Health insurance in the United States

Question

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

Answer 1

Center for Value-Based Insurance Design

The Center for Value-Based Insurance Design at The University of Michigan (V-BID Center) is an advocate for development, implementation and evaluation of clinically nuanced health benefit plans and payment models. Since its inception in 2005, the V-BID Center has been actively engaged in understanding the impact of value-based insurance design (V-BID) on clinical outcomes and economic efficiency in the U.S. health care system. The V-BID Center also works with employers, consumer advocates, health plans, policy leaders, and academics to promote the implementation and demonstration of value-based insurance design in health benefit plans, as well as in state and federal legislation. Co-founded by Dr. A. Mark Fendrick, MD, and Michael Chernew, PhD, the V-BID Center is based in Ann Arbor, Michigan and operates collaboratively with the University of Michigan School of Public Health, the University of Michigan Medical School, and the University of Michigan Institute for Healthcare Policy and Innovation.

Dr. A. Mark Fendrick, MD, is the current Director of the Center for Value-Based Insurance Design. Dr. Fendrick also serves as a Professor of Internal Medicine in the U-M School of Medicine and a Professor of Health Management and Policy in the U-M School of Public Health. The V-BID Center receives guidance and assistance from a professional advisory board, U-M faculty, and U-M students (graduate, doctoral, and medical).

The mission of the V-BID Center is to promote the development, implementation, and evaluation of insurance benefit programs that incorporate demand-side, value-based principles. The V-BID Center uses faculty-conducted research studies to provide evidence to further promote the incorporation of V-BID principles in health insurance benefit designs. In addition to research, the V-BID Center also works to educate private and public sector stakeholders to increase understanding of the V-BID concept, and assist in the creation and improvement of V-BID programs. This is accomplished through local and national conference presentations, as well as academic presentations.

In 2015, the V-BID Center joined the Smarter HealthCare Coalition (SHCC). The mission of the SHCC is "to enhance the patient experience – encompassing access, convenience, affordability, and quality – by working together towards achieving smarter health care, with a focus on integrating benefit design innovations and consumer/patient engagement within broader delivery system reform in order to better align coverage, quality, and value-based payment goals." The coalition involves significant policy and provider leaders in healthcare, including: Aetna, American Benefits Council, America’s Health Insurance Plans, Blue Cross Blue Shield Association, Blue Shield of California, CAPG, Centene, Evolent Health, Families USA, Institute for Medicaid Innovation, Medicaid Health Plans of America, Merck, National Coalition on Health Care, Pfizer, Pharmaceutical Research and Manufacturers of America, Public Sector HealthCare Roundtable, and U.S. Chamber of Commerce.

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Answer 2

Chargemaster

In the United States, the chargemaster, also known as charge master, or charge description master (CDM), is a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider. In practice, it usually contains highly inflated prices at several times that of actual costs to the hospital. The chargemaster typically serves as the starting point for negotiations with patients and health insurance providers of what amount of money will actually be paid to the hospital. It is described as "the central mechanism of the revenue cycle" of a hospital.

The chargemaster may be alternatively referred to as the "charge master", "hospital chargemaster", or the "charge description master" (CDM).The chargemaster is a master file built within hospital information systems, and designed to communicate (interface) with other software applications or systems to support government-mandated standard billing requirements. It contains data elements such as charge descriptions, billing codes, pricing, and many other necessary data elements. It is a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider. It is described as "the central mechanism of the revenue cycle" of a hospital. Chargemasters include thousands of hospital services, medical procedures, equipment fees, drugs, supplies, and diagnostic evaluations such as imaging and blood tests. Each item in the chargemaster is assigned a unique identifier code and a set price that are used to generate patient bills. Every hospital system maintains its own chargemaster.

The procedure of developing, maintaining, and monitoring the chargemaster and its pricing scheme often necessitates multiple hospital employees working under the supervision of a "chargemaster coordinator", a "charge master manager", or others in the health care system's operations or administrative support areas frequently called a "charge master team". Ultimate responsibility for ensuring accuracy of the chargemaster rests with each hospital's chief financial officer, compliance officer, and hospital Board. Approximately forty percent of hospitals pay outside companies to help create and then adapt their chargemasters on a yearly basis. According to Essentials of Managed Health Care, as of 2012 the chargemaster file typically included between 20,000 and 50,000 price definitions. The Lewin Group analyzed utilization of the chargemaster and found that a low proportion of hospitals carried out regular reviews of their chargemaster implementation. Costs for patients maintained on the chargemaster differ greatly from hospital to hospital.

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Answer 3

Dirigo Health

The Dirigo Health Agency (sometimes known simply as Dirigo Health) is a government agency run by the state of Maine in the United States. It oversees the state's subsidized health insurance program, DirigoChoice. The program was launched in 2005, and takes its name from the state motto of Maine, Dirigo, which is a Latin phrase meaning "I Lead."

Dirigo Health was created as part of Maine Public Law 469, also known as the Dirigo Health Reform Act. It was originally presented to the Maine Legislature by Governor John Baldacci in May 2003 and became law in June 2003. The law is a comprehensive reform of the state's health care system, addressing cost, quality and access. Along with DirigoChoice, it created the Maine Quality Forum, a state health plan and put forth measures to reduce the growth of health care costs in Maine, including asking hospitals to voluntarily cap their annual cost increases at 3% per year and their operating margins at 3.5% per year. The law further expanded Medicaid program in the state.

DirigoChoice is a subsidized health insurance program available to Maine businesses with fewer than 50 employees, the self-employed, and other individuals. The program is funded through a one-time grant of $53 million from the state, employer and employee contributions, Medicaid payments, and an ongoing assessment on insurance entities known as the "Savings Offset Payment" (SOP) based on savings attributable to the operations of Dirigo.

In 2002, it was estimated that over 100,000 Maine residents were uninsured. Almost 80% of enrollees have family incomes below 300% of the Federal Poverty Level. 700 small employers were enrolled in DirigoChoice, representing 2.5% of the firms that are eligible. The primary barrier for very small employers appears to be price. The revenues for the program have been lower than expected, creating political pressure to find other funding sources.

Harvard Pilgrim Health Care became the insurance carrier for DirigoChoice effective January 1, 2008.

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Answer 4

EHealthInsurance

eHealthInsurance

eHealth, Inc. advertises itself as America's first and largest private online marketplace for health insurance, with the company inception in 1997.

The company's website, which is eHealth.com (formerly eHealthInsurance.com), details prices for various health insurance plans and allows consumers to apply for coverage online. The pricing is fixed by law and consumers cannot get lower prices elsewhere.

eHealth maintains its license to market and sell health insurance in all 50 states and the District of Columbia, with agents licensed in all states and D.C.. eHealth also offers a wide variety of health plans from over 180 health insurance companies and offers more than 10,000 health insurance products.

eHealth, Inc. was founded in 1997, and its technology was responsible for the nation's first Internet-based sale of a health insurance policy. eHealth, Inc. is headquartered in Mountain View, California.

In 2013 eHealth, along with other "web brokers", signed deals with Healthcare.gov to enroll subsidy-eligible consumers in the newly approved health plans offered through the Affordable Care Act (Obamacare)

In 2016, eHealth announced that it had insured 5 million people.

Also in 2016, eHealth's Board of Directors appointed Scott Flanders, a director of the Company since 2008, to the role of Chief Executive Officer and appointed the Honorable Ellen Tauscher, a director of the Company since 2012, to the role of Independent Non-Executive Board Chair. Former CEO, Gary Lauer transitioned out as Chief Executive Officer and Executive Chairman of the Board, but continued on in an advisory role through the end of 2016.

eHealth is one of a handful of private companies that operate in partnership with the various government-run health insurance exchanges created as part of the Patient Protection and Affordable Care Act legislation.

eHealth has been politically active on issues related to health insurance. Testimony, editorials and letters to governmental bodies issued by eHealth are available online at its parent company's website. The company has issued a number of research reports on the individual health insurance and Health Savings Account markets, which are available on its website.

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Answer 5

Health insurance costs in the United States

The cost of health insurance in the United States is a major factor in access to health coverage. The rising cost of health insurance leads more consumers to go without coverage and increase in insurance costs and accompanying rise in the cost of health care expenses has led health insurers to provide more policies with higher deductibles and other limitations that require the consumer to pay a greater share of the cost themselves. Many people with pre-existing conditions such as cancer and depression are turned down for coverage, denied coverage of those conditions or are charged higher prices for coverage.

The US is the “only industrialized nation that relies heavily on a for-profit medical insurance industry to provide basic health care," as Senator Dianne Feinstein has said, and the Pulitzer Prize–winning PolitiFact watchdog group has confirmed. The Kaiser Family Foundation claims that health insurance costs are driven not only by the added cost of health insurers making their profits, but also by rising health costs and administrative costs.

In 2004, employer-sponsored health insurance premiums grew 11.2% to $9,950 for family coverage, and $3,695 for a single person, according to a survey by the Kaiser Family Foundation and Health Research and Education Trust. The survey also found that 61% of workers were receiving employer sponsored health insurance.

Five years later, Kaiser’s 2009 survey found that employer health insurance premiums were $13,375 for a family and $4,824 for a single person. About 60% of workers were receiving employer sponsored health insurance. Less than half (46%) of employees at small firms with 3 to 9 workers received coverage. As of 2008, the percentage of Americans receiving employer sponsored health insurance had declined for the eighth consecutive year, says the Kaiser Family Foundation.

From 1999 to 2009, Kaiser found that the insurance premiums had climbed 131% or 13.1% per year, and workers’ contribution toward paying that premium jumped 128% or 12.8% per year. In 1999, workers’ average contribution to the premium was $1,543, and in 2009 it was $3,515. For employers, their contribution was $4,247 in 1999 and $9,860 in 2009.

The lower a family's income is, the less likely that they can purchase health insurance, according to 2008 US Census figures. About 14.5% of households with $50,000 to $75,000 in income did not have health insurance. While 24.5% of households with $25,000 or less income went without health insurance.

A March 2010 study by the Center for Studying Health System Change, a Washington DC think tank, found that out-of-pocket costs for health insurance premiums and services were rising faster than family incomes. Published in the journal Health Affairs, the study found “…After accounting for general inflation, family incomes remained stagnant between 2004 and 2006, while out-of-pocket spending on premiums and health care services increased 8.5% over the two-year period. Overall, total out-of-pocket spending increased, on average, about 5 percent annually between 2001 and 2006, and was similar for the 2001–4 and 2004–6 periods.” The report found the largest increases in out-of-pocket expenses were for those with private health insurance, including middle- and higher-income families. The study was based on 2001 through to 2006 data.

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Answer 6

Consumer-driven healthcare

Consumer-driven healthcare (CDHC), defined narrowly, refers to third-tier health insurance plans that allow members to use health savings accounts (HSAs), Health Reimbursement Accounts (HRAs), or similar medical payment products to pay routine healthcare expenses directly, but a high-deductible health plan protects them from catastrophic medical expenses. High-deductible policies cost less, but the user pays medical claims using a prefunded spending account, often with a special debit card provided by a bank or insurance plan.

If the balance on this account runs out, the user pays claims just like under a regular deductible. Users keep any unused balance or "rollover" at the end of the year to increase future balances>or to invest for future expenses. CDHC plans are subject to the provisions of the Affordable Care Act, which mandates that routine or health maintenance claims must be covered, with no cost-sharing (copays, co-insurance, or deductibles) to the patient.

This system is referred to as "consumer-driven healthcare" because claims are paid using a consumer-controlled account versus a fixed health insurance benefit. That gives patients greater control over their own health budgets. According to economist John C. Goodman, "In the consumer-driven model, consumers occupy the primary decision-making role regarding the healthcare they receive."

Goodman points to a McKinsey study which found that CDHC patients were twice as likely as patients in traditional plans to ask about cost and three times as likely to choose a less expensive treatment option, and chronic patients were 20% more likely to follow treatment regimes carefully.

Consumer-driven healthcare received a boost in 2003, with passage of federal legislation providing tax incentives to those who choose such plans. Proponents argue that most Americans will pay less in the long haul under CDHC not only because their monthly premiums will be lower but also because the use of HSAs and similar products increases free-market variables in the healthcare system, fostering competition, which, in turn, lowers prices and stimulates improvements in service.

Critics argue that it will cause consumers, particularly those less wealthy and educated, to avoid needed and appropriate healthcare because of the cost burden and the inability to make informed, appropriate choices. "Consumer-driven healthcare is badly named, because it's certainly not driven by consumers," said Jonathan Oberlander. It is "really just shifting the cost of healthcare onto the backs of the patients". People with chronic illnesses, such as diabetes, will be hurt, because with a deductible of $3000 to $4000, such people will never be able to save anything in their savings accounts. "Employers like it because they're going to save money," but they're not going to fund these healthcare accounts adequately, he said. "Conservatives tend to support consumer-driven healthcare. They believe, as do a fair number of health economists, that people use too much healthcare, and use too much healthcare of little value. If you move to high-deductible plans, people will think twice. If I have a sore throat, instead of going to my physician, I'll have a cup of tea instead."

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Answer 7

Contraceptive mandate

A contraceptive mandate is a state or federal regulation or law that requires health insurers, or employers that provide their employees with health insurance, to cover some contraceptive costs in their health insurance plans. In 1978, the U.S. Congress made it clear that discrimination on the basis of pregnancy was discrimination on the basis of sex. In 2000, the Equal Employment Opportunity Commission ruled that companies that provided insurance for prescription drugs to their employees but excluded birth control were violating the Civil Rights Act of 1964.President Obama signed the Patient Protection and Affordable Care Act (ACA) on 23 March 2010. As of 1 August 2011, female contraception was added to a list of preventive services covered by the ACA that would be provided without patient co-payment. The federal mandate applies to all new health insurance plans in all states from 1 August 2012. Grandfathered plans do not have to comply unless they change substantially. To be grandfathered, a group plan must have existed or an individual plan must have been sold before President Obama signed the law; otherwise they must comply with the new law. The Guttmacher Institute noted that even before the federal mandate was implemented, twenty-eight states had their own mandates that required health insurance to cover the prescription contraceptives, but the federal mandate innovated by forbidding insurance companies from charging part of the cost to the patient.

In the United States, contraceptive use saves about $19 billion in direct medical costs each year.

About half of U.S. pregnancies are unintended. Highly effective contraceptives, such as intrauterine devices (IUDs), are underused in the United States. Increasing use of highly effective contraceptives could help meet the goal set forward in Healthy People 2020 to decrease unintended pregnancy by 10% before 2020. Cost to the user is one factor preventing many US women from using more effective contraceptives. Making contraceptives available without a copay increases use of highly effective methods, reduces unintended pregnancies, and may be instrumental in achieving the Healthy People 2020 goal.

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Answer 8

Essential health benefits

Essential health benefits (EHBs) have been defined since the 2010 United States Affordable Care Act as a set of benefits which Individually purchased health insurance in the United States and insurance plans in small group markets, both inside and outside of the Health Insurance Marketplace must cover for people. Exempt from the EHB requirement are large-group health plans, self-insured ERISA plans, and ERISA-governed multiemployer welfare arrangements not subject to state insurance law.

The 2010 Affordable Care Act (ACA) set forth the following ten categories of essential health benefits, at Section 1302(b)(1) of the ACA, codified at 42 U.S.C. § 18022(b):

Health insurance plans must cover these benefits i.e. they must cap people´s out-of-pocket spending and must not limit annual and lifetime coverage..

The 2010 Affordable Care Act (ACA) defines benefits which Individually purchased health insurance in the United States and insurance plans in small group markets, both inside and outside of the Health Insurance Marketplace must cover for people. Exempt from the EHB requirement are large-group health plans, self-insured ERISA plans, and ERISA-governed multiemployer welfare arrangements not subject to state insurance law.

The essential health benefits are a minimum federal standard and "states may require that qualified health plans sold in state health insurance exchanges also cover state-mandated benefits." The act gives "considerable discretion" to the Secretary of Health and Human Services to determine, through regulation, what specific services within these classes are essential. However, the Act provides certain parameters for the secretary to consider. The secretary (1) must "ensure that such essential health benefits reflect an appropriate balance among the categories ... so that benefits are not unduly weighted toward any category"; (2) may "not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life"; (3) must take into account "the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups"; and (4) must ensure that essential benefits "not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or the individuals' present or predicted disability, degree of medical dependency, or quality of life."

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Answer 9

Exchange Information Disclosure Act

Exchange Information Disclosure Act

The Exchange Information Disclosure Act (H.R. 3362) is a bill that would require the United States Department of Health and Human Services to submit weekly reports to Congress about how many people are using HealthCare.gov and signing up for health insurance. These reports would be due every Monday until March 31, 2015 and would be available to the public. The bill would "require weekly updates on the number of unique website visitors, new accounts, and new enrollments in a qualified health plan, as well as the level of coverage," separating the data by state. The bill would also require reports on efforts to fix the broken portions of the website.

The bill was introduced on October 29, 2013 in the United States House of Representatives during the 113th United States Congress. The House was scheduled to vote on it on January 10, 2014. On January 16th, 2014, the bill was passed. 226 Republicans and 33 Democrats have voted yes to the bill.

The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or "Obamacare", is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act, it represents the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.

The ACA was enacted with the goals of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage, and reducing the costs of healthcare for individuals and the government. It introduced a number of mechanisms—including mandates, subsidies, and insurance exchanges—meant to increase coverage and affordability.

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Answer 10

Exclusive provider organization

In the United States, an exclusive provider organization is a hybrid health insurance plan in which a primary care provider is not necessary, but in which health care providers must be seen within a predetermined network. Out of network care is not provided, and visits require pre-authorization. Doctors are paid as a function of care provided, as opposed to an HMO. In an EPO, the payment scheme is usually fee for service, in contrast to HMOs. In the latter, the healthcare provider is paid by capitation, and receives a monthly fee regardless of whether or not the patient is seen.

An exclusive provider organization (EPO) is a network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers. With an EPO, medical care providers enter a mutually beneficial relationship with an insurer. The insurer reimburses an insured subscriber only if the medical expenses are derived from the designated network of medical care providers. The established network of medical care providers in turn offer subscribed patients medical services at significantly lower rates than these patients would have been charged otherwise. In exchange for reduced rates of medical services, medical care providers get a steady stream of business.

An EPO earns additional money by charging an access fee to the insurer for use of the network. It also negotiates with the medical care providers of the organization in order to set fee schedules and help resolve disputes between the insurer and medical care providers. Sometimes EPOs even contract with one another to strengthen their businesses and positions in a certain geographic area.

The beneficial relationship between medical care providers and the insurer often transfers to the insured subscriber because lower rates of medical services means lower rates of increase in monthly premiums. Although a good deal, the downside of EPOs is that they can be quite restrictive. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for covered care. For example, going to a hospital outside of the network in an emergency, one may have to pay the medical bills partially or completely out-of-pocket.

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