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What health reform means for the people of Illinois

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Friday, March 11, 2011

Top Ten Health Care Reform Terms You Should Know (but were afraid to ask...).

On March 23, 2011, we will be celebrating the one year anniversary of the Affordable Care Act (ACA). Although we at Health & Disability Advocates are in the thick of ACA implementation, we know that many Illinoisans still are confused about the law. In fact, according to a recent Kaiser Tracking Poll, just over one in five Americans (22 percent) think that the law has been repealed. It has not, and many provisions are already in place and working. In honor of the one-year anniversary of the law, we have compiled the Top Ten Health Care Reform Terms You Should Know (but were afraid to ask...).

See our list below. If you have questions about how these and other "terms" will affect you now or in the years to come, submit your question to Illinois Health Matters (where it says "Get Answers") and our team of experts will answer it for you.

1. Affordable Care Act (or ACA) – a short name for the Patient Protection and Affordable Care Act of 2010 which is the federal health care reform bill which passed Congress and was signed into law by President Obama. Some provisions went into effect immediately on March 23, 2010 and others will be phased in for the next 8 years. On March 1, 2011, the Illinois Health Care Reform Implementation Council presented a report to Governor Quinn with their initial recommendations for implementation of the ACA in Illinois.
2. Accountable Care Organizations (ACOs) – a group of health care providers such as physicians, hospitals or clinics that have entered into a formal arrangement to assume collective responsibility and financial risk for the care of a specific group of patients and receive financial incentives to improve the quality and efficiency of health care. You are not alone if you are uncertain about what an ACO actually looks like (see this recent article in Politico). The Centers for Medicare & Medicaid Services Administrator Don Berwick said in a speech earlier this week that the pending rules on ACOs will be out soon.
3. Essential Health Benefits – This is the minimum level of coverage that must be offered by qualified health plans operating in state health insurance exchanges. Essential benefits are defined in relation to the classes of services and benefits covered, the level of financial protection against deductibles, and cost-sharing protection they provide. The ACA lists ten categories that HHS must include as essential, such as prescription drug coverage and emergency hospitalizations. But HHS has broad discretion within those categories to require generous coverage or allow limits. Health care policymakers and medical experts at the Institute of Medicine are studying this issue and will make recommendations on the criteria and methods for determining the essential health benefits package.
4. Health Care Exchange (sometimes called Health Insurance Exchange (HIE) or Health Benefits Exchange) – a competitive health insurance marketplace for individuals and small employers to purchase insurance or enroll in Medicaid after 1/1/2014. Exchanges will be an easy-to-use website, similar to Travelocity or Consumer Reports. They will be responsible for calculating premiums, enrollment, quality oversight, and certification of qualified health plans. By standardizing health insurance products, enrollment, operations, and oversight, exchanges are also meant to make the process of selecting insurance easier, less expensive and more transparent. The site will be closely monitored to prevent fraud and protect consumers. Members of Congress will be required to get their insurance through this marketplace—giving them the same options as millions of Americans. The Illinois Department of Insurance has established workgroups to solicit feedback from stakeholders regarding how an exchange should function in Illinois. A piece of legislation will be introduced soon in the Illinois General Assembly to establish the Illinois Health Benefits Exchange.
5. Health Information Technology (sometimes called Health Information Exchange (HIE) or Electronic Health Records) – Technology that allows the management of health information such as health records, laboratory tests, and radiology records, to be communicated electronically among health professionals, consumers, health care providers, health care payers, and public health agencies. A new study completed by the Office of the National Coordinator for Health Information Technology and published in the journal Health Affairs this week finds growing evidence of the benefits of Health Information Technology on key aspects of care including quality and efficiency of healthcare. In February 2010, Governor Quinn established the Illinois Office of Health Information Technology which developed a strategic plan for Health Information Exchange in Illinois.
6. High-risk pools – High-risk pools are operated by states during the period prior to the implementation of health insurance Exchanges in 2014 as a means of offering health insurance to individuals who otherwise cannot buy health insurance in the individual market because they have a pre-existing health condition. Illinois' federally funded high risk pool, established by the ACA, is called the Illinois Pre-Existing Condition Insurance Plan (IPXP). Illinois also has another high risk pool called the Illinois Comprehensive Health Insurance Plan, which is not federally funded and existed before ACA, but it serves a similar function.
7. Individual Responsibility (also called the Individual Mandate) – this is the term that refers to the requirement in the ACA that by January 1, 2014, individuals must purchase insurance if they are not otherwise covered by public programs or group health insurance.
8. Maintenance of Effort (MOE) – The ACA includes an important protection that prohibits states from reducing their Medicaid eligibility levels or changing the rules to make it harder for people to enroll in Medicaid. This protection is referred to as the “maintenance of effort,” or MOE, requirement.
9. Meaningful Use – this is a yet to be determined critical level of use of electronic health records (EHRs) and related technology within a healthcare organization to deliver coordinated and quality health care to patients. Through the ACA, Medicaid and Medicare will require that providers increasingly utilize "meaningful use" health information technology in their practice in order to receive reimbursement. If you are a health care provider in Illinois and you have questions about meaningful use incentive payments, visit the State of Illinois' Electronic Health Records page here.
10. Medical Loss Ratio – A medical loss ratio (MLR) is the proportion of premium dollars that an insurer spends on health care services and certain recognized plan administration costs relative to health insurance premium paid by subscribers. The ACA requires health insurers offering health insurance coverage in either the group or individual (non-group) market to submit an annual report to the Secretary of Health and Human Services on their MLR and to provide rebates in circumstances in which losses exceed permissible levels (80% in the individual market and 85% in the group market). Illinois State Senator Heather Steans has proposed a bill, SB 1618, which would bring Illinois law into conformity with this core consumer protection established by the ACA.

For more terms and definitions, see http://www.healthreformgps.org/glossary and http://www.healthcareandyou.org/glossary/.

Stephanie Altman and Stephani Becker
Health & Disability Advocates