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


by Stephani Becker and Stephanie Altman, Health & Disability Advocates and Illinois Health Matters


A little more than a month ago, on March 23, 2011, the country celebrated the one
year anniversary of the Affordable Care Act (ACA). Although as health care advocates,
we are in the thick of ACA implementation, we know that many Americans 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just over one in five Americans (22 percent) think that the law has been repealed.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 (and one month!) 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 that 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.

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).
On March 31, CMS (The Centers for Medicare and Medicaid Services) published the much-anticipated
rule for ACOs in the Federal Register and Healthcare.gov has a new ACO fact sheet
here.

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. If you want to see any example of an exchange established under the ACA,
California just established its Health Benefits Exchange Website
here.

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
finds growing
evidence of the benefits of Health Information Technology on key aspects of care
including quality and efficiency of healthcare.

6. Pre-Existing Condition Insurance Plan (PCIP)
– Under the ACA, Pre-Existing Condition Insurance Plans were established to provide
health insurance to individuals who otherwise could not buy health insurance in the
individual market because they had a pre-existing health condition. By January 2014,
private insurers will be required to provide health insurance for this population;
however, in the meantime, PCIPs are available to people who have been denied health
insurance. Some states have chosen to run their own PCIPs, while others have opted
to have the federal government run their plan. You can find more information about
the PCIP in your state
here.

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.

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).

For more terms and definitions, see the
Health Reform Glossary
and
Health Care and You.