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Affordable Care Act of 2010? Impact on Cost, Access, and
Quality Influence on Cost
Containment Types of Managed Care Medicare vs HMO & PPOs Managed Care &
Integrated Organizations Future for Medicaid in Florida Presumptive Eligibility for Pregnant Women (PEPW) - PEPW provides temporary Medicaid to provide pregnant women immediate access to prenatal care.
All pregnant women with family income less than or equal to 185% of the Federal Poverty Level may be eligible for coverage.
There is no asset limit and citizenship/alien status is not a factor of eligibility.
Simplified Eligibility for Pregnant Women (SEPW) - SEPW provides full Medicaid coverage for pregnant women.
All pregnant women with family income at or below 185% of the Federal Poverty Level may be eligible.
No asset limit
Pregnancy must be verified Requirements for Pregnant Women There are several coverage groups for children:
Children under age 1 with household income less than 200% of FPL.
Children ages 1 through 5 with household income less than 133% FPL.
Children ages 6 to 19 with household income less than 100% FPL.
There is NO ASSET LIMIT with KidCare.
Children from age 1 up to age 5 whose household income is between 133% and 200% of the Federal Poverty Level (FPL).
The household is responsible to pay the monthly premium.
Florida Healthy Kids:
Program provides medical coverage for children ages 5 through 18 in households whose income is over the Medicaid limit and under 200% of the FPL.
Househould is responsible for monthly premium.
Children’s Medical Services Network:
Eligible children from birth through age 18 who have special behavioral or physical health needs or have a chronic medical condition.
This network will provide case management services. Requirements for Children
Medicaid under this category is based on Section 1931 of the Social Security Act and is closely related to Temporary Cash Assistance (TCA) policy.
Low income families (with one or two parents) may be eligible for Medicaid.
Children up to age 18 and their parents or caretaker relatives may be eligible for Medicaid if the family’s countable income does not exceed the income limits and countable assets.
Parents must have at least one child that meets all technical factors of eligibility or be pregnant in order to receive Medicaid for themselves.
There is a $2000 asset limit and family income must be less than the income limit for Temporary Cash Assistance (TCA) after allowable deductions.
The income and assets limits for Medicaid for low income families and children is determined by the Florida Poverty Level (FPL) chart and varies depending on the family size. Requirements for low-income families Can I get Medicaid? As we all are aware, Federal Medical Law allows states broad discretion over Medicaid eligibility policy. Therefore, eligibility varies from state to state. Medicaid in Florida Since Medicaid is an “entitlement” program, anyone who meets eligibility rules has the right to receive Medicaid coverage.
Medicaid eligibility in Florida is determined by either the Department of Children and Families (DCF) or Social Security Administration (for SSI recipients).
DCF determines Medicaid eligibility for:
Low income families with children
Non-citizens with medical emergencies
Aged and/or disabled individuals not currently receiving Supplemental Security Income (SSI) As of January 4,2013, Florida Governor Rick Scott made a proposal to expand the Medicaid Program.
This expansion would boost economic activity in Florida by $8.9 billion in 2016 with more people being insured and job growth.
1.8 million uninsured Floridians would qualify for Medicaid through the Affordable Care Act.
However, State Senate panel rejected the proposal--they would instead compromise and accept the federal money but use it to put the low-incomers into private insurance plans.
Lawmakers have until May 3 to decide for
Medicaid. What is the Affordable Care Act Of 2010? What it means for Florida cont’d? “While the federal government is committed to paying 100% of the cost, I cannot in good conscience deny Floridians that needed access to health care.” – Rick Scott, Feb.,2013 What it means for Florida? Financing
Payment Integrated Functions of Managed Care Managed Care provides many different types of healthcare services to members enrolled in a managed care plan by contracting with many physicians and hospitals around the country What is Managed Care cont’d...? Managed Care, defined by the National Library of Medicine, “as programs or organizations intended to reduce unnecessary healthcare costs through a variety of mechanisms…” What is Managed Care? http://www.healthcare.gov/law/timeline/index.html Affordable Care Act of 2010: Timeline Mental health delivery: examining both qualitative and quantitative aspect of outpatient mental health treatment, managed care was found to achieve cost savings buy not at the expense of quality of care(Goldman et al.2003) Influence on Quality Care, cont. HMO and non HMO plans provided roughly equal quality of care
HMOs lower the use of hospitals and other expensive resources: Managed care plans have been cost effective, while delivering levels of quality either comparable to or better than traditional insurance plans. Influence on Quality Care, cont. Despite isolated stories propagated by the news media, no comprehensive research to date has demonstrated that manage care’s growth has been at the cost of quality in health care. On the contrary, quality of health care provided by MCOs has improved over time(Hofmann 2002)
In terms of benefits and costs, being white or a member of a minority class makes no difference for Medicare enrollees regardless of whether they are enrolled in Managed care or in the traditional fee-for-service program (Balsa et al.2007) Influence on Quality Care, cont. Physicians under capitation take full responsibility for the patient’s overall care.(Eikel 2002) Example: life treatment decisions, such as treatment of cancer patients(Bourjolly et al. 2004)
On the other hand, Medicaid patients under capitation, may not receive certain services for which the PCPs do not get additional compensation, which may impact patient’s quality of care.(Quast et al. 2008) Influence on Quality Care, cont. Managed care enrollees have good access to primary and preventive care.
2001-2003 More relaxed utilization controls by health plans in the years following the severe criticism of managed care.
Larger scale, manages care’s impact is not known.
1996-2000: employers offering insurance benefits increased from 59 to 67 % (3-199workers/3-9 workers), during unprecedented economic growth. Impact on Access HMOs include today complementary and alternative medicine (CAM) for its potential to save money, as well as improve quality.
Lower cost therapies: stress management and meditation classes can save numerous trips to physicians and costly diagnostic tests. Managed Care Managed Care Cost Across Plans Different qualities
Overall, equivalent fee-for-service plans
Disparities base on race and socioeconomic status, are unfounded (De Francesco 2002).
Evidence that quality of care may be lower in for-profit health plans , compared to nonprofit plans(Himmelstein et al.1999, Scheneider et al.2005). Influence on Quality Care 1998 : Enrollees an providers prompted MCOs to back away from aggressive cost control measures.
Full cost-containment of managed care was never realized, and private and public insurance plans have moved their enrollees from fee-for service plans to managed care and placed it in a dominant position in the health insurance marketplace.
Future cost reductions in costs, will sacrifice utilization, particularly on the use of expensive new technology. Open-panel options
Non capitation payment
Exclusive provider plan
Discounted fee arrangements
Owned by insurance companies, HMOs, hospitals and physicians
Gatekeeping is not employed Preferred Provider Organization San Joaquin County medical Society
HMO Act of 1973
Legal entity separated from the HMO
Represents a large number of physicians
HMO pays capitation to IPA
HMO responsible for providing health care services
IPA can be establish independently, by HMOs, or hospital based
Buffer between HMO and physicians
Most successful Independent-Practice Association (IPA) Contracts with more than one medical group practice
Physicians maintain offices
Compensated through capitation
Provide all physical services
Can see non-HMO and HMO patients
Offers patient choice of physicians and managed costs
Risky Network Model Classified in 2 ways
The group practice employs
All-inclusive capitation fee
Large group contracts
Benefits similar to Staff model HMOs
Kaiser Foundation Health Plan
The Geisinger Clinic Group Model Physician employees
Harvard Community Health Plan
Group Health Cooperative of Puget Sound
Salary and Work hours
No longer Popular Staff-Model Cannot be categorized
Combination of delivery systems
Widest variety of choice
Broadest geographic coverage to members Mixed Model Provides medical care to the ill
Provides services to maintain health
Requires Primary care physician
Provider is paid a fee regardless of service type
Health care is obtained from in-network hospitals
Exception is a carve out
4 common HMO models
Independent Practice Association (IPA) Health Maintenance Organizations Combines HMOs and PPOs
Alternative to restricted choice
Primary care doctor
Features from HMOs
Features from PPOs Point-of-Service Plan If you have Medicare and other health insurance or coverage, each type of coverage is called a "payer." When there's more than one payer, "coordination of benefits" rules decide which one pays first. The "primary payer" pays what it owes on your bills first, and then sends the rest to the "secondary payer" to pay. In some cases, there may also be a third payer. OTHER INSURANCES You are 65 or older
Received Social Security benefits
Are not getting Social Security benefits, but you have worked long enough to be eligible for them
Worked enough in a federal, state or local government job to be insured for Medicare Requirements Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities
Managed care contracts are commonly referred to as risk contracts in which the MCO is liable for services regardless of their expenses. It establishes that you cannot perform job duties
Your medical condition(s) must have lasted, or be expected to last, at least 1 year, or be expected to result in your death. To illustrate, patient with End-Stage Renal Disease. Disability Disease management focuses on groups of patients with the same chronic conditions. Health care professionals educate, train in self-management, monitor progress of disease, and follow up to ensure patients are following medical regiments. Disease Management Case management focuses on the individual. An experienced health care professional evaluates and coordinates care for patients with complex and potentially very costly problems. Patients are categorized as high-risk and usually require a variety of services from multiple providers. Case Management Cost Control Methods Prospective UR – Determined before care is given
Concurrent UR – Determined on daily basis, the time necessary for stay in a hospital
Retrospective UR – review of utilization after services are given 3 Types of UR A primary-care provider who coordinates patient care and provides referrals to specialists, hospitals, laboratories, and other medical services. Gatekeeping In-Network Access (close-panel)
An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates
Out-of-Network Access (open-panel)
An out-of-network provider is one not contracted with the health insurance plan Choice Restriction There are three types of utilization review:
Concurrent UR and discharging planning
Retrospective UR Analysis of the necessity, appropriateness, and efficiency of medical services, procedures, facilities, and practitioners. Also to ensure that services are cost-efficient. Utilization Review