1. Health Insurance Tolulope Ajifowobaje, RN & Annie Wiseman, MPH

2. History of Health Insurance https://www.youtube.com/watch?v=S9zRjKgv9 Qohttps://www.youtube.com/watch?v=S9zRjKgv9 Qo

3. Government Plans Health care ▫Retirees ▫Low-income and disadvantaged ▫Active or retired military personnel and their families

4. Medicare The largest federal program Managed by the Centers for Medicare and Medicaid Services (CMS) Medicare Part A ▫Hospital insurance ▫Financed by Federal Insurance Contributions Act (FICA) tax ▫Covers anyone with Social Security benefits

5. Medicare (cont.) Medicare Part B ▫Covers outpatient services ▫Voluntary program ▫Participants pay a premium Medicare health insurance card ▫Medicare number ▫Indicates eligibility

6. Medicare (cont.) Part C – 1997 ▫Provides choices in types of plans ▫Medicare Advantage plans Part D – prescription drug plan

7. Medicare (cont.) Medicare plan options ▫Fee-for-Service: The Original Medicare Plan ▫An annual deductible ▫After deductible, the patient pays 20 percent ▫Medigap plan – secondary insurance Medicare Administrative Contractor (MAC) Jurisdictions

8. Medicare (cont.) Medicare Managed Care Plans Medicare Preferred Provider Organization Plans (PPOs) Medicare Private Fee-for-Service Plans

9. Medicare Plans (cont.) Recovery Audit Contractor (RAC) Program ▫Designed to guard the Medicare Trust Fund ▫Identify improper payments Underpayme nt Overpayment

10. Medicaid Health cost assistance program not an insurance program Federal funds for mandated services States – additional optional services Accepting assignment Dual coverage

11. Medicaid (cont.) State guidelines ▫Verify Medicaid eligibility ▫Ensure that the physician signs all claims ▫Preauthorization required except in an emergency ▫Verify deadlines for claim submissions ▫Treat Medicaid patients with professionalism and courtesy

12. TRICARE and CHAMPVA TRICARE ▫Healthcare benefit ▫Eligibility – enrollment in the Defense Enrollment Eligibility Reporting System (DEERS) CHAMPVA ▫Civilian Health and Medical Program of the Veterans Administration ▫Eligibility determined by the VA

13. State Children’s Health Plan (SCHIP) Enacted in 1997 and reauthorized in 2009 State-provided health coverage for uninsured children in families that do not qualify for Medicaid

14. Tell me something you know about the Affordable Care Act (ACA)

15. The Patient Protection and Affordable Care Act of 2010 (ACA)

16. ACA – Forest View Largest overhaul since Medicare/Medicaid in 1965 Triple Aim Better healthcare for individuals Better health outcomes for populations Lower costs

17. ACA – Key Features ▫ Individual mandate ▫ Health Insurance Marketplace/Exchange ▫ Medicaid Expansion ▫ Pre-existing conditions ▫ Lifetime/annual benefit limits ▫ Young adults

18. ACA – Key Features ▫ Plain language ▫ Cancellation & Appeals ▫ Doctor choice/ER access ▫ Preventive care ▫ Meaningful Use of EHR ▫ New Models of Care ▫ Other: menu labeling, breastfeeding rules,

19. Source: www.apta.org

20. Question so far?

21. New Models of Care Patient Centered Medical Homes (PCMH) Health Homes Accountable Care Organizations (ACO) Chronic Care Model

22. Tell me something you know about these new models of care

23. New Models (Forest view) Quantity to quality Are we moving the needle? Patient-centered ▫ What is happening between doctor visits ▫ Shared goals, decision-making ▫ Care teams Prevention ▫ Access to primary care, preventive services, health educators ▫ Reducing avoidable hospitalizations/re-admissions Coordinated Care ▫ Mental/physical health ▫ Electronic Health Records (EHR) ▫ Care Managers, Navigators, Coordinators Reduce Costs ▫ It’s (always) all about the Benjamins

24. Patient-Centered Medical Home (PCMH)  NCQA program  For all patients  “Idealized primary care”  organizing care around patients  working in teams  coordinating and tracking care over time  3 level system of recognition  Institute designated level 3 in 2009

25. Developed by CMS 2005-2010 Medicare patients only Groups of health care providers come together to provide high quality, coordinated care ▫ Example – reduce inappropriate ER use Financially incentivizes collaboration ▫ Shared savings Accountable Care Organizations (ACO)

26. Health Homes Eligibility: ACTIVE Medicaid member with  Two or more chronic conditions OR  One chronic condition and at risk of a second OR  One serious/persistent mental health condition (SPMI) Conditions include but are not limited to: ▫ Substance abuse disorders ▫ Diabetes ▫ Asthma/COPD ▫ Heart Disease ▫ Overweight (BMI^25) ▫ Hypertension ▫ HIV

27. Health Homes Coordinated Care ▫ Mostly via a care manager, coordinator, navigator Services provided by network of organizations – providers, health insurance plans, community-based organizations ▫ InstituteLink

28. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model

29. Questions?