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.
HEALTHCARE LEGISLATION TERMS
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
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.
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.