The Affordable Care Act

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As with any other governmental program, acronyms are a given in the Affordable Care Act (ACA) healthcare legislation, and understanding the terms in the new legislation can take a backseat to daily concerns-even when it can impact your work. The latest installment of O&Pedia offers definitions of several terms that O&P professionals may need to know to prepare for the 2014 implementation of the healthcare law.



Affordable Care Act
ACA is the shortened name for the Patient Protection and Affordable Care Act (PPACA), the federal healthcare law passed in 2010. The ACA is intended to provide access to health insurance to all Americans and to control healthcare costs for individuals and for the government. Insurers will not be permitted to refuse to insure anyone, and lifetime and annual limits will be eliminated from health insurance policies.


Accountable Care Organization
ACOs are voluntary networks of healthcare providers that agree to coordinate the healthcare needs of Medicare beneficiaries. It is a key healthcare delivery system encouraged by the ACA. According to the Centers for Medicare & Medicaid Services (CMS), the goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. ACOs that save money while providing quality care are expected to share in the savings.


Bundled Payments for Care Improvement Initiative
BPCII created four reimbursement models that providers will use to propose nontraditional methods to provide coordinated, standardized care and cost savings by defining a single set payment amount for episodes of care at a hospital or post-hospitalization care. BPCII accepts applications from other healthcare providers instead of only physicians and hospitals, as in the ACO model. BPCII will also provide gainsharing, or sharing in any savings created by the bundled payments. O&P care is specifically included in models two and three, which relate to postacute care.


Center for Medicare & Medicaid Innovation
The CMMI tests and gathers data about the success of the new payment and service delivery proposals in reducing costs while preserving or enhancing the quality of care. CMMI also provides grants to states, local governments, and providers to do the same.

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Essential Health Benefits
EHBs are a set of ten benefits that must be included as part of any non-grandfathered health insurance plan in the individual and small-group market that is subject to the ACA and in each state's health insurance exchange. They are intended to give consumers a consistent way to compare and shop for health insurance plans and to ensure that all consumers are provided with adequate benefits. Hospitalization, maternity, and prescription drug coverage are examples of EHB inclusions. Specific coverage for O&P devices and services will be determined at the state level but are expected to be covered at some level under the rehabilitative and habilitative services and devices benefit.


Health Information Exchange
The HIE is the electronic sharing of healthcare information across organizations. The system will offer immediate access to all patient information across any healthcare information system, emergency room, or medical office. Improved information sharing is expected to decrease duplication of medical tests, reducing treatment costs.


Health Insurance Exchange
HIX, sometimes called the health insurance marketplace, the affordable insurance exchange, or state insurance exchanges, is an organized marketplace where consumers will shop for and purchase health insurance. HIX will provide insurance to anyone, with guaranteed acceptance, not eligible for private insurance through an employer. However, even those consumers with access to an employer plan can choose to purchase insurance through the HIX under certain circumstances defined by the exchange. Because individuals cannot be denied based on pre-existing conditions, the exchanges are a key component of the ACA. HIX enrollment is scheduled to begin October 1, 2013, for coverage to begin January 1, 2014.