obama care group 3. temporary high risk pool this will provide temporary health coverage to...

Obama CareGroup 3

Temporary High Risk Pool This will provide Temporary Health coverage to individuals with Pre-

existing conditions.

Us citizens who have a pre existing medical condition and how been uninsured for a minimum of 6 months will be eligible for this high risk pool and be eligible for subsidized premiums.

Medical Loss Ratio and Premium rate ReviewsIn the Large group market 85% of the money you pay has to go to

helping treat you.

In the small group market 80% of the money you pay has to go to helping treat you.

Medical Loss Ratio and Premium rate ReviewsThis requires states to review why they’re increasing premiums, and if the increase is unjustified or not.

Administrative Simplification They have a uniformed coding system that everthing means the same

thing for hospitals across the country.

Like BA would stand for Broken Arm in every hospital in America.

Dependent CoverageYour on your parent's coverage tell your 26.

Insurance Market Rules The new health rules will help states to make decisions regarding their exchanges and will help health insurance companies understand how to structure their plans.

Insurance Market Rules All the policies were required to follow one of the four benefit

categories, already existing individual and employer-sponsored plans don’t have to meet the new benefit standards.

Limitations were put on all waiting periods for coverage up to 90 days, as well as limits on deductibles. For families these were $4,000 unless deductibles were offset these limits. Individual groups had a $2,000 deductible.

A temporary reinsurance program was set in place to get the payments from individual, and group markets health insurers. States could also chose to merge individual and small group markets.

Consumer Protections/ Health Insurance Administration

They wanted to have a standard information source that is easy to access.

Wanted everyone with coverage to know all the information on coverage plans, to protect them from misleading rules and loopholes. [Went into effect July 1, 2010]

They set up a fund to change the healthcare system. Their limit was $1 billion.

Health Care Choice, Compacts, and National PlansStates were allowed to form health care choice compacts (the

responsibility of health care goods and services in their given boundaries) and insurers could sell policies within the compact.

Insurers can only sell the policies in the state where it is written.

State roleA program called SHOP was created to let small businesses get health

insurance. This was supposed to give employees a choice in plan.

States made an office for customer assistance.

States made a Basic Health Plan for middle class individuals with an income between 133% and 200% FPL

Maintain Medicaid and CHIP eligibility levels for all children till 2019.

States don’t have to keep up with the maintenance of non-disabled adults with incomes over 133%

Administrative SimplificationSimplify health insurance administration

Adopting one set of rules for eligibility and claim status.

Changing health care payment and remittance.

Health plans have to document acceptance to these standards or face a fee.

Medicare- If the hospitals doesn’t do good they will have money taken away

from them and given to some other hospital area.

- Stop the income for Medicare Part B premiums for eight years.

- They have a board made to give ideas to the government on how they are trying not to increase the cost of Medicare so that we can support the baby boomers that are now starting to leave the job force. Why we have not seen some of these Ideas is because Congress really has not done much with them.

- www.ama-assn.org/ama/pub/advocacy/topics/independente-paymnt-adisory-board.page

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Medicare Continued...- www.modernhealthcare.com/article/20140124/NEWS/301249973

- The government is also trying to encourage hospitals to take Medicare. A lot of hospitals don’t because Medicare does not pay as much as a private insurance company. That is why the government is offering them money.

- Then they also are trying to give the hospitals and government new ideas.

- Such as different payment plans or CHIP.

- CHIP: provides health coverage to eligible children, through both Medicaid and separate CHIP programs

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Medicaid- This is the 80 Billion deal from the drug company

- The will give you rebates like 23 percent on name brand drugs

- Then the rebate for Medicaid will be 13 percent

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Differences of Medicare and Medicaid

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Prescription Drugs●They approved biological drugs and pass that it can’t be copied for

12 years.○ Bio drugs are drugs that can help with genetic therapy.

○ regular drugs are like antibiotics pain reliever and such.

●Bio drugs were not covered by the hatch-waxman law in 1984. They can have a longer period over regular drugs.

Michael

Prescription drugs Cont.The Biological drugs/Biosimilars that were approved in the U.S.

because of obamacare.(Bio drugs/Biosimilars are different because the Biosimilars are highly similar to Bio drugs.)

Zarxio

This drug allows cancer patients to program the cells to become white blood cells or other kinds of cells.

that is all that the U.S. is make for right now.

Michael

Example Medicare FraudDoctor in Bloomingdale is caught for stealing $4 million dollars from

Medicare.Said that the patients need to have in - house treatment.

sentenced to two years in federal prison.

medicare sent over $20 million in orders from that doctor.

Michael

Example of Medicare FraudSouthern California Doctor Johnson gets 9 years in federal prison for

stealing $20 million dollars from medicareHe attempted to defraud medicare and medical programs

He purchased over $20 million antidepressants

Johnson is one of three co-conspirators in this act.

Michael

Example of Medicare Fraud Doctor in pennsylvania prescribed medication for one of his patients

and started taking the medications that was meant for the patient.this is medicare fraud because of the doctor writing a prescription for the patients

and stealing from medicare.

also giving some of that medication to a few other patients that appeared to didn’t need it.

Michael

http://www.tiogapublishing.com/free_press_courier/news/feds-announce-charges-pleas-in-wellsboro-medicare-fraud-case/article_88c16498-b57b-11e5-a724-57fcd3ea45cb.html

Sources www.ama-assn.org/ama/pub/advocacy/topics/independente-paymnt-adisory-board.page

www.modernhealthcare.com/article/20140124/NEWS/301249973

www.modernhealthcare.com/article/20140124/NEWS/301249973

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