe the VA's medical record program and update plan that interfaces with other EHR that uses different standards and values. The VA was the first entity that could share its information among other VA facilities going back about 25 years. Electronic Inspection Reports (EIR)Electronic Inspection Reports (EIRs) replacing all Inspection Reports (IRs). These are reports used for life insurance to typically verify income. Electronic Personal Health Information (e-PHI)
https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html?language=es
Elevance (Anthem - Blue Cross)See: Anthem Elevation Certificate (EC)A report provided by a licensed surveyer detailing the feet above sea level a property is located. Properties are classified according to a FEMA designation. See: Flood Elevation Certificate a documet produced by a qualified entity used to convey a property's distance from a surrounding area's water table level. In general, many carriers use a 10 Ft level being considered a good risk. Despite Flood insurance risk being 100% taken by the federal government (but distributed by private carriers), there are substantial differences in the rates quotes. Ex: I quoted my own and the premium rate for my 2023 Flood policy renewal was $1,200, and when quoted from a "private" carrer was over $14,000! Its usually not that high but savings at 10%-25% are not unheard of. 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:
- 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)
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: 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
Elimination Period A defined minimum period (usually in days) after the coverage triggering event that benefits are eligible for payout. These are defined in LTC and Disability policies. A policy can have two elimination periods with one being 0 days and that relate to what type of eligible claim is being triggered. Emergency Medicaal Condition Care defined by managed care contract provision that may be guided by Section 4704 of the Balanced Budget Act 1997. Since emergency care is billed (to the patient) and reimbursed by the carrier at in-network rates, how it is defined effects patient out of pocket costs a lot. There are several law that can effect what is, and is not emergency care. I.e. going to the ER for a cold on the weekend, is not emergency care, and patients get hammered by the hospital charges that can typically start at $1200 - 1500. Emergency Temporar Standerds COVID A term used by OSHA for just about anything they want to issue as directed by the White House, etc. The COVID 19 ETS mandates employers over 100ee's are required to ensure employees are fully vaccinated, or require unvaccinated workers to produce negative weekly test result. September 2021 Emergency Temporary Standard (ETS)A temporary order invoked by a federal (like OSHA) or state regulating entity, mandating worker safety employer-actions and protections. See: EO. Good luck figuring out if OSHA fines an employer over 100 lives, if that employer has real problems litigating to get out of the fine that I.e. the Supreme Court recently ruled OSHA ETS unenforceable - Employee vaccination mandate. Gets even more complicated in some states with COVID regs, and other states ignoring prudent responses based on real-science. Emergency Temporary Standard (ETS)See: Federal Emergency Temporary Standard, OSHA, EO 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/
Emerging Therapy Solutions (ETS)High tech medical therapys. See: TIL Employee Assistance Programs (EAP (workers Comp))Means many things related primarily to "early intervention" benefits offering more services to employees, but whose costs are usually shared with the employee. Workers Compensation carriers typically tout goals to reduce injuries, get people back to work, and avoid depression caused absences, etc. 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 Experience (EX)Slange used discussing programs aimed at addressing employee burn-out or team building programs. Employee Retention Credit (PPP)See: PPP, and cross reference CARES act law. If a company got CARES money, then they may not be eligible for the ERC. Talk to you CPA. https://www.irs.gov/coronavirus/employee-retention-credit
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 (not MEWAs), unions, trusts, and associations. ERISA extends to Level Funded plans, which are typically a kind of "poor-mans' Self Funded Medical plan, meaning, the stop loss deductibles are typically not over $50,000, and are around $20,000 - $30,000. See: Level Funded Plans, PEL effects, and know the difference between their "fully-funded" premium, and traditional (much higher deductibles) Self-Funded plans with materially more risk. ERISA laws can be interpretated and enforced differently by different administrations and states. Although ERISA law purpose is to create greater choice and savings for employers by superceding various state solvency/capitalization mandates (that compete directly against insurers who contribute to policital campaigns), it also holds language requiring state regulatory solvency/capitalization compliance (including mandated low stop loss deductibles making its option unaffordable in some states) within various time limits. in short, an ERISA plan must eventually meet state guidlines, so think twice about forcing a plan into existance where state regulators are set to pounce at year two or three of plan formation. 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 (Fiduciary) offerings. The purchase of Specific and Aggregate reinsurance is optional, but usually done to transfer the risk of unpredictable catastrophic losses. (See Specific, Aggregate and Inner Ag stop loss options) ERISA is regulated by the EBSA (Employee Benefits Security Administration). ERISA is complex, and typically requires legal advice to navigate wisely. Its traditional purpose operates in complement to state insurance regulations that typically are tasked with monitoring insurance and reinsurance by state (rights versus federal supersession over state laws). Recent EBSA final-rules protecting single employer medical plans were reinstated to assure QHP EHB minimal insured protections to workers.
ERISA typically preempts state laws, but it is not absolute. See: UCR and know that courts are viewing any separate "promises" (marketing presentations) as separate promises to pay a higher rate than what the SPD states. Call for details. https://www.dol.gov/general/topic/retirement/erisa
https://www.federalregister.gov/documents/2024/04/30/2024-08985/definition-of-employer-association-health-plans
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 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 Plans (Group Plans)In context to medical insurance - An single entity offering medical insurance to W2 employees, and who posses a FEIN #. Trump EO's 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. See: 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 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 Sponsored Coverage (ESC)Term used by Federal Marketplace to describe employer medical insurance offered coverage. Employer Sponsored Retirement Plans (Pension plans)See: 401, 403, TSP, DBP, SEP IRA Employer Stop Loss (ESL) Employment Private Insurance (EBPI)A term used by the RAND corporation to survey and report findings in context to a stakeholder. Specifically where medical costs to the employee's family exceed 10% of MAGI. See: ACA law and rules allowing group employees to become APTC eligible where (premium only) ee medical insurance exceeds 9.5%. End-User Customer Experience (UX)See: EX, HR, etc. Engagement Specialist (ES)What some population health companies call the person who actually contacts the patient for care management, etc. Enhanced Ambulatory Patient Grouping (3M EAPGs)Call for details Enhanced Direct Enrollment (EDE)A term used to describe a vender's marketplace health plan web enrollment portal that interfaces with IRS for official APTC (that reduces the premium paymment for the eligible insured). These sites offer unlimited health insurance (10 EHB) for both individuals and SHOP. Enhanced Direct Enrollment A term used to describe a Marketplace (FFE) on-line enrollment site (and product review site) that includes the federal tax credit(s) that typically reduce out of pocket premium costs. 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. Enhanced subsodies See: ACA APTC, etc, along with Special Enrollment periods. Enrollee See: 45 CFR 155.20
See: Enrollment Reconciliation Enrollment A contractually guided function establishing insurance coverage to an entitiy at a specific date and time. The term is different for various kinds of insurance/reinsurance meaning. The issue can get contentious. https://www.cms.gov/files/document/4120-health-insurance-exchanges-2020-open-enrollment-report-final.pdf
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 Enterprise Risk Managment Jargeon used to describe a large organizations coordinated risk management initiatives. It can mean many things. Episode of Care (Bundled Payment)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, outcome, period of time of treatment, etc), 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.
Ragardless, this is the future for the well managed organizations who understand how (primarily) hospitals are getting forced to "focus", evolve, and coordinate with employers, payers, doctors and patients, etc. Hospitals who have not done the work to configure competitive market driven services that can be sustainably funded will fail over the long term.
See: McKesson, Prometheus payment 5.0, and ERC Logic (Evidence-informed Case Rate), Bundled Payments, DRG, Catalyst, 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.
See: CMO
https://innovation.cms.gov/initiatives/epm/index.html
Episodic models See: Bundled payments, VBP, and DRG - and hold on tight. These may apply to all types of care delivered to patients from age one day to 99 years of age. One of the most common involved obstectrics. There is massive opportunity to advance EBM - lower cost high quality outcomes balance, but that means finding the leaders able to muster physician advocacy. Equitable Lein When a claimant gets a claim paid, and accepts it. Then later, the self funded plan tries to subrogate to recover more funds (they already paid out), after the insured got paid. The Self funded plan is out of luck if they cant get a hold of the plan member to subrogate knowing what that person actually got (settlement funds) paid. A legal term applying after a claim gets paid, where a self funded plan can sue other potentially liable payors. Its complicated and also applies to subrogation. The "lowest intermediate rule balance" is the maximum amount a plan can recover (directed by TPA detailed claims). The court determined it is the (self funded) plan's burden to prove the balance. Also means, that the plan CAN go after the member's attorney if the member cant be found. ERISA's Prudent Man Rule See: ERISA ESG Funds (Green Investments)Environmental, Social and Governance investments supporting an agenda of philanthropic concerns - especially "green" technologies replacing conventional polluting technologies, or organizations that do not promote agenda beyond maximizing stock holder equity. President Biden declares building back better means developing the "next" generation of green technologies ... 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." "
https://www.cms.gov/newsroom/press-releases/hhs-releases-policies-make-coverage-more-accessible-and-expand-behavioral-health-care-access."
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.
Note: EHB is not Actuarial Value defined by ACA. See: ERISA https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html
Event Cancelation Insurance A coverage typically insuring a major event subject to terms and provisions of the policy. See: Anonamous Life insurance, etc. Evidence Based Medicine (EBM)Scientifically produced medical care outcomes derived by refereed interpretation of medical treatment and cure data. The goal is to get physicians to accept them in context to tort, and allegations of cookbook medicine claims from decentors. Another goal is to get payors to accept the standards and authorize payment. See: Value Based Reimbursements. Overal goal is to improve medical outcomes at a lower cost. Most common (about 80%) of contracts today include EBM for Diabetes, Hypertension, Heart Disease, COPD and Asthma. See: Medicare demonstration projects, and not 100% of all Medicare payments are value based. Evidence of Coverage (EOC)See: Credible Coverage Excepted Benefits Insured plans that do not meet ACA rules for QHPs. In other words, any plan that limits a "10 essential benefit". See: IRS, DOL, HHS joint regulations, and ACA Final Rules. 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. Excess Provision An insurance policy provision limiting coverage to the amounts excess of any other eligible policy coverage. These get tricky. Some excess policies mandate "primary" coverage, to trigger a "secondary" coverage (separate policy) eligibility trigger, and other policies will still pay out as the primary policy if no other policy coverage is present at time f insured loss.
These are almost always in reinsurance and stop loss policies. Accident only, Hospital indemnity, critical care policies must be read to know if an excess provision applies, or not. Excess provisions is not the same as Excess and Surplus (reinsurance) policy coverage. IMPORTANT: Claims bases used to calculate (second policy excess coverage) reimbursement may not be the same as the mandated primary coverage claims bases, so most people will struggle to figure out if their claims have been paid accurately. Auditing these claims is recommended. See: Subrogation
Exchange (Marketplace, FFE, FFM)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. Federally Facilitated Exchange means the same thing as Federally Fecilitated Marketplace, or Marketplace. It get complicated with SB- FFM's. See: FFE, FFM, FF-SHOP, FFM, and multiple state based (managed) (SB- FFM) exchanges definitions offering different types of major medical products approved by CMS Exclusions Homeowners There are 8 exclusions or sets of exclusions pertaining solely to the dwelling and other structures, including the following. • Property Section Exclusions • Collapse Exclusion • Freezing of Plumbing, Heating, Air Conditioning, or Sprinkler Systems, and Household Appliances Exclusion • Freezing, Thawing, Pressure, or Weight of Water or Ice Exclusion State specific policy form applies: Generally, there are 8: • Theft Involving Dwelling under Construction Exclusion • Vandalism and Malicious Mischief for Vacant Dwellings Exclusion • Mold, Fungus or Wet Rot Exclusion • Wear and Tear Exclusions 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. EPO's can also look like PPO plans but typically do not INSURE out of network (non contracted provider) care. Beware what is and is not insured, and for big balance billing issues governed by each state's insurance regulations. Executive Order (Medicare Executive Order)See: ACA, ACA Executive Order, price transparency, Immigrant insurance requirement injunction, Conscience Rule injunction, Healthcare Choice plan sales across state lines order, etc. https://www.whitehouse.gov/presidential-actions/executive-order-protecting-improving-medicare-nations-seniors/
https://www.federalregister.gov/public-inspection/current
https://www.federalregister.gov/documents/2017/10/17/2017-22677/promoting-healthcare-choice-and-competition-across-the-united-states
Executive Order (Presidential) ACA law applies where "enforced", but without Individual Mandate Penalty. Pay special attention to EHB, QHP, CSR, Open Enrollment, and carrier reinsurance safety net. Read Trump-ing Health Care Reform at www/providerrisk.com and click on Articles.
See CRA (Congressional Review Act) that technically can invalidate any EO taking effect less than 60 days after the EO was published. The Biden administration is reviewing all of President Trump's EO's, especially the ones rush in the last 60 days of his presidency. See: Medicare Executive Order https://www.federalregister.gov/presidential-documents/executive-orders/joe-biden/2021
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. Experimental care (Quaterinary Care)Generally, care that is not approved by FDA or as generally practiced by the greater majority of medical providers. Quaterinary care is a term apparently created by bord lawyers/acidemicians to represent sophiscotated and specialized care that is not widely available, or that is considered experimental. 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. Explanation of Review (EOR)A term used by some repricing companies to describe where they see errors, or potential discounts as compared to other medical pricing schedules. Expression Logical Model (ELM)See: ecQM Extended Non-Network Reimbursement Program (MNRP)A United Healthcare RBP claims payment protocol. Extended PIP In context to Florida No Fault PIP it means PIP coverage must pay up to 100% (as opposed to 80%) of medical treatment/services, plus lost wages, and funeral expenses caused in automobile accident (up to $10,000). See: No Fault, IUM, and exceptional events causing more than $10,000 losses insured with additional limits and coverages. 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. Extreme and Uncontrollable Circumstances (EUC) (CMS-EUC)See: PHE per Hawaii fires https://www.fema.gov/disaster/4724
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. Failure to File and Reconcile (FTR)A FFM term that generally means the insured did not prove their lower income to qualify for their APTC. It can mean many thins. Fair Access to Insurance Requirements (FAIR) Fair Market Pricing An amount both providers and payers agree to accept for their services/products. See: Repricing, contracted rate, VBR, QPP, etc. Companies offering discounting services can lower the amount accepted but charge a percentage of the fee saved under the billed charge. Lots of litigation and decisions in this area, with the biggest being: Surprise billings laws, along with where United Healthcare lost at trial and had to forfeit authority to set prices it paid to providers who felt UHC materially underpaid or discounted billed charges by hospitals and doctors. United was forced by court order (a SUNY affiliated pricing expert PhD supervised) to establish "fair" reasonable and customary charges by region, and/or pricing going forward. Pricing is guided by plan type, and laws surrounding commercial, Medicare, and Medicaid pricing. Then there are squirrelly issues of what hospitals charge/report for "self-pay" or bad debt patients which can be 100% more then is routinely accepted by hospitals and doctors under contracted rate scenarios. Fair Rate (Benchmarking)See R&C. Very contentious Faith Based Groups (CMS Rules: Faith Based Groups)Get an attorney to explain this one. This rule is more the Interim Final Rule than the Final Rule given its Executive Order mandating it in Dec 2020. See: CRA https://public-inspection.federalregister.gov/2020-27084.pdf
Faith Based Plan See Ministry Health Plans Families First Coronavirus Response Act (FFCRA)Reles affecting groups greater then 50 FTE's, enforced under OSHA, detailing coverage requirements carriers must insure. One was blocked (mandated COVID vacination) coverage for employees), and the other one related to OTC medicines. See: Families First Act (FFA) Families First Coronovirus Response Act (FFCRA)An act that expanded Medicaid eligibility and APTC increases for the Individual marketplace market. See: PHE Family First Coronavirus Response Act (FFCRA)See: Families First Coronavirus Response Act (FFCRA)
In addition to traditional paid and sick leave (PSL - Paid Sick Leave), COVID-19
spurred the passing of the Families First Coronavirus Response Act (FFCRA), which includes the Emergency Family and Medical Leave Expansion Act and the
Emergency Paid Sick Leave Act. The FFCRA requires employers with 500 or fewer employees to give employees expanded paid family and medical leave, and emergency paid sick leave. FFCRA lowers cause of action requirements allowing some employees who have been denied their rights to sue their employer for COVID related FLMA prohibited, or mandated actions.
FMLA is complicated and applies more than it does not apply, but is contingent upon several facts: State emedical leave rules may be more generous, that telemedicine visits can qualify for illness severity and subsequent leave (three or more days unable to go to school, or seeking treatment from a licensed doctor for serious health condition, that the employee worked for 12 months - not less than 1250 hour the previious year, and at a location where at least 50 employees are employed by the employer within 75 miles. Private employers are subject to FMLA if thay have 50 or more employees in any of preceeding 20 workweeks. Public agencies (federal state, local government, elementary school, secondary schools are covered FMLA employers. National guard, reserve military and uniformed services employement and reemployement rughts apply (USERRA). Employers must continue healthcare insurance benefits during qualified leave. ============HR Directors earning their pay this year - you bet. Check with each state's DOL See: FFCRA, and know that the Supreme Court blocked one of the two requirements - Mandated employee vacination (groups over 50 FTE) https://www.federalregister.gov/documents/2020/09/16/2020-20351/paid-leave-under-the-families-first-coronavirus-response-act
Family Medical Leave Act (CARE's Act)These are two different laws organized under COVID threat, and designed to help people care for themselves and/or their families, and insuring job security. FMLA has a second law passed making it easier to sue employers by lowering the cause of action requirments. Bottom line: If an employee is sick and or needs to care for a sick relative, that employee must be provided time off to take care of it. In some states, some larger employers are also required to pay the employee while absent. Speak with a attorney or HR professional for details. 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. Fast Healthcare Interoperability (FHIR)An open-source data standard for health data exchange(s). Many are trying to consolodiate it, and be in charge of it. This also streaches to the data being available on multiple device types, with differing levels of access. Favored Nations Clause A contract provisions setting medical claims reimbursement to the lowest accepted PPO
(RBS, etc) rate a provider has negotiated and accepted with any carrier for that product or service. These are especially important in stop loss recoveries, and can dramatically reduce reimbursement of eligible charges. In stop loss the idea is to cover the actual cost, and not a profit center. ANother usage to the favored nations clause rlates to President Trumps Executive Order allowing "some" (who knows?) drug prices be comparable (or same?) drug prices from other countries. Lots of issues here... Just a note that ACA repealed the President Bush signed regulation-law prohibiting Medicare and Medicaid from bidding for lowest cost drugs, but somehow, their is another practice or rule that prohibits it? 60 minutes has a great show detailing the 3AM congressional hearing that passed the original law, and the guy that went to work for the pharmaceutical company right after passage at a very high salary. FDA-CDER (Food & Drug Adm - Center Drug Evaluation & Researc)Food and Drug Administration’s (FDA) Center for Drug Evaluation and Research (CDER)
"“The new pharmaceutical pipeline is anticipated to be a strong headwind to any medical cost trend improvement. The median annual price for new drugs being approved by the U.S. Food and Drug Administration’s (FDA) Center for Drug Evaluation and Research (CDER) increased from $180,000 in 2021 to $222,000 in 2022, implying double-digit annual growth in price,” the report states. “Pharmaceutical manufacturer pricing is expected to be in the high single or double digits from 2023-2024. New drugs typically exist in the market for 15 years on average without competition from generic drugs, along with general increases in drug prices over time. Multiple insurers report that the trend used for pricing 2023 plans was lower than actual experience, driven by higher-than-expected pharmacy trends for both brand and specialty drugs.” "The rise of GLP-1 drugs and new gene therapies"
Source: BenefitsPro Dan Cook | October 02, 2023 https://www.pwc.com/us/en/industries/health-industries/library/assets/pwc-behind-the-numbers-2024.pdf
Fear of Missing out (FOMO)A term borrowed from the investment community, describing a buying opportunity motivated by low rates, or profit opportunity. Timing matters with insurance rates, and individual carrier-reinsurer risk-on-appetite. Fecal Imunochemical Test (FIT)I lab test that detects colon cancer. If you are 45 or older, a FIT Colorectal Cancer Screening may be covered by your health insurance or Medicare at no out-of-pocket cost when ordered by your doctor. Contact your doctor to explore this option. Federal Arbitration Act (FAA) 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 Agent Licensing Exam Jan 2019 Federal Pandemic Unemployement Compensation (FPUC)In context to APTC, its important to not include it ($300 per month extra) in FPL calculation that may also include CSR benefit. Federal platform for eligibility and enrollment functions (SBM-FPs)A federal term used to denote various sites the public can access for pricing individual and small group (SHOP) plans that are eligible for tax credits (APTC). 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%). See: President Biden and updated CMS increased subsidies above 400% (to 800%) to qualify for increased tax credits.
See Links:
ACA law authorizes substantial APTC for eligible people earning between 100% and 400% FPL. People earning between 100% - 250% also qualify for cost sharing that lowers deductibles and MOOP substantially. The idea here is to lower the barrier for poor people to see a doctor for a chronic condition that when left untreated causes a $100,000- $500,000 ICU bill - like older Americans with neglected or ignored diabetic conditions, hypertension, lower back pain, asthma, prostate screenings, mammograms, thyroid super inexpensive meds... See: CSR
Federal Poverty Level Guidelines
https://aspe.hhs.gov/system/files/aspe-files/107166/2020-percentage-poverty-tool.xlsx
Federal Privacy Impact Assessment (PLA)See: HIPPA, PII, OMG memorandum M-03-02, OMG Guidance for implementing Privacy Provisions of the E Government Act of 2002 (Spet 26, 2003) and good luck. Federal Provider Penalties (Patient Dumping)HHS Increases Civil Monetary Penalties
http://www.healthcare-informatics.com/news-item/payment/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.
Federal Tax Information (FTI)Info accessed by the federal government to verify Marketplace APTC. 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. Feduciary Status A legislated status that applies materially more accountability to its assigneee. We may have PBM get hit with it, and make them very responsibile for denying medications that work versus some meds that dont work - or work as well (to be determined by a jury if one gets sued). It essentially means, if someone gets sued, they are probably going to lose. 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. Fidicuary Insurance Yes, it is available for ERISA self funded Plan Sponsors and/or Plan Administrators. Call for details. Fiduciary Duty (Fediciary "rule" Rule 9550, 4111)A legally defined standard of service epitomized by selfless noble action(s) in best interests of client gain or lowering risk. In context to ERISA medical plans, the Plan Sponsor must assure paramount and transparent member protection subject to prudent SPD management (and potentially other important documents guiding benefits, intent, express performance, employment agreements, employee handbooks, and accepted transaction(s). Recent filed breach of fiduciary allegations against a (large) Plan Sponsor for NOT prudently managing PBM contracts center around contracting on bases of "spread-pricing" versus "pass-through" pricing, where the (large) PBM marks up costs unreasonably while "stearing" PBM formulary management for their highest returns (with contracted authority), and inefficient Plan Sponsor Rx supervision. Plan Sponsors are well advised to document transparant PBM selection-assignment-evaluation, and prudent managment. I have personally been involved with a heavily litigated case incuring $6.8M in high cost Rx incurred in 82 days, wow!. I just read about another stop loss claim over $11M in one year. ======= The vast majority of licensed Insurance Agents are not Broker Dealers selling securities, and do not usually deal with qualified funds (untaxed) retirement investments subject to complex taxing issues. Securities licensed professionals do routinely deal with qualified funds (retirement accounts) for investments, and are fiduciaries required to disclose all compensation. In simpler contexts: Agents are not licensed to sell products that can crash with stock/bond market crashes, but most Financial Planners deal with qualified funds to sell/manage securities that do crash with the stock market crashes. Its pretty clear that any agent dealing with retirement account funded-transaction (like buying an annuity with 401 or IRA balances) are subject to a fiduciary standard.
The latest rule 4111 essentially mandates segregation of funds drawn from qualified accounts (untaxed), and that represent a person's retirement nest egg with special protections to the customer, including mandated disclosure of compensation, including potential profit sharing, contingency fees, fees, charges, performance commissions, etc. The paperwork must be enormous, especially with companywide incentive programs meeting sales goals and triggering production/profit sharing compensation to the senior-regional- executives that local sales people know nothing about. ==================
DOL issued guidelines April 2021, mostly directed at stockbrokers and broker-dealers licensed to sell securities, dealing with client retirement account investing - especially where larger sums are withdrawn and taxed to then invest into marketable securities (or variable annuities and/or product offerings, etc) exposed to stock market crash risk, etc. I.e. Recommendations to investments with long periods must make sense in context to the investors age, and financial suitability (there is a required form for Annuity buyers called Senior Suitability Disclosure) over the clients normal life span. See: DOL link, Senior Suitibility, Retirement Security Rule 2024, arbitration of breach of fiduciary duty claims under the Employee Retirement Income Security Act (ERISA) Section 502(a)(2).
Insurance agents have long been required to complete Senior Suitability applications to place annuity products that cannot crash in the market (because the insurd's principal or cash-value is not directly invested in a security), therefore, its quite important to differentiate products that can, or cannot crash in the stock or bond market when establishing BIC. Insurance agents are not licensed to sell securities that can crash in the market, but for one product called a Variable Annuity - in some states.
In sequence and context of "best interests" contracts (BIC) it may follow an increasing liability progression standard characterized by an: obligation, responsibility, duty, express duty, and fiduciary-duty. Many laws already apply such "standard", like ERISA and long standing best-interest laws following a caveat emptor standard. See: Reg BI
See: Final Draft from SEC link. (Re: Securities brokers and/or dealers)
"D. Broker-dealers (selling securities) and investment advisers have disclosure and compensation reporting obligations
under state and federal laws, including, but not limited to, obligations under the
Exchange Act, the Advisers Act, and the respective rules, etc. In general, it applies to not referring clients into investments (especially IRA's, 401s, etc., that are controlled by the broker making the recommendation), and disclosure of compensation(s) or potential conflicts of interests so the investor can be advised before putting in retirement directed funds, or cashing out (and paying tax on, and potentially 10% penalty tax above INCOME TAXES - prior to age 59.5) retirement funds to be used to purchase a recommended security or investment. Broker-dealers 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."
February 2020 Supreme Court ruling detailed opinion on "constructive" versus "informed" knowledge of the plan participant (on how his retirement funds were invested) comprising "actual" versus "constructive" knowledge by the member. All courts have long held Caviet Emptor applicable to personal responsibility in any transaction. The decision detailed "the ERISA participant cannot sue the plan sponsor after the earlier of six years from the time of a fiduciary breach, or the three years after the time the plaintiff had "actual" knowledge of the violation, ..." It should be noted that sending a letter or email that may not get read by the investor does not constitute constructive knowledge. Source: BenefitsPro 2020 ======= Although ERISA's intent is to empower large multi-state medical plans, by superseding more restrictive state laws and uses a standard of whether a state-law interferes with a plan's "central operations", many courts find a delicate balance related to a "starting" ERISA plan must eventually (within 2 years) comply with state guidelines in context of federal supersession of state law authority. See: MEWA Assigning a fiduciary duty to both a Plan Sponsor, and Plan Administrator is not a given, although many cases fiercely allege both entities hold duty. The Biden Administration recently updated rules related to fixed annuities purchased with qualified funds. See link.
Recently, DOL updated the rule with three primary clarifications:The definition excludes sales pitches.
The definition would include individualized advice.
It could include transactions involving health savings accounts. Source: Think Advisor 04/2024 https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/retirement-security-rule-and-amendments-to-class-pte-for-investment-advice-fiduciaries
https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/retirement-security-rule-and-amendments-to-class-pte-for-investment-advice-fiduciaries
https://www.federalregister.gov/documents/2020/12/18/2020-27825/prohibited-transaction-exemption-2020-02-improving-investment-advice-for-workers-and-retirees
Fiduciary Insurance Insurance that transfers fiduciary duty risk. Call for details. Field Marketing Organization (FMO)A sales and/or marketing organization typically organized to sell various kinds of insurance policies. CMS call them TPMOs. 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. FMO's can involve multiple levels of commission splitting, and/or administration - in context to the product-line being managed through a form of GA contract. Latest trends in distributing involve more simplified underwriting (or guarantee issue) policy forms (coverages). The goal of this is streamlined policy placement, and electronic (digital) administration, but many challenges can and do derail that goal - especially in senior care and retirement-like products like Medicare Supplementals, MA, MA-PD, LTC, annuities, etc. Selling complex MA plans, to seniors who fear technology, and have memory issues is anything but easy.
Different carriers coin different definitions, and requirements. Almost all of them mandate individual E&O prerequisite. See: IMO, BGA, MLM, SGA MGA, GA, MGU, TPMO, aligned agency networks, and Web-Broker, Fiduciary duty standards. https://www.benefitspro.com/2021/06/24/are-erisa-breach-of-fiduciary-duty-claims-arbitrable/?kw=Are%20ERISA%20breach%20of%20fiduciary%20duty%20claims%20arbitrable?&utm_source=email&utm_medium=enl&utm_campaign=retirementadvisorpro&utm_content=20210701&utm_
Filing Window Termonology stipulating the time a claim is incurred, and reported and/or paid. Typical stop loss has 3-6 months to either report and/or pay the claim as ban be stipulated by a 12/15 or 12/18. Latest extentions are up to 15 months, or 12/27.
See: claims submission deadlines, and not invaladating the entire claim by inserting claims that fall outside of the deadline. See: Bundled services where SPD, TPA and Stop Loss through same company and dont assume they will all agree. 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 Coronavirus Response Act (FFCRA)The act that also requires employers under 500 FTE to properly handle employees seeking leave for taking care of themselves or a family member. Has both criminal and civil penalties. This peril is related to EPLI coverage many employers never buy, or underinsure. See: FMLA and supplemental federal law affecting same. 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 Account (FSA)One of many types of medical plan accounts allowed by IRS that gets funded by employers to pay for eligible medical expenses during the policy year. Funds are deposited pre-tax. It is not an HSA, HRA, MSA. See: FSA, ERISA self-funded plans, HSA, ICHRA, MSA, etc. https://www.irs.gov/publications/p969#en_US_2015_publink1000204174
https://www.uhc.com/content/dam/uhcdotcom/en/B2B-Newsletters/b2b-pdf/covid-19/faqs-fsa_hra_hsa_account.pdf
Flexible Spending Accounts (FSAs, Section 125 plans)A FSA is an employer sponsored (and administered) medical spending plan and account that allows employees to pay (usually with a Debit Card) for eligible medical expenses with pre-tax dollars. FSA funds are not available to pay premiums. 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 are not HRA's. FSA's get funded by the employee, and HRA's get funded by the employer
https://www.natlawreview.com/article/irs-releases-2022-benefit-plan-limits-and-thresholds-updated-fsa-limits
https://www.irs.gov/publications/p969#en_US_2015_publink1000204174
Flood Coverage (Flood)All Flood Coverages are not the same. "Dwelling coverage up to $2m and Contents Coverage up
to $500k with an option to add additional coverages to
protect your client for items not covered in the National
Flood Insurance Program:
Basement Contents (up to $10k)
NFIP only covers limited basement contents, such as wall
fixtures, elevators, air conditioners, andwasher/dryer.
Pool Repair and Refill (up to $10k)
The NFIP specifically excludes coverage for swimming pools.
With this endorsement, Neptunewill cover swimming pool
repair & refill costs.
Unattached Structures on Property (up to $50k)
Neptunewill pay up to the limit purchased forALLUnattached Structures combined. This limit is in addition to Coverage A.
Temporary Living Expenses (up to $10k)
If your client is unable to live in their home, Neptunewill reimburse up to $100 each day for temporary housing and up to $35 a day for
each family member residing in the home for food during this time for up to 3 months.
$1,000 — $1,250 — $2,000 — $5,000 AVAILABLE DEDUCTIBLES: — $10,000 — $25,000"
Source: Neptune Flood program. Florida Guarantee Insurance Association (FIGA)"SECTION 1. REGULATORY AWARENESS
LESSON 1.11 Guarantee Association
The statutory authority of the Florida Insurance Guaranty Association may be found in Chapter 631 (Insurer Insolvency – Guaranty of Payment) of the Florida statutes.
The Florida Insurance Guaranty Association (“FIGA”) is part of a non-profit, state-based, statutorily-created system that pays certain outstanding claims of insolvent insurance companies. By paying these claims, guaranty associations protect policyholders and claimants. Guaranty associations are active in every state, the District of Columbia, Puerto Rico and the Virgin Islands. State laws require that licensed property and casualty insurance companies belong to the guaranty associations in every state where they are licensed to do business. A guaranty association system also exists in Florida for the life, health and annuity insurance industry; but they operate independently from the property and casualty system.
Guaranty associations ease the burden on policyholders and claimants of the insolvent insurer by immediately stepping in to assume responsibility for most policy claims following liquidation. The coverage guaranty associations provide is fixed by the policy or state law; they do not offer a “replacement policy.” By virtue of the authority given to the guaranty associations by state law, they are able to provide two important benefits: prompt payment of covered claims and payment of the full value of covered claims up to the limits set by the policy or state law.
FIGA is largely funded by industry assessments, which are collected following insolvencies. These assessments raise funds to pay claims and administrative and other costs related to the FIGA’s claim paying activities. FIGA’s assessments are capped at 2% of a company’s net direct premium for regular assessments, and an additional 2% for emergency assessment for insolvencies relating to hurricanes, on premium written in similar lines of business in Florida the prior year. The other source of funding is recoveries from distributions of the insolvent insurance companies.
In most cases, an insurance company that is in liquidation will not yield sufficient money to pay claims in full; and most are not able to pay claims in a timely manner. For this reason, FIGA and other state guaranty associations step in (depending on the number of states in which the failed company wrote business) to cover certain claims. The insurer’s creditors not covered by the guaranty associations usually receive only partial payment on their claims.
If your insurance company has been declared insolvent, covered claims will be paid by FIGA. The maximum amount FIGA will cover is $300,000 with special limits applying to (1) damages to structure and contents on homeowners’ claims and (2) on condominium and homeowners’ association claims. For damages to structure and contents on homeowners’ claims the FIGA cap is an additional $200,000. For condominium and homeowners’ association claims the cap will be the lessor of policy limits or $100,000 multiplied by the number of units in the association. No claim will be paid in excess of this cap. All claims are subject to a $100 FIGA deductible in addition to any deductible identified in your policy. You may file a claim against the assets of the insurance company estate for the $100 deductible and for amounts over the cap. The Receiver will send proof of claim forms and instructions for filing a claim. Claims not covered by FIGA may be claims against the remaining assets (estate) of the insurance company and will be considered after all covered claims have been processed.
Claim payments usually begin as soon as possible once a company is ordered liquidated. FIGA, coordinating with the receivers of the liquidating companies, works hard to avoid delays in claim payments, but it is not uncommon for delays of 30-60 days after the order of liquidation." Source: Insurance U Agent CE Exam 2022
Note: Annuity FIGA limits are not the same as P&C above. Florida Hurricain Catastrophy Fund (FHCF)A $2 billion find that carriers do not have to pay into for what is essentially a layer of "reinsurance" (risk held by state of Florida) funded by the people of Florida to help stabilize the Florida Property WINDSTORM-market.
"SECTION 2. INSURANCE LAW UPDATE
LESSON 2.1 New Laws
The Florida Legislature concluded a Special Legislative Session specifically to address property insurance. The Legislature passed two bills - Senate Bill 2D and Senate Bill 4D – and Governor DeSantis signed each on May 26, 2022. Both bills include changes that impact property insurance policyholders. All changes were effective upon signing.
CS/SB 2-D - Property Insurance
The bill addresses the increasing lack of access and affordability of property insurance in Florida.
Reinsurance to Assist Policyholders (RAP) Program
The Reinsurance to Assist Policyholders program authorizes a $2 billion dollar reimbursement layer of reinsurance for hurricane losses directly below the mandatory layer of the Florida Hurricane Catastrophe Fund (FHCF). The FHCF mandatory retention is $8.5 billion for the 2022-2023 contract year.
The RAP program must reimburse 90 percent of each insurer’s covered losses and 10 percent of their loss adjustment expenses up to each individual insurer’s limit of coverage for the two hurricanes causing the largest losses for that insurer during the contract year. Each insurer’s limit of the $2 billion in RAP coverage is their pro-rata market share among all insurers that participate in the RAP program. Thus, an insurer with five percent of the total risk reimbursed by RAP coverage would have a limit of coverage of $100 million." Source: Insurance U Agent CE Exam 2022 See: FIGA Florida Insurance Fraud Education Committee (FIFEC) Florida Roof Deductibles "SECTION 2. INSURANCE LAW UPDATE
LESSON 2.1 New Laws
==Separate Roof Deductibles
The bill allows property insurers to include in a personal lines residential property insurance policy a separate roof deductible of up to two percent of the Coverage A limit of the policy or 50 percent of the cost to replace the roof. The policyholder must also be offered the option to decline the roof deductible by signing a form approved by the Office of Insurance Regulation (OIR). If a roof deductible is added to the policy at renewal, the insurer must provide a notice of change in policy terms and allow the policyholder to decline the separate roof deductible.
Policyholders that select a roof deductible must receive an actuarially sound premium credit or discount.
A roof deductible does not apply to:
A total loss to the primary structure in accordance with the valued policy law under s. 627.702, F.S., which is caused by a covered peril.
A loss caused by a hurricane.
A roof loss resulting from a tree fall or other hazard that damages the roof and punctures the roof deck.
A roof loss requiring the repair of less than 50 percent of the roof.
When a roof deductible is applied, no other deductibles under the policy may be applied. A roof deductible only applies to a claim adjusted on a replacement cost basis.
A roof deductible provision must be clear and unambiguous. A policy with a roof deductible must include the following disclosures:
On the page immediately behind the declarations page, notice that a roof deductible may result in high out-of-pocket expenses to the policyholder.
On the policy declarations page, prominent display of the actual dollar value of the roof deductible at issuance and renewal. Allows an insurer to limit payment on a roof claim to actual cash value until the policyholder pays the roof deductible.
An insurer may limit the claim payment for a roof to the actual cash value of the loss to the roof until the insurer receives reasonable proof of payment by the policyholder of the roof deductible.
Roofs – Insurer Underwriting
The bill prohibits an insurer from refusing to issue or refusing to renew a homeowner’s insurance policy insuring a residential structure with a roof that is less than 15 years old solely because of the age of the roof. If the roof is at least 15 years old, an insurer must allow a homeowner to have a roof inspection performed by an authorized inspector at the homeowner’s expense before requiring the replacement of the roof as a condition of issuing or renewing a homeowner’s insurance policy. The insurer may not refuse to issue or refuse to renew a homeowner’s insurance policy solely because of a roof age of at least 15 years if an inspection of the roof of the residential structure performed by an authorized inspector indicates that the roof has five years or more of useful life. The bill specifies that the roof’s age shall be calculated using the last date on which 100 percent of the roof’s surface area was built or replaced or the initial date of a partial roof replacement when subsequent partial roof repairs are completed that cumulatively result in 100 percent of the roof’s surface area being built or replaced." "Roof Deductible
This allows insurance companies to patch rather than replace significant portions of your hurricane-damaged roof. Previously, if a roof was damaged more than 25%, it had to be replaced. The law is as follows:
§553.844 Windstorm loss mitigation; requirements for roofs and opening protection.—
Notwithstanding any provision in the Florida Building Code to the contrary, if an existing roofing system or roof section was built, repaired, or replaced in compliance with the requirements of the 2007 Florida Building Code, or any subsequent editions of the Florida Building Code, and 25 percent or more of such roofing system or roof section is being repaired, replaced, or recovered, only the repaired, replaced, or recovered portion is required to be construction in accordance with the Florida Building Code in effect, as applicable The Florida Building Commission shall adopt this exception by rule and incorporate it in the Florida Building Code….a local government may not adopt by ordinance an administrative or technical amendment to this exception. …" Source: Insurance U Agent CE Exam 2022 Font line worker A person defined by regulation as an essential worker (hospital workers, fireman, etc) whose medical claims fall under special COVID regulated protections. Its very important for TPA's to process claims consistently to SPD, and defined employee handbook (HR policies), especially with regard to appeals (now granted one year for each charge). Forbearance (Moritoria, Business Decision)Many meanings. In context of debtors unable to make a loan repayment, its the lender allowing them to miss it under condition of payment under future "informal" or "formal" terms. In context of insurance / reinsurance, it is a typically a business decision by the carrier to pay an uninsured (disputed) claim with tangible expectation of policy renewal or continuance. In other words, the carrier will take a loss now, in hopes of lower claims and profit in the future renewal. This is not uncommon, and broker relationships can and do have real effect. Fraud An intentional act to mislead. Fraud OSHA See: Proof of Vaccine https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title18-section1001&num=0&edition=prelim
https://www.osha.gov/laws-regs/oshact/section_17
Fraud Waste & Abuse (FWA) Free Care Centers (Community Health Centers)Fees for care depend on many factors. This gets complicated figuring out where Medicaid eligibility starts/ends, CHIP, dual eligible (Medicare), etc. https://www.healthcare.gov/shop-calculators-taxcredit/?utm_campaign=hcgov_shop&utm_content=enroll2021&utm_medium=email&utm_source=govdelivery
Free Standing Emergency Departments (FSED)An ambiguous term used to describe a type of urgent care center available to the public. Some of these bill like hospitals at materially higher rates. 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. FSA Dependent Care (Dependent Care FSA)An untaxed contribution up to $5000 per year an employee who has an FSA can contribute to cover the costs of childcare, and other eligible expenses. See: MSA, HSA, HRA and talk to an expert. See: H.R. 6800, H.R. 6958, H.R. 7008, and S. 3972 Fudge Factor A percentage increase applied to the coming year's premium renewal premium rate 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. In other words, an actuary's tenure may be based on accurately pricing premium above a future year's actual expenses. An actuary may (almost always) use a fudge factor as his hedge against underestimating FUTURE claims expenses. (Lower premiums charged than claims liability ... plus the add ons)
See: Underwriting. and know it can be different at different carriers. Full Financial Risk See: Meaningful Financial Risk, Stark law, Shared services, Value Based Reimbursement, Final Rules and safe harbours/exceptions. Be careful. Full Retirement Age (FRA)For Social Security, it is the age where full social security benefits are available without discount. i.e. age 65 - 67+ depending on year of birth. Means many things in context to vesting of investments, Defined contribution Plans, and/or Defined Benefit Plans, and Life insurance policies with high cash values designed into "golden handcuffs" benefits design and within IRS compliance.
See: Social Security FRA, DCP, DBP, https://crsreports.congress.gov/search/#/?termsToSearch=R44670&orderBy=Relevance
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) Funds Transfer Fraud (FTF)See: Cyber LiabilityG
Gag Clause (GCPCA Act or CAA)Part of the federal Consolidation and Appropriations act prohibiting any entity providing access to medical or network providers (TPA's, PBM, Provider Networks, Plan Sponsors, repricers, contractors, etc) - from blocking access to quality and/or utilization encounter data. Its intent appears to be to help the feds or other quality monitoring authorities get information needed to accurately track cost per EBM outcomes. See: EBM and good luck. Starts in 2021. Call a lawyer if you are not sure. See: Recent mandates for hospital cost estimating reports, and transparante best-prices (contracts) with the largest regional carriers. Applies transparancy to most health plans, hospitals, provider networks, ERISA, etc plans. See: HIPPA, Mental health parity, Broker compensation, severability provisions potentially making gag clauses unenforcable (because they are prohibited or illegal), etc. See: CMS breakdown. Bottom line many lawyers will suggest is to just get rid of any Gag clauses, and then log into CMS and attest there are no gag clauses. If its not submitted properly, liability falls on the plan (TPA) and / or the plan fiduciary. Dont attest there are no gag clauses, if there are gag clauses. Seeek a "warrenty" from the group swearing no gag clauses exist and confirming plan sponsor has reviewed all their network contracts dont have gag clauses. This is not legal advice. Galileo Health Platform United's member portal focused on fast primary care, urgent care, chronic care access and treatment. https://galileohealth.com/united
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 by SPD conflicts between the plan document and any other document or coverage – 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.
5. A GAP plan can also be directed to insure or partially insure charges caused by a balance billing event in RBP plan coverage.
6. etc.
Garbage In - Garbage Out (GIGO)A very old term used to describe data entry errors. Super important that data integrity is high, so it's analysis is accurate. The implied meaning is that everyone must sweat the details, and NOT just leave it to the low man on the totum pole, and assume its right until the wheels come off the bus - especially when senior management has little or no experience with targeted data sets. 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. Gene Therapy Solutions (GTS)A copy righted term used by HCC (Tokyo Marine) related to (genetic) Hemophilia treatment efficacy and insurance eligibility. 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.
General Liability A commercial insurance policy and coverage that can take many forms, and mean many things. It can be a policy including the simpliest kind of "slip and fall' protection coverage, to the most involved "package" policies insuring (property, liability, wind/hail, BI, "roofs", docks, overland marine, cargo, property in transit, etc) whatever a carrier is willing to offer on an admitted (eligible, authorized and elibigle, etc) policy form. 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 & Professional Direct Contracting (GPDC)As part of its renewed vision and strategy for driving health system transformation (PDF), the Center for Medicare and Medicaid Innovation (CMS Innovation Center) is releasing a Request for Applications (RFA) (PDF) for the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model.
ACO REACH is a redesign of the Global and Professional Direct Contracting (GPDC) Model in response to stakeholder feedback, participant experience, and the Biden-Harris Administration’s priorities, including a commitment to advancing health equity. Its new name better reflects the purpose of the model: to improve the quality of care for people with Medicare through better care coordination, reaching and connecting health care providers and beneficiaries, including those beneficiaries who are underserved.
Further, in an effort to improve transparency, CMS is releasing more information on current GPDC model participants (PDF) and strengthening model monitoring to ensure beneficiaries whose providers participate in GPDC and ACO REACH continue to receive high-quality, patient-centered care.
GPDC will transition to ACO REACH on January 1, 2023. Current GPDC Model participants must agree to meet all the ACO REACH Model requirements by January 1, 2023 to continue participating in the ACO REACH Model as ACOs.
CMS will be hosting an overview webinar on the ACO REACH Model RFA on March 1 at 4 PM Eastern Time. Please click here to register for this event.
Additionally, CMS is announcing the permanent cancelation of the Geographic Direct Contracting Model (Geo). The Geo Model was announced in December 2020 and paused in March 2021 and is being canceled because it does not align with CMS’ vision for accountable care and concerns raised by stakeholders. See: ACO Reach, ACO, QPP
https://innovation.cms.gov/strategic-direction-whitepaper
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. GLP-1's GLP-1s, a class of drugs that reduce blood sugar and assist in weight loss. GLP-1s Jargeon used to classify the newer weight loss drugs being prescribed, and that are expensive. Glugogen-Like Peptide See: PBM GME (Medicare GME)CMS subsidy paid to two or more hospitals that combine to train residents. https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-10-08-mlnc#_Toc52944267
Golden Handcuffs See: Defined Contribution & Defined Benefit plans Goof Faith Estimates See: No Surprises Act, and good luck. The biggie here is that hospitals and Plans must publish their (confidential - contracted rates) best-"partner" deals, showing the public how much more or less than charge commercially insured people than Medicare people. Change is coming... 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. Graded Benefit A term that can mean many things, but is typically describing a policy feature reducing a death benefit over the first 1-3 years of a life insurance policy. Old people use Final Expense life insurance to pay death benefits to cover funeral expenses, etc - and carriers offer guarantee issue policies that reduce coverage if the insured dies in the first 1-3 years. i.e. Graded Death Benefit
• 1st year: ROP + 5% (full death benefit paid immediately for accidental death)
• 2nd year: 50% of Face Amount
• 3rd year: 100% of the Face Amount
See: Advanced Death Benefit, Accelerated Death Benefit. 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. Many Grandfathered plans have materially less coverage than ACA compliant plans. Group (employer) 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)===="The following actions will cause a plan to lose its grandfathered status:
The elimination of all or substantially all benefits to diagnose or treat a particular condition;
Any increase in percentage cost-sharing requirements (such as coinsurance);
An increase in fixed-amount cost sharing other than a copayment (such as a deductible) of more than medical inflation plus 15%;
An increase in a copayment of more than medical inflation plus 15% or $5 increased by medical inflation, whichever is greater;
A decrease in the proportion of premiums paid by the employer of more than 5%;
Addition of an annual limit on benefits if the plan had neither an annual or lifetime limit in place on March 23, 2010;
Addition of an annual limit that is lower than the lifetime limit the plan had in place on March 23, 2010; or
Decrease of an annual limit that was in place on March 23, 2010." Source: Fl Agent CE Exam 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 (GHP)A commercially available 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. Level Funded plans are underwritten. GHP Open Enrollments are not the same as individual plan OEP or SEP. Medicare and Medicaid plans are not GHP, and follow completely different rules. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview
https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting-group-health-plans/user-guide
https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting-group-health-plans/user-guide-of-benefits-and-recovery/mandatory-insurer-reporting-for-group-health-plans/ghp-user-guide/ghp-user-guide
Group Health Plan (GHP)How CMS refers to employer sponsored fully-insured and ERISA self-funded (ERISA, Fully insured, groups over and under 40 full time employees). See: MSP, subrogation issues related to rights of recovery, and order of payment liability among multiple carrier insuring the same patient. CMS (HHS) defines when the commercial plan or Medicare elible claims are subrogated.
"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. See GHP link for CMS mandated Group Reporting.
See: MSP, SHOP, etc. https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting-group-health-plans/user-guide
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/GHP-User-Guide/GHP-User-Guide
https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting-group-health-plans/user-guiden-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview
Group Health Plan Alerts (GHP Alerts)CMS mandated reporting for Group health plans. Section 111 Group Health Plan (GHP) alerts posted since the last publication of the GHP User Guide can be found in the Downloads section below. Information in published Section 111 alerts supersedes information published in the GHP User Guide. To obtain the most up to date information and requirements related to Section 111 reporting. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/GHP-Alerts/GHP-Alerts
https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting-group-health-plans/user-guide
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.
Coverage Provided
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 Association A state organized association insuring "admitted" (eligible and authorized carriers paying premium taxes into it) policies in their respective state. ======Note: Surplus Lines Companies are not guaranteed-insured in FIGA. See: FIGA Guarantee Issue (GI)A policy feature, provision, and / or coverage offering that is also offering policy issue and/or policy renewal. Terms for these are many, but the take away is to define the percentage increase limit of potential current premium offer stipulated one (or more) years from policy issue date, or at renewal date. Some carriers may NOT stipulate or guarantee coverage remaining constant, so it may it takes a pro to vet. There may also be claims reimbursement issues affecting accurate comparison from original coverage offer... Guarantee Issue or Guarantee Renewability A term typically referring to a medical, life, dental or vision plan rates or policy issued without underwriting, and availale to people under 65. On larger stop loss policies, It can mean many things, but usually is used to lock in rates (with or without small rate increase) over 1-3 years. The term applies to any policy be it L&H or P&C.
Many laws, and rules apply by type of coverage, insurance/reinsurance. It can be a policy provision specifying renewability of an insurance/reinsurance policy under contingent provisions (i.e. MLR plus administrative load plus actuarial fudge-factor, profit commission, premium rebates, etc) specifying a maximum premium rate increase range relative to a spedified matric. =============ACA offers guarantee issue policies during OEP and SEP each year. Stop loss policies can be offered with multi-year guarantee renewability features as well. i.e. MLR ratios below 60% - 65% with contingent profit share splits, etc, and or renewing premium increases over a 1-3 year time period, Stop loss policy premium renewal provisions specifying range limits. It is a negotiated process on stop loss, reinsurance, captive, captive cell, etc, but a straight forward process on most fully-insured policies if offered at all by the carrier. Brokers can add much value knowing what is, and is not possible in context to placing business in a hungry market.
In context to Marketplace offered Plans (FFM), it means offering all types of plans available to all eligible people. Guaranteed Minimum Death Benefit (GMDB)An annuity feature describing the return of PREMIUM (not life insurance death benefit), where the annuitant dies during the annuity term. Many provisions can relate to GMDB, so read the annuity and ask questions until you understand all the features, or dont buy it. See: DBL Guaranteed Minimum Income Benefit (GMIB)The lowest amount of guaranteed interest credited in an annuity. Guaranteed Minimum Withdrawal Benefit (GMWB)The smallest (typically) annual distribution from an annuity. It has a premium charge, and various features that allow for distributions over 10%, but that can affect or cancel other possible guarantees in the annuity. 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 Guideline Premium Test An IRS test on life insurance policies that allow loan distributions to be taken (loans to self) without being taxed as income, as apposed to a MEC, whose growth is taxed as income. Putting in too much "premium deposit too fast an can convert a life insurance policy to a MEC. IRS has two tests, and (PERMANENT) life insurance policies. The essence of customer benefit here is to compare investing in taxible pension products like: MECs, 401s and most IRAs versus 10-50 years of growth not being taxed as income within IRS compliant life insurance policies (IUL, UL, Whole Life policies that guarantee minimum interest crediting, and/or contractually promissed capped ranges of interest) Do the math: Pay your income tax on a lifetime of interest growth/value in retirement, or pay a very small (net) IRS compliant loan interest charge. Some refer to this as a tax loophole, but it essentially mirrors the same structure as 529's, and Roth IRAs where tax is paid on the seeds, and not the harvest. Rules allow depositing much more than the annual insurance premium charges, and to earn interest on the cash value (sometimes called the Accumulation value). See: Details of EACH policy and the illustration's assumptions. Actuarial Rule 49H
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
Hazard "A hazard is defined as a condition or conditions that increases the probability of a loss. A hazard can result in increases in the frequency of losses and/or the severity of losses. The three types of hazards are physical hazards, moral hazards, and morale hazards" A moral hazard concerns intentional acts committed by the insured that either create or exaggerate a loss. Moral hazard is measured by the character of the insured and the circumstances surrounding the subject of the insurance." "Morale hazard, as contrasted to moral hazard, does not imply a propensity to cause a loss, but implies an indifference to loss simply because of the existence of insurance. " Source: Florida CE exam course 2021 HCC Risk Adjustment (HCC)See: CAHIMS, CPHIMS, VBM, MACRA
An underwriting tool that measures expected (inpatient hospital) claims for individuals (and possibly groups). Note: Above professional designations are not universally accepted as standard.
HCC in context to Medicare and sometimes Medicaid when states choose to use it, or the feds mandate it - means Hierarchical Condition Categories (CMS inpatient hospital data designed to eliminate a switch to encounter data.)
See: RAPS, Star Ratings, etc. https://www.healthit.gov/curesrule/
HCC Risk Conditions (CMS HCC, or HHS HCC)A CMS (CMS-Hierarchical Condition Category) list of expensive medical conditions targeting (by both CMS and HHS a little differently) expensive-mostly-chronic-medical care programs, with goal of improving co-morbidity outcomes (EBM), and lowering costs.
Examples of disease registries that correlate with HCC conditions include:
Arthritis.
Atrial fibrillation.
Congestive heart failure (CHF)
Chronic kidney disease (CKD)
Chronic obstructive pulmonary disease (COPD)
Depression.
Morbid obesity. CMS-HCC Model refines ICD-10 diagnosis codes into 70,000 ICD-10-CD codes, 805 Diagnostic Groups (DXGs), 189 Condition Categories (CCs), and 79 HCCCs. Good Luck!
See: Risk Adjustment, outliers, DRG, RAF, HHS-HCC, etc.
https://bok.ahima.org/doc?oid=302516#.Yj3idufMJMw
HCPCS Pharmacy billing codes. HCQRIS member (HQRIS)HARP log-in credentials allowing access to CMS's MIPS data (if the provider submitted data as a participant). See: ACR - 30 Day ALL-Call Readmission measures, QPP, MACRA, MIPS, etc. https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDIsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMDA4MDUuMjUzMTMxMjEiLCJ1cmwiOiJodHRwczovL3FwcC1jbS1wcm9kLWNvbnRlbnQuczMuYW1hem9uYXdzLmNvbS91cGxvYWRzLzMzNS9RUFAlMkJBY2Nlc3MlMkJVc2VyJTJC
Health and Human Resources (HHS)Federal Department of Health and Human Resources - the agency charged with managing ACA and CMS, etc. Health at Scale Walmart's employee health benefits portal used to manage many types of care. Health Care and Education Reconciliation Act of 2020 (HCERA)See: ACA 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 Payment Learning and Action Network (HPC-LAN)An association trying to established agreed medical care standards centering on VBP. 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.
NOTE: This is not legal advice. Claims liability subject to different interpretations of insurance gets complicated. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0600-0699/0627/Sections/0627.6131.html
Health Equity See: Network Adaquacy. In context to CMS, see underserved communities and special funding for additional residency slots, or facilities in rural or inner city regeons. May also relate to prior-authorization in commercial insurance where medical provider access is not reasonably available. Health Equity (Federal Definition of Health Equity)"Sec. 2. Definitions. For purposes of this order: (a) The term “equity” means the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.
(b) The term “underserved communities” refers to populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, as exemplified by the list in the preceding definition of “equity.” See: link, PA, Network Adaquacy, etc https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/
Health Equity and Advisory Team (HEAT)See: VBP, LAN, CMS innovation, MIPS, MACRA, and good luck figuring out who is in charge. https://hcp-lan.org/health-equity-advisory-team/
https://hcp-lan.org/
Health Equity Index A CMS created number tasked with creating more transparency on MA plans care for disadvantaged enrollees. See: RUral and urban underserved populations, VBR, MA Plans, Part D plans, QPP, MIPS, MACRA Health Fanancial Management Association (HFMA)See: ACHE, AMA, AHA Health Foods Card (HFC)What Humana calls the card they issue to Medicare members that pays for Medicare covered food. The about $100 per month benefit is relatively new for Medicare. Medicare finally figured out that poor nutrician can mean old people get sicker more often, and more intensely. Hopefully they also figure out a way to fund poor (or no) Dental care causing higher frequency/intensity/expense diseases. 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 Advisory Committee (HITAC)(Under GAO) The 21st Century Cures Act established HITAC to provide recommendations to the National Coordinator for Health Information Technology on policies, standards, implementation specifications, and certification criteria relating to the implementation of a health information technology infrastructure that advances the electronic access, exchange, and use of health information. The Act gave the Comptroller General of the United States responsibility for appointing a portion of HITAC’s members. 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.
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, but its important to assure PII privacy. 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 1996)Federal Law effort originally started to help people keep their insurance between jobs (i.e. Health Insurance Portability), and ended up adding massive electronic personal information (Personally Identifiable Information - PII) 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)
See: PHI, PII, PIA https://www.dol.gov/ebsa/newsroom/fshipaa.html
https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html?language=es
Health Level 7 (HL7)A term used by some entities trying to establish a standardized data access, matching, naming authority, etc for the purposes of more effectively communicating scientifically prescribed (proven) information to various stake holders. "...health IT community were hesitant at the mention of a new data standard. However, mCODE filled a gap in the data exchange ecosystem." See: EHR Intelligence - MCODE http://How mCODE is Driving EHR Interoperability for Cancer Research
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 Arrangement (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 - ICHRA), 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: ICHRA, HRA, FSA, MSA, MEWA, Minimum premium plans, SHOP, Small Group plans.
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.agentbrokerfaq.cms.gov/s/article/What-is-an-individual-coverage-Health-Reimbursement-Arrangement?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery
https://www.cms.gov/files/document/hra-model-noticepdf
https://www.irs.gov/pub/irs-drop/n-21-26.pdf
Health Resources Account (HRA, Cafateria Plan)An HRA is a medical savings account funded by the employer on a tax preferred (not taxed) bases. Funds are eligible to pay for (typically using a debit card) medical expenses such as deductibles, co insurance, Co Pays, MOOP, and other eligible out-of-pocket medical expenses during a calendar plan year - that IRS allows such as air conditioning for children with asthma, etc. Funds are typically "use it or lose it" during the year. (HSA's are not, "use it or lose it.")
Total annual deposits are regulated and limited per calendar year. Tax considerations and regulations are many, and must be confirmed with Licensed Agents, CPA’s and attorneys.
Trump administration has changed the rules to allow use of funds for short term plans, and ICHRA's - 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 GROUP plan, and buy a tax credited (FFM) individual plan. See: ACA ALE employer penalties and speak with your Agent, CPA to understand tax liability.
Effective Jan 2020, HRA accounts can be funded by employers to pay for INDIVIDUAL ICHRA (outside of a group health plan offering) 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, MSA's, or FSA's. https://www.irs.gov/pub/irs-drop/n-21-26.pdf
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
Health Resources Account (HRA)See: ICHRA, FSA, HSA, MSP, Section 125 plans, Cafeteria plans, etc.
A Health Reimbursement Arrangement is an employer-funded (with pre-tax dollars) account that helps employees pay for eligible medical expenses not covered by their health plans.
HRA, MSP, HSA, ICHRA plans and tax programs are not the same.
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. Note: ICHRA allows employers to give pre-taxed dollars to employees who buy ACA QHP APTC eligible plans. https://www.federalregister.gov/documents/search?conditions%5Bterm%5D=HRA+Accounts
https://www.irs.gov/pub/irs-drop/n-21-26.pdf2021/05/05/2021-09102/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2022-and
https://www.uhc.com/content/dam/uhcdotcom/en/B2B-Newsletters/b2b-pdf/covid-19/faqs-fsa_hra_hsa_account.pdf
Health Resources and Services Administration (HRSA (HHS))See: Provider Relief Fund (PRF) I.e. $2.5 Billion paid by Medicare for uninsured COVID. See: STROBE - https://jamanetwork.com/journals/jama-health-forum/fullarticle/2788516
https://www.equator-network.org/reporting-guidelines/strobe/
Health Risk Assessment (HRA)A recent term used for smart phone or laptop reported personal information that directly comes from and goes to the patient, and whose goal is to figure out what (SDOH included and things like smoking, mental health, obesity, nutrician, etc) behaviours and medical conditions are accepted by the patient to effect positive change and/or the patient's well being, or objective medical benchmarking comparitive data. In short, if the patient does not want to change, nothing positive happens even if the system shows an eminent health attack. A central component is to what benchmark will a given group, or individual be compared which can be very different in various locations. See: Wellsource Health Savings Account (HSA)An Individual or Group health savings account (HSA) is a special tax-exempt (not taxed) account an INDIVIDUAL (not Group or employer) establishes with untaxed funds to pay for qualified medical expenses. When these were established many years ago, they required high deductibles to be considered an eligible plan so employees could use pretax dollars to fund future expected medical bills. ACA "wellness/preventive" care being mandated at no OOP costs by newer ACA law undercuts original HDHP HSA purpose (for lower premium cost HDHP), as does the new reality of massive deductibles many employers make their employees satisfy each year, so the employers can afford to offer a group medical plan. HSAs are typically used in conjunction with high-deductible health plans (HDHPs) offered/and potentially funded by many insurance companies that IRS accepts as eligible. GAP, and accident only plans can offset some of the burden, but with a separate policy. The maximum amount that may be contributed to an HSA is set by law changes 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. Untaxed money is deposited into an account and accessed via a special debit card. Note: interest on these (sometimes lifetime) accounts is practically nil, so ask how much sometimes very large amounts, funded but not used each year, earn interest over a 10-40 year period, so you know if it is even keeping up with inflation.
See: HRA, FSA (For Groups not individual plans), ICHRA
https://www.irs.gov/pub/irs-drop/rp-21-25.pdf
https://www.irs.gov/pub/irs-drop/n-21-26.pdfdf
https://www.uhc.com/content/dam/uhcdotcom/en/B2B-Newsletters/b2b-pdf/covid-19/faqs-fsa_hra_hsa_account.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,
Healthshare
Medical Cost Sharing Plan,
Christian Medical Sharing,
Christian Healthshare,
Christian Medical 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 may not be authorized as traditional insurance, but as a health cost share plan where some states have a specific statute allowing these plans.
We are aware of active Class-Action litigation in the space. Agents and customers are advised to be cautious and to clearly understand differences between the four primary types of major medical insurance and discounted reimbursement plan options. Most plans (Like STM, that are typically authorized) offer little or reduced: ER, Rx, outpatient surgery, surgery, etc coverages. PreX is handled differently. See: Ministry Health plans, Limited Medical Plans, Balance Billing, Eligible and authorized plans, Authorized plans, etc. See: PIVOT (at www.providerrisk.com, and scroll down), Reahlm Health, OneShare Health, Aliera, SGH SafeGuard Health, etc. These plans can be insurance, discount plans, health cost sharing, Gap, RBP plans, etc., and take an expert to vet by state guidelines for compliance and coverage. 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.
Numerator Options:
Performance Met: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed (G2102)
OR
Performance Met: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed (G2103)
OR
Performance Met:
Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed (G2104)
OR
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 mostly ignores small Group and / or Individual premium increases per year. There are at least 20 million individuals who do not have access to large group coverage or, premiums (and that potentially enroll in individual Marketplace plans). The better index is Healthcare SPENDING inflation that tells the story of what it really costs people to buy health insurance (the premium plus MOOP), access care, 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 than Individual premium increases, and do not add-in out-of-pocket patient responsibility cost each person has to pay to actually buy healthcare, and that are well beyond any wage increases. Sustainable - not?
See the linked article for latest CMS (Medicare mostly, but it could be including Medicaid) spending forecasted at $7 Trillion by 2030, and with 2021 spending at about 19% of GDP - massive.
(for 2019)
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%. (ERISA Stop Loss trend is supposed to be double what is first dollar risk is charged) - 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%. In 2019, my personal Blue Cross Plan premium increased 45% in just one year. Eliminating the massive outlier in one's statistics representation means the reported premium increases can be well understated. "CMS (Medicare not Commercial rate inflation) is proposing an effective growth rate of 4.75%, and an overall expected average change in revenue of 7.98%. 2022 saw a 4.08% revenue increase." Source: Healthcare Finance
https://www.healthleadersmedia.com/clinical-care/cms-projection-healthcare-spending-expected-reach-68-trillion-2030
https://www.healthcarefinancenews.com/news/cms-releases-2023-medicare-advantage-and-part-d-advance-notice
Healthcare Innovation Awards (HCIA) Healthcare Interoperability A pretty complex term that means the efficient exchange and/or access of (PII) information from multiple sources (Health Information exchange, EHR, Physicians, Hospital recoreds, primary care history notes, PBM data, SDOH, etc) causing better medical outcomes (post-acute-care PAC), at lower costs than typically fragmented FFS systems. See: VBR, MACRA, QPP, etc. Proponents are using terms lime patient-centric interoperability to focus on pre-and-post care regimines inclusive of extreemely expensive (and mostly unaddressed) issues involving pallative and hospice care. See: Healthy Communities Healthcare Minimim Standards NY See: ACA EHB. Means different things on Individual and or Group coverages (and does or does not apply to Medicare plans, limited Medical plans, ect). NY law mostly relates to carrier obligations by form type and notice provisions. Point is that EHB and QHB are not the same accross the board when an insured might think all health insurance is the same, or regulated the same. https://www.dfs.ny.gov/system/files/documents/2024/06/rf_ins_a66reg62_text.pdf
Healthcare Minimim Standards NY See: ACA EHB, QHB. Means different things on Individual and or Group coverages (and may not apply to Medicare plans, limited Medical plans, ect). NY law mostly relates to carrier obligations by form type and notice provisions. Point is that EHB and QHB are not the same accross the board when an insured might think all health insurance is the same, or regulated the same. https://www.dfs.ny.gov/system/files/documents/2024/06/rf_ins_a66reg62_text.pdf
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 Spending "Government programs, such as Medicare, made up 42% of spend or $1.8 trillion, while private insurance programs, including employer-sponsored plans, made up 28% of spend, or about $1.2 trillion." "During the peak COVID timeframe in 2021, the U.S. spent nearly $4.3 trillion on health care. Government insurance programs, such as Medicare and Medicaid, made up 42% (or a whopping $1.8 trillion of national health care spending) in 2021. That’s according to the Centers for Medicare and Medicaid Services (CMS), which says private insurance programs, including employer-sponsored plans and plans purchased through the Affordable Care Act, made up 28% of spending, or about $1.2 trillion." Source: ALMBenefits Pro. See: US National Debt Clock 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 Herfindahl-Hirschsprung Index (HHI Scores)The AMA used measure of market concentration, Herfindahl-Hirschsprung Index (HHI) scores.
THe AMA uses these scores to rank carrier competition by regions.
HHI scores can range from 0 to 10,000, with 10,000 meaning one carrier like Blue Cross monopoly in many rural areas. https://www.gao.gov/products/GAO-21-34?utm_campaign=usgao_email&utm_content=daybook&utm_medium=email&utm_source=govdelivery
HHC Star Ratings https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIHomeHealthStarRatings
HHS "Group" Religous Rights Rule (HHS Religous Rights Final Rules)"Several provisions of Federal law protect the conscience rights of certain federally funded health care entities and prohibit recipients of certain Federal funds from requiring individuals and entities to participate in actions they find religiously or morally objectionable. They include the following provisions:" Source: HHS https://www.federalregister.gov/documents/2024/01/11/2024-00091/safeguarding-the-rights-of-conscience-as-protected-by-federal-statutes
HHS Hierarchacal Condition Catagory (HHS-HCC)A risk adjustment factor that uses this years diagnosises to predict this years costs. See: CMS-HCC. It deals with more than just Medicare Advantage (ACO) pricing and reimbursement. This factors in Rx costs, whereas CMS-HCC does not factor in drug costs. Important! HHS OASH U.S. Department of Health and Human Services’ (HHS) Office for the Assistant Secretary for Health (OASH) - works with CMS Hick Picks (HCPCS)The Healthcare Common Procedure Coding System "hick picks" is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT). These can get complicated - especially for pharmacy. 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 High Risk Disease Detection (HRDD)See: ChenMed. Relates to staff model PCP management of seniors in "compliance" with complex CMS quality indices at cost effective practices. HIT New & increasing tax ($11.3 B) on Fully-Insured medical carriers, but not ERISA plans.
Home and Community Based Services (HCBS)HCBS is an important benefit for the elderly, the disabled, or individuals with intellectual disabilities. Exactly what does and does not apply to Medicare may not apply evenly to Medicaid insured individuals. These services can get confused with some of the newer Medicare eligible benefits to seniors recieving food, in-home nursing (like LTC but not called that), etc. See: SDOH and know it is smart money to provide $100 of food or "custodial-care" to avoid a $300K ICU hospital bill for a diabetic (or dementia) crash. Home and Community-Based Services (HCBS)Term Medicaid uses 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 Health Aid (HHA)A certified (licensed) aid delivering care in the home. 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. Homeowners Vacancy Permit An endorsement added to a homeowner policy that extends insurance while it is vacant. Hospice Abstraction Reporting (HART)HART (Hospice Abstraction Reporting Tool) v1.6.0 is now available
HART (Hospice Abstraction Reporting Tool) v1.6.0 is now available in the Related Links section at the bottom of the HIS Technical web page. HART is a Java based software application that provides an option for Hospice facilities to collect and maintain facility, patient and HIS Record information for subsequent submission to the appropriate national data repository. HART is free software provided by the Centers for Medicare and Medicaid Services (CMS) and is offered in two configuration types, standalone and network client. 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 Aquired Infections (MRSA rates)An infection transmitted to a patient, that the patient did not have prior to admission. Medicare sometimes refuses to pay for extremely expensive care that CMS/ HHS perceives to be caused by poor medical manaagment. https://khn.org/news/article/health-care-paradox-medicare-penalizes-dozens-of-hospitals-it-also-gives-five-stars/
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 Consumer Assessment of Healthcare Providers (HCAHPS)A measure some tout as a nationally standardized (surveyed) measures of patients' perceptions of their hospital experience. See: Quality, EBM (reality versus perceptions), Direct Contracting of ALL buyers inside or outside of a PPO/HHO/EPO/etc. 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 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. See: Hospital Outpatient Prospective Payment (OPPS) Final Rule (CMS-1736-FC) as an interim final rule with comment period (CMS-1736-IFC). https://www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf
Hospital Price Transparancy (Transparancy)Rules effective January 1, 2020 https://www.cms.gov/hospital-price-transparency
Hospital Readmission Reduction Program (HRRP)CMS defined 30-day [risk-standardized readmission rates]
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) Hospital Value Based Purchasing (HVBP)See: HITEC act, QPP, MACRA Hospital Value Based Purchasing (HVBP)See: HITECH 2009 act, QPP, MACRA 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 Humana Center Care (Walmarts Primary Care office space)"The number of CenterWell senior care locations increased from about 65 three years ago to nearly 300 last spring. CenterWell accounted for slightly less than 3% of Humana's total revenue in the company's latest quarter ended March 31, bringing in $787 million. Revenue rose 4% from the same quarter in 2023, driven largely by growth in the primary care and home solutions businesses, the company said in its April earnings release." "Humana announced on Wednesday that CenterWell, its health care services business, will lease 23 Walmart Health locations in four states." Source: ALM Benefits Pro 7/24/24
Note: Humana exited the commercial insurance space in Florida, so only Medicare eligible members are their target in Florida unlike other states. 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 Diagnosis Codes (ICD 10 2025 codes)Codes CMS publishes that are required for CMS reimbursement. See: ICD 10 Procedure Codes https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-cm
ICD-10-Procedure Codes (ICD 10 codes 2025)A 5 digit hospital procedure coding system for billing purposes. See: ICD 10 Diagnosis Codes https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-pcs
https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html
https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html
IFP Successor Agreements What United Health Care calls agreements to transfer books of business when an agent retires or sells their book of business. Its purpose is to plan for change, and not disrupt enrollments, or renewals. See: Succession Planning Implicit Bias (Cultural Competency)A newer liability term or liability mitigation training used to sensitize doctors and/or hospitals to classes of people who have been historically discriminated against.
I.e. Afro-Americans and / or women who some studies suggest are misdiagnosed, or not treated the same as white males, and whose statistics detail higher mortality or morbidity caused by the insured's care, or lack of it. Implicit Biases (Blind spots)A risk management term referring to a known population(s) higher adverse outcomes, and/or personal prejudices explaining adverse outcomes - etc. Income Protection Agreement (IPA)An elected permanent life insurance policy feature establishing an interest crediting rate over an elected/defined installment period(s). See: Income Protection Flex Agreement (not the same) Remember, Income for life features are by nature (separate from indexed crediting or lifetime policy guarantees) are materially higher than interest crediting guarantees, and contractually promised interest crediting rates. Talk to an expert. Indemnification Agreement (Hold Harmless provision)A common contract provision binding the parties to reimbursement from the offending party to the non-offending party not directly responsible for damages or a loss. See: Action Over, Subrgation Indemnity Several meanings. In context of classical or traditional insurance that for the most part is not available today buy at prices non one will pay premium costs, it means, to return an individual/company to the financial place they occupied before the loss event. This gets a bit complicated where coverages are accepted on a cost versus revenue bases. See: Direct Service Independent Contractor A definition that means many things. See: Bidens proposed rule aboloshing Trump's rule as related to not having to establish financial dependency on an employer to cause a contractor to become an employee, and whose employer is required to fund payroll taxes.
"Executive Summary
The FLSA requires covered employers to pay their nonexempt employees at least the Federal minimum wage for every hour worked and overtime pay for every hour worked over 40 in a workweek, and it mandates that employers keep certain records regarding their employees. A worker who performs services for an individual or entity (“person” as defined in the Act) as an independent contractor, however, is not that person's employee under the Act. Thus, the FLSA does not require such person to pay an independent contractor either the minimum wage or overtime pay, nor does it require that person to keep records regarding that independent contractor. The Act does not define the term “independent contractor,” but it defines “employer” as “any person acting directly or indirectly in the interest of an employer in relation to an employee,” 29 U.S.C. 203(d), “employee” as “any individual employed by an employer,” id. at 203(e) (subject to certain exceptions), and “employ” as “includ[ing] to suffer or permit to work,” id. at 203(g). Courts and the Department have long interpreted the “suffer or permit” standard to require an evaluation of the extent of the worker's economic dependence on the potential employer—i.e., the putative employer or alleged employer—and have developed a multifactor test to analyze whether a worker is an employee or an independent contractor under the FLSA. The ultimate inquiry is whether, as a matter of economic reality, the worker is dependent on a particular individual, business, or organization for work (and is thus an employee) or is in business for him- or herself (and is thus an independent contractor)." https://www.federalregister.gov/documents/2021/01/07/2020-29274/independent-contractor-status-under-the-fair-labor-standards-act
Independent Dispute Resolution (IDR)A regulated process required to determine "competitive fair market rates" comprising a Qualified Payment Amount (QPA) paid to providers for medical care. See: No Surprises Act (NSA). This can get very complicated with various COVID laws taking, or not taking precedent over Federal law and/or regulations under OSHA, and presidential executive orders. Multiple dates are involved with formally auditing when and what applies.
"The IDR process requires that the IDR entity choose either the offer submitted by the provider, or the offer submitted by the payer. Each party will submit their offer within 10 days after the IDR entity is selected. The offers must include a dollar amount and percentage of the qualified payment amount (QPA)." Good Luck.
Our advice is to act prudently since - remembering how expensive it is to litigate and win. See: Balance Billing, QPA, Batched Claims, ghost rates, NSA, interim final rules. See: Open Negotiation period, and what comprises good faith, and landmines.
https://www.federalregister.gov/documents/2021/07/13/2021-14379/requirements-related-to-surprise-billing-part-i
https://www.psafinancial.com/2021/11/independent-dispute-resolution-process-under-the-no-surprises-act-benefit-minute/#:~:text=The%20IDR%20process%20requires%20that,qualified%20payment%20amount%20(QPA).
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. Independent Review Organization (IRO)See: IDRE, ERISA, Surprise Billing, CAPs, IDR, Balance Billing, etc. Trump Executive order requires hospitals to publish their best contracted rates in transparant fashion. This gets squirelly to figure out what the "real" rate charged is average, or what is accepted... https://www.dol.gov/agencies/ebsa/employers-and-advisers/guidance/technical-releases/11-02
Indexed UL A life insurance policy that credits interest on Cash Value at a percentage of a selected index. i.e. S&P, NASDQ, Russel 2000, etc. 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 and Family Plans (IFP)What United (UHC) calls their marketplace offered plans. They may also use the same term for plans not offered on the marketplace but available directly from the carrier. 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 to their carrier 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
ICHRA.
• 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
with HRAs.
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
$183.22.
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 cost is
not considered affordable. (See: ARP that puts it now at 8.5%) 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 for employers over 50 FTE) 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 plan 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.
This gets a bit confusing in that under original ACA, employees being offered coverage lose APTC eligibility, where monthly (Marketplace offered) plan cost exceeds 9.78% of AGI or MAGI.
See: HRA, HFA, HSA, etc. See CMS Presentation link
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 9.78% for plan years beginning in 2020. The percentage for plan years beginning in 2021 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 not allowed APTC for their Marketplace coverage regardless of whether the employer plan is affordable or provides minimum value. " Source: Marketplace Exam
" https://www.federalregister.gov/documents/2019/06/20/2019-12571/health-reimbursement-arrangements-and-other-account-based-group-health-plans
https://www.healthcare.gov/small-businesses/learn-more/individual-coverage-hra/?utm_campaign=hcgov_hra&utm_content=enroll2020&utm_medium=email&utm_source=govdelivery
https://www.agentbrokerfaq.cms.gov/s/article/What-is-the-Affordability-of-Employer-Coverage-for-Family-Members-of-Employees-rule-change?utm_campaign=&utm_content=english&utm_medium=email&utm_source=govdelivery
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 Marketplace Authorized Functions (Marketplace Agent Authority with PII)INDIVIDUAL MARKETPLACE AUTHORIZED FUNCTIONS
Section II(a) of the Individual Marketplace Privacy and Security Agreement identifies the following
authorized functions for which an agent or broker may create, collect, disclose, access, maintain, store, and
use personally identifiable information in a Health Insurance Marketplace1 Individual Marketplace.
1. Assisting with applications for qualified health plan (QHP) eligibility
2. Supporting QHP selection and enrollment by assisting with plan selection and plan comparisons
3. Assisting with applications for the receipt of advance payments of the premium tax credit (APTC) or
cost-sharing reductions (CSRs), and selecting an APTC amount
4. Facilitating the collection of standardized attestations acknowledging the receipt of the APTC or CSRs
determination, if applicable
5. Assisting with the application for and determination of certificates of exemption
6. Assisting with filing appeals of eligibility determinations in connection with the Marketplace
7. Transmitting information about the consumer’s, applicant’s, qualified individual’s or enrollee’s decisions
regarding QHP enrollment and/or CSRs and APTC information to the Marketplace
8. Facilitating payment of the initial premium amount for the appropriate QHP
9. Facilitating an enrollee’s ability to disenroll from a QHP
10. Educating consumers, applicants, qualified individuals, or enrollees on insurance affordability
programs, and if applicable, informing such individuals of eligibility for Medicaid or the Children’s Health
Insurance Program
11. Assisting an enrollee’s ability to report changes in eligibility status to the Marketplace throughout the
plan year, including changes that may impact eligibility (e.g., adding a dependent)
12. Correcting errors in the application for QHP enrollment
13. Informing or reminding enrollees when QHP coverage should be renewed or when enrollees may no
longer be eligible to maintain their current QHP coverage because of age, or to inform enrollees of
QHP coverage options at renewal
14. Providing appropriate information, materials, and programs to inform and educate consumers,
applicants, qualified individuals, and enrollees about the use and management of their health
information and services and options offered through the selected QHP and among the available QHP
options
15. Contacting consumers, applicants, qualified individuals, and enrollees to assess their satisfaction or
resolve complaints with services provided by the agent or broker in connection with the Marketplace or
QHPs
16. Providing assistance in communicating with QHP issuers
1 When used in this document, the term “Health Insurance Marketplace” or “Marketplace” refers to
Federally-facilitated Marketplaces (FFMs), including FFMs where states perform plan management
functions and also refers to State-based Marketplaces on the Federal Platform (SBM-FPs).
17. Carrying out the agent’s or broker’s legal responsibilities related to QHP issuer functions in the
Marketplace, as permitted or required by the agent’s or broker’s contractual relationships with QHP
issuers
18. Other functions substantially similar to those enumerated above and such other functions that may be
approved by the Centers for Medicare & Medicaid Services in writing from time to time Source: Marketplace Exam 2022 Individual Medical Questionair (IMQ)A term used by Aetna for their (2 page) Level Funded Enrollment form. The term can mean many things, but typically refers to an underwritten quoting process for Group plans, and where the goal is to get a composit rated plan that shares in good claims experience with the pooled employees for better rates (as appoised to getting individual undiscounted-rates by age, smoking status, and location. I typical discount might be 10% off the manual rates. Individual Retirement Account (IRA)There are many types of IRA's. 529 for college where income tax is paid on the funds going in, but not coming out, 401's and SEP for various business uses, Roth IRA for various needs that allow funds out without Income tax. IUL's also offer superior tax preferred benefits, and unlike IRA's come with interest crediting contractual promises and guarantees. Speak to an experienced agent and or your CPA or tax advisor. Yes, it makes a big difference in how much you get to spend versus how much you will have to pay Uncle Sam if you fail to plan for your retirement, or large college expense. https://www.irs.gov/pub/irs-drop/n-20-79.pdf
Inflation (Medical Cost Inflation)"In July 2022, however, prices rose by 8.5% across the economy from the previous year, compared to 4.8% growth in prices for medical care.
Overall price growth was at 8.5%, and core inflation (excluding food and energy) was at 5.9%. Many essential goods and services saw larger increases. Food prices grew by 10.9% and electricity costs grew by 15.2%. Many other household expenses, such as rent and clothing, have also seen larger price increases in the past year than medical care. By far the fastest-growing essential household expense has been gasoline – whose price has increased by 44% since July 2021.
Prices for hospital services, both inpatient (3.9%) and outpatient (3.5%), as well as for nursing homes (4.5%), rose faster, while drugs and physicians' services had lower price increases (2.8% and 0.8%, respectively). Rising average employee wages and continued staff shortages in the wake of the pandemic may put upward pressure on operating costs." Source: Healthcare Finance - see link.
In context to Medical pricing, its the percentage load underwriters use to estimate claims payments. 4%-7% is typical for large employers, but Individual Major Medical inflation rates can be massively higher, and tend to ignore subset age banded increases applied to some age banded ratings - i.e. years ago Blue Cross marketplace plan premium increased 45% in one year. See: CAGR, CPI, IRR, effective rates of returns, COLA. An inflation percentage is relative to a "market basket of goods" purchased. Social Security periodically increases benefits each year by COLA. CPI is probably the most widely used gage of real overall price increases. This is important for many things, especially retirees trying to earn more interest on their long term retirement accounts so they don't run out of money in old age. Ex. a 2% fed targeted inflation rate over a 10 year period means that 10 years from today, $1.00 buys only $.80 of same basket of goods purchased today. (That's 20% less buying power than today, and 40% less in year 20 - so not investing to stay even with inflation means real problems for those who fail to plan for "expected" and especially unexpected inflation). https://www.healthcarefinancenews.com/news/healthcare-pricing-protected-so-far-inflation-bls-data-shows
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. Inflation Rider A policy provision that increases the paid-out benefit by what the customer selects. Inflation riders cost more for higher percentages, and 3% is likely a solid election, but higher and lower options are usually available. This are common in LTC policies, but are found in a variety of insurance products. See: Return of Premiums, Continuation of Benefits, etc. Initial Compensation First year agency commission or payment. See: Renewal Commission. 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)
Reduction Program." https://www.federalregister.gov/documents/2020/09/18/2020-19637/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the
https://www.beckershospitalreview.com/finance/cms-final-inpatient-payment-rule-for-2021-7-things-to-know.html?origin=CFOE&utm_source=CFOE&utm_medium=email&oly_enc_id=0117J8507389D2U
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 2021 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)"
Source: CMS
See: KTCH, HH QRP, IRF, and rule CMS-1747-P)
https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf
http://www.inpatientqualityreporting.com
https://iqies.cms.gov/
Inpatient Rehabilitation Facility Quality Public Reporting (IRF QPB)See: Preview Report Access link first.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-Provider-Preview-Report-Access-Instructions.pdf
See: HH QRP, LTCH, IRF, and rule CMS-1747-P https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-PAI-and-IRF-PAI-Manual
https://www.federalregister.gov/public-inspection/current
Institute for Clinical and exonomic Review (ICER)Medical informatics platform purporting to convey information on EBM and cost to its subscribers.. Institute’s Health Insurance Policy Simulation (HIPSM)Urban Institute’s Health Insurance Policy Simulation Model. Insur Tech Latest jargeon describing on-line agent generated applications, and simetimes binding authority. Relates mostly to smaller simplified policy forms and coverages (usually less coverage, but not always). Its essense lay in carriers trying to lower costs of aquisition - moving to win policies on smaller lower risk perils and hazards without having to hire their own sales forces which is expensive. But, for complicated coverages, or additional coverages not offered for policy binding on-line, brokers must access other markets for best rates and available terms. Insurance Certifications See: CPCU, FLMI, AAI, ARe, CPIA, CLU, CSR, HIA, etc. 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 Literacy A term used to convey insurance knowledge, particularly with the four primary coverage features common to all ACA QHP. (Deductible, Co insurance, Copays, and MOOP). There are several other important considerations that follow generic plan types. See: HMO, PPO, EPO, Health cost sharing plan, Discount plan, RBP plans, GAP, etc. 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) Insurance to Value ratio (ITV)Property insurers use it (instead of for example, a windstorm deductible based on only the Coverage A DWELLING value) to calculate the "finished" home value limits, which directly affects the deductible at time of loss. In other words, it is essentially less coverage then a homeowners policy whose deductible is based a smaller Dwelling value and not total insured valueS (Coverages A, B, C, D, E). LLoyds is known for insuring residential properties on a TIV bases (Total Insured Value of all coverages). Integrated Care See: EBM, etc. Take all these with a grain of salt, and know that nothing sustainable happens without physician buy-in. https://www.uhc.com/content/dam/uhcdotcom/en/B2B-Newsletters/b2b-pdf/Total-Cost-of-Care-white-paper.pdf
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.
Interactive Voice Response (IVR)An automated voice system that allows individual patients to pay any part of their medical bill at any time. The term also relates to accessing EHR. 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. In contexts to federal regulations, an abbreviated list of the most important rules pending Final-Rules promulgation by the assigned federal agency regulating the subject matter. Sometimes we never get the ratified and approved final rules... 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 )Codes determine how care is classified and insured. Many who follow medical claim reimbursement standards know that the newer ICD-10 68,000 diagnosis codes and 72,000 procedure codes, up from the simpler ICD-9's 14,000 diagnosis codes and 3,800 procedure codes, make up-coding and up-billing more difficult. See: CMS HCC. International Drug Pricing (CMS Rule for Doctors Office Drug Pricing)See: EO and this rule "interim final rule" released 61 days before President Trump's last day in office. See: CRA. Medicare Drug Rebate Rule. https://innovation.cms.gov/media/document/mfn-ifc-rule
https://www.federalregister.gov/documents/2020/11/30/2020-25841/fraud-and-abuse-removal-of-safe-harbor-protection-for-rebates-involving-prescription-pharmaceuticals
Interoperability and Patient Access See: Link, and "current" Executive Order (10/17/17 allowing cross state line plan sales without active license in that state - at least in the beginning) we will have to see if Biden overturns it. Know most executives would not do something that would cause another state's ire. See: MEWA https://www.federalregister.gov/documents/2020/05/01/2020-05050/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-interoperability-and
https://www.federalregister.gov/documents/2017/10/17/2017-22677/promoting-healthcare-choice-and-competition-across-the-united-states
Interroperability (Medicare Interoperability)See MIPS, and EHR in context to merging both. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index?redirect=/EHRIncentivePrograms/
https://www.cms.gov/files/document/cms-9115-f.pdf
Involuntary termination Term used in Group (employer) plans when an employee loses his job. Can get squirrely - includes constructive discharge and termination for cause, but not gross misconduct... See: ADA, AFLA, EPLI, etc. IoT (Internet of Things)An amorphous term coined to mean the connection of billions of smart devices through a network. In context to insurance, it means the inclusion of AI and its alogarithisms "predicting" outcomes by interpreting values monitored by various "smart" devices used to confirm or identify risk-factors used to underwrite (price and renew) many kinds of coverage. Ex. GL-BOP with BI, roofing, EPLI, and proximity to risk factors predicting losses. Key liability (privacy) issues - both personal and commercial involve express or implied agreement by an individual to their PI. Laws and opinion on what causes a violation are many. 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 ISO 45001 An OSHA international standard of employee safety. See OHSAS 18001, and ILO-OSH Guidelines https://www.iso.org/iso-45001-occupational-health-and-safety.html
Issuer See: ACA LawJ
Johns Hopkins Adjusted CLinical Grops (ACGs)A ICD-10 comorbidity assessing system to one or more of 32 agregated diagnosis goups (ADGs) -mostly used for commercial patients, not Medicare or Medicaid. 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 Journal of the American Medical Association (JAMA) Junk Insurance Jargon used by EBSA to describe some medical policies failing minimum coverage standards. Know there are MANY kinds of medical insurance from fully insured, to self funded, to limited medical plans that may offer good value for their cost a person may or may not afford or be willing to pay.
Our quasi-free-market healthcare system is heavily subsidized directly by many programs, and indirectly by cost shifting, so its not simple. For example, if Medicare Supplimental premiums were not heavily subsidized, they would cost not $550 (Part A , B and D) month (for Medicare Supplimental plans A-N), but between $2500 to $7500 per month, depending on age and location (and health history that IS used today for Medicare supplimental plan underwriting) See: QHP, ESB.K
Kaiser Family Foundation (KFF)Great source for accurate information on complex medical financing subjects that matter. https://www.benefitspro.com/2021/04/13/obamacare-cut-uncompensated-care-costs-by-one-third-kff-study-says/?kw=Obamacare%20cut%20uncompensated%20care%20costs%20by%20one%20third%2C%20KFF%20study%20says&utm_source=email&utm_medium=enl&utm_campaign=healthcare
Key Performance Indicators (KPI's)Variables measuring primarily revenue streams of practicing physicians in context to payor contracting, trends, anaytics, and strategic/tactical planning. It can mean many things.L
L&H (Life & Health)Accident and Health. The term typically relates to agent or policy form license or authorization by each state. L&H (Life & Health)The term typically relating to agent or policy form license or authorization by each state. Labor Law Exclusions (Action Over claims, Scaffolding Act in NY S240)Generally, an exception to CGL common exclusions related to liability coverage over the "insured contract" as related to employee injuries on the job, and that are not insured by workers compensation.
In other words, CGL insures "contractual liability". Latent Variable Modeling (LVM)See: CMS Hospital Compare. In short it is the ongoing attempt by CMS to accurately measure hospital performance by the quality metrics they select and somehow try to get accepted by stakeholders. Law of Large Numbers The law says that the larger the statistical sample, the closer the sample average is likely to be to the true average. Leakage Se: Steerage Learning and Action Network framework (Medicare LAN)See Health Care Transformation Task Force (HCTTF) A CMS directed entity aligned to improve QPP. A multi-stakeholder driven public pritate partnership tasked with improving medical outcomes using EBM at lower cost. Published results do show VBM increasing usage as a percentage of total spending. See: MACRA, CMMI, APM, VBP, CMS. https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4
https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDQsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMDA4MDYuMjUzNTA1MTEiLCJ1cmwiOiJodHRwczovL3FwcC1jbS1wcm9kLWNvbnRlbnQuczMuYW1hem9uYXdzLmNvbS91cGxvYWRzLzExMDAvMjAyMSUyMFFQUCUyMFByb3Bvc2Vk
Leased Paper See: Fronted and Reinsured assignments Leave of Absence (LOA)(In context to continuation of coverage, etc) A term that typically aligns with the employee handbook, SPD and reinsurance/stop loss contract. Important to define it by each state's definitions of leave, etc. It means the time which an employee leaves an approved absence. Many things have to align to avoid potential coverage denials in context to what the carrier underwrote, rated and accepted. See: Plan descretion, carrier descretion, explicit hazardous activities within the bounds of teh SPD. Leave of Absence (LOA)(In context to continuation of coverage, etc) A term that typically aligns with the employee handbook, SPD and reinsurance/stop loss contract. Important to define it by each state's definitions of leave, etc. It means the time which an employee leaves an approved absence. Many things have to align to avoid potential coverage denials in context to what the carrier underwrote, rated and accepted. See: Plan descretion, carrier descretion, explicit hazardous activities within the bounds of teh SPD. Lenders Loss Payable provision A property and casulty policy provision allowed by the policy owner, authorizing insurance recoveries be paid directly to the lender, or lessor, or title insurance company, etc (and not to hte policy owner - insured). Very important to understand if there is a fire, and total loss, the property owner may not get paid what he need to repair the damage and bring the property back to rentable condition, etc. Talk to a qualified lawyer when agreeing to these. 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 Funded Premium (LFP or Minimum Premium)An underwritten ERISA qualified fully-priced and paid plan, that offers a premium rebate for favorable claims experience, typically triggering when actual claims (by month 14 of a 12 month policy) fall under 120% of the previous years trended claims histery. Typical premium surplus is split 50:50 with the carrier. Level Funded plans can price about 15%-20% less than comparably funded "Fully insured" plans. Claims comming in above 120% of last year's claims, and cause a loss are carried forward to offset succeeding year's potential rebates, if any. Bottom line is the employer is on the hook for only the fully-funded premium for their employees, and does not pay more than the assigned premium accepted to start the plan. They are very popular plans. Level or Increasing An elected (UL, Wholelife, IUL) life insurance policy feature operating the death benefit payout limit. Increasing means the death benefit increases during the term of the policy, and upon death, the beneficiary gets both the cash-value (aka Accumulation Value) and the death benefit. Increasing means the premium also increases as the person gets older, even in single premium policies. in an IUL, Level means the beneficiary gets just the death benefit. The features are designed to meet the insured's lifetime plan to protect their family (or business partner) with maximum death benefit at a cost meeting the lifetime plan. There are two primary rules governing IRS compliance to keep from MEC conversion, so be cautous. Cost of insurance can substantially decrease following the needs of the insureds with level, and go up with increasing. See: IUL.
Also be aware that late in life when policy value is near or above the death benefit, the carrier does not charge insurance for the entire death benefit, only the difference between the Cash-Value and Death benefit. Other charges may apply, so work with an experienced agent and declare your primary needs so the policy matches its policy features (lifetime plan that can change with features allowed in a policy). In other words, the proper analytical method for a life insurance transactions involve a long term of typically 10-50 years, not one year. Understanding the four primary leverages that occure in a properly writtin life insurance policy, especially one designed to maximize pension payments (actual spending in retirement that does not tax growth as income when spent). See: No lapse guarantee, or Guaranteed minimum death benefit, or Guaranteed life time interest crediting, etc. Liability Coverage In context to insurance, it means different things in different policies. Three main types of Liability policies are E&O (professional liability = Errors and Omissions), D&O (professional liability Directors & Officers of a corporation with a fiduciary duty), and liability coverages and limits attached in package insurance policy forms like General Liability, Property, Homeowners, Auto, and Umbrella. Almost all liability polices detail coverage by insured peril and it's limit. Liability coverage almost always is limited to a location, or asset (house, car, boat, business) address. Some liability coverages travel with the person, or the asset, and some act like umbrella coverages increasing limits on both property and liability.
In context to lawyers being involved in filed lawsuits, it means a responsibility for a stated (or estimated) damage amount, alleged against a defendant for some kind of negligence, tort, loss, damage or breach of contract. Integral to assessing liability attribution is defining the disputing party's relationship as a trusted advisor, order taker or something in between. The law (I am not a licensed lawyer, and am not providing advice) stipulates higher duty in many relationships, like Doctor-Patient, Attorney-Client, Guardian-Ward, Financial Planner-Client, etc. Typically, legal expenses are unlimited, and not part of the stated limit of the policy.
See: Negligence, and fiduciary duty, causation, proximate cause, etc. We recommend speaking with licensed attorneys, and agents. Licensed Only Agent (LOA)A licensed agent or the person actually soliciting business.
Its a term used in hierarchy's of appointments and commission assignments.
A term mostly applicable to life insurance FMO's.
See: BGA 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, VBT.
Normally the place you would most handily find the RMD tables is IRS Publication 590-B, "Distributions from Individual Retirement Arrangements (IRAs)." https://www.ssa.gov/oact/STATS/table4c6.html
https://www.irs.gov/irb/2020-49_IRB#TD-9930
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. https://www.ssa.gov/oact/STATS/table4c6.html
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, VBT https://www.ssa.gov/oact/STATS/table4c6.html
Limited English Proficient (LEP)A conclution that may create eligibility for interpreters for Marketplace and CMS and Medicaid plan eligibility and enrollment. 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
Line of Athority (LOA)Jargon used to define what types of insurance an agent is licensed to sell in a particular state. I.e L&H is Life and Health, and P&C is Property and Casualty 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 (Accelarated Payments)A term used by some life insurers featuring early death benefit payouts for terminally ill insureds. See: Viatical Living Benefits (Terminal Illness Rider)particla Death Benefit paid to an insured with a life ending diagnosis, prior to death. Typically total amounts payable in the last two years of (expected) life are available for various medical an palliative care. THese are not always straight forward, and can combine with LTC benefits in combined life-LTC policies.
Policy eligibility provisions are pretty specific.
See: Viaticals, LE, Life Settlements, etc. 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 (ADL's) that are considered “custodial" (not acute hospital inpatient or outpatient care, and where the patient-member is not getting better after a 30 - 60 day SKF-home health insured period) and excluded under typical major medical (Accident and Health) insurance policies. Medicare pays for some of these "eligible rehabilitative expenses" (where the person is getting better) AFTER an eligible 3 day inpatient hospital stay, and with a physician's order for rehabilitation (restorative) care, up to a 30-60 day limit, but does not insure LTC as a rule, so speak with a pro to know your exposure.
There are essentially two types of LTC policies. One finances a big bucket of cash like $250K, and can be spent as LTC expenses are incured wihtout daily limits. The second tiype insures a policy max (like $250K, but can only be spent UP TO a DAILIY maximum set in the policy, like $250 per day). Do the math: $250 x 30 days x 12 months = $90,000/year of insurance). The second type if far more common because it costs lots less than the first type.
see: Custodial Care,
Originally, ACA back in 2010 included a LTC mandated coverage, but it got deleted because of the added cost to fund it. CA link below offers some insight to fixing the problem of covering the uninsured. Pay attention to the $144K per person benefit, and that is very expensive. in 2023, the cost to care for a person in a nursing home that cannot get out of bed is over $12,000 per month. https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201920200AB567
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/IRF-Quality-Reporting/Downloads/IRF-Provider-Preview-Report-Access-Instructions.pdf https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/LTCH-Quality-Public-Reporting.html
https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDAsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjAyMDEuNTI3MjcyNDEiLCJ1cmwiOiJodHRwczovL3d3dy5tZWRpY2FyZS5nb3YvY2FyZS1jb21wYXJlLyJ9.3u9iT5q_BvtGWmdtL8zrDKU4qj6pVyZLssBhbQ7r7ls/s/35957
https://data.cms.gov/provider-data/topics/long-term-care-hospitals
Long Term Services & Support (LTSS)See: Doal eligibles and measures directed at chornic care, and try not to get confused with what Medicare-Medicaid insures, and LTC policies insure. https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDgsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMTA0MTYuMzg5MzQwMjEiLCJ1cmwiOiJodHRwczovL3d3dy5jbXMuZ292L0Fib3V0LUNNUy9BZ2VuY3ktSW5mb3JtYXRpb24vT01IL0Rvd25sb2Fkcy9EYXRhLUhpZ2hsaWdodF9I
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 for "necessary suffering", and 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 CommitteeM
MA Risk Score Medicare Advantage Risk Score is a metric CMS assigns to individual MA, and Part D insured members (HMO/PPO Medicare insured with private carriers that may also have a Part D Rx plan) that affect the premiums for those insureds. 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. Mandatory Group Reporting https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview
Mandatory Reporting See: RRE, MSP, MMSEA, GHP 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 Market-based Medicare Severity-Diagnosis Related Group weights See: Supreme Court ruling forcing hospitals to publish the best prices they contract (or customarily accept as full payment) from their biggest insurance carriers....A CMS initiative to reduce Medicare reimbursement on procedures hospitals charge Commercially insured people less than Medicare currently reimburses. Changes are coming. Marketplace - Obama Care (Federally facilitated exchange, ObamaCare, FFM, et)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 (if offered by commercial carriers) during OEP and SEP, and with APTC. The actual plan(s) and financial risk are managed by commercial carriers, not the government. SHOP plans are rarely offered, and priced so high, thay are not typically purchased by the Small Groups struggling to insure their employees.
See: ACA final Rules
"The Centers for Medicare & Medicaid Services (CMS) reports that nearly 16 million Americans have signed up for 2023 individual market health insurance coverage through the Marketplaces since the start of the 2023 Marketplace Open Enrollment Period (OEP) on November 1. This enrollment represents a 13% increase over last year, including over 3 million people new to the Marketplaces." Source: CMS Annual enrollment tends to range in the 16 - 20 million range and depends a lot on Medicaid expansion, APTC expansion, eligibility, and agent representation. The Fed's continue funding (tens of millions) distribution to on-line unlicensed "navigators" who technically do not commission on sales, but get paid for 45 day jobs enrolling people, and who are unemployed if problems come up - leaving the insured to fend for themselves without a trained advocate. Current enrollments are at about 16 million, but down from bigger years at 20 million because licensed agents cant really make a living on $25-$30 per month commissions, and dont chase people to explain highly complex: new plan designs, provider network changes, pharmacy benefits, and especially tax credit and enrollment issues.
"The table below represents activity through Week 10 (November 1, 2022–January 7, 2023) for the 33 states using HealthCare.gov and through Week 9 (November 1, 2022–December 31, 2022) for 17 states and the District of Columbia with State-based Marketplaces (SBMs).
Marketplace and Consumer Type Cumulative
2023 OEP Plan Selections
Total: All Marketplaces 15,878,982
New Consumers 3,099,387
Returning Consumers 12,779,595
Total: HealthCare.gov States 11,859,230
New Consumers 2,602,598
Returning Consumers 9,256,632
Total: SBMs 4,019,752
New Consumers 496,789
Returning Consumers 3,522,963" Source: CMS
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/CMS-9926-F-Fact-Sheet.pdf
Marketplace 150% SEP "Until December 31, 2025, APTC-eligible consumers with expected household incomes at or below 150% of the federal poverty level (FPL) can select a plan under the 150% SEP by submitting a new application or updating an existing one online at HealthCare.gov, or with the help of an EDE partner, a Classic DE partner that supports SEPs, or the Marketplace Call Center." Source: CMS https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/150FPLSEPTATIPSHEET
Marketplace 834 transaction The application following all the rules. Marketplace BAR Batch Auto Re-enrollment (BAR) - Marketplaces term for auto-re-enrolling people to their plans. Marketplace CIC "If the consumer’s eligibility application has already been completed and the consumer has received an EDN, the consumer can submit a change in circumstances (CiC), where the consumer can enter your NPN on the eligibility application. If the consumer does not qualify for a SEP when the CiC is reported (and it is not during the OEP), CMS will still send any new NPN to the issuer on an 834 enrollment transaction after completion of the CiC." Source:Marketplace Exam 2024 Marketplace Data Matching "The HHS Notice of Benefit and Payment Parameters for 2024 Final Rule finalized changes to accept the household’s income attestation when the Marketplace requests tax return data from the IRS to verify attested projected annual household income but such data is not available. Such cases often occur when household composition changes across tax years (marriage, divorce, birth of a child) or if individuals were previously below the filing threshold. All individuals receiving APTC are required to file taxes and to reconcile those payments with final annual income. Additionally, enrollees with income inconsistencies will receive an automatic 60-day extension in addition to the 90 days currently provided to allow applicants sufficient time to provide documentation to verify household income." Source: CMS Marketplace easy Pricing Plans "Within health plan categories, some plans are considered easy pricing plans. These plans are also known as standardized plan options. These plans have the same out-of-pocket costs within their health plan category for deductibles, out-of-pocket maximums, copayments, and coinsurance rates for a key set of EHB. They also include a range of benefits before a consumer reaches their deductible. For these easy pricing plans, consumers will only need to pay a copayment for services like primary care visits, urgent care visits, mental health and substance use disorder outpatient office visits, specialist visits, physical therapy, occupational therapy, speech therapy, and generic and preferred drugs – without first needing to meet the deductible." Source: Marketplace Eam 2024 Marketplace Enrollment " Enrollment in health plans for 2021 through HealthCare.gov and state-run exchanges was about 5% higher than sign-ups during open enrollment for the 2020 plan year, but enrollment remains below the 2016 peak level, according to a CMS report. The proportion of enrollees who are new to the marketplace has declined to 21%, compared with 25% in the 2020 plan year and 39% for 2016." Source: Health Affairs ===== Individual and SHOP enrollments reported by CMS, HHS, etc. https://www.cms.gov/files/document/4120-health-insurance-exchanges-2020-open-enrollment-report-final.pdf
Marketplace Learning Management System (MLMS - run by CMS)CMS's agent training site used to complete CE's for marketplace certification of unlicensed Navigators and and licensed agents and brokers.
https://portal.cms.gov/portal/
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 Notice (MOEN)A federal Marketplace notice of Open Enrollment. 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). Marketplace: APTC Eligibility (APTC Eligibility)"Eligibility for APTC with ESC
ESC is considered unaffordable for an employee 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 household income. The percentage is 9.12% for plan years beginning in 2023.
The IRS finalized a new rule on October 11, 2022, that changed the way affordability is determined for members of an employee’s family. Beginning in 2023, if a consumer has an offer of employer coverage that extends to the employee’s family members, the affordability of that offer of coverage for the family members of the employee will be based on the family premium amount, not the amount the employee must pay for self-only coverage.
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 employees or their family members actually enroll in the ESC, then they are not allowed APTC for their Marketplace coverage regardless of whether the employer plan is affordable or meets the minimum value standard." 2024 Marketplace Exam Maryland All Payor Model (MAPM)Take note:
Medicare QPP model achieving results. https://downloads.cms.gov/files/md-allpayer-finalevalrpt.pdf#page=15
Maryland Total Cost of Care (MD TOC)See: CMS Maryland Total Cost Of Care Model (MDTCOC)A Maryland model of primary care, bundled payments, and healthcare equity measures (pretty much as yet undfined) reimbursements based CMS is agressively looking at to use in other states. Mass Tort (Class Action Disputes)See: Class Action of one or more people and whose damages are monitary; or Multi-District Litigation where everyone's individual suites are consolidated into one case for Discovery (Federal Court only), then everyone can go it idependently after the first part of the process. Talk to an experienced attorney. 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. Material non-Public Information "Material Non-Public Information
Under the federal securities laws – and our Terms & Conditions – you are strictly prohibited from sharing MATERIAL NON-PUBLIC INFORMATION with any of our Clients
Non-public information is information that a company has not disclosed to its shareholders or other potential investors
Material Information – The federal courts have defined "material" information as information that
"would have been viewed by the reasonable investor as having significantly altered the total mix of information" available and for which
"there is a substantial likelihood that a reasonable investor would consider it important" in deciding whether to buy, sell or hold a security" Source: Guidepoint Maturity Learning to like what you have to do anyway. Can you say "parenting teenagers".... 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, or Out of Pocket Maximum (OOPM))For the 2024 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $9,450 for an individual and $18,900 for a family.
Medicare plans are not the same.
The maximum (annual) amount a single/family insured member must pay before their plan pays 100% of costs for eligible care - consisting of (eligible) Deductible(s), Copays, and Coinsurance payment patient liability. Not all medical insurance plans have a MOOP. Note: where care is received from out of network providers who "balance bill" the patient for the difference between the billed charge, and the allowable amount - balance billing amounts, or ineligible care costs do not attribute to MOOP, and can be UNLIMITED - subject to state or federal laws that get enforced, or PBM accurate administrative management of tiered (out of pocket) costs.
Deductibles, Co Insurance, and Copay(s) amount(s) typically attribute to MOOP.
Note: ineligible care from unapproved out of network providers or for ineligible care, including (uninsured) balance billed charges above the "contracted rate" or "Allowed amount" do not accrue to MOOP. See: RBP, Health cost share plans, Contracted rate, Balance Billing, and several kinds of ancillary medical plans. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/
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.
Overview
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.
Assurances
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: Medical plan sold whose plan document details it is not insurance.
See: Health Cost Share, and Ministry Health plans (that may or may not be 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 12-15 categories of eligible people, and coverage. According to CMS, Medicaid insures 80 million in 2021, up from about 56 million in 2013, or a growth rate of 40%. Without Medicaid, many hospitals would go bankrupt. Typically, the federal government donates 50% of a state’s Medicaid budget. Under ACA, Medicaid eligibility was expanded from 100% to 138% of FPL (it changes by President) for eligibility in states electing to expand Medicaid eligibility. 13 states elected not to expand Medicaid eligibility under ACA (make available to people earning a little over 138% FPL). The Supreme Court allowed states to bail from the ACA law causing many hospital insolvencies.
See: Home and Community-Based Services (HCBS)
http://www.cms.gov
Medicaid Continuous Enrollment "Since the onset of the novel coronavirus disease of 2019 (COVID-19) Public Health Emergency (PHE), state Medicaid agencies made policy, programmatic, and system changes to respond effectively to the pandemic. State Medicaid agencies also made changes to qualify for the temporary Federal Medical Assistance Percentage (FMAP) increase under Section 6008 of the Families First Coronavirus Response Act (FFCRA).* As a condition of receiving the increased FMAP, state Medicaid agencies were required to maintain continuous enrollment for most Medicaid (and in some cases, CHIP)* beneficiaries who were enrolled on or after March 18, 2020. Under the Consolidated Appropriations Act (CAA) of 2023, the expiration of the Medicaid continuous enrollment condition and receipt of the temporary FMAP increase is no longer linked to the end of the COVID-19 PHE. The continuous enrollment condition ended on March 31, 2023, and the FFCRA’s temporary FMAP increase will be gradually reduced and phased down, which began April 1, 2023, and will end on December 31, 2023.
The March 31, 2023 end of the continuous enrollment condition meant that state programs began to return to normal eligibility and enrollment operations, including processing Medicaid terminations for individuals who are determined no longer eligible; this return to normal operations is known as “Medicaid unwinding.”
States have up to 12 months to initiate, and 14 months to complete, a renewal for all individuals enrolled in Medicaid, CHIP, and the Basic Health Program (BHP) following the end of the continuous enrollment condition. Beginning April 1, 2023, states claiming the temporary FMAP increase under the FFCRA have been able to terminate enrollment for ineligible individuals enrolled in Medicaid, following a redetermination.
During Medicaid unwinding, some individuals will lose their current Medicaid or CHIP coverage and need to transition to other health insurance, such as coverage through a Health Insurance Marketplace®. The earliest date that impacted individuals could lose Medicaid/CHIP coverage was April 1, 2023. CMS is conducting a multi-pronged effort to help facilitate continuity of coverage for impacted individuals as they transition from Medicaid or CHIP to Marketplace coverage." Source:2024 Marketplace Exam Medicaid disproportionate share hospital (MDH)Relates to a controversial CMS regulation apportioning Medicaid reimbursements to hospitals. Medicaid eligible Coverage (MEC)"ndividuals who are determined to be eligible for Medicaid that is considered MEC or CHIP are ineligible for APTC and income-based CSRs to help pay for a Marketplace plan premium and covered services, if applicable." Source: 2024 Marketplace exam Medicaid Expansion A voluntary state expansion of Medicaid eligibility offered under ACA by the Federal Government for three years. The provision allows poor people earning under 100% of FPL 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) https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/
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 https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/
Medicaid Expansion "Under the ACA, states may expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19–64 with a household income up to or below 133% of the FPL who are not otherwise eligible for and enrolled in Medicaid coverage and are not entitled to or enrolled in Medicare Parts A or B. This is known as "Medicaid expansion."
Some states have not expanded Medicaid to this population. In those “non-expansion states,” the above consumers who have household income under 100% of the FPL may be eligible to enroll in a Marketplace plan without APTC and CSRs. However, immigrant consumers with incomes below 100% of the FPL and who are ineligible for Medicaid based on their immigration status but who meet immigration rules for Marketplace coverage may be able to receive APTC and CSRs." Source: 2024 Marketplace exam Medicaid For All A ambiguous term used differently by policital parties. The term typically refers to a one payer (Government) system, but ignores the massive federal and state (funded or regulated) EXISTING public entitlements in place now with Medicare, Medicaid, Tricare, INS, workers compensation, and PIP (no-fault) mandated coverages, reimbursement schedules and network access panels.
We currently have a quasi-free-market system that is mostly funded by the government, not the commercial carriers, and the Silver-Sunami is increasing government liability. Current MEDICARE ADVANTAGE (HM0s/PPOs), and Medicare SUPPLEMENTAL plans are ALL managed by commercial carriers, not the federal governement. (MA plan designs: Plans A-N are the same with ALL carriers, but the networks and RX designs are different between carriers), and the commercial carriers are at financial risk of budget overruns. Original Medicare is managed completely by the federal Government, and the Feds are at financial risk. Medicaid is paid 50:50 by the federal:state governemnt. Tricare is managed by the Feds for military in rural areas where provider access is unavailable, and its cost is born by the military budget. Workers Comp, and No-fault (PIP) is managed at the state level, but claims are administered-paid for by the commercial market to state schedules. The "Medicare For All" lable tends to get used by fearful people who are unwilling to do the work to understand our highly complex US healthcare system: administration, financial-risk structures, ACCESS, FEE SCHEDULES, PROVIDER PANELS, Rx, and REINSURANCE cost-benefit comparison. Me and my wife's annual COMMERCIAL (Aetna) premium is now $26,000 per year plus, an out-of-pocket max costs at $4,000. That means if we both use the plan in the same year, it could cost $30,000 EACH year, and I am insured!? See: Medicare For All.
According to CMS, Medicaid insures 80 million poor people in 2021, up from about 56 million in 2013, or a growth rate of 40%. WOW! Without Medicaid, many hospitals would go bankrupt. What has been happening for many years is poor uninsured people go to the hospital ER when they are sick. Because all hospitals are required to treat and stabilize people showing up, they do so by charging the ("self pay" or uninsured rate) maximum charge-master rate, which is drastically more then what hospitals currently accept from commercial HMO's and PPO's, and overstates the charity care. The unsustainable "premium cost-shift" charged to the commercial-insurance customar is the result. There are some very good Level Funded and ERISA traditional self funded alternatives available with experienced leadership - but, it does take an experienced expert to navigate sustainable solutions that compete with the status quo of for-profit medicine, that like good-capitalists are always interested in maximizing ROI. https://www.thinkadvisor.com/2020/02/04/what-medicare-for-all-should-mean-to-us/?kw=What%20Medicare%20for%20All%20Should%20Mean%
https://thehill.com/policy/healthcare/3826215-57-percent-support-federal-government-ensuring-universal-health-care-survey/
Medicaid HCBS Medicaid Home and Community Based Services. See: www.CMS.gov and prepare yourself for a difficult journey to understand eligibility, with Dual Eligibility (Medicare & Medicaid), and public health for the poor. See: www.CMS.gov, LTC, DI, public health administration and politics... Medical Cost Inflation A term usually reported as a percentage increase experienced in the past year on large group premiums, without adding in massively increasing deductible and out-of-pocket costs born by the insured. Some studies try and account for it, but brokers (and other stakeholders) can cause actual trend figures to be materially less, so take each estimate with a grain of salt. Some call it "Trend". Trend is typically double for stop loss premiums than for a fully insured premium an employer or individual pays. (Talk to a qualified broker to get the big differences) Historically, medical inflation outpaces CPI by 200% - 400%. 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. (and its updated version) =====================
Milliman is a company specializing in advanced medical cost analysis and trend. Milliman is well known for establishing underwriting parameters.
https://www.benefitspro.com/2024/07/17/group-medical-cost-trend-to-hit-8-in-2025-pwc/
http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2018-milliman-medical-index.pdf
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
Medical Cost Sharing Plan See: Health Cost Sharing plan Medical Group Management Association (MGMA)See: HFMA, ACHE, AHA 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)The percentage of premium paid on claims, and traditionally defined as Total Claims paid/Total Premiums. The idea is that if carriers charge too much, then after 15 months (12 months of the policy and three months run-out of IBNR) claims are paid, then if the carrier does not spend AT LEAST 80% (for INDIVIDUAL plans, or 85% for Group plans, which I think includes SHOP plans, but not sure) of the total premiums on claims, then the carrier has to refund the difference back to the people who paid for the insurnace. I do not believe it applies to "all" "Medicare" plans, but it probably does for Medicare Supplemental plans. It does not apply to the many kinds of short term medical, critical care, cancer-cardiac plans, etc. Additional items (counted in the total paid claims number) "may" be included in the "claims" number used, like quality assurance, or member wellness communication and preventive care, etc. The law-regulation mandates a refund of excess premiums paid, back to the insured when claims paid is less than 80% for individuals, and 85% for Groups (groups 1-50 ee, or 1-100 ee depending on the market).
Commissions and profit margin are not part of MLR, and neither are the tens of millions the federal government pays unlicensed Navigators Who are emplyed for only the 45 day Open Enrollment period.
(source: United Healthcare Agent advisory)
See Link for 2019 and 2022 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.
MLR does not apply to ERISA self funded employer plans.
MLR is based on legal entity, state and size of employer, and payouts are based on an aggregate of those factors – not on performance of a specific employer group or individual.
For 2021 reporting, most states use 1–50 ATNE to determine small group. Only 4 states use 1– 100 ATNE for reporting – California, Colorado, New York and Vermont." Double check COVID federal EO's, and updated regs following ARP are followed in context to emergency temporary standards promulgated by federal agencies. Source: United Healthcare Agent Advisory 2021
The bigger idea is that health care is a right, NOT a privelege. And, the federal government recognizes that carrier are NOT subject to anti-trust for sharing pricing data, and fixing prices in MANY areas of the country where only one carrier offers COMMERCIAL coverage. Carriers are blocked from buying each other and creating their own monopolies most of the time (except Aetna and Coventry merger). Anti trust has a percentage of market share limit at 20% and we hanve many carriers in MANY markets who control over 20%. SO, the feds limit profits on a quasi-free market oligopoly, which has conspired to create a healthcare system with the most advanced medical technology, at 17%-18% GDP pricing that many can not afford to buy insurance. My wife and I's Aetna premium is $26,000 per year EVERY year plus a $6,000 family out of pocket cost ($32,000 EACH YEAR if we both get sick) and I am insured? https://www.healthcarefinancenews.com/news/insurers-likely-pay-11-billion-rebates-fall
https://www.uhc.com/content/dam/uhcdotcom/en/HealthReform/PDF/Provisions/reform-mlr-external-flier-final-payout-report.pdf
Medical Reasonable Opportunity Period a time froam typically 90-95 days that an individual can resolve outstanding medicaled eligibility issues related to continued or original acceptance into Medicaid coverage. 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
Medical Science Liasons (MSLs)Jargeon used to try and capture the personal involved with merging MD expertise with IT, wireless, and state of the art technologies representing both the patient's treatments and its cost effect on it's institution(s) bottom line. Its serving two masters. 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 340B Drug Discounts https://www.hrsa.gov/opa
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.
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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)
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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.
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https://www.healthleadersmedia.com/finance/most-medicare-value-based-hospitals-will-get-more-money-2019
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, Medicare Part C)See: Medicare Part C 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 and Medicare Coordination Office (MMCO)Another CMS office tasked with coordinating Medicare and Medicaid initiatives. Medicare Benchmarks See: CMMI re: MA plan standards 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 Cancer Payment Modle (Cancer Moonshot, Enhancing Oncology Model)The Centers for Medicare & Medicaid See: QPP, VBP, etc A CMS program collecting and reporting selected quality metrics on many kinds of health care services from medical providers. I.e. Service’s (CMS) Innovation Center’s new, voluntary Enhancing Oncology Model (EOM) is intended to transform care for cancer patients, reduce spending, and improve quality of care. It is designed to test how best to place cancer patients at the center of the care team that provides high-value, equitable, evidence-based care. EOM aims to improve care coordination, quality, and health outcomes for patients while also holding oncology practices accountable for total costs of care to make cancer care more affordable and accessible for beneficiaries and Medicare, which are key priorities described in the CMS Innovation Center’s strategy refresh. https://www.medicare.gov/care-compare/
https://www.cms.gov/newsroom/fact-sheets/enhancing-oncology-model
https://data.cms.gov/provider-data/
Medicare Compare A web site showing some of the public comparative statistics for nursing homes, hospitals and other providers of care. https://www.medicare.gov/care-compare/
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 Payment Percentage See HHS qualification for federal grants to hospitals treating higher percentage of Medicare insured people. Currently:To qualify for a slice of the funding, safety-net hospitals must have average uncompensated care per bed of at least $25,000, profitability of 3 percent or less and a Medicare Disproportionate Payment Percentage of 20.2 percent or greater. (Source: Becker Hospital Review) Medicare Disproportionate Share (MDS)CMS programs to help guarantee rural hospital access to Medicare and Medicaid lives.
Medicare Disproportionate
Share Hospital (DSH) Payment
Adjustment, Medicare-Dependent Small
Rural Hospital (MDH) Program, and
Low-Volume Hospital Payment
Adjustment Issues. https://www.beckershospitalreview.com/finance/how-much-federal-covid-19-aid-are-safety-net-hospitals-getting-a-state-by-state-analysis.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_source=BHRSUN&utm_medium=email&oly_enc_id=0117J8507389D2U
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 Drug Price Negociation "For decades, Americans have spent more on prescription drugs than people in other countries — paying two to three times more for the same drugs. The Biden-Harris Administration has made lowering high prescription drug costs in America a key priority, and the Inflation Reduction Act makes changes to Medicare so that millions of people with Medicare will spend less on their prescriptions. For the first time ever, the HHS Secretary will be able to negotiate directly with drug manufacturers for prices of prescription drugs on behalf of Medicare, starting with a selection of 10 high-cost Medicare Part D drugs." Source: CMS https://www.cms.gov/files/document/drug-price-negotiation-timeline-2026.pdf
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 (Authorized) Allowable rate versus (much higher - about 120% - 240% of Medicare allowable) 100% of the Medicare (RBRVS, or DRG, etc.) pricing schedule participating providers cannot balance bill (above). Most do not understand that "Original Medicare" insures only 150 Days, plus about 20 more days per LIFETIME (not unlimited QHP in ACA qualified plans mandated by ACA law), 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" (individuals personally paying a premium for the insurance) 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 COMMERCIALLY priced Marketplace plans, "participating" providers will have to function on less revenue from Medicare For All plan members. We can expect the AMA and AHA will act to protect their special interest group. 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 in the shorter term(s), and viability of competing commercially offered plans. We would not bet on hospitals being able to indefinitely "cost-shift" higher commercial premiums to broke people, so it means getting lots better at reducing costs to keep the small town hospital solvent.... https://providerrisk.com/articles/index.php
https://www.cbo.gov/publication/57020?utm_source=feedblitz&utm_medium=FeedBlitzEmail&utm_content=812526&utm_campaign=Express_2021-04-07_14:30:00&utm_medium=FeedBlitzEmail&utm_content=812526&utm_campaign=Express_2021-04-07_14:30:00
https://www.beckershospitalreview.com/finance/state-by-state-breakdown-of-897-hospitals-at-risk-of-closing.html?origin=BHRSUN&utm_source=BHRSUN&utm_medium=email&utm_content=newsletter&oly_enc_id=0117J8507389D2U
Medicare For All (Buy-In to Medicare)A term used by many that typically means allowing everyone to buy insurance offering Medicare participating provider networks, with (ACA QHP benefit levels, not current Medicare Part A, B, C, D offerings), but whose benefits are insured to the MA limited (days, etc) amount, and not HMO/PPO/EPO, etc contracted rates. So far it pretty much focuses network access/eligibility to such participating Medicare provider networks to people over 50, however Biden's new bill is attempting to lower Medicare eligibility to 60 from 65. Its just a bill, and whether it is totally or partially funded by the federal government is not defined yet... There is no doubt that premiums for 60 - 64 year old people are astronimically high. Mine (and wife) is about $24,000 a year with a $6,000 family deductible. (that means $30,000 out of pocket costs PER YEAR, EVERY YEAR, and I am insured?! It is impossible for anyone to ignore current pricing that without the ACA APTC's, millions would not purchase insurance, and MANY more hospitals would face insolvency, even many big hospitals without massive endowments.
Medicare for all is not typically described as a total federal entitlement give away. People would pay (like now under ACA APTC) more or less depending on AGI/MAGI.
See: Articles at www.providerrisk.com, click, ARTICLES
There is no question it would cost people a lot less because the provider reimbursement rates would be a lot less, so we can expect AMA and AHA push back. Current research (accross the board for all medical charges comparison) detail Medicare authorized payments are about 240% less than commercially insured payments - and for the same procedures. Price for insurance is directly tied to expected claims schedule, so it can dramatically change premium pricing.
It gets complicated...
See: Articles, at www.providerrisk.com https://providerrisk.com/articles/index.php
https://www.kff.org/medicare/issue-brief/limiting-private-insurance-reimbursement-to-medicare-rates-would-reduce-health-spending-by-about-350-billion-in-2021/
https://www.cbo.gov/publication/57918?utm_source=feedblitz&utm_medium=FeedBlitzEmail&utm_content=812526&utm_campaign=Express_2022-05-16_14:30:00&utm_medium=FeedBlitzEmail&utm_content=812526&utm_campaign=Express_2022-05-16_14:30:00
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. Using the Medicare networks is lots less expensive than using commercial HMO/PPO networks that pay doctors and hospitals more. Medicare LAN See: LAN 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 National Correct Coding Initiative (NCCI) https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare
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.
Source: 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 Open Payments https://www.cms.gov/openpayments
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 Outpatient Surgical Care Rule (Out Patient Surgical Care Rule)A rule by CMS, (with some kind of bearing to an EO) that requires some surgeries to be performed in certain settings to be eligible for CMS reimbursement. https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-9913-F.pdf
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))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, or not per an annual doller limit like regular medical insurance), and that also insures eligible hospital-outpatient care, up to 100 days of 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. In short, "Medicare Part A insures
inpatient hospital, inpatient rahabilitation services offered at skilled nursing facilities, and some home healthcare. Original Medicare Part A allows the beneficiaries to go to ANY doctor who accepts the Medicare authorized maximum payment.
Medicare part A does not pay for most out-patient drugs (except under a separate paid for Part D), or annual physical exams beyond one physical a year. It 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 care is typically excluded, but it gets squirrelly to figure out.=================
People who have not paid into the system can purchase Part A for about relatively small premium, and can purchase Part B. These rates are massively subsidized by the government, and cost shifting to the commercial medical premium paying market
ORIGINAL medicare (Part A) does pay for care to non participating medicare physicians, but exposes the member to balance-billing where that physician bills higher then the Medicare authorized amount.
=========Per AARP: Part A "There usually is no monthly premium, but you'll pay the forst $1,632 (deductible) for most hospital stays (in 2024) before coverage gets started. In general, Part A will cover most, if not all costs of a stay of 60 days or less. (the point here is that Original Medicare insures a limited number of days, unlike most health insurance policies that insure an unlimited annual dollar limit. http://www.ssa.gov/medicare/mediinfo.html
https://www.cms.gov/newsroom/fact-sheets/2023-medicare-parts-b-premiums-and-deductibles-2023-medicare-part-d-income-related-monthly
Medicare Part B (Part B Doctor Coverage)Medical insurance covering doctor visits, and other outpatient care, plus ampulance services, some medical equipement and preventive ("wellness" or care to help the member NOT get sick or sicker) care. Part B is a Federal medical insurance for people over 65 that pays primarily for physician services, and some outpatient hospital services. Medicare Part A pays for Hospital services. Recent changes to Medicare now offers extended benefits for "Dual Eligible" (Medicare and Medicaid eligible) lives and pays for things like food after a hospital stay, transportation to medica appointments some medications, some in home care that used to be considered LTC care, and in some cases, grocery funds for poor people who have not recently been in the hospital. Its complicated and involves dealing with Medicaid and Medicare simultaneously.
Part B typically is paid as an automatic deduction from ones social security pension payment. Those that fail to elect to start the monthly deductions (at age 65) are penalized about 1% per month for every month they fail to elect coverage (and for life).
Eligible persons wishing to elect a low cost Medicare Advantage (Medicare part C plans: HMO or PPO that insure Hospital, Physician, and typically include 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. ========= Per AARP: The monthly premium for 2024 is $174.20 (based in income, if you get social security, the premium will be deductied from each monthly check). Other costs: coinsurance of 20 percent of approved charges, plus possible deductibles. See: AARP explanation, Medicare Interoperability, Special Enrollment Period https://www.cms.gov/newsroom/fact-sheets/2023-medicare-parts-b-premiums-and-deductibles-2023-medicare-part-d-income-related-monthly
https://www.federalregister.gov/documents/2020/12/28/2020-26815/medicare-program-cy-2021-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part
https://www.cms.gov/files/document/reduced-coinsurance-part-b-rebatable-drugs-oct-dec-2023.pdf
Medicare Part B Penalty A 10% increased premium penalty for EACH after age 65 that an eligible member fails to enroll in Medicare Part B - for life of buying Medicare Part B. I.e. 10% if buying it, starting at age 66, and 20% if starting at age 67...for life. (2024 premium is about $145/month, and Part B deductible is $240-$174/yr depending on income.) See: Special Enrollment Period Medicare Part C (Medicare HMO & PPO plans with Network access requi)Legislation enacted to offer HMO, PPOs, and MSOs to Medicare eligible people, and at $0 or very low premiums costs (Taken from the Social Security amount/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. See Medicare Shared Savings and ACO's
MA plans typically come with a Part D (pharmacy) plan attached, and at little no additional premium, unlike Medicare Supplemental plans (A-N) that mandate selection of a drug plan at an additional monthly cost of about $30 - $95 (in addition to about $250-400/m Supplemental plan premium, (and Part B premiums). MA plans typically insure additional items some low income people might desire, 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, or insure at higher out of pocket costs.
THe base difference between MA Plans (HMO/PPO) and Supplemental (Medigap plans) is that MA plan typically require seeing network contracted providers, and Supplimental insurance (plans A-N) allow seeing any provider, but only insures up to the Medicare ALlowable amount - meaning the insured will be exposed to balance billing.
Selecting a MA plan (HMO/PPO) 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 (Medigap) plans. There can be big differences in formulary Tier Copays on certain drugs selected from HMO and PPO plans. Remember, the Tier copay can change DURING the year without much or any notice. ========== https://www.cms.gov/newsroom/fact-sheets/2023-medicare-parts-b-premiums-and-deductibles-2023-medicare-part-d-income-related-monthly
Medicare Part D (MA-PD, Medicare Prescription Drugs coverage)A stand alone Drug plan required to complete coverage for Medicare Supplemental (private insurance for any Doctor or Hospital care, up to the medical authorized amount) insured people. These plans are offered-managed by commercial carriers, but supervised by the Feds. There are no HMO/PPO networks in Medicare Supplimental plans, and each insured can use any willing provider (physician or hospital) who can and do balance-bill the patient. Most drugs are insured to a fee scheduled amount, but it is always safe to ask what they are charging and confirm the Medicare Authorized reimbursement is accpeted as full payment by the carrier, so a surprise bill, or balance bill is not recieved unexpectedly. Formularies and Copay Tiers are different among the carriers. In some instances, MA-PD plans are also available at extra cost for MA PPO plans. Most Medicare Advantage plans insure pharmacy coverage, and do not require Part D separate election. and monthly premium obligation.
See link for 2022 deductibles and Copay obligations.
Know that there are significant differences in formularies, copays and what attributes to maximum out of pocket cost (liability) between plans. Its get very squirrely trying to figure out if there is a true MOOP within MA plans that have very high Tier 4 or 5 Copays, and if ALL of the out of pocket costs attrigute to MOOP. Find an experienced agent. Do the work to understand what you are buying.
See: Credible Coverage Medicare Coverage Gap Discount Program.
https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2792763
https://www.cms.gov/newsroom/fact-sheets/2023-medicare-parts-b-premiums-and-deductibles-2023-medicare-part-d-income-related-monthly
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 Payment Advisory Commission (MedPAC) Medicare Physician Fee Schedule Final Rule (PFS Final Rule)"Physician Fee Schedule Update
On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):
• Provided a 3.75% increase in MPFS payments for CY 2021
• Suspended the 2% payment adjustment (sequestration) through March 31, 2021
• Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
• Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024
CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage". Source: CMS
See: PFS, MSP, MA-PD, Medicare Part B https://www.cms.gov/newsroom/fact-sheets/final-policies-medicare-diabetes-prevention-program-mdpp-expanded-model-calendar-year-2021-medicare
https://public-inspection.federalregister.gov/2021-14973.pdf
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. See: MSSP, ACO, etc 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. CMS also calls it Medicare Savings Programs (MSPs), in which states cover Medicare premiums and/or cost sharing for
low-income people with Medicare.
Typically, it refers to the oftentimes contentious subrogation issue(s) of 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
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-User-Guide/NGHP-User-Guide
https://www.cms.gov/files/document/benefits-coordination-recovery-center-non-group-health-plan-beneficiary-recovery-process-webinar.pdf
Medicare Secondary Payer Act (MSP)MSP regulation is recently fortified. See: Updates to the act
See: Subrogation
Know that Medicare lien resolutions both plaintiff and defendant are big business, and a negotiated processes of hospitals trying to get paid timely to an acceptable reimbursement. Also know that hospitals charge on average about 240% more for commercial patients than they do for Commercial patients. Lots of rules to follow.
See: NGHP for subrogation, GHP, CRC, CRCP, 42 USC 1395yb https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Medicare-Secondary-Payer/Medicare-Secondary-Payer.html
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Group-Health-Plan-Recovery/Group-Health-Plan-Recovery
https://www.cms.gov/files/document/technical-alert-implementation-provide-accurate-information-directly-paid-act.pdf
Medicare Secondary Payer Mandatory Liability Insurance (MMSEA)Subrogation rules relative to Medicare beneficiaries COB of No-Fault (PIP), 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, GHP, CRC, CRCP https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Group-Health-Plan-Recovery/Group-Health-Plan-Recovery
Medicare Sequester A program of continuing a delay in implementing a 2% reduction of Medicare Authorized reimbursements to providers who are not incompliance. See:
QCDR, MIPS, QPP, etc. Congress must re-approve it, to not have a 2% reduction. 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 Set Aside Arrangements (WCMSA)A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease. These funds must be depleted before Medicare will pay for treatment related to the workers’ compensation injury, illness, or disease. https://www.cms.gov/medicare/coordination-of-benefits-and-recovery/workers-compensation-medicare-set-aside-arrangements/wcmsa-overview
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 set FFS budget for that population. When it comes in less than FFS, then they split the savings with the feds. These contracts require medical providers to earn less than a FFS equivelent if they are unable to manage the care of the "capitated" population under the budget, and are typically managed over a three year term. See ACO contract. See: Medicare Shared Savings. See: ACO, MACRA, QPP, etc.
"September 02, 2021 - The Medicare Shared Savings Program (MSSP) saved over $4 billion in 2020. Between the $1.9 billion in Medicare savings and $2.3 billion in accountable care organization (ACO) savings, this represents the program's best performance to date." Source: Revcycle Intellegence 9/2021 https://qpp.cms.gov/docs/QPP_MSSP_and_QPP.pdf
https://revcycleintelligence.com/news/10-acos-with-the-highest-shared-savings-payments-in-2020
https://data.cms.gov/resources/performance-year-financial-and-quality-results-methodology-2021
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 Spending "The result, the CBO estimates, is that combined spending on Social Security and Medicare will almost double by 2033, when required funding for the two programs will approach $4 trillion, representing more than 10 percent of the country’s total economic output.
Another consequence, said CBO Director Phillip Swagel, is that Social Security now faces a funding shortfall in 2032 — two years sooner than the previous projection. " "Democrats such as Biden and Larson have floated a series of tax hikes on the wealthiest taxpayers to cover the shortfalls, including a proposal to apply the Social Security tax — which is currently capped at earnings up to $160,200 — to much higher incomes." "Social Security spending will almost double, from $1.2 trillion in fiscal 2022 to almost $2.4 trillion in 2033, the CBO estimated. As a percentage of gross domestic product (GDP), it will grow from 4.8 percent to 6 percent over that span. The jump begins immediately, with a $123 billion increase in fiscal 2023, a 10 percent spike, largely due to the large, 8.7 percent cost-of-living increase for Social Security beneficiaries that took effect last month.
Medicare spending will more than double over the same span, from $710 billion in the last fiscal year to more than $1.6 trillion in 2033, when it will represent 4.1 percent of GDP, the CBO reported.
Spending on other mandatory health care programs, including Medicaid, the Children’s Health Insurance Program and ObamaCare subsidies, will also rise significantly, from $695 billion in 2022 to $1 trillion in 2033, the CBO said." Source: The Hill 2/21/23 https://thehill.com/finance/3860012-cbo-warns-of-sharp-uptick-in-social-security-medicare-spending/
Medicare Spending 2020 "...Medicare spending accounted for 20% of US health care expenditures in 2020 and 12% of the national budget, while Medicare benefit payments rose from $200 billion in 2000 to $769 billion in 2020, representing a 7.1% annual growth rate. Medicare Advantage is expected to account for 54% of Medicare spending by 2030, up from 46% last year, while Medicare enrollment is predicted to increase to 93 million in 2060 from 63 million in 2020." Source: Beckers Payer Issues 4/28/22 https://www.kff.org/medicare/issue-brief/higher-and-faster-growing-spending-per-medicare-advantage-enrollee-adds-to-medicares-solvency-and-affordability-challenges/
Medicare Summary Notices (eMSN's) Medicare Supplemental Insurance (MediGap)Private commercially available indemnity insurance run by commercial carriers, not the federal government. Federally stipulated plans A-N Plan designs are standard by CMS, but run by commercial carriers in all states. Medicare Supplemental plans are not run by the government, and are run by commercial carriers. Plans are quarantee issue to a person within 6 months of turning 65, without underwriting. MediGap plans do not have PPO or HMO networks per say, so insureds can go to any provider.
Going to a non-"participating" Medicare provider means being exposed to balance billing liability. People over 65.5 in age, and that have a preexisting medical condition can be denied coverage, and be required to seek MA plan enrollment. Most common plan is Plan F or G. Note: Newer regulations prohibit any plan from waiving Part B deductibles. A typical person electing Medicare Supplemental coverage is also required to buy both Medicare Part B AND, a Medicare Pharmacy plan.
Cost for Medicare Supplimental plans differs by age, sex, and location and is about $33 - 450/month. (Part B and Part D PBM premiums are deducted from one's social security check.
"In practice, the MACRA Medigap deductible provision means that many people who, in the past, would have bought Medigap Plan F or G 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.
See: Balance Billing https://www.cms.gov/Medicare/Health-Plans/Medigap/index.html
https://www.cms.gov/Medicare/Health-Plans/Medigap/index
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 and Marketplace Strategy (3 M's) https://www.cms.gov/files/document/cross-cutting-initiativesintegrating-3ms-fact-sheet.pdf
Medicare-Medicaid Coordination Office (MMCO)See: Dual Eigibles Medicare-Medicaid Coordination Office (MMCO)Good luck. Member Experience Score (MEF)A patient satisfaction percentage score or term used by some HMO/PPOs that causes a provider bonus payout of sorts, if example it is above 85%. Its unique to each managed care organization's incentive structure. 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. MemberMonths The number of months a premium was paid on a group of individuals insured by an employer. It is primarily an underwriting term used to detail paid premium, that is provided by the broker to the carrier to rate stop loss premiums of an annual term. Mental Health / Substance Use Disorder (MH/SUD) Mental Health Parity Addition Equity Act (MHPAEA 2008, Mental Health Parity)See: Mental Health Parity and Addiction Equity Act of 2008, NQTL , CAA 202, NQTLs,Non-Quantitative Treatment Limitations Good luck https://www.gao.gov/products/gao-21-437r
Merrit Based Value Pathways (MIPS-VP)Key areas CMS is trying to get the best outcomes at the best price by attempting to coordinate care, or get EMB based outcome reimbursements. https://qpp.cms.gov/mips/explore-mips-value-pathways
Metal Values Term used to describe Marketplace plans from Platenum, Gold, silver, Bronze and Expanded Bronze plans denoting actuarial value pricing from 90%, 80%, 70%, and 60% to 58%-65%. Metalic Plans A CMS term used to describe four Marketplace plans types meeting Actuarial Value guidelines for coverage. I.e Bronze, Silver, Gold and Platenum whose benefits insure MLR at prescribed Actuarial Value customer out of pocket costs. Bronze pays the least, but the premium is lower too. See: Actuarial Value Midwife (Doula) Milliman Advanced Risk Adjusters (MARA)Estimates multiple levels of care types for Medical Commerical and Medicaid populations. 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. Mineral (UHC's 2 - 99 group HR offering)Mineral™ will be included with your small business (2-99) clients’ UnitedHealthcare plan to help them handle a wide array of human resources and compliance issues. Source: UHC https://cdnapisec.kaltura.com/html5/html5lib/v2.83.2/mwEmbedFrame.php/p/2297431/uiconf_id/40040682/entry_id/1_8rhoqqk3?wid=_2297431&iframeembed=true&playerId=kaltura_player&entry_id=1_8rhoqqk3&flashvars%5bstreamerType%5d=auto&flashvars%5blocalizationCode%
http://www.trustmineral.com
Minimal Common Oncology Data Elements (mCODE)Codes used by researchers, practioners, government, and others to hopefully agree on key cancer data elements (nomenclature) for greater interoperability effectiveness. Just who is the gate keeper is part of the process. 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.
"Sec. 2711. No lifetime or annual limits. Prohibits all plans from establishing lifetime or unreasonable annual limits on the dollar value of benefits.
Individuals who lost coverage under a plan because they reached the lifetime maximum must be given notice that lifetime limits no longer apply and be given a special enrollment period for enrollment under the same terms and conditions as a similarly situated individual who did not lose coverage because they exhausted a lifetime limit.
In order to mitigate the potential for premium increases for all plans and policies, while at the same time ensuring access to essential health benefits, this provision was phased in, with no limits (as required by the law) beginning in 2014 and the following limits during the phase-in period.
Annual limits on essential benefits are limited to:
$750,000 for plan years beginning 9/23/2010-9/23/2011.
$1.25 million for plan years beginning 9/23/2011-9/23/2012.
$2 million for plan years beginning 9/23/2012-12/31/2013.
The restricted annual limits are designed to ensure, in the vast majority of cases, that individuals would have access to needed services with a minimal impact on premiums. So that individuals with certain coverage, including coverage under a limited benefit plan or so-called ‘‘mini-med’’ plans, would not be denied access to needed services or experience more than a minimal impact on premiums, the regulations provide for the establishment of a program under which the requirements relating to restricted annual limits may be waived if compliance with these interim final regulations would result in a significant decrease in access to benefits or a significant increase in premiums." Source: 2022 Florida Agent Licensing Exams Minimum Aggregate Deductible Typically means, the lowest possible Aggregate (stop loss) Deductible applicable to the Contract Period or fraction thereof. See: ASD, etc. 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.=====In context to SHOP plans, MPR is 70%, but rules on MPR are different during Open Enrollment. Rates can differ by state. Minimum Premium A term used to describe the lowest premium amount a carrier feels justifies underwriting, administrative, profitability and risk charges or "loads". This can also mean a kind of level-funded medical plan pricing structure with or without profit sharing or "surplus" shararing. See: MVP and know the differences between fully-insured, self insured, ACA compliant EHB, etc. 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)An RBS medical product that is not (usually) insurance. 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, Health Cost Share plans, RBS plans, etc.) Some of the early marketing efforts had people calling and detailing eligibility was contingent upon being a follower of Christ. 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 with limited benefits in key areas of EHB (i.e. surgical services, hospital charges, ER, Rx). 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 at about 240% of MA amount) "self pay, or Bad Debt" amount charged by many providers who do not accepting RBP. Religious affiliation may not be a requirement but is usuall part of the marketing process for "ministry" plan sales. See: Balance billing, RBP, Medicare Authorized charge, STM, Risk Bearing Entities, etc. There is no universally accepted 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. Several states have specific law affecting these less expensive plans. 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.
MIPS (2023 Quality ICD-10 Quality Measures)10% of the ICD-10 coding measures for hospital charges were changed (in 2024) by CMS to better comply with the 9 - 12 month reporting requirement, and to ease provider frustration and compliance concerns. Easing is in the eye of the beholder required to submit quality measures, or risk not getting paid by CMS, getting in trouble with CMS thereby threatening CMS participation eligibility. See: CMS MIPS MIPS Extreme and Uncontrollable Application (MIPS EUA QPP)QPP guidelines can change each performance year. https://qpp.cms.gov/mips/exception-applications?py=2021
https://qpp.cms.gov/mips/apm-performance-pathway
https://mail.google.com/mail/u/0/#inbox/FMfcgzQVzFbDzXtpPVpPTzzfpdhSDttB
Mission Toot hClause A Dental Plan provision excluding dental implant insurance where the targeted site already has a missing tooth. Dental plan require studying limits, exclutions and waiting periods. Most dental INSURANCE (not discount plans) mandates a 1 year waiting period for extensive dental procedures like root canals, crowns and implants (where insured). 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 Duty Options A term used when an injured worker returns to work at lesser ability function while in recovery, and typically accompaning an adjustment to his workers compensation dissibility income beneifit. The goal is to get the worker back to work and productive. 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 Monthly Income Protection See: Term life insurance product option that pays death benefits in the form of a Monthly Income Protection benefits stream. Final Expense (for funeral costs) can be added as well for additional premium.
This is not a annuity like product that guarantees a fixed percentage (See GMIB sometimes called an "income Roll- up percentage credited when the annuity owner elects forced annuitization) of the annuity total each year that the beneficiary uses as income that cannot be outlived. Life insurance policies can also be endorsed with LTC provision for extra premium too. Rules and premium charges governing these kinds of offerings from converted Term policies to Whole Life (or UL) policies vary amoung carriers. 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 Mrketplace User Fees (FFM and SBM-FP User Fees)For the 2024 benefit year, CMS is finalizing a user fee rate of 2.2% of premium for QHPs sold on the FFMs, and a user fee rate of 1.8% of premium for QHPs sold on the SBM-FPs. We anticipate these user fee rate decreases may exert downward pressure on insurance premiums for consumers. https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-final-rule
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 Year Guaranteed Annuities (MYGA)A general term used to describe annuities structured to provide income for life. Income for life annuities (almost always) guarantee interest accrual at a substantially higher interest rates than the same annuity earns without forced annuitization. Think of it as two columns earning guaranteed interest, with the income for life being much higher than the fixed rate stated in the asset. The catch is that it might guarantee 8% (ie. versus a standard 4%, but only allow a maximum of 5% (or 3%-4% distribution depending on age of the beneficiary at income distribution start). Do the numbers (with tax expense) at 5% dispursements over a 20 - 30 year bases, and compare it to... (call for details). Annuities using qualfied funds come with senior suitibility requirements and fiduciary duty obligations regardless of broker-dealer licensure designation. Multi-factor Authentication (MFA)A term that can mean many things, but mostly refers to at least two identity matching processes to confirm a log in, or access to account access, or PII. ****
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. Cee: CMS MFA multi systems access. https://www.cob.cms.hhs.gov/CRCP/
Multi-Factor Authorization (MFA)A security process of sending ID identifiers to multiple devices. I.e. texting a security code to input into a log in site before accessing the log in credintials. 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, Open MEP, closed MEP, Common Interests, ARP (essentially a MEP). See: ACA Section 6606 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 context to applied stop loss coverages, aggregate and/or 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 from state insurance solvency and licensing regulations. The grey area is where some states prohibit plans without Certificates of Authority, and federal law(s) allow them accross state boarders. Of the protected classes ERISA legislation governs: (Associations, Trusts, Self funded Employers and Unions), MEWAs are rare, and so are MEPs. (See: Trum Executive Order allowing MEPs accross state lines which is nothing innovative) 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 primary 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. Participating employers may not fully appriciate group's evolving riskk(s), so experienced brokerage-consulting is advisable, if not essential. ERISA details high levels of potential liability for Plan Sponsors, Employers, etc. 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 are a couple of key reinsurance/stop loss provisions that satisfy State DOI requirements for Certificates of Authority. There is long history of states aggressively moving to eliminate MEWA's not meeting state solvency and transparency standards compliance, regardless of federal ERISA supersession. 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 fund predictable first and second dollar risk positions. Structuring reinsurance (or stop loss) placement takes real experience, and carrier appetite to insure sustainable committment and tenure.
ERISA plans enjoy greater flexibility of benefits to employees in context to SPD. Presidential Executive Orders, and DOL agency non-enforcement of ACA law agenda cloud compliance consideration(s).
We strongly 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, legal, or accounting advice. https://www.gpo.gov/fdsys/pkg/FR-2018-06-21/pdf/2018-12992.pdf
https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/publications/compliance-assistance-publication-ahp.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. Musculoskeletal Disorders (MSD's)A term typically used in context to a workers compensation claim or injury, and that are reported to be about 1/6th of all US health care spending... "The annual cost of musculoskeletal disorders (including health care costs and lost worker productivity) is around $600 billion, which is greater than heart disease ($309 billion), cancer ($243 billion) and diabetes ($188 billion)." Source Risk & Insurance article "This Employer Reduced MSD's by 86%. 7/27/22N
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 Association of ACOs (NAACOs)See; VBP https://www.naacos.com/assets/docs/pdf/2024/PlaybookVoluntaryBestPracticesVBCPaymentArrangements.pdf
National Association of Independent Life Brokerage Agencies (NAILBA) National Association of Insurance and Financial Advisors (NAIFA)One of many associations for insurance and financial professionals. NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)One of the main federal committees charged with establishing and certifying medical care standards. issue reports annually. NCQA’s Health Plan Ratings (2022) include commercial, Medicare, and Medicaid health plans. The overall rating is the weighted average of a plan’s HEDIS® and CAHPS® measure ratings, plus bonus points for plans with a current Accreditation status as of June of the subject year. https://www.ncqa.org/hedis/reports-and-research/ncqas-health-plan-ratings-2022/
National Correct Coding Initiative (NCCI)See Link. It also refers to the workers compensation organization tasked with setting MOD's for "class" comp rates, and regulations. https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci
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
KEY TAKEAWAYS
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 Emphasis Program (NEP)See: OSHA https://www.osha.gov/sites/default/files/enforcement/directives/DIR_2021-01_CPL-03.pdf
National Flood Insurance Policy (NFIP) National Healthcare Policy The link is for CMS's Medicaid and Medicare, but it leads what becomes policy for commercial carrier reimbursements and managed care ... See: QPP, VBR https://innovation.cms.gov/strategic-direction-whitepaper
National Insurance Producer Registry (NIPR)The Federal agency that assigns a six digit ID national number for each licensed insurance agency. 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 Insurance Registry (NIPR)The federal agency that assigns already licensed agents (in their domiciled state) a 6 digit number called the National Producer Number. National Producer Number (NPN)Federal ID number assigned to each state licensed agent who sells medical insurance. https://data.healthcare.gov/ffm_ab_registration_lists
National Quality Forum (NQF)A medical expert forum that publishes maximized clinical practice standards. See HEDIS NavigateNOW (UnitedHealthcare NavigateNOW)United's Level Funded agent/employer on-line administrative portal.
"Introducing NavigateNOW
Introducing UnitedHealthcare NavigateNOW, a level funded health plan offering for new business (5-300) in select Florida counties with June 1, case effective dates. NavigateNOW is a new virtual first health plan that offers a single, digital entry point to medical, behavioral, and pharmaceutical services that begin virtually and move to in-person when necessary. You can begin to quote NavigateNOW plans today.
About NavigateNOW
NavigateNOW was created to be a part of your clients’ overall health plan offerings and must be paired with a standard UnitedHealthcare Level Funded health plan.
• Designed for convenience, and affordability, NavigateNOW offers quicker access to care with online scheduling and same day appointments. On average, NavigateNOW is 15% lower cost than a UnitedHealthcare Level Funded Choice Plus plan1.
• With NavigateNOW, care begins with the member’s virtual primary care provider (PCP) and connects to other care providers, such as behavioral health specialists, at the touch of a button. The virtual PCP is supported by a personal Care Team that helps coordinate other services that may be needed, including in-person care with local providers that are in UnitedHealthcare’s broad Navigate Network. The Virtual Care Team is comprised of clinical and non-clinical staff, can be accessed 24/7, and provides white glove service to member’s care needs.
• All NavigateNOW plans have $0 copays for primary care visits, behavioral health visits, virtual visits for urgent care, and Tier 1 prescriptions" Source United Healthcare agent advisory
Navigation Services See: RBP in context to contracts held directly by carriers, hospitals, employers versus by venders offering their networks. I.e. Claims handling services, pricing models (DRG, case rate, FFS, bundled payment, gain-sharing agreements, risk based, capitation, VBP, quality metrics, provider access, outcomes, EBM, etc) See: Healthcare Advocate Navigator (Certified Application Counselers, Assistors)A CMS term for an unlicensed person who helps a person enroll in a Marketplace offered health plan, and who is typically employed for 45 days of the year (during OEP), and unable to be called directly by any of the people they enroll. These temporary employees will not divulge their location, last name, or call back number where they can be reached. No one seems to know if an Assistor is certified with an exam passing (like agents are required) to handle PII, and all the complicated highly regulated confidentiality and security agreements (and exams) mandated by the same entity making mandated for licensed agents. === Good luck!
Organizations (private for profit companies) that are approved by and receive grants from the Marketplace have certified Navigators who, among other things, assist consumers in applying for and enrolling in health coverage through the Marketplace." Navigators are prohibited from commissioning on health plans sales, but we can tell if they commission on the Dental plan sale? "Health insurance and stop loss insurance issuers and their subsidiaries are expressly prohibited from being Navigators." Source: Marketplace Exam
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) Navigator Notice of Funding Opportunity (NOFO)$80 Million funding to help distribute Marketplace individual and SHOP plans. See: Navigator, and know that most are unemployed after 45 days of Open Enrollment, and none will give their last name, the supervisors last name, or a direct contract number for any accountability. 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 Adaquacy Health Professional Shortage CMS funded 200 residency slots funded a year for five years by CMS where Health Professional Shortage Areas dictate as defined by CMS https://www.cms.gov/newsroom/press-releases/cms-awards-200-new-medicare-funded-residency-slots-hospitals-serving-underserved-communities
https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page
Network Adequacy Marketplace Plans Federal and or State defined minimum standard for QHP eligibility.
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 Marketplace Exams See related Essential Community Providers regulations by CMS, Professional Shortage Areas, IPPS, critical access hospitals, and realted Medicare funding of Primary care residency slots. See: SECURE ACT federal policy statement https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-03027.pdf?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery
https://www.cms.gov/newsroom/press-releases/cms-awards-200-new-medicare-funded-residency-slots-hospitals-serving-underserved-communities
Network Performance Fees A type of pay-for-performance fee that may or may not be a SPD fee for services rendered and typically insured and reinsurered (stop loss but it is changing). These fees are billed as part of the provider fees, but the fees are extra to the amounts charged by providers and tied to performance figures that are not readily obtainable - falling outside of the hospital transparancy statutes and regulations. See: Stop loss contracts Never Events Jargon used by hospitals and physicians describing avoidable events like amputating the wrong arm, or removing the wrong eye, and /or unreasonable hospital acquired infection "rates", etc. The stuff no one wants to own or be responsible for... New Engliand Journal of Medicine (NEJM)Like JAMA, a leading journal of science based medical review and effect. 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. Next-Generation Risk Adjustment Methodology that includes a zero-sum coding intensity adjustment to ensure there are no increases in payments triggered solely by coding intensity. See: CMMI https://www.cms.gov/blog/cms-innovation-center-year-review
No Surprises Act (NSA)A federal law prohibiting hospital based physicians from charging the patient separately or above what is insured IN NETWORK. In other words, charges IN NETWORK must all be feed at in-network prices, and that price is only negociated between the carrier and the billing provider - not the patient. Same goes for Emergency services OUT OF NETWORK. Jargon used by some claim administrators related to hospital based provider/services billing direct to the patient in violation of several regulations. No Surprises Act Final Rules (NSA)An act that prohibits additional charges from out of network (non contracted) providers to the patient for services rendered in the patient's in network (contracted) facility. Common provider conflicts typically occur with ER physicians, radiolotists, ambulance companies, pathology (labs from the ER). One component that portends difficulties to plans, and Plan Sponsors is that the act does not specifically limit an unreasonable charge to a common standard like (a percentage of) the Medicare Allowable amount to R&C, or even the commonly accepted amount paid to providers in a specific zip code. (Remember, Hospitals must publish their best contracted prices per a a regulation, that many fail to do, or have never done in material manner.)
See: IDR (Independent Dispute Review, part of the NSA managed process rendering a decision on disputed bills, and keeps the patient out of the process, especially on out-of-network billings) a process submitted through a centralized process of a billing dispute that is designed to solicit an offer of payment. Notice is key to the process, and the process of "open negotiations" is not tracked. I.e. if the provider elected to file incorrectly (to defend his bill), or at all, to determine response. Good luck re: default judgements. So, if the provider just not respond more then just saying IDR is in process, good luck. The NSA has no enforcement protocols. IDRs have six factors: Training of the provider, market share, teaching status, sickness acuity, demonstration of past efforts to enter into payment contracts, etc.
There are other rules, like paying fees withing two days... Batching of claims limits, etc. Manufacturer coupons (see: CSR and be careful NOT applying available discounts), providing assistance on out-of-pocket employee costs. Self Funded plans must move cautiously ... https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act
Non Abusive Business Practices See: Final Rules Value Based contracting in context to Stark and CMS safe harbour. 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, MSP, RRE https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-User-Guide/NGHP-User-Guide
Non Public Personal Information (NPPI)See: HIPPA, and PI Non Qualified Limitations (NQTL)See: Mental Heatlh Parity. Relates to mental health benefits and procurement of services not be different then QHP mandated ACA benefits. Non Quantitative Treatment Limitation analysis (NQTLs)Federal structure to determine if mental health parity is met. Plan Sponsors have to show their work when proving they accurately and properly reduced coverage using non-numerical limits on the scope or duration of benefits for treatment of mental health beginning 2/1/21, and presumably other insured benefits. See: CAA, MHOAE, Mental Health Parity Act. See: SIIA Non Renewal In context to insurance policies, it is notice from the carrier of not offering a renewal offer. Lots of rules apply. Non Risk Patient Equivelents (NPE)A contracting term used in some managed care agreements referring to rovider (Bonus) surplus payouts to physicians (or Hospitals) who manage budgets under a targeted MLR (for FFS) or capitated arrangement. Non-Effectuated Enrollee A Marketplace enrolled customer who has not paid the premium by deadline. Molina uses the term. Non-Group Health Plan (NGHP)See: Medicare BCRC, RAR, 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
https://www.cms.gov/files/document/commercial-repayment-center-crc-non-group-health-plan-nghp-recovery-town-hall-presentation.pdf
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Beneficiary-Services/Medicares-Recovery-Process/Medicares-Recovery-Process
Non-Quantifiable Treatment Limitations Reporting (NQTL)See: CAA 2021, MHPAEA 2008, and new reporting requirements especially for MHPAEA. Non-Quantitative Treatment Limitations (NQTLs) (NQTLs)See: regulations Notice A legal term defining the amount of time an entity has to notify an assigned recipient of such notice. In context to ARP, it means an employer must notify their x employee of expiring federal premim payment assistance for covering COBRA (medical benefits extention for up to 18 months) within 60 days of that person becoming eligible for such support, and or when premium assistance will expire. For health plans, their notice of expiring federal payments of the x employees "notice of expiring benefits" (COBRA medical benefits federal subsodie) must be at least 60 days from the date benefits end. These rules are different for QSEHRA, FSA, Medicare eligibility, or if the x employee is eligible for another group medical plan, etc. Find an experienced agent. ending September 2021, eligible Medicaid, and Marketplace people are NOT eligible for COBRA subsodie, whereas people eligible for Medicare, traditional Group coverage (employer plan) or Group coverage through a spouses plan are eligible. Nursing Home Quality Measures (NHQM)See related measures
16 Quality Measures https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/NHQM-Final-Analytic-Report-2012.zip
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 Occupationtional Safety and Health Administration (OSHA)A federal agency charged with overseeing safe employee working conditions. Very important for employers to manage these regulations and avoid penalties.
2021 OSHA mandates testing and or vaccinations for employers with over 100 employees, now that the FDA approved the vaccine, and to protect the greater population from C19 death. Biden characterizes as an epidemic of the unvaccinated....
Supreme court overturned the mandate, and OSHA responded. "Regardless of the ultimate outcome of these proceedings, OSHA will do everything in its existing authority to hole business accountable for protecting workers, including under the COVID-19 National Emphasis Program and General Duty Clause." Means, be prepared to defend themselves on any harm inflicted on employees deemed negligent by current and future administrations, so probably safe to practice prudence. See: ERISA fiduciary duty of plan sponsors and cross potential application of meeting even one of the standards. https://www.osha.gov/sites/default/files/enforcement/directives/DIR_2021-01_CPL-03.pdf
https://content.govdelivery.com/accounts/USDOL/bulletins/305940a
Occurrence A coverage for losses incurred within the policy period, and reported during or after the policy period. Occurance coverage can be substantially more expensive than Claims Made coverage. Claims Made coverage insures claims incurred and reported within the policy period.
Occurrence can mean different things, in different policies. I.e. Professional Liability versus Builders Risk policies. See: Claims Made coverage Occurrence Limit of Liability (OLLE)"Occurrence Limit of Liability
SS
(OLLE) Scheduled Limits
SS
Blanket coverage for first-party property insurance risks has become increasingly difficult to secure
and often is not available regardless of price.
SS
Please note that your quote may not provide coverage on a blanket basis and, based on current
market conditions, a blanket coverage option might not be available. Any reference(s) to an
Occurrence Limit of Liability Endorsement (OLLE), margin clause, maximum amount payable, and/or
scheduled limits indicate that blanket coverage is not provided. Instead, the amount of recovery
afforded by the policy is limited in some respect to the amount(s) set forth on the Statement of Values
(SOV) provided to the insurer. This potentially can materially reduce the insured’s recovery in the
event of a loss as compared to blanket coverage. Additionally, the policy language for these clauses
may vary by insurer and some insurers limit the amount recoverable for extensions of coverage,
additional coverages, and additional covered property to the values as shown on the SOV (statement of values)." Source: Scottsdale GL - Property policy. See: Occurrence, Claims Made policy forms, and various provision affecting bound coverages. OCORI Fee A mandated ACA (including ERISA plans) fee ($2.54 2020) extended through 2029 used by HHS to figure out efficacy of treatment. Of Cycle Termination A term some carriers use on (group) Level Funded plan terminations meaning a minimum of 30 days notice is required to cancel the plan outside of Open Enrollment. Off Set The amount a carrier can reduce a paid claim - calculated by the amount of premiums by and insured. The claim is "off-set" (reduced) by the premiums due. Office of Burden Reduction & Health Informatics (OBRHI)CMS rules designed to lift some of the burden from medical providers treating Medicare patients. May also apply to Tricare and or Medicaid members.
"Final rule gives providers access to patient treatment histories, and streamlines prior authorization to improve patient experience and alleviate burden for health care providers
Today, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.
“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”
The “CMS Interoperability and Prior Authorization” rule is the next phase of CMS interoperability rulemaking, aimed at improving data exchange while simultaneously reducing provider and patient burden. This final rule requires the payers regulated under this rule (namely, Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)) to implement application programing interfaces (APIs) that will give providers better access to data about their patients, and streamline the process of prior authorization. APIs are the foundation of smartphone applications, and when integrated with a provider’s electronic health record (EHR), they can enable data access at the touch of a button. By exchanging relevant health information between patients, providers and payers, APIs support a better health care experience for patients. Patients have easier access to their own health information, their providers have a more complete picture of their care, and patients can take their information with them as they move from plan to plan, and from provider to provider throughout the healthcare system. This ensures more coordinated, quality care, and less repetitive and unnecessary care that is costly.
Today’s final rule requires Medicaid and CHIP (FFS) programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to include, as part of the already established Patient Access API, claims and encounter data, including laboratory results, and information about the patient’s pending and active prior authorization decisions. These payers are also required to share this data directly with patients’ providers if they ask for it and with other payers as the patient moves from one payer to another. In this way, patients, providers, and payers have the data when and where they need it, to help ensure that patients receive the best possible care. While Medicare Advantage plans are not included in and therefore not subject to this final rule, CMS is considering whether to do so in future rulemaking.
Prior Authorization Burden Reduction
Payers use prior authorization as a way to manage health care costs and ensure payment accuracy. For certain services, providers request approval from payers before rendering care to ensure that the payer will determine that the care is medically necessary, a threshold requirement for care to be reimbursed under the patients’ health coverage. This administrative process can be burdensome, and the challenges of the prior authorization process have motivated industry efforts to develop tools to increase automation. This final rule aims to reduce the inefficiencies and burdens of the prior authorization process for providers, and give them back time to focus on what matters most, treating patients in a timely manner.
The final rule requires Medicaid and CHIP FFS programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to build, implement, and maintain APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to support automation of the prior authorization process, specifically addressing the challenges raised by both providers and payers. The requirements of this rule specify that each of these payers will build an API-enabled documentation requirements look-up service, and make these public so providers may access documentation and prior authorization requirements from their EHR platforms. Once a provider knows what is required for each prior authorization, the next step is submitting it electronically. The final rule also requires Medicaid, CHIP, and QHP payers to implement and maintain prior authorization support APIs using the HL7 FHIR standard, which will advance a streamlined approach for communicating prior authorization requests and responses between those payers and provider EHR platforms or other practice management systems.
The final rule also requires Medicaid and CHIP (FFS) programs, and Medicaid and CHIP managed care plans to meet reduced decision timelines for prior authorizations. These payers will now have a maximum of 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests, and all payers subject to the rule are required to provide a specific reason for any denial, which will allow providers some transparency into the process beginning January 1, 2024 or the rating period that starts on or after January 1, 2024. In addition, to promote accountability, the rule requires these payers, to make public, prior authorization metrics that demonstrate how they operationalize the prior authorization process. All of these requirements together will promote a more streamlined and efficient prior authorization process for providers and payers alike.
The rule will improve the patient experience as well. When a patient sees, for instance that a prior authorization is needed and has been submitted for a particular item or service, they will better understand the timeline for the process and be able to work with their provider to plan accordingly.
Today’s final rule aims to improve longstanding inefficiencies in the healthcare system —including the lack of data sharing and access. This final rule expands the current Administration’s goals of quality and lower costs in health care as payers and providers will now have access to more complete patient histories, allowing for more coordinated and seamless patient care.
The final rule is available to review today at: https://www.cms.gov/files/document/11521-provider-burden-promoting-patients-electronic-access-health-information-e-prior.pdf" Source: CMS
See: Final rule. Office of Insurance Regulation (OIR)What Florida calls the Department of Financial Services, which administers insurance regulations. Florida Auditors come from the OIR. Office of Minority Health (OMH)A CMS agency designated to primarily help people over 65 understand insruance, access and timely care. https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/from-coverage-to-care
Office of the National Coordinator (ONC)See: MACRA, CMS, QPP, CMMI, and good luck! Office of the National Coordinator for Health Information Technology (ONC)A federal office whose purpose is to refine data collection and disbursement into more effective public information delivery. See: CMMI 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. Omnibus Claus Liability insured in a BAP policy insuring against losses caused by "the conduct of an insured—includes any person or organization not otherwise included or excluded by the first two categories of insureds, to the extent this third category of insureds is vicariously or statutorily liable for another insured’s conduct." Source CE exam CGL material 2021 On line Service Center (OSC)See: FMO, TPA, etc On-site Clinics A concept effectuated several ways by some carrier like Blue Cross, but mostly meaning by Employers with an on site nurse or even a doctor. The goal is to reduce medical fragmentation by earlier intervention and treatment of conditions that avoid hospital admissions, Classic programs include: preventive and acute care, chronic disease management, and on-site medication dispensing. Onboarding (Account Installation)A loose term for enrolling people in a policy, or efficiently orienting a client with required reporting, and premium payments. Its also a term used to convey established (or absent) account installment requirements or events fostering account retention and management. Larger policies involving premium/claims reconciliations and/or interdepartmental reporting typically have more well defined installation procedures. Onsite Mitigation Project Management (OPM)A property insurance term used to describe then carriers (themselves) or by subcontrated specialist put a loss mitigation specialist (i.e. ServPro) on site to remediate the loss, or determine scale and risk management. The goal is to lower overal costs, and get the insured back to business faster after a major property loss. Open Access A term that typically means being able to see a specialist physician without referral from a primary care physician. It can also be a term used to describe insuance coverage of non contracted medical providers. 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 licensed providers delivering accident/sickness care. 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, Balance billing, RBP, etc.
Open Enrollment Final Rule https://www.cms.gov/files/document/cms-9911-f-patient-protection-final-rule.pdf?utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery
Open Enrollment Period (OEP)See: ARPA, and Biden special EO or directives that modify OEP 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 OEP are not the same. SHOP OAP may be the same as Marketplace individual OAP. Employer Open enrollment periods are not the same.
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 renewing plan start (and old plan expiration as applicable See: Virgin Groups) Lots of rules governing guarantee issue coverages apply. Employer new plans do not have a open enrollment period. One life Employer groups have a separate annual 30 day OEP period, but rates for those proprietors are very high do to adverse selection (but, coverae is guarantee issue).
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
Open Risks Policy In context of Property (land, buildings, Contents, etc.) it refers to a high coverage policy were general practices (and in states that have specific laws directing property policies, especially Homeowners policies) and standards cause any hazard or peril not specifically Excluded or limited to be insured. Most AOP (All other Perils coverages are Open Risks Policies. For example, in Florida windstorm is many times insured under separate HO3 coverage/policy, while AOP applies to losses that are no caused by Wind/Hail/Hurricanes. See: Your state's laws. 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
Ordinance or Law coverage (Ordinance)A property coverage that costs more, and that increases replacement cost coverage to damaged property to meet upgraded buildang ordinance permitting requirements. Municipalities have their own rules about when the Ordinance compliance to new building code construction applies, but typically follow a 50% rule of replacing a structure. Roofs are not the same - Florida's is 25% replacement that can mean mean the entire roof must be upgraded to current wind storm material and bracing. requirements. Organization for COmmunity Assisted Health Plans (ACAP)An organization striving to level descrepencies in healthcare access to various underserved populations. https://www.communityplans.net/wp-content/uploads/2022/06/ACAP-Pathway-to-Health-Equity.pdf
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. OT App Security Software or hardware that defends or securely allows access to/from specific devices. See: Cyber secirity OTC Health Solutions (OTCHS)An Aetna term for over-the-couter products available from targeted sellers for a $100 per year amount of coverage. Next step is to figure out how much of a hassle it is to submit bills for small amounts, to deal with ordering through their ap. https://www.cvs.com/bizcontent/otchs/catalog/2024_OTCHS_Catalog_English_IFP_Aetna%20CVS%20Health_FINAL_REMEDIATED.pdf
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 (costs) (OOP)Out of pocket typically refers to direct customer paid costs at time of service consisting of: Deductibles, Co insurance, Copays each plan defines as insured (eligible). See: MOOP Balance Billing
Note: Link relates to Group OOP, not Individual OOP. 2022 MOOP is $8,700 (single) and $17,400 Family 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
Out Patient Professional Services (Medicare reimbursement for OPPS)A term used to represent the contentious area of HHS 2019 decision to lower off-campus out patient services on Medicare patients. AHA lost, then won, then lost on appeal and is asking the supreem court to decide it. Outbreak Period In context to federal extensions of periods in response to Covid 19. See: Open Enrollment, Special Enrollment, COBRA enrollment, premium extensions. Make sure SPD matches up for active risk management. Not same for benefit payments. Outcomes Based Agreements (OBA's)See: VBR, QPP, MACRA 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. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/Outpatient-PPS-Pricer-Code
Outpatient Quality Reporting (OQR)See: Hospital Quality Reporting, Prospective Payment Over the Counter (OTC)A term typically referencing Rx available without prescription. More recently, relates to reduction of ER visits caused by over the counter care benefits available by Urgent care, and various "company" sponsored nursing services designed to triage simple and complex (high/low cost) medical events. 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
Paid Time Off (PTO) Paid Up Additions (PUA)A permanent life (whole life, or UL) insurance policy premium deposit account used to pay a lump sum (premium deposit) into, but apply premiums from it into a life insurance policy, in compliance with (two) IRS compliance tests, thereby avoiding a life insurance policy (loan distributions) converting to a (income taxable) MEC. PUA accounts pay guaranteed fixed-interest on remaining funds as they get applied each month into the policy. Some carriers use different terms like, Paid up insurance, or Account A (holding account) and Account B (Policy cash value or accumulation value). Super leverage is available when distributing pension "Loans" using cash value as collateral, but without reducing cash value (used as collateral to any loan) that then gets credited contractually promised interest 0% to the cap, and with the IRS compliant loan offering tax preferred advantage. (If it converts to MEC, Growth gets taxed as income in the year it is spent.) Note: Cash value is not reduced by loans or loan interest. We advise double checking facts with an experienced agent, and accountant specializing in tax. See: GMP rule, Account A olicy crediting explanations, etc. Similar to fixed annuities, PUI is held by the carrier outside of the policy until such time as it is applied into the policy following two IRS MEC tests. Carriers use these set-ups to simplify life insurance premium payments for clients who want to make one large up-front premium payment, and keep the tax preferred features, including planned pension loan distributions for maximum leverage (growth), but without stock market crash risk. We recommend speaking with an experienced agent. Pallative Care (Costodial or Hospice care)
A term typically used to describe medical care for terminally ill patiens in the last 2 (or 30 days) weeks of life. There is acute care (insured by most major medical policies) for care resulting in the patient getting better, then there is Palliative care that is insured by Long Term Care policies insuring Activities of Daily Life care, and not insured by major medical policies. Most people do not buy LTC policies. 2020 24/7 bedridden patient-care cost about $12,000 per month for LTC SNF care. WOW!
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.
(From Article)
"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
See: Medicare Choices
https://hospicenews.com/2019/12/09/california-palliative-care-rule-could-serve-as-national-model/
https://www.cms.gov/priorities/innovation/data-and-reports/2023/mccm-fifth-annrpt
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...) Participating Provider A term first used to define a Medicare contracted physician or hospital who accepts as full payment the Medicare Authorized amount. It now includes any contracted medical provider who accepts the contracted rate. Participation A group medical insurance term expressing the minimum percentage (50% - 70%) of qualifed employees required to quality for a QHP. Different participation rates apply to different kinds of group (employer) plans. Individual and group plan rules are not the same. See: underwriting quidelines
See: Simultaneous Contribution rules. See: SHOP. It can be confusing, especially with what qualifies for QHP. Talk to an experienced agent, Participation (MPR or minimum participation rate)A term that means several things: 1. A contracted medical provider considered "in-network", 2. A Medicare contracted provider 3. The minimum percentage (i.e. 75%) of employees who must elect major medical coverage to qualify for a "group" major medical plan. This gets a bit complicated. See: Contribution
FFM has a MPR calculator to help with Marketplace offered SHOP plans 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 Bill of Rights See: Americal Patients Rights Association, and try and be aware of many Patient (not physician) driven measures of EBM, transparant pricing, transparant second medical opinions, transparant medical error communications, responsible-competent Hospitalist services, patient outcome EBM access in a format targeted to non physicians trying to understand their disease, diagnosis, and many availailbe options (provider procedure accessability, and pricing in context to insured, available and eligible care, etc) Its a work in progress that has many powerful players jockying for medical information disemination, authority and market share. https://patientengagementhit.com/news/patient-advocates-explore-a-patient-bill-of-rights-for-ai?utm_campaign=newsletter&utm_medium=email&utm_source=nl&asrc=EM_MDN_292406216&uid=26342860&bt_ee=wC8fHFOZ%2Bh4KlsMG8CTAJRh6yyL2%2F1SbyL%2FEH06GOUKdLLHb2dNSqF5T7
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
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/OutcomeMeasures.html
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf
Patient Focused Episodes (3M PFEs)A coorbity measure of total illness burden that qualtigies the patient's acute and post-acute resource needs using an imediate, and base line starting value. See: DRG and many other efforts designed to improve medical outcomes at lower cost(s). Patient Matching and Transparency in Certified Health IT (MATCH IT) (MATCH IT)Proposed legislation that may improve or increase patient transfer of PI to recognized or certified medical providers, and that proposes somekind of reduce costs. This gets complicated... https://www.himss.org/resources/interoperability-healthcare
Patient Protection and Affordable Care Act (Affordable Care Act / Obama Care / ACA / PPACA)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 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: QHP (Qualified Health Plans meeting minimum essential Health benefits) 10 unlimited Essential Healthcare Benefits (EHB, tax credits for individuals earning between 100% - 400%+ of Federal Poverty Level (FPL) (up to and now beyond 9.83% FPL under Binden), and Cost Sharing for people earning between 100%-250% FPL (see Silver plans). Cost sharing reductions (CSR) lower deductibles and max-out-of-pocket member costs, thereby limiting total annual Individual or SHOP enrollee's health spend from (about) 2% - 8.5% AGI/MAGI, and for "INDIVIDUALS" earning under 400%+ FPL. ACA law is not repealed, but for the Individual penalties for not being insured with AHP coverage. Medicaid eligibility is expanded under Biden.
Small employers (see: ALE - under 50 ee) (for profit gets 50% tax credit, and Not for Profits get 35% tax credit in first two years of plan placement). Marketplace offered SHOP plan availability is mostly unavailable (not offered by commercial carriers) in most states. As a rule the SHOP program has failed (still none offered in Florida since ACA passage in 2010), and few plans are offered in any state. (There is very long history of carriers doing everything legal to not write SMALL-GROUPs under 4 lives - like paying commissions of $0 to $3.50/ee (FL) to the agents, etc, and/or not hiring staff to process applications by deadline.)
We are seeing epidemic closures of small hospitals accross the country. That means if your loved one has a heart attack or stroke more then 45 minutes from a hospital, somebody dies are can become totally disabled causing more problems for the overloaded state funded social worker programs. Lowered hosptial credit ratings are expanding, and are well known, but not discussed very much because it means hospitals and doctors just keep increasing their prices, and not deal with physician participation accountability to EBM that takes a lot of unpaid time. If ACA APTC tax credits were repealed, all hospitals would be in deep trouble with health insurance being unaffordable accross the board for most lower and middle class income citizens, despite the age-compression (premium rating ACA - age-banding) rule. Me and my wife's insurance premium is now $26,000 per year with an out-of-pocket family maximum over $6,000. The wake up call is that if we both get sick in the same year, it costs $32,000 EACH year for healthcare ACCESS - and we are insured? The quasi-free-market (commercial Individual/Group, workers comp, PIP auto) bears massive "cost-shifting" of hospital and doctor pricing, along with well acknowledged defensive medicine practices providers blame on inadaquate Tort reform. ACA has just kicked the can down the road untill real healthcare access anger creates policital will to fund hospitals, or be exposed to a system where a loved one dies on the way to the nearest emergency department that is still open. What is costs employers to buy insurance for their employees matters a lot in a world economy competing with much lower worls market labor costs.
See; ACA final Rules, cost shifting, MLR, APTC, OEP, SEP, CSR, QHP, SHOP, reinsurance, ACA final rules, etc. See: article Trumping Healthcare Reform for 10 bullets of ACA law. https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
https://www.congress.gov/bill/115th-congress/house-bill/1
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08017.pdf
Patient Reported Outcome Performance Measure (PRO-PM)See: QPP, CORE, MIPS, TEP Pavider Fargeon used to describe a risk bearing provider group contract with an authorized insurer. See: IDS Paycheck Protection Program (PPP)A COVID federal loan program to small businesses whose liability gets forgiven under certain quidelines. https://www.sba.gov/funding-programs/loans/covid-19-relief-options/paycheck-protection-program
https://directforgiveness.sba.gov/requests/borrower/login/?next=/
Payor Provider Relations Coordinator (PRC)A value based reimbursement (personnel assignment) title, who is responsible for population based and individual based data analysis, and whose goal is to reduce ED visits, and lower costs. They may be part of the patient contact team to bring in unstable chronic co-morbitity cases sooner to avoid expensive hospital care. The PRC deelops best practices and provider implementation and use protocols. In short, it means bringing care to the patient, not waiting for the patient to come in with the very expensive problem. No, dont shoot the messenger - I did not say house calls - but, we all know that community health centers, and company-nurse programs save major money. PDM (Periodic Data Matching )See Advance Payment Tax Credit PE A term that can mean many things. In context to Covid19 401 plan disbursements, it means DOL has approved penalty free 401 disbursements in private-equity funds and investments heretofore considered more risky than public ETF's etc. 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 Employee Per Month (PEPM) Per Employee Per Year (PEPY) 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. Percent of Premium (POC Contract)A type managed care reimbursement contract that pays providers a set percentage of the total charged premium. ACA regulations set forth minimum amounts a carrier MUST pay in eligible medical claims, or be required to refund amounts under 80% or 85% back back to the policy holder (customer). This gets complicated, but in general, a plan must pay at least 80%/85% of INDIVIDUAL COMMERCIAL OR MEDICARE / GROUP Medical premium in claims, or must refund the amount not used for claims under the assigned percentage. It can also mean the percentage paid of total charged premium paid to contracted medical providers. POC contracts may, or may not be risk-bearing, and/or offer gainsharing without (catastrophic claims) "risk". 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 Performance Year (PY)See: MSSP Peril In context to insurance coverages insured - peril means a specific cause of loss. I.e. Windstorm/Hail, Fire, sink hole, crime, fidelity, earthquake, etc. The word can get interchanged with hazard (insured), or with a specific "cause of loss" an eligible claim of damage is filed. Periodic Data Matching (PDM)See: Authorized Marketplace federal access to PII re APTC. HIPPA, etc. Persistency Bonus (Reimbursement of Expenses Bonus)A IUL feature that credits back all or almost all of any loan interest charge for funds "loaned to yourself". Typical credits are less in the first 10 years than succeeding years. I.e. If the Loan interest charge is 4% fixed, then the annual credit is about 3% - 3.25%. Different carriers have different loan interest fixed charges. The feature allows policy owners to take IRS compliant loans (to themselves on all the growth over their lifetimes), that are not taxed as income, while continuing to earn interest on the same values used as collateral to the loans. Unlike 401 loans, Cash Value is participates (earns interest) the same with these funds that never leave the account. 401 loans are placed in very low interest accounts for the remainder of the owners life. This leverage comparison is apples to oranges with IUL being clearly superior and without exposing the insured to market crash risk. This is not tax advice. Personal Auto Policy (PAP) Personal Injury In context to CGL: “Personal injury” refers to a variety of offenses against a person other than a physical injury, such as invasion of privacy, slander, libel, trespass, and false imprisonment. May also involve "Advertising injury". See: Property Injury. Personal Injury Protection (No Fault - PIP)In some states, No-Fault insurance is required for purposes of auto claims less than $10,000. Travelers policy states: "
UNINSURED MOTORI STS AND PERSONAL I NJURY PROTECTION COVERAGE IMPORTANT - PLEASE READ CAREFULLY
YOUR OPTIONS REGARDING PERSONAL INJURY PROTECTION ARE DESCRIBED BELOW
Personal Injury Protection (PIP) must be provided for any motor vehicle subject to the Florida
Motor Vehicle No Fault Law. We will pay, in accordance with the Florida Motor Vehicle No-Fault
Law, as amended, to or for the benefit of the injured person as follows: (a) 80% of medical
expenses, if an insured receives initial services and care within 14 days after the motor vehicle
accident, and (b) 60% of work loss and (c) replacement services ex penses, and (d) death benefits
of $5,000 per each insured. The total limit available for medical expenses, work loss, and
replacement services expense is $10,000. We will pay up to $10,000 for medical expenses that have
been determined to be an Emergency Medical Condition and up to $2,500 for medical expenses that
have been determined to be a Non-Emergency Medical Condition in accordance with the Florida Motor
Vehicle No-Fault Law.
Please refer to your Travelers policy and endorsement(s) for a detailed explanation of PIP
coverage.
There are several premium-saving Personal Injury Protection options available to you as the
person(s) identified in the Named Insured section of the Declarations. A premium reduction will
result from these elections.
The named insured may elect a deductible and exclude coverage for loss of gross income and loss of
earning capacity ("lost wages" or "work loss benefits"). A premium reduction will result from these
elections. A named in sured can select a deductible of $250, $500, or $1,000. When making your
decision on whether to choose a de ductible and for what amount, consider your ability to pay a
portion of your medical expense and/or whether your health insurance carrier will meet the costs of
these expenses.
You also have the option to exclude benefits for lost wages due to an auto accident. If the insured
or dependent resident relatives are unemployed or retired, you may want to select this
exclusion.You are advised not to elect the lost wage exclusion if the named insured or dependent
resident relatives are employed, since lost wages will not be payable in the event of an accident.
You may choose to have these options (deductible and/or exclusion of work loss benefits) apply to
the "named insured alone" or to the "named insured and all dependent resident relatives". In making
this election, a resident spouse is treated as a named insured and not a dependent resident
relative.
THIS NOTICE DOES NOT ALTER, AMEND OR CHANGE THE COVERAGES AFFORDED BY YOUR POLICY.
The coverages currently provided by your policy are indicated in the Declarations provided with
this Notice.If you would like to make any changes to your Personal Injury Protection
coverages, please do not hesitate to call your agent or representative." Source: 2021 Auto Travelers policy
See: Uninsured Motorists, Comprehensive, and Collusion coverage. 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 Protective Equipment (PPE) Personal Representative A term defined by HIPAA related to handling PHI with prudent confidentiality defined under the law. Personal Time Off (PTO) Personally Identifiable Information (PII)As Defined by CMS for Federal Marketplace Agent annual exam study material:
Key consideration is if the information can be linked to identify and individual.
============================
PII is defined to have the meaning contained in Office of Management and Budget (OMB) Memoranda M-17-12 (January 3, 2017) and refers to information that can be used to distinguish or trace an individual's identity, either alone or when combined with other information that is linked or linkable to a specific individual. Section II(b) of the Individual Marketplace Privacy and Security Agreement and the Small Business Health Options Program (SHOP) Privacy and Security Agreement specifies the types of PII that an individual may encounter in performing the role of an agent or broker in the Individual Marketplace or SHOP.
• 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
• Race/ethnicity
• 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 Sex
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
See: HIPPA, Marketplace Agent Exams
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 costs and utilization administration. A PBM may also be a specialized entity for a specific high cost drug such as factor agents for hemophiliacs, cancer infusion, dietary feeding, and an array of infusion therapies. Lots has been made over the effectiveness or legitamacy of PBM services, but experienced consultants know their are many ways to lower the costs by moving from a brand name drug to an equivelent generic, or by more efficiently distributing-administering (batched) dosages super high cost Rx. Pharmacy has for over 10 years been the fastest growing component of the healthcare dollar inflation - especially for coumpounded and/or specialty drugs. ACA unlimited EHB includs Rx, and is directly responsible for some pharmacy charges to be higher then we have seen in 25 years, and potentially capable of bankrupting self funded employers who have not effectively worded SPD's to limit potential liability. It is not a straight forward issue, but we have seen significant litigation surrounding levels of Rx charges that border on fantacy, abuse, and cost shifting driving premiums to even more unaffordable levels. ==========="Prices in the United States are higher than those in all comparison countries
U.S. prices were 256 percent of those in the 32 comparison countries combined.
In comparisons with individual countries, U.S. prices ranged from 170 percent of prices in Mexico to 779 percent of prices in Turkey.
The gap between U.S. prices and prices in other countries was larger for brand-name originator drugs.
U.S. prices were 84 percent of prices in all non-U.S. countries for unbranded generics.
U.S. prices were 190 percent of prices in other countries after adjusting U.S. prices downward to account for rebates and other discounts." Source RAND Research See: Stark and various safe harbour rules, Biosimilars https://www.federalregister.gov/documents/2020/11/30/2020-25841/fraud-and-abuse-removal-of-safe-harbor-protection-for-rebates-involving-prescription-pharmaceuticals
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2792763
https://www.rand.org/pubs/research_reports/RR2956.html
Pharmacy Inflation We will see if the Feds actually do negociate better prices for Medicare and Medicaid beneficiaries, let alone Tricare military dependents... https://thehill.com/homenews/administration/3669326-hhs-price-of-more-than-1200-drugs-outpaced-inflation/
Pharmacy Inflation "About 150 pharmaceutical manufacturers had increased prices on 866 drugs by an average of 6.6% as of Jan. 20, nearly matching the US economy's 7% rate of inflation, according to data from Rx Savings Solutions. Top-selling medications including AbbVie's anti-inflammatory treatment Humira, Eli Lilly and Co.'s diabetes therapy Trulicity, and Pfizer and Bristol Myers Squibb's anticoagulant Eliquis were among the products that saw price hikes." Source: Beckers Hospital Review link. https://www.beckershospitalreview.com/pharmacy/drugmakers-raise-prices-6-6-this-year.html
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. Phsical Damage A term used in many types of policies. In contingent GL BI policies, physical damage caused by a covered peril is oftentimes required to trigger BI coverage. Technology is changing how this is done. 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/
https://data.medicare.gov/data/physician-compare
Physician Compensation 2017 Source: Medscape Medscape report
Physician Fee Schedule (PFS, or CY 2023 Physician Fee Schedule)Term used by CMS when discussing proposed Medicare Part B QPP related matters, and/or medical physician fee schedule final rules related to their conversion factor. "CY 2023 PFS Ratesetting and Conversion Factor
CMS is finalizing a series of standard technical proposals involving practice expense, including the implementation of the second year of the clinical labor pricing update. We also included a comment solicitation seeking public input as we develop a more consistent, predictable approach to incorporating new data in setting PFS rates. Per statutory requirements, we are also updating the data that we use to develop the geographic practice cost indices (GPCIs) and malpractice RVUs.
With the budget neutrality adjustments, which are required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending, the required statutory update to the conversion factor for CY 2023 of 0%, and the expiration of the 3% supplemental increase to PFS payments for CY 2022, the final CY 2023 PFS conversion factor is $33.06, a decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61." https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule
https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other
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.
Additional Resources
• 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
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html
https://ecqi.healthit.gov/sites/default/files/2021-CMS-QRDA-III-Eligible-Clinicians-and-EP-IG-508.pdf
PII Employee Information 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 Sex
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 PII Employer Information Employer Name/"Doing Business As”
Employer Federal Tax ID Number
Employer Address
Business Type
Employer Attestation to SHOP Eligibility Requirements
Employer Contact Information
Employer Contact Name and Title
Employer Contact Mailing Address (if different than employer address)
Employer Contact Phone Numbers (and type)
Employer Contact Spoken and Written Language Preference
Employer Contact Email Address
Employer Contact Fax Number
Secondary Contact Name (optional)
Secondary Contact Phone number (and type)
Secondary Contact Fax Number
Secondary Contact Email Address
Secondary Contact Authorizations
Employer Coverage Offered
Employer-selected AV Levels (Bronze, Silver, Gold, or Platinum)
Benchmark Plan
Offer of Dependent Coverage
Agent/Broker/Assister/Navigator Name, Organization Name, Contact Information, FFM User ID
Employer Contribution Information:
Benchmark Plan ID number-Medical Plan
Benchmark Plan ID number-Dental Plan
Percentage towards Employee-Medical Coverage
Percentage towards Employee Dental Coverage
Percentage towards Dependent Medical Coverage
Percentage towards Dependent Dental Coverage
Employer Offering-Single QHP or Single Metal Level or Single Issuer
Employer Offering-Single Stand-alone Dental Plan (SADP) or multiple SADPs
Offer of Stand-alone Dental Coverage
Desired Effective Date of Coverage
Employee Selection Due Date
Waiting Period for New Hires to Enroll
Employee List, including
Employee Name
Employee Date of Birth
Employee Age
Employee Social Security Number
Employee Email Address
Employee Employment Status
Employee’s Other Coverage
Number of Dependents
Dependent information, including Dependent Name
Dependent Date of Birth
Dependent Age
Dependent Social Security Number
Dependent Email Address
Dependent’s Other Coverage
Payment Method options, including
Electronic Funds Transfer Information (Checking Account Number, Routing Number)
Credit Card information (Credit Card type, Name on Credit Card, Credit Card Number, Expiration Date, Signature, Signature Date)
Checking Information
Employer Attestation to Consolidated Omnibus Budget Reconciliation Act (COBRA)/Medicare Compliance Questions Pilot Provider See: Value Based Reimbursement, PRC Plan Appointed Claim Evaluator (PACE)A typically certified or very experienced professional hired by the plan who can service multiple functions in context to traditional plan management, and price/costs review of billed charges and stop loss application recovery(s). Plan Star Documents (PRDs)See Plan Star Ratings Plit-Doller Life Insurance See Defined Benefits Contribution plans, etc. "Split Dollar is deferred compensation that permits the employer to control the life insurance policy cash values during the employee’s working life. Deferred compensation is a non-qualifying plan that is a written agreement between an employer and an employee where the employee voluntarily agrees to have part of their compensation withheld by the company, invested on their behalf, and given to them at some pre-specified point in the future. Non-qualifying differs from qualifying in that:
Employers may also pick and choose which employees they provide deferred compensation benefits to rather than being required to offer the same plan to all employees.
They offer flexibility. The employer can treat those chosen differently. The benefit promised need not follow any of the rules associated with qualified plans. The vesting schedule can be whatever the employer would like it to be.
Companies may provide deferred compensation benefits to independent contractors, not just employees.
The employer contributions are not tax deductible.
Employees must pay taxes on deferred compensation at the time such compensation is eligible to be received (not just when it is actually drawn out)." Source: Insurance U Agent CE Exam 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.
Policies In Force (PIF)Jargon used by some TPAs to describe their client's eligible claims (from policies in force at time of claim adjudication). Policy Cancelation A term that can mean different things in different situations. See: Policy Rescission, Policy Termination. Policy Equity In context to a Split Dollar life insurance, it refers to, "The cash surrender value of the policy eventually exceeds the reimbursement right of the employer, and this additional value in the policy is referred to as "policy equity." Source: Insurance U Agent CE Exam 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. Polychonic care (comorbidiies)The latest term being given to EBM in context to effectively caring for people with multiple serious diseases.
"...serving polychronic patients means considering social determinants and health equity. It means making real efforts to improve patient engagement and prioritizing care with the right information. Find out how you can enable fundamental changes in the health care system. Reinvent processes, priorities and systems to treat the whole person and help change the trajectory of health care costs." Source: Optum
See: CMS Interoperability Pooled Employer Plans (PEPs)See: Secure Act, MEWA https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/secure-act/pooled-plan-provider-registration.pdf
Pooled Plan Provider (3(38) Fiduciary)A DOL fiduciary appointed for oversight of MEP, ARP's etc. See: Secure Act, PEO's Pooled MEP's, etc. Poor Man's Self FUnded (Level Funded Medical plan)An fully funded (premium paid monthly) ERISA eligible plan that essentially looks the same to employees, but that has materially lower stop loss $30,000 not $50,000+) deductibles. These come in many sizes and shapes, with Premium rebating features paid out in months 14-18 on a 12 month policy period cycle. They are not all the same. Pop up Clinics Term used to define a pandemic related clinic that usually becomes an eligible expense under an insurance policy. 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.
Possessed Insurance A policy owned by a leasing company on aviation assets, and other types of assets. See: Contingent insurance. Post Acute Care (PAC)CMS term used in context to billing coding. See: Web based training - three courses, Understanding Prior Functioning and Prior Device Use, GG0131 Self Care items, and GG170 Mobility items. Post Acute Network (PAC)Jargon used to describe the facilites used and or managed after patient discharge. See: Long term care, Pallative care, hospice, etc. Post Acute Providers (PAC)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 Potentially Preventable Admissions (3M PPAs)A patient in-patient hospital admission value highlighting iniffecient or incompetent triag where outpatient care was indicated. Potentially Preventable Complications (3M PPCs)A term whose history lay in health maitenance practices. It relates more to the process of care than natural progression of a disease. See: PPRs Potentially Preventable Readmissions (3M PPRs)See penalties CMS for readmission of a patient within 24 hours, 48 hours, 7 days, 30 days, etc. Pay attention to very different carrots and sticks used on this one. Hospitals get hammered on this one. Potentially Preventable Services (3M PPS)A measure identifying high cost ancillary services that may not provide useful information for diagnosis or treatment. See: redundant care. Practice Improvement and Measures Management Support (PIMMS)See: MIPS, TEP Pre-Obamacare Health Plan Rule (Grandfathered Plan rule)A rule allowing some employers to keep grandfathered plans (pre ACA plans) that some say allow those employers to shift more costs to employees, and perhaps lower some coverage-benefits. https://public-inspection.federalregister.gov/2020-27498.pdf
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 Analytics See: Disease Management, TQI, TQM, EBM, etc. Can mean many things, but tends to focus on Rx profiling, or diagnosis (or specific procedures like lower back scans) triggers that set in action medical interventions to lower the bill, and/or to focus specialized regimes of care for better outcomes. These programs are more or less common/ sophisticated by insurance types (not all carriers are the same) like workers comp or traditional major medical. 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 which 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)
See: ACA "Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status. No group health plan or insurer offering group or individual coverage may impose any pre-existing condition exclusion or discriminate against those who have been sick in the past. As amended by Section 10103, applies the prohibition on pre-existing condition exclusions with respect to children effective for plan years beginning six months after enactment. Source: FL Agent CE Exam http://www.lifehealthpro.com/2013/02/26/average-pcip-enrollee-cost-32108-per-year?slreturn=1487602895
Premium Dollar Breakdown Few methods provide more information than a simple commercial premium dollar breakdown. "Medication and medical services accounted for 81.6 cents of the health care premium dollar.
21.5 cents are used to pay for prescription drugs.
19 cents are used to pay for in-patient hospital costs, while 19.8 cents are used to pay for out-patient hospital costs.
12.1 cents are used to pay for doctors’ visits.
4.6 cents are used to pay for federal, state, and local taxes.
2.4 cents are used to pay for the prevention of fraud, waste, and abuse.
Only 3 cents of every health care dollar go toward health insurance provider profits." Source AHIP https://www.ahip.org/your-health-care-dollar-new-ahip-analysis-shows-where-it-goes/
Premium Tax Credit (PTC)See: APTC. Relates to tax return reconciliation of actual income versus estimated income an APTC paid in the previous year - and determines if a person has to repay an overpayment of the APTC if they made more income than estimated in the previous year. Premium Tax Credit (PTC)See: APTC, ARPA 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. Presumption Law A liability suite filed presuming the injury was caused by an insured hazard. I am not a lawyer. I.e. Someone dies from COVID, and their family files a workers comp claim that the injury was caused by a work related event (without any direct proof of infection being any different from being infected from another source or event). See: Proximate cause, and call a lawyer to figure it out in you state. 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. Preventive Medical Services In context to ACA Law:"
SECTION 2. TITLE I - QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
LESSON 2.2 Subtitle A - Immediate Improvements in Health Care Coverage for All Americans
01:20 PM Today
The covered preventive services for children are:
Alcohol and Drug Use assessments for adolescents.
Autism screening for children at 18 and 24 months.
Behavioral assessments for children of all ages.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Blood Pressure screening for children.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Cervical Dysplasia screening for sexually active females.
Congenital Hypothyroidism screening for newborns.
Depression screening for adolescents.
Developmental screening for children under age 3, and surveillance throughout childhood.
Dyslipidemia screening for children at higher risk of lipid disorders.
Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Fluoride Chemoprevention supplements for children without fluoride in their water source.
Gonorrhea preventive medication for the eyes of all newborns.
Hearing screening for all newborns.
Height, Weight and Body Mass Index measurements for children.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Hematocrit or Hemoglobin screening for children.
Hemoglobinopathies or sickle cell screening for newborns.
HIV screening for adolescents at higher risk.
Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:
Diphtheria, Tetanus, Pertussis
Haemophilus influenzae type b
Hepatitis A
Hepatitis B
Human Papillomavirus
Inactivated Poliovirus
Influenza (Flu Shot)
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Rotavirus
Varicella
Iron supplements for children ages 6 to 12 months at risk for anemia.
Lead screening for children at risk of exposure.
Medical History for all children throughout development.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Obesity screening and counseling.
Oral Health risk assessment for young children.
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
Phenylketonuria (PKU) screening for this genetic disorder in newborns.
Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk.
Tuberculin testing for children at higher risk of tuberculosis. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Vision screening for all children." Source FL Agent CE Exam 2022 Price Transparancy (Healthcare Transparancy)Means many things: A federal rule mandating hospitals publish their best (HMO/PPO/EPO) contracted prices publically, that takes affect 1/1/2021. Or, 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. See: Trump EO. Hospitals are fighting it, and want to keep cost-shifted (to people buying commercial insurance versus Medicare insurance) higher charged prices secret from those that have to pay them. See: RBP
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, and losing), Medicaid work requirements (injuncted by a federal judge), federal Marketplace reinsurance program uncertainty (millions less insured during Trump's tenure), immigrant health insurance visa requirements (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 charged to commercially insured patients than is charged for the same service delivered to a Medicare insured person) because that cost-shifting-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.
See: RAND Employer Hospital Price Transparancy Project
See: Biden Federal Rules related to Medicare Supplimental pharmacy pricing bing applied to assure discounts are passed through to the Medicare Supplimental insured and not to the PBM or pharmacy store. The proposed rule wants to require all Part D plans to apply the concessions at the pharmacy counter.
“CMS is proposing to redefine the negotiated price at the baseline, or lowest possible, payment to a pharmacy, effective January 1, 2023,” a fact sheet on the regulation said. “This policy would reduce beneficiary out-of-pocket costs and improve price transparency and market competition in the Part D program.” https://www.govinfo.gov/content/pkg/FR-2019-11-27/pdf/2019-24931.pdf
https://www.hhs.gov/sites/default/files/cms-9915-p.pdf
https://www.govinfo.gov/content/pkg/FR-2019-11-27/pdf/2019-24931.pdf
Price Transparancy Means many things, especially if speaking with lawyers involved with ERISA and applicable potential fiduciary, and/or the Trump EO that Biden did not revoke. In context to national healthcare policy, see Presidential Executive Orders, and deadlines imposed on hospitals mandating disclosure of confidential "best price" contracted rates for procedures and services. See: CMS Price Transparancy.See: Biden Federal Rules related to Medicare Supplimental pharmacy pricing being applied to assure discounts are passed through to the Medicare Supplimental insured and not to the PBM or pharmacy store. The proposed rule wants to require all Part D plans to apply the concessions at the pharmacy counter.
“CMS is proposing to redefine the negotiated price at the baseline, or lowest possible, payment to a pharmacy, effective January 1, 2023,” a fact sheet on the regulation said. “This policy would reduce beneficiary out-of-pocket costs and improve price transparency and market competition in the Part D program.”
In context to hospital mandated price transparancy: "machine-readable file (MRF). Starting January 1, 2025, you’re also required to encode additional data elements.
Visit the Data Dictionary GitHub Repository to access the CMS templates and data dictionary with technical instructions for encoding your required standard charge information
Use the Online Validator Tool to check that your MRF complies with the CMS template layout and data encoding requirements
Hospital Price Transparency regulations require each hospital operating in the U.S. to publish a comprehensive MRF with the standard charges for all items and services they provide." See: CMS https://www.govinfo.gov/content/pkg/FR-2019-11-27/pdf/2019-24931.pdf
Primary Care First Models -CMS Primary care First is a CMS model designed to interface primary care acute care, chronic care and hospice (palliative care) organized by CMS. Know that getting control of Palliative (end of life care) is a major step in controlling costs, and improvine health outcomes for patients willing to make decisions about "herioc" medical care in the last weeks of life. "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." Source CMS https://innovation.cms.gov/innovation-models/primary-care-first-model-options
https://innovation.cms.gov/pcf-intro
Primary Insurance Amount (PIA)The amount Social Security pays an eligible insured (who has paid into the system long enougn) when that person starts the payments. See: Social Security, and Medicare eligibility. As a general rule, it is a good idea to never start the payments before FRA, and delaying payments beyond FRA means increasing each payment about 8% each year, and to death. Makes a lot of sense to not start it if you can survive without out it past full retirement age. For example, a person born in July 1959 FRA is 66 and 10 months. Wating to start until 67 asn 10 months means getting 8% more for the rest of life. 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 Prior Authorization A term used in most (commercial) MA, HMO, and some PEO or EPO health plans denoting a primary care physician's referral to a specialist prior to seeing the specialist for an insurable event. Medicare and Medicaid rules are not the same. See: Gatekeeper HMO
The term has come under scrutiny by the AMA, and MGMA in context to MA plans and their surveys of physians, etc. AMA study concludes 3 in 10 physicians feel PA criteria has nothing to do with patient care or quality of care. PA has much to do about the contract of insurance the individual or Group (employer) chose that restricted care or not. That said, there are several other factors such at network adaquacy, and the grey areas of case managment directed (or authorized) specialty care access guided by a plan's physician-executive. In other words, the issue is old, but has nuances specific to each case. https://www.cms.gov/files/document/121020-reducing-provider-and-patient-burden-cms-9123-p.pdf
Privacy An indivuals right to control the use or disclosure of personal information. Source: Federal Marketplace Exam 2022 Privacy Impact Assessment (PIA)See: HIPPA Privacy Notice PUBLIC FACING NOTICE: In compliance of Federal Marketplace Privacy Notice Statement we declare for our clients and customers:
We are authorized to collect personally identifiable information (PII) from you by many carriers we are appointed (Humana, Aetna, Cigna, United, and sundry MGA agreements affirming appointed powers to represent various P&C coverage too with many carriers). Any PII we collect is used only for the purposes of soliciting, binding (where authorized), managing, renewing or replacing policy coverage(s) we service in our clients best interests. We will never sell your information. Where we are required to disclose any PII under prevailing state stature/regulation, federal statute, or court order, we will contact counsel to determine if we are violating any HIPPA laws, etc. If you choose not to provide us with the PII requested, or not to respond to certain questions ore requests for information from your insurance carriers, your coverage may be cancelled, rescinded, pending carrier response caused by your decision to not supply requested PII. We will always work in our clients bests interests, and follow all available security laws applicable to licensed insurance agents and agency policy administration. 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 Annuitant (PA)A private annuity is an unsecured promise of one person (the Obligor) to make a fixed payment to another person (the annuitant) for life in return for the transfer of property from the annuitant to the obligor. Source: Benefits Pro Nov 2021 Private Equity Medical Dept financing (Medical Debt v Oligopoly v personal bankruptcy)"RIP Medical Debt, which buys bundled medical debt portfolios from providers, including hospitals and commercial debt buyers. Illinois recently passed two laws that would allocate about $10 million to purchase outstanding medical debt and make debt ineligible to include in a credit report." Medical debt is a leading cause of bankruptcy. It is a rare thing to see effective leadership that balances (economic, social and political) limited community wealth with freer market capitalistic policy. Miami Florida charges a 1% tax to fund the Health Trust (Jackson Memorial Hospital NFP mission). https://www.benefitspro.com/2024/08/23/new-jersey-cancels-100m-in-medical-debt-for-almost-50000-patients/?kw=New%20Jersey%20cancels%20100M%20in%20medical%20debt%20for%20almost%2050,000%20patients&utm_position=2&utm_source=email&utm_medium=enl&utm_campaign
Private Equity Medical Dept financing (Medical Debt v Oligopoly v personal bankruptcy)"RIP Medical Debt, which buys bundled medical debt portfolios from providers, including hospitals and commercial debt buyers. Illinois recently passed two laws that would allocate about $10 million to purchase outstanding medical debt and make debt ineligible to include in a credit report." Medical debt is a leading cause of bankruptcy. It is a rare thing to see effective leadership that balances (economic, social and political) limited community wealth with freer market capitalistic policy. Miami Florida charges a 1% tax to fund the Health Trust (Jackson Memorial Hospital NFP mission). https://www.benefitspro.com/2024/08/23/new-jersey-cancels-100m-in-medical-debt-for-almost-50000-patients/?kw=New%20Jersey%20cancels%20100M%20in%20medical%20debt%20for%20almost%2050,000%20patients&utm_position=2&utm_source=email&utm_medium=enl&utm_campaign
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. Probable Maximum Loss (PML)"Virtually all cat models generate a loss distribution curve as part of their risk evaluation. A single point on the curve (though not always the same point), known as probable maximum loss (PML), has become the most commonly used measure of risk. Yet the use of PML remains popular for a variety of reasons. It is a simple way to express the results of a complex model. The models themselves make it easier to produce single point estimates of PML. And regulators and rating agencies use it to calculate the financial strength of a risk taker. Insurers must carry reinsurance a certain levels that are indicated by the PML model, for example, the 1 in 100 year level. Insurers use these models as an underwriting tool to select the risks that most favorably impact their PML and therefore their cost of reinsurance." Source: Insurance U Agent CE Exam 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. Program Business Slang for many kinds domestically and offshore offered of insurance, or reinsurance supported risk transfer structures/facilities that can take the form of reinsured, fully insured, partially self-funded, and fully self-funded offerings and administration. Program for Evaluating Payment Patterns Electronic Reports (PEPPERs)See: Medicare relating to short term acute care hospitals. https://pepperfile.cbrpepper.org/#
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
Prohibited Transaction Exemption (PTE 84-24)See: Fiduciary Rule (DOL) effective 1/22/22
" Are You an ERISA Fiduciary?
The DOL Fiduciary Rule updates expanded the interpretation of the existing 5-part test to determine when an individual is an ERISA fiduciary:
1. You render advice about plan assets (401(k), 403(b), IRA, etc.);
2. On a regular basis;
3. Pursuant to a mutual agreement;
4. The advice serves as a primary basis for investment decisions; and
5. The advice is individualized.
The DOL’s new interpretation makes fiduciary status more likely, especially for rollover recommendations. The new interpretation includes:
1. Providing a rollover recommendation meets the “render advice” prong (#1 above);
2. Statements disclaiming a mutual agreement do not control;
3. Statements forbidding reliance will not control; and
4. All facts and circumstances will be considered, and marketing materials that indicate that you are a trusted adviser or want an ongoing relationship with clients will be viewed as more likely to meet the 5-part test.
If a producer is an ERISA fiduciary, he/she cannot receive compensation related to that investment advice unless he/she complies with the requirements of a PTE. Notably, an existing PTE – PTE 84-24 – is available for producer use to receive compensation for investment advice. The general conditions of PTE 84-24 include:
1. That a recommendation is made in the ordinary cause of business and is as favorable as an arm’s length transaction with an unrelated party would be;
2. The combined total of all fees, commissions, etc. received by the producer must not be in excess of “reasonable compensation”; and
3. The producer may not have certain relationships with the plan or IRA including acting as a trustee, or administrator to the plan or employer.
PTE 84-24 also requires that a producer disclose:
1. The nature of any affiliation or relationship with the insurance company whose contract is being recommended, and any limitations on the products that can be recommended;
2. The sales commission, expressed as a percentage of gross annual premium payments; and
3. Any charges, fees, discounts, penalties or adjustments under the annuity contract." Source: Lafayette Life Agency Advisory
Prohibited Transaction Exemption (PTE)See: FIduciary, BIC, etc. Proof of Vaccination Status acceptable proof delivered to Employers ((over 100 employees): 1. The record from a physician or Pharmacy, 2. US CDS Covid-19 card detailing the date of vaccine recieved, 3. a medical record copy of the vacciniation, 4. state or tribal immunization information document, 6. any other official documents detailing type of vaccine delivered, dates of administration and name of entity delivering the vaccine. See: OSHA for changes if any. Property & Casualty (P&C)Property and Casualty: The term typically relating to agent or policy form license or authorization by each state. See: L&H Property in Transit Property in transit risks must be conveyed by the insured so their agent knows to offer coverage for it where the property is at time of loss. See: General Liability package, trucking policies, cargo, overland marine, etc. ProPublica Treatment Tracker A report made available by CMS of transactional frequencies between fee-for-service Medicare Providers. Prospective Payment A term usually referring to a complex system of rules from CMS that pay hospitals. We used to call the inpatient-outpatient part that hospital recieve monthly the PIP.
See: Out patient Prospective Payment Rules. https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-17086.pdf
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 Emergency (PHE)See: COVID and the many Medicaid offered eligibilities to assure public right to care, expecially during a pandemic. See: APTC https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient
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.
Public Use Files (PUFs)Jargon CMS uses to describe publically available information from statre and federal authorities. Public Use Micro Data Areas (PUMAs)"Public Use Microdata Areas (PUMAs)—or regions with no less than 100,000 residents—with the highest coverage losses except for two were found in nonexpansion states. Six out of the top ten PUMAs with the highest uninsurance growth were found in Texas." Source: Health Payer Intellegence January 2023 https://aspe.hhs.gov/reports/changes-health-insurance-coverage-2019-2021
Purchaser Collaborative A nuanced term that can mean many things, but that usually means a network of medical providers willing to bill their services in a "bundled payment", not usually taking any down side financial risk. Currently, it is more an idea of getting buyers and providers on the same page to effect higher quality care at lower costs supported by real EBM. The patient is not typically part of the conversation.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 Qualifed Payment Amount (QPA)This is not QPP. See: Balance Billing, MSP, NSA, etc, and know that COVID makes it complicated. Qualified Clinical Date Registry Measure Specifications (QCDR)CMS Quality standards and reporting quidelines and requirements. See: QPP https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fqpp-cm-prod-content.s3.amazonaws.com%2Fuploads%2F2174%2F2023_QCDR_Measure_Specifications.xlsx&wdOrigin=BROWSELINK
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 Longevity Annuity Contract (QLAC)An anntuity used that typically offers an income for life ("Pension" like) benefit. Qualified Medicare Beneficiary (QMB) Qualified Payment Amount (QPA)The median in-network (contracted rate) amount PAID for a given medical SERVICE in a region (zip code). This gets complicated because of the many rules and current litigation in process. See: IDR in context to Interim Final Rule HHS will enforce, but some courts (like TX) are litigating it...
See: Balance Billing, No Surprises Act. "During the IDR process, an arbiter is directed to consider all information submitted by the physician and insurer, including the median in-network rate, complexity of the case, previously contracted rates, and market power of the physician and insurance company, among other things." Source: health Leaders March 2022 Qualified Payment Amount (QPA)See: IDR Qualified Pension Administrator (QPA) 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.
Its gets complicated. Employees electing to buy an Individual Marketplace plan with help from the APTC, must reduce (or pay back at year end) the APTC by the amount an employer contributes to ICHRA. Call a CPA. https://www.congress.gov/bill/114th-congress/house-bill/34
https://www.youtube.com/watch?feature=youtu.be&utm_campaign=hcgov_ab&utm_content=english&utm_medium=email&utm_source=govdelivery&v=8K6c39Yyb78
https://www.congress.gov/bill/114th-congress/house-bill/34
Qualifying Life Event See: SEP in context to eligibility to enroll in Marketplace plans. Qualifying Longevity Annuity Contract (QLAC)A fancy name for an annuity offering lifetime income payments (that are taxed as INCOME at distribution(s). See: Non qualifying deferred annuities. Annuities can have multiple interest rates running in the same annuity when an income for life feature is elected. In general, all annuities except Variable annuities offer MINIMUM interest guarantees (sometimes called roll ups). Fixed and Fixed-Indext annuities guarantee principal safety and interest rate guarantees. (i.e. Fixed 10 years at 2.5%, and Fixed-Indexed "range" at 85 BP up to say 3%). Variable annuities (value) follow their index selection growth, or decline (can crash when the index crashes and lose both principal and interest in that period). DIfferent companies offer different "Income-for-life" options that always guarantee more than the minimum interest guarantees offered. (I.e. up to 8%), so think of it as one, or two colums running simultaneously in the same annuity, and whose values all start with the same premium deposit (plus bonus if offered). (Pure Fixed means one colume, Fixed-Indexed means two columes detailing a range of about 85 basis points up to 3% and the minimum guaranteed interest credit, and Variable is typically two columes detailing Indexed interest credit growh or loss, and the Income-for Life credit (i.e. 8%). To get the 8% guaranteed interest, the annuitant must accept "forced-annuitization", which means the owner gets a guaranteed 8%, but cannot liquidate (cash in the Face) should there be an emergency need for funds - once the payments begin (typically at the end of the annuity term). Many carriers will offer (forced) annuitization election at annuity maturity (i.e. end of 10 years). The primary benefit of an income for life benefit lay in not outliving ones money, but it comes with a tradeoff. Lastly, the actual income distribution payment to the annuitant each year is a fixed (for life) percentage (of the total Face + accumulated interest) and is always less than 8% following the schedule accepted by the insured. (I.e. at age 70, maximum payment would tyically be 5%, age 80 at 6%, etc).
Read the annuity to see for yourself. Quality and Resource Use Reports (QRUR)See MACRA, MIPS, PQRS Quality Care A contested definition, mostly determined by a patient's perceived restoration of health and function enjoyed prior to disease onset, and treatment.
More recently inspired thinking includes not just financial and medical outcomes, but also what is termed an experiential quality as deemed valuable by the patient, and the patient's long-term engagement and commitment to maintaining healthy chronic care management activities, and their associated lower cost outcomes. See: EBM, RPM, HCAHPS, QPP, Bundling, VBR and the many constant attempts by many players to quantify it while ignoring the patient's opinion as to their overal satisfaction of care. https://www.ahip.org/news/press-releases/cqmc-updates-core-measure-sets-with-additional-patient-focused-measures
Quality Clinical Data Registries (QCDR)See MIPS, MACRA, QPP https://qpp.cms.gov/resources/resource-library
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
https://ecqi.healthit.gov/system/files/QDM_v5_4_508.pdf
Quality Data Reporting Architecture III (QRDA reporting) https://ecqi.healthit.gov/qrda?qt-tabs_qrda=about
https://ecqi.healthit.gov/sites/default/files/2021-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
Medicare beneficiaries.
Quality Medical Care The least expensive legally defensible care supported by EBM. See: CAHPS, QPP, APM
============================= Most of us believe in free markets and capitalism. When profit margins (or Retained Earning for not-for-profit entities) are percieved to be threatened, be not surprised when the AHA and AMA attempt to crush them, regardless of batient benefit. So, it ends up being the classic argument (and hypocrisy) of big government versus small government, and what institutions declare they dislike despite aggressive acceptance of payment by federal and state programs dealing with the poor, uninsured, or unvaccinated populations. Any society that considers itself civilized is judged by how it treats vulnerable children, the poor elderly, and mentally incompetent. I did not think that one up, but it follows sound principles of love, and its shared purpose being the glue that holds society together. 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
==============================
"Changes to 2023 Submission Experience
For the last several years, we’ve provided clinicians and their representatives with preliminary scoring information during the submission period and preliminary feedback. This has meant seeing an overall preliminary score as well as preliminary, weighted category-level scores. While we recognize that this has provided some measure of comfort in understanding how you’re progressing towards the performance threshold, it’s important to remember that the preliminary scoring information you’ve seen in prior years during submission and preliminary feedback has never been your final score and shouldn’t be interpreted that way. Final scores have always differed from the preliminary scoring available during submission and preliminary feedback.
As the MIPS program has matured and expanded, the reliability of these preliminary scores has decreased. Preliminary scores have always been subject to change, as new data is calculated and added to your profile following the submission period. This data includes:
Administrative claims quality measures.
There are now 4 available in traditional MIPS, which means that up to 40 additional points could be available in the quality category.
There are 2 administrative claims measures scored under the APM Performance Pathway.
There’s 1 population health measure calculated for every MVP participant, and the potential to be scored on an additional outcomes-based administrative claims measure if selected during registration for applicable MVPs.
Administrative claims cost measures.
There are 25 available for the 2023 performance period.
CAHPS for MIPS Survey measure.
Complex patient bonus.
Up to 10 points added to your final score.
Improvement scoring for cost and quality.
Performance period benchmarks for quality measures.
These calculations can shift the measures you’re scored on (when submitting more than the required number).
Reweighting the cost category.
Although cost measures aren’t evaluated until after the submission period, preliminary scores and weights for the other performance categories have assumed that you will be scored on cost.
Scores shift dramatically if the 30% weight for the cost performance category is redistributed to another performance category (or categories) because you can’t be scored on any cost measures.
Beginning in 2023, clinicians may also have different data sets reported for up to 3 MIPS reporting options: traditional MIPS, MIPS Value Pathways (MVPs), and the APM Performance Pathway (APP).
The increasing volume of scoring information that can change after the submission period has made this information too unreliable. As a result, we’re eliminating the Preliminary Score and preliminary category level scores from submission beginning with data submission for the 2023 performance year. We wanted to introduce this change in a year where there’s stability with the performance threshold; the performance threshold for the 2023 performance year is 75 points, just as it was in the 2022 performance year. In the CY 2024 Medicare Physician Fee Schedule Notice of Proposed Rule Making, we proposed to increase the performance threshold to 82 points for the 2024 performance year.
What should we expect during submission?
When you sign into the QPP website during the submission period, you’ll continue to see much of the same information you’ve always seen:
Measure-level scores for the quality measures you’ve submitted to date, and a sub-total of points earned for these measures.
Activity-level scores for the improvement activities you’ve submitted to date, and a sub-total of points earned for these activities.
Measure-level scores for the Promoting Interoperability measures you’ve submitted to date, and a sub-total of points earned for these measures.
The number of objectives you’ve reported completely for the Promoting Interoperability performance category.
An indicator of any performance categories that will be reweighted (if applicable).
We’ll also provide you with information to help you understand how the information you see during submission informs final scoring.
When will our 2023 final score be available?
You’ll be able to preview your 2023 final score in mid-June 2024 and view your 2025 MIPS payment adjustment information in mid-August 2024. This is the same timeline as the 2021 and 2022 performance years.
We recognize this is a big shift, but any preliminary scoring information has always been for informational purposes and has always been subject to change. We want to help clinicians and practice representatives avoid making an incorrect assumption about their final score given the volume of scoring information that’s applied following the submission period." Source: CMS =========================
See: MACRA, MIPS, QPP, PQRS, HCTTF
https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other
http://file:///C:/Users/Steve's%20Laptop/Downloads/2024QPPFinalRuleMVPGuide%20(3).pdf
Quality reporting Can mean many things, especially with VBR, QPP.
See: HEDIS Quality Reporting Program (QRP) Means many things to many carriers, and populations, and programs. For CMS, HHS and IRS mandated medical cost, and detail reporting aka Patient Centered Outcomes Research (PCORI). , it is 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. This tax may not still be mandated, but we are not sure? The ACA act was not repealed (except the individual tax penalty mandate), but many provisions are not being enforced.
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.
Quality Strategy CMS https://www.cms.gov/files/document/cross-cutting-initiativesintegrating-3ms-fact-sheet.pdf
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
Ransomware A software program designed to defeat cyber-security measures, comit a crime, and whose methods include making the attacked entities' data unavailable until an extorted payment is made. More and more D&O/E&O/GL policies are now including specific language limiting or excluding coverage for Ransomware attacks. See: Cyber Liability policies Rap Fund (Florida Property Reinsurance Layer)A slang term used by Florida to discuss its reinsurance efforts to support a struggling Florida property wind storm reinsurance program said to comprise a first layer of reinsurance purchased by the state (not the policy holder) projected to cause a 2-3% reduction in homeowners premiums. Details are are not settled. https://www3.ambest.com/ambv/sales/bwpurchase.aspx?record_code=320513&_ga=2.176844325.1443783029.1654707205-659447813.1654707205
Rasomware-as-a Service (Raas, or Affiliate Program)A "Dark Web" offered software ("service or subscription") whose goal is to defeat cybersecurity defenses and commit a crime.
Rate of Retuen (ROR)See: AOR, and CAGR Rated (Carrier strength)A term used to convey well accepted bond rating companies financial strength of a specific carrier. In context to insurance/reinsurance companies, it means the reputation for paying claims on time as would be expected by substantial capital and/or surplus reserves conservatively funded to pay expected claims. There are several well regarded rating agencies. For insurance company ratings AM Best is considered the top with S&P, MOODIES and FITCH also important where multi agency ratings are available on a specific company. For most of these companies, a carrier rated A+ must be at least 10 years old, and not have excessive complaints filed against them for non payment or untimely payment of claims. http://See: AM BEST, or S&P
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. Re-Hire versus New-Hire A carrier specific technical definition used to describe an employee's group-insurance eligibility and enrollment process. Re-Hire appplies to x-employees offered major medical enrollment within 12 months, and New Hire applies to new (or re-hired employees) enrolling after one year from lay off or terminiation. Not all carriers follow the same rule. See: Eligibility 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
Rebasing A baseline updating method that is not standardized, but that may have common elements to standardized trend analysis pricing. Rebuttable Presumption In context of Covid 19, federal position that some employees did in fact contract C 19 at work, and would be eligible for workers compensation insured losses. (as apposed to requiring a burden of proof that work related injury in fact did occur at work) Reciprocal A state authorized risk bearing entity that is typically not assessable to it's capitalizing 'association" membership. Referenced Based Pricing (RBP, or contracted rate)A plan still subject to the No Surprises act", but just does not use a network of providers. A term used to define medical reimbursement claims bases in Plans insuring, or "reimbursing" members up to an "established" fee schedule as directed by the Plan Document (SPD). The Medicare Allowable amount is commonly use, SPD reimbursement bases is not an absolute assignment if additional promises by a TPA, carrier, insurer, etc., verbally modifies the contract, or is not completely clear about subrogation rights, and stipulated payment/reimbursement(s) bases. Lots of rules apply, See: Risk Bearing entities, RBP, VBP, STM, Ministry health share plans, Health Cost Sharing plans, Limited Medical plans, scheduled medical, medical discount plans, ACA compliant QHP.
I.e. Claims from out-of-network providers will be paid using Extended Non-Network Reimbursement Program (ENRP) or Maximum Non-network Reimbursement Program (MNRP) guidelines where applicable. Processing claims at ENRP or MNRP rates rather than discounted Shared Savings Program rates will help decrease the All Savers out-of-network spend, and provide a greater financial incentive for members to use network providers and further align All Savers with fully insured reimbursement policies.
Be cautious about Plan Sponsor signed agreements (about claims reimbursement bases payments, and subrogation provisions that conflict with what untrained TPA staff may promise over the phone) and important subrogation provisions that may cause state law dominance over ERISA preemption (suit brought under ERISA, or under state law courts) which may not favor the Plan Sponsor. When doing precertifications, assure verbal statements by the Plan Administraters (or Plan Sponsors) match actual subrogation language in the SPD.
(Some considerations... Key points from a couple of articles to keep in mind:)
Avoid ambiguous subrogation or claims bases reimbursement language that will allow state courts to preempt ERISA
(federal) juristiction. ... Were members notified of program changes?
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
Some of the success stories include agreed discounts on the following that caused lower medical expenses to plans, and therefore lower renewal premiums. I.e.
• Knee replacements;
• Hip replacements;
• Cataract surgery;
• Colonoscopies; and
• Imaging
etc.
Several studies have estimated that the average (Commercially insured employee) billed charge is 240% more than the Medicare Allowed amount. Means, (when the bill is big) lots of litigation if the Plan Document is not clear and aligns with what TPA staff verbally detail that may not match SPD contracted rate assignments. Staff trainning is very important, and not just on reimbursement bases in contracts, but on high risk stop loss renewals left to junior employees.
Bottom line, is your EXPERIENCED attorney should review the SPD to assure clear RBP, and subrogation assignments. Call your lawyer or ask us for a referral. https://www.healthcarefinancenews.com/news/linking-us-prescription-drug-prices-those-paid-other-nations-could-cut-costs-half
Registered Health Information Technicians (RHITs) (RHITS) Registered Independent Advisor (RIA)A licensed financial professional who sells/services securities. See: RSC 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.
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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
Background
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: RBRVS, CMS final rule PFS (physicia Fee schedule). I.e. for 2022 conversion factor reduced from $34.89 to $33.59, eliminate geographic restrictions in telehealth visits for behavioral health services, some audio-only telehealth is allowable, and increase payments for administering vaccines for influenza, pneumonia and other common diseases. See: special COVID rules https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-final-rule
Remote Patient Monitoring (RPM or Telemetry)An ambiguous term referencing eligible reimbursement or data transfer on Medicare and perhaps some commercially insured patients. See: Telemedicine, and a myriad of wireless heath data transmission/collection devices and services. Remote Patient Monitoring (RPM)A wireless monitoring system of appliance device, and professional medical observation whose goal is to mitigate disease, disease symptoms and morbitity. See: Brittle well, a term used to describe chronically ill members, and disease intervention techniques. The trend is to automate chronic care management to engage the patient in their own wellness, and much lower costs avoiding massive hospital bills to manage critical care. Key requirements include engagement from physicians, and especially patients in their own care (high risk stratum managment and intervention). Many types of incentives are used to engage the patient. Commonly targeted diseases include: Diabeties, Hypertention, obesity, cardiac care, back pain, asthma, etc. See: Telemetry (the old term for some devices that manage mobile patients) Replacement Cost (RC)The cost of replaceing property with like kind and equal quality or effectiveness. Replacement Cost is a "Claims Payment" reimbursement method in property policies insured at policy inception. Replacement Cost is also a (future) repair cost estimated by the carrier at time of loss. Almost all "Replacement Cost" property policies have an "80% of Replacement Cost provision" protecting the carrier from underinsured property losses. The 80% provision allows the carrier to reduce claims payment (from 100% to 80%) where the Dwelling limit insured is less than 80% of the actual damage - at time of loss. In other words, When a Dwelling is not insured to at least 80% of what it really costs to repair it (replacement cost at time of loss), then the coverage is less, and adjusted down in proportion to the GREATER OF 80% of the Replacement Cost
estimated (at time of loss), or the Actual Cash Value the insured paid to repair the property. In both cases, neither
reimbursement bases can exceed the limit stated in the Declaration pages of the policy. The policy details how claims are calculated. We recomend all insurds read their policy carefully, and ask questions if they are unsure about policy language coverage and reimbursement bases, especially where insurds estimate future total losses versus much smaller partial losses recoveries scenarios.
See: ACV, MGRC, Inflation Guard coverage provisions and conditions where offered. Representations and Warrentees Insurance (RWI)Insurance used in M&A Reprice A generic term used to convey a billed medical charge being itemized (typically discounted) to a RBP schedule. See: RBP, QPP, cost shifting, MACRA, etc.
Re: RAND Study of $33.8 Billion of charges studied _ "Key Findings:
In 2018, employers and private insurers paid 247% of Medicare. This difference increased from 224% of Medicare in 2016 and 230% in 2017.
From 2016 to 2018, the overall relative price for hospitals increased from 224 to 247%, a compounded annual rate of increase of 5.1%.
High-value hospitals exist; low prices + high safety. There is no clear link between price and quality or safety." Rand Nationwide Evaluation of Health Care Prices Paid by Private Health Plans.
Most recent research has the average commercial pricing at 240% more than the Medicare authorized amount.
Repricing is relative to the population and location of services rendered. i.e. COmmercial Medicare, Medicaid, workers Compensation, PIP, Tricare, ACO special contracts, bundled payments, value based pricing, etc.
See: Rand report link https://www.rand.org/pubs/research_reports/RR4394.html
https://www.cms.gov/files/document/mm12080.pdf
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
https://home.treasury.gov/news/press-releases/sm564
http://providerrisk.com/articles/trump-reform.php
Request For Application (RFA)Term CMMI uses to announce next demonstration initiative to lower costs and improve quality. Request For Proposal (RFP) Required Minimum Distribution (RMD)A federal law mandating a person reaching 70.5 years of age spend (withdraw and pay tax on) a minimum of 5% of the total IRA/401 amount. See: Roth IRA's and most IUL's that don't have it. See IRS guidelines and talk to your CPA. Talk to an agent about IUL while you are under 55 or have 10+ years of Life Expectancy. 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... Resident Relative A term used to apply Uninsured Morists coverage in Florida, contingent upon the actual policy wording and coverage. The point is that not everyone in the car is insured for necessary Medical claims caused by "the uninsured or underinsured accident causing driver". It means a family member who is living in the same house, and in the vehicle at time of accident. Policy wording may be different in differnt states, and afford coverage for NON-relative passengers in the not-at-fault or the at-fault vehicle. Resident Relative A term used to apply Uninsured Morists coverage in Florida, contingent upon the actual policy wording and coverage. The point is that not everyone in the car is insured for necessary Medical claims caused by "the uninsured or underinsured accident causing driver". It means a family member who is living in the same house, and in the vehicle at time of accident. Policy wording may be different in differnt states, and afford coverage for NON-relative passengers in the not-at-fault or the at-fault vehicle. Resident Relative PIP A term used to convey eligible PIP coverage to a driver of a vehicle not insured directly as the named insured. These coverage eligibility rules are many times governed by state laws, so always double check it if a claim gets denied. Another very important rule this relates to is uninsured motorists coverage that guided by state law, INSURES medical benefits for injuries caused by the "other" driver (not the driver of the vehicle the injured person is riding with). As a rule, (in Florida) UM medical claims coverage applies only to an imediate family (daughter, son, wife, husband) member currently residing in the SAME home as the insured driver who did NOT cause the accident. These claims get complicated with overlapping coverages. See: Homeonwers liability, PIP, Auto insurance liability, individualgroup medical insurance, etc. Resources for Integrated Care (RIC)See: MMCO which is a CMS related.
Responsible Iterative Deployment A Larry Summers term for proper generative AI developement. Failing to do it, cedes it to adversaries of democracy and economic US growth. 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
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview
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.) https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Group-Health-Plans/Overview
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. Retirement Security Rule The rule and amended PTEs will protect retirement investors by requiring trusted advice providers to follow high standards of care and loyalty when they make investment recommendations. Under the final rulemaking, trusted advisers will have to:
Meet a professional standard of care when making recommendations (give prudent advice);
Never put their financial interests ahead of the retirement investor's when making recommendations (give loyal advice);
Avoid misleading statements about conflicts of interest, fees, and investments;
Charge no more than what is reasonable for their services; and
Give the retirement investor basic information about the adviser's conflicts of interest. The Department's final rule provides that a financial services provider will be an investment advice fiduciary under federal pension law if:
the provider makes an investment recommendation to a retirement investor;
the recommendation is provided for a fee or other compensation, such as commissions; and
the financial services provider holds itself out as a trusted adviser by
specifically stating that it is acting as a fiduciary under Title I or II of ERISA; or
making the recommendation in a way that would indicate to a reasonable investor that it is acting as a trusted adviser making individualized recommendations based on the investor's best interest. Source: DOL See: BIC, Fiduciary, Prohibited Transaction Exemptions https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/retirement-security-rule-and-amendments-to-class-pte-for-investment-advice-fiduciaries
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, or a reduced death benefit payout in the first 1-3 years of the policy. 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 (or rescinded by the carrier). These are not uncommon in Long Term Care policies whose policy ROP features detail the percentage return over an extended number of years, i.e. 20% ROR in year 10, not 100%. Different carriers offer different terms. Read the policy carefully. ACA regulations mandate ROR or Premium rebating (for overcharged individual policy holder as a class), where MLR is less than 80% for Individually insured's and 85% for Group insureds.
Many exceptions on the healthcare insurance products side.... See: Premium Rebates, MLR on marketplace plans, Policy rescission, policy termination, policy replacement, policy cancelation. i.e. on Life insurance Final Expense (funeral costs policies guarantee issue to high age customers), and other policies: • Graded Death Benefit
• 1st year: ROP + 5% (full death benefit paid immediately for accidental death)
• 2nd year: 50% of Face Amount
• 3rd year: 100% of the Face Amount
Return to Office (RTO)Jargeon used to try and articulate employee aquisition and retention, and that my apply to EPLI issues. Revenue Cycle Management (RCM) Reverse Payment A tactic used by brand name drug manufacturers to delay competitive generic versions coming to market. This gets complicated, and may run afoul of some rules. 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 (Marketplace User fees that increase premiums)For the 2024 benefit year, CMS is finalizing a user fee rate of 2.2% of premium for QHPs sold on the FFMs, and a user fee rate of 1.8% of premium for QHPs sold on the SBM-FPs. We anticipate these user fee rate decreases may exert downward pressure on insurance premiums for consumers. https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-final-rule
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.
"HHS-Operated Risk Adjustment Program
For the 2024 benefit year risk adjustment models, CMS finalizes the use of 2018, 2019, and 2020 enrollee-level EDGE data for model recalibration for all coefficients, with no exceptions. Consistent with prior benefit model recalibrations, this involves the use of the three most recent consecutive years of enrollee-level EDGE data that were available for the applicable benefit year. The model coefficients for the 2024 benefit year listed in Tables 1 through 6 of the final rule are based on a blend of separately solved, equally weighted coefficients from the 2018, 2019, and 2020 benefit years of enrollee-level EDGE data for all coefficients. Using the three most recent consecutive years for recalibration of the risk adjustment models provides stability and minimizes volatility in changes to risk scores between benefit years due to differences in the dataset’s underlying populations, while reflecting the most recent years’ claims experience available. Additionally, CMS will continue to apply a market pricing adjustment to the plan liability associated with Hepatitis C drugs in the risk adjustment models for the 2024 benefit year.
CMS also finalizes, beginning with the 2023 benefit year, the proposal to collect and extract from issuers’ EDGE servers a new data element, a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) indicator, including the phased implementation approach, as well as to extract plan ID and rating area data elements issuers have submitted to their EDGE servers from certain benefit years prior to the 2021 benefit year. We also finalize a risk adjustment user fee for the 2024 benefit year of $0.21 per member per month.
Finally, we finalize repealing the ability of prior participant states to request a reduction in risk adjustment state transfers calculated by HHS under the state payment transfer formula in all state market risk pools starting with the 2025 benefit year. We also approve the request submitted by Alabama to reduce risk adjustment state transfers by 50 percent in its individual (including catastrophic and non-catastrophic risk pools) and small group markets for the 2024 benefit year.
HHS Risk Adjustment Data Validation
CMS finalizes further refinements to HHS Risk Adjustment Data Validation (HHS-RADV) to promote the goals of HHS-RADV and support the timely release of HHS-RADV results. Beginning with the 2021 benefit year of HHS-RADV, CMS finalizes no longer exempting exiting issuers from adjustments to risk scores and risk adjustment transfers when they are a negative error rate outlier in the applicable benefit year’s HHS-RADV results. Additionally, CMS finalizes changing the materiality threshold for random and targeted sampling for HHS-RADV participation from $15 million in total annual premiums Statewide to 30,000 total billable member months Statewide, beginning with the 2022 benefit year of HHS-RADV. CMS also finalizes shortening the window to confirm the findings of the Second Validation Audit (SVA) or file a discrepancy report, to within 15 calendar days of the notification by HHS, beginning with the 2022 benefit year of HHS-RADV. Further, CMS is discontinuing the use of the lifelong permanent condition list and the use of non-EDGE claims in HHS-RADV beginning with the 2022 benefit year of HHS-RADV, to better align HHS-RADV policies and the EDGE Server Business Rules used for EDGE data submissions." Se Link https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-final-rule
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 Adjustment Rule See: EO
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-9913-F.pdf
Risk Based Capital (RBC)A term used by carriers, or captives describing the amount of money available to pay claims. The point being that the insurer intentionally budgets for losses above minimum capital reserves (amount) to plan for appropriate cushion against unexpected losses.
The term can mean many things, and its calculation can be directed by the entities domicile. See: Surplus Reserves, Capital Reserves, Finite Reinsurance, etc. 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 Level Data Report (RLD)Slang for a detailed Bourderough Report showing individual (properties or assignments) by premiums, limits and TIV. I.e. property policies detail Coverage A, B, C, D and bulding characterists. 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 Rating 2.0 (Flood Insurance FEMA designation)RISK RATING 2.0: EQUITY IN ACTION | PHASE II - RENEWALS
FEMA is changing the way it views flood risk and prices flood insurance, making it easier for insurance agents to write and sell flood insurance policies.
The National Flood Insurance Program's new rating methodology, Risk Rating 20, will deliver rates that are easier to understand and better reflect a property's unique flood risk. Rates will now be developed on a structure-by-structure basis, offering your clients a more individualized picture of their risk.
The NFIP has moved into Phase II of Risk Rating 2.0: Equity in Action with the focus on transitioning existing policies.
Beginning April 1, 2022, all policies will be priced under Risk Rating 2.0: Equity in Action at their next renewal.
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. Risk Scoring (ACO Reach Model)A method of paying ACO's for their care delivered to ACO members whose risk score is calculated, and that can cause the reimbursement to increase 3%. See: DRG, CMS, updated Risk Scoring component, Risk Scoring abuse Risk Transfer (Risk cede)An amorphous term describing risk cede of a defined peril or hazard. Risk can be ignored, funded, or transferred. An insurance policy transfers the majority of a defined risk in context to covered perils, limits, and the policy terms. Various self funded options provide for transferring a defined risk (by a deductible, claims reimbursement bases, etc), and is typically designed to trigger above where the insured in not comfortable, or unable to solvently assuming all the risk. Two old addages say it best - How do you manage catastrohhic risk, "Spread it out", and/or "Dont take it all." Remember that when pricing (brokering) risk for best rates, it is more what the underwriter believes is risky, than the entity's opinion seeking to transfer the risk. We recommend experienced brokerage with trusted relationships.
In general context, risk transfer relates to population size and location, changes to that population or the plan design, SIR, claims handling experience, reserving practices, IBNR claims, loss prevention (risk manament) and mitigation, etc. It essentially boils down to the seven components of premium, and assigning credibility weights. 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. Not the same as roll-up, which is typically a term used when describing interest rate performance in an annuity. It can also mean a marketing action promoting a new Insurance product. Roof Types Hipped, Gabled, Flat. A hipped roof typically performs better in windstorms because of its aerodynamic properties and typical construction techniques. A hipped roof is one that slopes upward from all sides of the building. A gabled roof has two slopes that come together to form a ridge or a peak. Gable end roofs are two-sided roof structures with two sloped roof surfaces and a vertical wall section at each end. 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 in a specific market. Typical lengths of time may be statutorily defined, and are contingent upon carrier solvency, and/or court receivership assignment/management. Run out may also mean the undefined or defined term taken to let a book of business expire, renew, non-renew, or be transferred to another agent or agency. 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: RBRVSS
Safe Harbour In context to health care delivery, insurance and administration - Safe Harbor means a state or federally scheduled exception from an existing law prohibiting payments to or from self referring entities. See: Stark.
"Anti-Kickback Safe Harbors (Portfolio Excerpt)
(Excerpted from HLBS 1500 Federal Anti-Kickback Law, by Precious M. Gittens, Fresenius Medical Care North America, and Joseph
LaMagna, Partner, Hooper, Lundy & Bookman, P.C., San Diego, Calif.)
Value-Based Arrangements
The following three safe harbors protect exchanges between
or among participants in a value-based arrangement, to foster
better coordinated and managed patient care.1
Although the safe harbors differ in level of financial risk
assumed by the eligible parties, they share a commonality
when it comes to which entities are ineligible for protection.
Ineligible entities include:
(i) pharmaceutical manufacturers, wholesalers, and
distributors;
(ii) PBMs;
(iii) laboratory companies;
(iv) pharmacies that primarily compound drugs or primarily
dispense compounded drugs;
(v) manufacturers of devices or medical supplies;
(vi) entities or individuals that manufacture, sell, or rent
DMEPOS (other than a pharmacy or a physician, provider,
or other entity that primarily furnishes services, all of
whom remain eligible); and
(vii) medical device distributors or wholesalers that are not
otherwise manufacturers of devices or medical supplies.2
a. Care coordination arrangements
(1) General requirements
The first value-based arrangements safe harbor, the care
coordination arrangements safe harbor, was developed to
facilitate value-based care and improved care coordination for
patients by providers and others that may be assuming little
or no substantial downside financial risk. It protects in-kind
remuneration exchanged between a VBE and qualifying VBE
participant or between qualifying VBE participants pursuant to
a value-based arrangement that satisfies certain requirements.
The terms of the value-based arrangement must be put into
writing and signed by both parties prior to, or simultaneously
with the commencement of the arrangement.3
Protected remuneration must predominantly be used to
engage in value-based activities that are directly connected
1 These safe harbors were created by a final rule published Dec. 2, 2020. See 85 Fed. Reg. 77,684 § III.B.1. (effective Jan. 19, 2021).
2 The care coordination arrangements safe harbor includes a separate pathway, with specific conditions, that protects digital technology arrangements (as defined
at paragraph §1001.952(ee)(14)) involving manufacturers of devices or medical supplies and DMEPOS. 42 C.F.R. § 1001.952(ee)(13); 85 Fed. Reg. 77,684 § III.B.1.
(Dec. 2, 2020, effective Jan. 19, 2021).
3 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.3. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee).
4 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(9).
5 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(10).
to the coordination and management of care for the target
patient population. Further, protected arrangements cannot:
• induce VBE participants to furnish medically unnecessary
care or reduce medically necessary care;
• limit medical decision-making or patient freedom of
choice; or
• take into account the volume or value of business outside
of the value-based arrangement.
All recipients must pay 15 percent of the offeror’s cost or 15
percent of the fair market value of the remuneration.
(2) Monitoring and assessment
The VBE, a VBE participant in the value-based arrangement
acting on the VBE’s behalf, or the VBE’s accountable body
or responsible person reasonably must monitor and assess
the following no less frequently than annually or at least
once during the term of the value-based arrangement for
arrangements with terms of less than one year:
(i) the coordination and management of care for the target
patient population in the value-based arrangement;
(ii) any deficiencies in the delivery of quality care under the
value-based arrangement; and
(iii) progress toward achieving the legitimate outcome or
process measure(s) in the value-based arrangement.4
If the VBE’s accountable body or responsible person
determines, based on the monitoring and assessment, that the
value-based arrangement has resulted in material deficiencies
in quality of care or is unlikely to further the coordination and
management of care for the target patient population, the
parties must within 60 days either terminate the arrangement
or develop and implement a corrective action plan to remedy
the deficiencies within 120 days.5
b. Value-based arrangements with substantial
downside financial risk
The second value-based arrangements safe harbor protects
both monetary and in-kind remuneration exchanged between referring entities.
"Anti-Kickback Safe Harbors (Portfolio Excerpt)
(Excerpted from HLBS 1500 Federal Anti-Kickback Law, by Precious M. Gittens, Fresenius Medical Care North America, and Joseph
LaMagna, Partner, Hooper, Lundy & Bookman, P.C., San Diego, Calif.)
Value-Based Arrangements
The following three safe harbors protect exchanges between
or among participants in a value-based arrangement, to foster
better coordinated and managed patient care.1
Although the safe harbors differ in level of financial risk
assumed by the eligible parties, they share a commonality
when it comes to which entities are ineligible for protection.
Ineligible entities include:
(i) pharmaceutical manufacturers, wholesalers, and
distributors;
(ii) PBMs;
(iii) laboratory companies;
(iv) pharmacies that primarily compound drugs or primarily
dispense compounded drugs;
(v) manufacturers of devices or medical supplies;
(vi) entities or individuals that manufacture, sell, or rent
DMEPOS (other than a pharmacy or a physician, provider,
or other entity that primarily furnishes services, all of
whom remain eligible); and
(vii) medical device distributors or wholesalers that are not
otherwise manufacturers of devices or medical supplies.2
a. Care coordination arrangements
(1) General requirements
The first value-based arrangements safe harbor, the care
coordination arrangements safe harbor, was developed to
facilitate value-based care and improved care coordination for
patients by providers and others that may be assuming little
or no substantial downside financial risk. It protects in-kind
remuneration exchanged between a VBE and qualifying VBE
participant or between qualifying VBE participants pursuant to
a value-based arrangement that satisfies certain requirements.
The terms of the value-based arrangement must be put into
writing and signed by both parties prior to, or simultaneously
with the commencement of the arrangement.3
Protected remuneration must predominantly be used to
engage in value-based activities that are directly connected
1 These safe harbors were created by a final rule published Dec. 2, 2020. See 85 Fed. Reg. 77,684 § III.B.1. (effective Jan. 19, 2021).
2 The care coordination arrangements safe harbor includes a separate pathway, with specific conditions, that protects digital technology arrangements (as defined
at paragraph §1001.952(ee)(14)) involving manufacturers of devices or medical supplies and DMEPOS. 42 C.F.R. § 1001.952(ee)(13); 85 Fed. Reg. 77,684 § III.B.1.
(Dec. 2, 2020, effective Jan. 19, 2021).
3 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.3. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee).
4 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(9).
5 85 Fed. Reg. 77,684 (§ III.B.3.k.) (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ee)(10).
to the coordination and management of care for the target
patient population. Further, protected arrangements cannot:
• induce VBE participants to furnish medically unnecessary
care or reduce medically necessary care;
• limit medical decision-making or patient freedom of
choice; or
• take into account the volume or value of business outside
of the value-based arrangement.
All recipients must pay 15 percent of the offeror’s cost or 15
percent of the fair market value of the remuneration.
(2) Monitoring and assessment
The VBE, a VBE participant in the value-based arrangement
acting on the VBE’s behalf, or the VBE’s accountable body
or responsible person reasonably must monitor and assess
the following no less frequently than annually or at least
once during the term of the value-based arrangement for
arrangements with terms of less than one year:
(i) the coordination and management of care for the target
patient population in the value-based arrangement;
(ii) any deficiencies in the delivery of quality care under the
value-based arrangement; and
(iii) progress toward achieving the legitimate outcome or
process measure(s) in the value-based arrangement.4
If the VBE’s accountable body or responsible person
determines, based on the monitoring and assessment, that the
value-based arrangement has resulted in material deficiencies
in quality of care or is unlikely to further the coordination and
management of care for the target patient population, the
parties must within 60 days either terminate the arrangement
or develop and implement a corrective action plan to remedy
the deficiencies within 120 days.5
b. Value-based arrangements with substantial
downside financial risk
The second value-based arrangements safe harbor protects
both monetary and in-kind remuneration exchanged between
2021 Outlook on Health Law 24
a VBE, that assumes substantial downside financial risk,6 and
a payor under one of three methodologies . A qualifying
VBE participant must meaningfully share the financial risk.
The terms of the value-based arrangement must be put into
writing and signed by both parties prior to, or simultaneously
with the commencement of the arrangement.7
Protected remuneration must predominantly be used to
engage in value-based activities that are directly connected to
the items and services for which the VBE has assumed (or has
entered into a written contract or value-based arrangement
to assume within the next six months) substantial downside
financial risk.
In line with the other two value-based arrangement safe
harbors, protected arrangements cannot:
• take into account the volume or value of, or condition the
remuneration on, referrals of patients outside of the target
patient population or business not covered under the
value-based arrangement;
• limit the VBE participant’s ability to make decisions in the
best interests of its patients; or
• induce the VBE or VBE participants to reduce or limit
medically necessary items or services furnished to any patient.
c. Value-based arrangements with full financial risk
The third value-based arrangements safe harbor protects
both monetary and in-kind remuneration exchanged between
a VBE and a VBE participant pursuant to a value-based
arrangement where the VBE has assumed, or is contractually
obligated to assume full financial risk8 for a term of at least
one-year.9
Protected remuneration must predominantly be used to
engage in one or more of the VBE’s value-based purposes.
In line with the other two value-based arrangement safe
harbors, protected arrangements cannot:
• take into account the volume or value of, or condition the
remuneration on, referrals of patients outside of the target
patient population or business not covered under the
value-based arrangement;
• limit the VBE participant’s ability to make decisions in the
best interests of its patients; or
• induce the VBE or VBE participants to reduce or limit
medically necessary items or services furnished to any patient.
6 A VBE can assume risk from the payor through an arrangement that meets the definition of “value-based arrangement,” or a VBE can assume risk from a payor
through a written contract that places the VBE at substantial downside financial risk.
7 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.4. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(ff).
8 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.5. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(gg)(2).
9 The value-based arrangement must be set forth in writing, signed by the parties, and specify all material terms, including the value-based activities and the term.
85 Fed. Reg. 77,684 § III.B.5.f. (Dec. 2, 2020, effective Jan. 19, 2021); 42 C.F.R. § 1001.952(gg).
10 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.6. (effective Jan. 19, 2021); 42 C.F.R. § 1001.952(gg)(2).
11 Safe harbor protection extended to a VBE participant that provides patient engagement tools or supports through a third party that qualifies as an “eligible
agent,” as defined in §1001.952(hh)(9). Arrangements under this safe harbor are also protected under the Beneficiary Inducements CMP. 42 C.F.R § 1003.110(10);
85 Fed. Reg. 77,684 § III.B.6.d. (Dec. 2, 2020, effective Jan. 19, 2021).
Patient Engagement and Support
The patient engagement and support safe harbor, 42 C.F.R.
§ 1001.952(hh), protects patient engagement tools and
supports—in-kind items, goods, and services564— furnished
directly by VBE participants to patients in a target patient
population of a value-based arrangement to which the VBE
participant is a party.10 Patient engagement tools or support
cannot be funded or contributed by a VBE participant that is
not a party to the applicable value-based arrangement or by
an entity listed at §1001.952(hh)(1)(i) through (viii).11
The aggregate retail value of patient engagement tools and
supports furnished to a patient by a VBE participant on an
annual basis cannot exceed $500.
Any protected tool or support must have a “direct connection”
to the coordination and management of care of the
target patient population and must not result in medically
unnecessary or inappropriate items or services reimbursed in
whole or in part by a Federal health care program.
The tools and supports must advance one or more of the
following goals:
• Adherence to a treatment regimen determined by the
patient’s licensed health care professional.
• Adherence to a drug regimen determined by the patient’s
licensed health care professional.
• Adherence to a follow-up care plan established by the
patient’s licensed health care professional.
• Prevention or management of a disease or condition as
directed by the patient’s licensed health care professional.
• Ensure patient safety.
The following entities are not eligible for protection under this
safe harbor:
(i) pharmaceutical manufacturers, wholesalers, and
distributors;
(ii) PBMs;
(iii) laboratory companies;
(iv) pharmacies that primarily compound drugs or primarily
dispense compounded drugs;
(v) manufacturers of devices or medical supplies (except with
respect to digital health technology, as described below);
2021 Outlook on Health Law 25
(vi) entities or individuals that sell or rent DMEPOS (other than
a pharmacy, a medical device or supply manufacturer that
also sells or rents DMEPOS, or a physician, provider, or
other entity that primarily furnishes services, all of whom
remain eligible);
(vii) medical device distributors or wholesalers that are not
otherwise manufacturers of devices or medical supplies;
and
(viii) medical device manufacturers, distributors, or wholesalers
with ownership or investment interests held by physicians.
CMS-Sponsored Models
a. General requirements
The safe harbor created at 42 CFR § 1001.952(ii) protects
certain financial arrangements and patient incentives related
to the Medicare Shared Savings Program under section 1899
of the Act and models established and tested by CMS under
section 1115A of the Act. The CMS-sponsored model patient
incentive must have a direct connection to the patient’s health
care, unless the participation documentation specifies a
different standard.12
b. Duration of protection
(1) For a CMS-sponsored model governed by participation
documentation other than the legal instrument setting
forth the terms and conditions of a grant or a cooperative
agreement, the exchange of remuneration between CMSsponsored model parties that occurs on or after the first day
on which services under the CMS-sponsored model begin and
no later than 6 months after the final payment determination
made by CMS under the model.
(2) For a CMS-sponsored model governed by the legal
instrument setting forth the terms and conditions of a grant
or cooperative agreement, the exchange of remuneration
between CMS-sponsored model parties that occurs on or after
the first day of the period of performance (as defined at 45
CFR § 75.2) or such other date specified in the participation
documentation and no later than 6 months after closeout
occurs pursuant to 45 CFR § 75.381.
(3) For a CMS-sponsored model patient incentive, an incentive
given on or after the first day on which patient care services
may be furnished under the CMS-sponsored model as
specified by CMS in the participation documentation and no
later than the last day on which patient care services may be
furnished under the CMS-sponsored model, unless a different
timeframe is established in the participation documentation. A
patient may retain any incentives furnished in compliance with
paragraph (ii)(2) of this section.
12 A final rule published Dec. 2, 2020 added this safe harbor. See 85 Fed. Reg. 77,684 § III.B.7. (effective Jan. 19, 2021).
Cybersecurity Technology and Services
42 CFR § 1001.952(jj) created a safe harbor to address the
growing threat of cyberattacks impacting the health care
ecosystem and protect nonmonetary donations of certain
cybersecurity technology and related services necessary and
used predominantly to implement, maintain, or reestablish
effective cybersecurity.568
This safe harbor will not protect the following donations:
• donations where donors directly take into account the volume
or value of referrals or other business generated between
the parties when determining the eligibility of a potential
recipient for the technology or services, or the amount or
nature of the technology or services to be donated;
• donations where donors condition donations of technology
or services, or the amount or nature of the technology or
services to be donated, on future referrals; and
• donations where the recipient or the recipient’s practice
(or any affiliated individual or entity) makes the receipt
of technology or services, or the amount or nature of the
technology or services, a condition of doing business with
the donor." Source: Bloomberg 2021 Outlook on Health Law https://assets.bbhub.io/bna/sites/7/2021/02/2021_Outlook_Health.pdf?utm_campaign=BLAW_Confirmations_Report&utm_medium=email&utm_source=Eloqua
Safety Net Provider A CMS term for primary care physician availability or access to care in underserved areas of poor people. See: Value Based Care. https://innovation.cms.gov/strategic-direction
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. SAMx (UHC Level Funded Plan Tools)What UHC calls the training tools for their Level Funded and Fully Insured plans. 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. Secondary Annuity Market (Factored Structored Settlements)As with just about all assets, life insurance and annuity products, there are primary, secondary and tertiary markets offering lump sum payouts in return for the asset. How it gets taxed by the buying entity makes a big difference. Secondary Water Resistance Discounts The seams between the deck sheathing allow water to enter the home even if the entire roof structure is intact.
Homeowners can install rubber or asphalt sheets with peel and stick undersides to provide secondary water resistance for their home. By applying strips of the rubber or asphalt sheets to the outside joints/seams of the roof decking, all joints/seams in the sheathing will be sealed. Section 125 Plans (FSA, 125 Plans)Medical benefit plans employers can establish to pay for eligible insurances with pretax funds, and thereby save on payroll taxes. Funds can also be applied to things like parking expenses, so talk to a CPA. 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.
New options are also available, and change the calculation of what is affordable (i.e. 9.61% of Employees AGI/MAGI) that now INCLUDES cost insuring the employee's family, and not just the cost of the employee. See: ICHRA, QSEHRA's. Talk to a CPA, and good luck figuring out exactly how much the employee's famuily gets (in addition to the employees total compensation benefits package) in a tax cedit to the employer to insure his family. https://www.irs.gov/pub/irs-drop/n-22-41.pdf
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 Secure Act An law that lowers the requirements for non-similar business entities to offer retirement plans. See: MEPS, ARPS, PEPS, PEOs, MEWA. ======================Related to lowering the requirements needed to reimburse employees directly with "pretax" earnings for individual health insurance purchased when the employer does not insure employees with a group plan paid for my the employer.
"Beginning in 2021, small-business clients will have more retirement benefit options.
The Secure Act removed the commonality of interest requirement that previously limited multiple employer plans (MEPs) to business owners who shared the same geographic location or industry—creating a new type of MEP. Under the Secure Act, employers will be able to offer MEPs, association retirement plans (ARPs) and pooled employer plans (PEPs)."
"Association Retirement Plans (ARPs): The 2019 DOL Regulations
In 2019, the DOL released regulations designed to expand access to MEPs. Some in the industry began referring to these new MEPs as association retirement plans (ARPs) to differentiate from the original “closed” MEP, and to clarify that ARPs must satisfy additional criteria in order to be treated as qualified plans. Essentially, the ARP is a type of MEP, and the terms have mostly been used interchangeably.
Under the ARP structure, employers that share only the same geographic location or industry are permitted to join together in the MEP. The participating employers can be located in the same city, county, state or even multi-state region. Companies operating in the same industry can join together even if they operate in entirely different regions. The ARP can be sponsored by a permitted group of employers if certain formalities are satisfied (the organization of employers must be bona fide, with organizational documents and control over the MEP in substance and in form, directly or indirectly, among other requirements).
In the alternative, ARP members can now join together in a plan sponsored by a professional employer organization (PEO). When a PEO is used, that PEO must accept administrative responsibility for substantial employment-related duties, such as responsibility for paying wages to the participants’ employees, including all withholding and reporting responsibilities. The PEO must also have a role in recruiting, hiring and firing employees of the participating employers, and must play a substantial role in administering the employers’ benefit offerings."
"Pooled Employer Plans (PEPs) Post-Secure Act
Building upon the momentum surrounding MEPs, beginning in 2021, the Secure Act permits MEP participation for employers who share no common interest apart from the desire to offer a retirement plan. The Secure Act also eliminated many concerns about the “one bad apple” rule by providing that the entire plan would not be disqualified based on a single participant’s actions.
Under the Secure Act, these types of MEPs are also called pooled employer plans (PEPs)—another name for a type of MEP that meets certain additional requirements to avoid the commonality of interest requirement and one bad apple rule. The PEP will be treated as a single retirement plan."
"This type of “open MEP” must be administered by a pooled plan provider (generally, a financial services firm). Use of the pooled plan provider to act as both plan administrator and a fiduciary with respect to the plan is intended to ease both the administrative burden and fear of fiduciary liability for small business owners."
"The pooled plan provider must register as a fiduciary with the Treasury Department and the DOL. The pooled plan provider also must have a trustee responsible for monitoring contributions and dealing with subsequent issues that arise."
Small business clients should understand that, as employer, they continue to bear fiduciary responsibility with respect to selecting and monitoring the pooled plan provider. Pooled plan providers can outsource investment decisions to another fiduciary (likely what is known as a “3(38) fiduciary”). This arrangement does spread the costs of investment advice among the MEP participants to reduce expenses, but the extent of the employer’s fiduciary exposure still remains unclear under the law." Source Think Advisor: June 2020 https://www.thinkadvisor.com/2020/02/19/secure-acts-new-retirement-plans-meps-arps-peps/
Secure Act A law guiding ARP's, MEPs, PEPs that effectively removed the commonality rule that used to be required for multiple employer (ERISA) associations to insure their employees inside of states, and across state lines. See: MEWA, and try to differentiate what they offer that MEWA's did not already offer...? Focus on why States would challenge them, and the state's ultimate power to impose cease and desists authority over any insuring entity failing to meet state solvency, or certificate of authority mandate. See: MEWA SECURE Act signed 2022 A federal set of laws governing retirement accounts. http://file:///C:/Users/Steve's%20Laptop/Downloads/Introducing_Highlights_of_Secure_Act_2.0_Client._pdf.pdf
Security The mechanisms in place to protect the confidentiality and privacy of personal information (PII). Source: Federal Marketplace Exam 2022 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 Self Insurer's Bond A bond purchased by a self insured employer to cover retnetion, and free up lines of credit while meeting state guidelines to have money on hand in the event of a loss. I.e. For Wokers Compensation SIR Self Referral See: Stark and complicated safe harbors. "Centers for Medicare & Medicaid Services (CMS) finalized changes to outdated federal regulations that have burdened health care providers with added administrative costs and impeded the health care system’s move toward value-based reimbursement. The Physician Self-Referral Law, also known as the “Stark Law,” generally prohibits a physician from sending a patient for many types of services to a provider that the physician owns, is employed by, or otherwise receives payment from—regardless of what that payment is for. The old federal regulations that interpret and implement this law were designed for a health care system that reimburses providers on a fee-for-service basis, where the financial incentives are to deliver more services. However, the 21st century American health care system is increasingly moving toward financial arrangements that reward providers who are successful at keeping patients healthy and out of the hospital, where payment is tied to value rather than volume." Source: CMS https://www.cms.gov/newsroom/press-releases/cms-announces-historic-changes-physician-self-referral-regulations
https://www.federalregister.gov/documents/2020/12/02/2020-26140/medicare-program-modernizing-and-clarifying-the-physician-self-referral-regulations
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 SEP IRA (Simple IRA) https://www.irs.gov/retirement-plans/plan-sponsor/simple-ira-plan
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 during the Benefit Year
The transitional reinsurance and permanent risk adjustment programs functioned smoothly for 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.
It can also be 