HIV/AIDS Care in a Changing Healthcare Landscape
Healthcare Reform Timeline and Glossary
Timeline and Glossary
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Healthcare Reform Timeline*
January 1 Medicaid expansion takes effect1 (not all states participating8)
March 23–30 Healthcare reform bills signed into law1,2
Individual mandate begins1
April 1 States offered federal matching funds to expand Medicaid programs1
Health insurance marketplaces begin operation1 Plans in marketplaces must offer essential health benefits9†
July 1 Pre-existing Condition Insurance Plan formed1 (plan ends in 2014 when insurer limitations on pre-existing conditions are eliminated3)
Insurers in marketplaces prohibited from setting premiums on the basis of health status1 Insurers prohibited from denying policies to individuals with pre-existing conditions1
August 6 Funding provided to expand and improve community health centers4 September 23 Children permitted to stay on parents’ policies until age 261
June 28 Supreme Court upholds constitutionality of the Patient Protection and Affordable Care Act (ACA) but strikes down requirement that states expand Medicaid7
Cost sharing prohibited for certain preventive services1 Insurers barred from rescinding coverage1 2010
Lifetime limits on coverage for essential benefits removed5
Timeline and Glossary
2011
*
2012
March 31 Centers for Medicare and Medicaid Services (CMS) proposes rules for Medicare accountable care organizations6
October 1 Hospital value-based purchasing program takes effect1
2013
January 1 Medicaid payments to primary care physicians to match Medicare rates through 20141 October 1 Enrollment begins in health insurance marketplaces1
Subsidies available to low-income individuals purchasing coverage in marketplaces11; tax credits available to some low-income individuals11 and small businesses1
2014
Annual dollar limits on coverage of essential health benefits removed5
2015
2016
January 1 Small businesses (≤100 covered workers) allowed to shop for employee benefits in health insurance marketplaces15
2017
January 1 Out-of-pocket costs for essential health benefits limited to maximum threshold of high-deductible health plans12
January 1 Large businesses (≥101 covered workers) allowed to shop for employee benefits in health insurance marketplaces15
Businesses with ≥50 full-time employees must “play or pay” 13 Physician Value-Based Payment Modifier program takes effect1,14 †Employer-based, self-funded plans are exempted from the essential health benefits requirement.10
Timeline is based on information available at the time of printing (August 2013).
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Healthcare Reform Timeline*
January 1 Medicaid expansion takes effect1 (not all states participating8)
March 23–30 Healthcare reform bills signed into law1,2
Individual mandate begins1
April 1 States offered federal matching funds to expand Medicaid programs1
Health insurance marketplaces begin operation1 Plans in marketplaces must offer essential health benefits9†
July 1 Pre-existing Condition Insurance Plan formed1 (plan ends in 2014 when insurer limitations on pre-existing conditions are eliminated3)
Insurers in marketplaces prohibited from setting premiums on the basis of health status1 Insurers prohibited from denying policies to individuals with pre-existing conditions1
August 6 Funding provided to expand and improve community health centers4 September 23 Children permitted to stay on parents’ policies until age 261
June 28 Supreme Court upholds constitutionality of the Patient Protection and Affordable Care Act (ACA) but strikes down requirement that states expand Medicaid7
Cost sharing prohibited for certain preventive services1 Insurers barred from rescinding coverage1 2010
Lifetime limits on coverage for essential benefits removed5
Timeline and Glossary
2011
*
2012
March 31 Centers for Medicare and Medicaid Services (CMS) proposes rules for Medicare accountable care organizations6
October 1 Hospital value-based purchasing program takes effect1
2013
January 1 Medicaid payments to primary care physicians to match Medicare rates through 20141 October 1 Enrollment begins in health insurance marketplaces1
Subsidies available to low-income individuals purchasing coverage in marketplaces11; tax credits available to some low-income individuals11 and small businesses1
2014
Annual dollar limits on coverage of essential health benefits removed5
2015
2016
January 1 Small businesses (≤100 covered workers) allowed to shop for employee benefits in health insurance marketplaces15
2017
January 1 Out-of-pocket costs for essential health benefits limited to maximum threshold of high-deductible health plans12
January 1 Large businesses (≥101 covered workers) allowed to shop for employee benefits in health insurance marketplaces15
Businesses with ≥50 full-time employees must “play or pay” 13 Physician Value-Based Payment Modifier program takes effect1,14 †Employer-based, self-funded plans are exempted from the essential health benefits requirement.10
Timeline is based on information available at the time of printing (August 2013).
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Glossary of Healthcare Reform Terms Accountable Care Organization (ACO) A network of physicians and hospitals that share responsibility for providing high-quality, efficient care to a defined population.16 ACOs are forming in Medicare and commercial plans, and some demonstration projects are underway in Medicaid.
Actuarial value (AV) Defines the percentage of healthcare costs a plan will pay on behalf of an enrollee. If a plan has 60% actuarial value, for instance, the plan will pay about 60% of a patient’s overall healthcare expenses, while the patient can expect to pay about 40% of his or her healthcare costs9 (exclusive of premiums17), including co-payments, co-insurance, and deductibles. (See Bronze, silver, gold, and platinum plans.)
AIDS Drug Assistance Program (ADAP) ADAPs provide HIV-related prescription medications to low-income people with HIV/AIDS who have limited or no drug coverage.18 ADAPs make up Part B of Ryan White programs (see Ryan White programs).
Annual dollar limits Maximum benefits payable, in terms of dollars, by an insurer for a beneficiary during a plan year. The ACA eliminates annual limits for essential health benefits in 2014.5
Benchmark plan A health plan whose benefits form the model for coverage in a state’s health insurance marketplace. Plans sold through the marketplaces must offer benefits comparable to the benchmark plan in that state.9
Bronze, silver, gold, and platinum plans Designations for helping people compare plans in the health insurance marketplaces. Bronze plans have 60% actuarial value; silver, 70%; gold, 80%; and platinum, 90%.9 (See Actuarial value.) As AV increases, premiums tend to be more expensive while total cost sharing drops.
A set of service categories, such as prescription drugs, hospitalization, and outpatient services, that plans sold through health insurance marketplaces must cover. Specific benefits under each category must be “substantially equal” to the benchmark plan in a given state.9 (See Benchmark plan.)
Federal Poverty Level (FPL) A marker, measured against one’s household income, for the purpose of determining eligibility for Medicaid or for subsidies and tax credits to buy coverage through health insurance marketplaces. In 2013, FPL is $11,490 for an individual and $23,550 for a family of 4.21
Federally qualified health center (FQHC) A reimbursement designation that allows participation in federal programs. Ryan White clinics that achieve FQHC status can contract and interact with Medicaid programs and health plans.22
Guaranteed issue The concept that insurers must accept all applications for coverage, regardless of a person’s health status, claims history, or other historical barrier to obtaining coverage. All health plans sold in the health insurance marketplaces are guaranteed issue.1
Health insurance marketplaces Previously called exchanges, health insurance marketplaces are online portals for individuals and small businesses to purchase health insurance. People without job-based benefits or public coverage (such as Medicaid or Medicare) will purchase insurance through the marketplaces in 2014.1
HIV/AIDS Medicaid Health Homes A variation of the Patient-Centered Medical Home. Medicaid has permitted creation of HIV Health Homes, led by providers who specialize in the treatment of HIV/AIDS, to coordinate healthcare needs for this patient population.23,24 (See Patient-Centered Medical Home.)
Individual mandate The federal requirement that people without job-based benefits or public coverage (such as Medicaid or Medicare) purchase insurance.25
Cost sharing Co-payments, co-insurance, deductibles, and other out-of-pocket expenses an insured patient must pay for healthcare services, prescription drugs, and devices. Cost sharing does not refer to a patient’s health plan premiums.17
Culturally competent care A combination of attitudes, skills, and knowledge that allows healthcare providers to provide high-quality care for patients whose cultural backgrounds, religious beliefs, gender, and social experiences are different from their own.19,20
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Essential health benefits (EHB)
Lifetime limits Maximum benefits payable, in terms of dollars, by an insurer for a beneficiary over his or her lifetime. The ACA eliminated lifetime limits for essential health benefits in 2010.5
Medicaid A joint federal-state health insurance program for low-income and disabled individuals. States administer Medicaid programs, and some states rename them (eg, Medi-Cal in California and Commonwealth Care in Massachusetts). In 2014, people with incomes ≤138% FPL (see Federal Poverty Level) will be eligible for Medicaid in states expanding their programs.1,26 5
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Glossary of Healthcare Reform Terms Accountable Care Organization (ACO) A network of physicians and hospitals that share responsibility for providing high-quality, efficient care to a defined population.16 ACOs are forming in Medicare and commercial plans, and some demonstration projects are underway in Medicaid.
Actuarial value (AV) Defines the percentage of healthcare costs a plan will pay on behalf of an enrollee. If a plan has 60% actuarial value, for instance, the plan will pay about 60% of a patient’s overall healthcare expenses, while the patient can expect to pay about 40% of his or her healthcare costs9 (exclusive of premiums17), including co-payments, co-insurance, and deductibles. (See Bronze, silver, gold, and platinum plans.)
AIDS Drug Assistance Program (ADAP) ADAPs provide HIV-related prescription medications to low-income people with HIV/AIDS who have limited or no drug coverage.18 ADAPs make up Part B of Ryan White programs (see Ryan White programs).
Annual dollar limits Maximum benefits payable, in terms of dollars, by an insurer for a beneficiary during a plan year. The ACA eliminates annual limits for essential health benefits in 2014.5
Benchmark plan A health plan whose benefits form the model for coverage in a state’s health insurance marketplace. Plans sold through the marketplaces must offer benefits comparable to the benchmark plan in that state.9
Bronze, silver, gold, and platinum plans Designations for helping people compare plans in the health insurance marketplaces. Bronze plans have 60% actuarial value; silver, 70%; gold, 80%; and platinum, 90%.9 (See Actuarial value.) As AV increases, premiums tend to be more expensive while total cost sharing drops.
A set of service categories, such as prescription drugs, hospitalization, and outpatient services, that plans sold through health insurance marketplaces must cover. Specific benefits under each category must be “substantially equal” to the benchmark plan in a given state.9 (See Benchmark plan.)
Federal Poverty Level (FPL) A marker, measured against one’s household income, for the purpose of determining eligibility for Medicaid or for subsidies and tax credits to buy coverage through health insurance marketplaces. In 2013, FPL is $11,490 for an individual and $23,550 for a family of 4.21
Federally qualified health center (FQHC) A reimbursement designation that allows participation in federal programs. Ryan White clinics that achieve FQHC status can contract and interact with Medicaid programs and health plans.22
Guaranteed issue The concept that insurers must accept all applications for coverage, regardless of a person’s health status, claims history, or other historical barrier to obtaining coverage. All health plans sold in the health insurance marketplaces are guaranteed issue.1
Health insurance marketplaces Previously called exchanges, health insurance marketplaces are online portals for individuals and small businesses to purchase health insurance. People without job-based benefits or public coverage (such as Medicaid or Medicare) will purchase insurance through the marketplaces in 2014.1
HIV/AIDS Medicaid Health Homes A variation of the Patient-Centered Medical Home. Medicaid has permitted creation of HIV Health Homes, led by providers who specialize in the treatment of HIV/AIDS, to coordinate healthcare needs for this patient population.23,24 (See Patient-Centered Medical Home.)
Individual mandate The federal requirement that people without job-based benefits or public coverage (such as Medicaid or Medicare) purchase insurance.25
Cost sharing Co-payments, co-insurance, deductibles, and other out-of-pocket expenses an insured patient must pay for healthcare services, prescription drugs, and devices. Cost sharing does not refer to a patient’s health plan premiums.17
Culturally competent care A combination of attitudes, skills, and knowledge that allows healthcare providers to provide high-quality care for patients whose cultural backgrounds, religious beliefs, gender, and social experiences are different from their own.19,20
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Essential health benefits (EHB)
Lifetime limits Maximum benefits payable, in terms of dollars, by an insurer for a beneficiary over his or her lifetime. The ACA eliminated lifetime limits for essential health benefits in 2010.5
Medicaid A joint federal-state health insurance program for low-income and disabled individuals. States administer Medicaid programs, and some states rename them (eg, Medi-Cal in California and Commonwealth Care in Massachusetts). In 2014, people with incomes ≤138% FPL (see Federal Poverty Level) will be eligible for Medicaid in states expanding their programs.1,26 5
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Patient-Centered Medical Home (PCMH)
Sequestration
Typically, a primary care–driven affiliation of healthcare providers. Each patient’s care is coordinated by a primary care physician who leads a team of specialists, pharmacists, and institutions.27 (See HIV/AIDS Medicaid Health Homes.)
Patient Protection and Affordable Care Act (ACA) One of two bills that make up healthcare reform (the other is a subsequent correction bill, the Healthcare Education and Reconciliation Act).2 Frequently, healthcare reform is simply referred to as the ACA.
Pay or play The requirement that employers with ≥50 full-time employees offer these workers health insurance or pay a per-employee fine.28
Pent-up demand High demand for healthcare services following a period during which a patient or population has not received regular healthcare services.29 Pent-up demand is common in previously uninsured individuals who obtain coverage.30
Automatic federal spending cuts mandated by the Budget Control Act. The “sequester” involves $1.2 trillion in spending cuts over a 9-year period.32
Treatment cascade The HIV/AIDS treatment cascade depicts the continuum of HIV/AIDS care. This provides a framework for assessing drop-offs along the care continuum and identifies opportunities for intervention. The biggest drop-off occurs after the initiation of care and retention in care.33
Value-Based Purchasing (VBP) Program A Centers for Medicare and Medicaid–driven hospital payment reform intended to improve quality of care.34
Waiver A tool that allows states to waive government-mandated Medicaid requirements for the purpose of introducing flexibility in their programs.35
Physician Value-Based Payment Modifier (VBPM) program A Centers for Medicare and Medicaid–driven physician payment reform intended to improve quality of care.14
Pre-existing Condition Insurance Plan (PCIP) Established under the ACA, this insurance plan provides coverage for individuals who cannot obtain insurance on the market because of a previous diagnosis. PCIPs will cease to exist on January 1, 2014, when health plans are prohibited from denying coverage to applicants on the basis of their health history.3
Pre-existing conditions A diagnosis made prior to a person’s application for health insurance. In 2014, the ACA will prohibit denials of coverage on the basis of pre-existing conditions.1
Rescissions of coverage Retroactive denial of health insurance benefits.1
Ryan White HIV/AIDS programs Provide HIV-related services to more than half a million people with HIV/AIDS who do not have sufficient healthcare coverage or financial resources to address their disease.31 Ryan White programs can fill gaps in care not covered by insurers, but the programs do not satisfy the individual mandate.22
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Patient-Centered Medical Home (PCMH)
Sequestration
Typically, a primary care–driven affiliation of healthcare providers. Each patient’s care is coordinated by a primary care physician who leads a team of specialists, pharmacists, and institutions.27 (See HIV/AIDS Medicaid Health Homes.)
Patient Protection and Affordable Care Act (ACA) One of two bills that make up healthcare reform (the other is a subsequent correction bill, the Healthcare Education and Reconciliation Act).2 Frequently, healthcare reform is simply referred to as the ACA.
Pay or play The requirement that employers with ≥50 full-time employees offer these workers health insurance or pay a per-employee fine.28
Pent-up demand High demand for healthcare services following a period during which a patient or population has not received regular healthcare services.29 Pent-up demand is common in previously uninsured individuals who obtain coverage.30
Automatic federal spending cuts mandated by the Budget Control Act. The “sequester” involves $1.2 trillion in spending cuts over a 9-year period.32
Treatment cascade The HIV/AIDS treatment cascade depicts the continuum of HIV/AIDS care. This provides a framework for assessing drop-offs along the care continuum and identifies opportunities for intervention. The biggest drop-off occurs after the initiation of care and retention in care.33
Value-Based Purchasing (VBP) Program A Centers for Medicare and Medicaid–driven hospital payment reform intended to improve quality of care.34
Waiver A tool that allows states to waive government-mandated Medicaid requirements for the purpose of introducing flexibility in their programs.35
Physician Value-Based Payment Modifier (VBPM) program A Centers for Medicare and Medicaid–driven physician payment reform intended to improve quality of care.14
Pre-existing Condition Insurance Plan (PCIP) Established under the ACA, this insurance plan provides coverage for individuals who cannot obtain insurance on the market because of a previous diagnosis. PCIPs will cease to exist on January 1, 2014, when health plans are prohibited from denying coverage to applicants on the basis of their health history.3
Pre-existing conditions A diagnosis made prior to a person’s application for health insurance. In 2014, the ACA will prohibit denials of coverage on the basis of pre-existing conditions.1
Rescissions of coverage Retroactive denial of health insurance benefits.1
Ryan White HIV/AIDS programs Provide HIV-related services to more than half a million people with HIV/AIDS who do not have sufficient healthcare coverage or financial resources to address their disease.31 Ryan White programs can fill gaps in care not covered by insurers, but the programs do not satisfy the individual mandate.22
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References 1. Department of Health and Human Services. Key Features of the Affordable Care Act, by Year. http://www.healthcare.gov/law/ timeline/full.html. Accessed May 29, 2013. 2. CCH Group. Congress Completes Overhaul of Health Care Law, Makes Many Tax Changes. March 30, 2010. 3. Kaiser Family Foundation. Health Insurance Market Reforms: Pre-Existing Condition Exclusions. September 2012. 4. Department of Health and Human Services. Community Health Centers and the Affordable Care Act: Increasing Access to Affordable, Cost-Effective, High-Quality Care. August 6, 2010. 5. Department of Health and Human Services. Lifetime and Annual Limits. September 23, 2010. 6. Centers for Medicare and Medicaid Services. Accountable Care Organizations: Improving Care Coordination for People With Medicare. March 12, 2012. 7. Kaiser Family Foundation. A Guide to the Supreme Court’s Affordable Care Act Decision. July 2012. 8. Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013. http://kff.org/medicaid/ state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed July 12, 2013. 9. Centers for Medicare and Medicaid Services. Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage. http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html. Accessed May 22, 2013. 10. Kaiser Family Foundation. How Does the New Law Apply to Companies With Self-Funded Plans? http://healthreform.kff.org/faq/ how-does-new-law-apply-to-companies-with-self-funded-plans.aspx. Accessed April 8, 2013. 11. Kaiser Family Foundation. Explaining Health Care Reform: Questions About Health Insurance Subsidies. July 2012. 12. United States Department of Labor. FAQs About Affordable Care Act Implementation Part XII. February 20, 2013. 13. US Department of the Treasury. Continuing to Implement the ACA in a Careful, Thoughtful Manner. July 2, 2013. http://www.treasury.gov/ connect/blog/pages/continuing-to-implement-the-aca-in-a-careful-thoughtful-manner-.aspx. Accessed July 12, 2013. 14. Centers for Medicare and Medicaid Services. Value-Based Payment Modifier. April 17, 2013. 15. Kaiser Family Foundation. Explaining Health Care Reform: Questions About Health Insurance Exchanges. April 2010. 16. Centers for Medicare and Medicaid Services. Summary of Final Rule Provisions for Accountable Care Organizations Under the Medicare Shared Savings Program. November 2012. 17. American Academy of Actuaries. Actuarial Value Under the Affordable Care Act. July 2011. 18. Kaiser Family Foundation. AIDS Drug Assistance Programs. Fact Sheet. April 2008. 19. American Academy of Orthopedic Surgeons. Diversity and Culturally Competent Care. http://orthoinfo.aaos.org/diversity/index.cfm. Accessed May 29, 2013. 20. Department of Health and Human Services. Secretary Kathleen Sebelius. http://www.hhs.gov/secretary/about/goal1.html. Accessed May 29, 2013. 21. Centers for Medicare and Medicaid Services. 2013 Poverty Guidelines. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ By-Topics/Eligibility/Downloads/2013-Federal-Poverty-level-charts.pdf. Accessed May 23, 2013. 22. Project Inform. Healthcare Reform and People Living With HIV. September 2011. 23. Department of Health and Human Services. Statement from HHS Secretary Kathleen Sebelius on World AIDS Day. November 29, 2012. 24. Kaiser Family Foundation. An Update on the ACA & HIV: Medicaid Health Homes. December 10, 2012. 25. Aetna. Individual Mandate Q&A. https://www.aetna.com/health-reform-connection/questions-answers/individual-mandate.html. Accessed May 30, 2013. 26. Crowley JS, Kates J. The Affordable Care Act, the Supreme Court, and HIV. What Are the Implications? Kaiser Family Foundation. September 2012. 27. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home website. http://www.ncqa.org/Portals/0/ PCMH2011%20withCAHPSInsert.pdf. Accessed May 29, 2013. 28. Lipsig E, Keller ER. 5 PPACA pay-or-play compliance techniques to consider. Law360.com. February 19, 2013. 29. BusinessDictionary.com. Pent-up demand. http://www.businessdictionary.com/definition/pent-up-demand.html. Accessed June 11, 2013. 30. Sommers BD, Baiker K, Epstein AM. Mortality and access to care among adults after state Medicaid Expansions. N Engl J Med. 2012;367:1025–1034. 31. Health Resources and Services Administration. Ryan White HIV/AIDS Program Part A Manual. http://hab.hrsa.gov/tools2/PartA/parta/ ptAsec7chap5.htm. Accessed May 28, 2013. 32. Miller L. What Is the Sequester? Huffington Post. March 1, 2013. http://www.huffingtonpost.com/2013/03/01/what-is-thesequester_n_2783917.html?view=print&comm_ref=false. Accessed May 29, 2013. 33. Centers for Disease Control. HIV in the United States: The Stages of Care. July 2012. 34. Centers for Medicare and Medicaid Services. Frequently Asked Questions Hospital Value-Based Purchasing Program. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/ FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdf. March 9, 2012. Accessed May 29, 2013. 35. Medicaid.gov. Waivers. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Waivers.html. Accessed June 11, 2013.
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