Catastrophic Medical Claimants After ACA's Removal of Annual and Lifetime Limits

Among the many provisions of the Affordable Care Act, one that initially received lesser attention or concern was the removal of annual or lifetime dollar maximums on group and individual health insurance. It was a rare occurrence for claimants to even approach the formerly lofty limit of perhaps $1 million or $2 million lifetime. However, their removal has aligned with a significant uptick in severely catastrophic claimants--particularly those in excess of $1 million or more. The drivers are several, and alert plan sponsors need to take proper actions to protect the financial viability of their self-funded medical plans.

Health reform and its aftermath

The Patient Protection and Affordability Act, H.R. 3509, that was signed into law by President Obama in March 2010 might just as easily have been subtitled the "Attorneys, Accountants, Lobbyists, and Public Relations Personnel Relief Act of 2010." As components of the law unfold over the next decade, thousands of pages of regulations must be written to explain how to implement the various provisions in the 906-page engrossed version of this legislation. Key segments of the health care industry in the form of practitioners, insurance companies, pharmaceutical manufacturers, medical device companies, and academic institutions with programs in the health sciences will be affected in diverse ways. History being a reliable guide, it is safe to posit that these entities will respond in the usual manner by employing armies of lobbyists, public relations specialists, and attorneys to enhance the likelihood that the ensuing regulatory environment will not be too inimical to their respective interests.

Impeding Earl Warren: California's health insurance plan that wasn't and what might have been

It is widely believed that the turning point for U.S. health insurance came in 1949 when Congress failed to adopt President Harry Truman's proposal for a national system. The possibility that a system of state-level health plans might have emerged before Truman's plan has received little attention. Yet several attempts to enact such a plan were made in California by Governor Earl Warren in the mid-1940s. Had Warren succeeded, the California example might have been emulated by other states and the United States might have evolved a system similar to Canada's provincial programs.

Copayments for inpatient hospital care and outpatient medical care. Interim and final rule

This document amends VA's medical regulations to set forth a mechanism for determining copayments for inpatient hospital care and outpatient medical care. This is necessary to implement provisions of the Veterans Millennium Health Care and Benefits Act and to set forth exemptions from copayment requirements as mandated by statute.

[Medical, social, economic, and legal grounds for compulsory medical insurance in Ukraine]

The article focuses on problems of bringing social compulsory medical insurance under regulation, reflected by the Bill, directed towards improvement of medical care provision for the population of Ukraine.

Impact of the Medicare Catastrophic Coverage Act on nursing homes

The Medicare Catastrophic Coverage Act (MCCA) of 1988 altered eligibility and coverage for skilled nursing facility (SNF) care and changed Medicaid eligibility rules for nursing-home residents. Detailed data on the residents of a for-profit nursing-home chain and Medicare claims for a 1 percent sample of beneficiaries were used to examine the impact of the MCCA on nursing homes. The case mix of nursing-home admissions was scrutinized, specifically for length of stay, discharge disposition, rate of hospitalization, and changes in payer source. Findings revealed that, although the proportion of Medicare-financed nursing-home care increased, as did the case-mix severity of residents during the MCCA period, there was no corollary reduction in hospital use by nursing-home residents.

Is a medical savings account in your future?

Proposed federal legislation would expand the coverage options Medicare beneficiaries have. One option--Medisave--would enable beneficiaries to replace traditional Medicare coverage with a catastrophic insurance policy coupled with a medical savings account. At least initially, this risky insurance product is likely to appeal to only a small segment of the Medicare population.

Increasing cost-consciousness for managed care: reforming the tax treatment of health insurance expenditures

The current Internal Revenue Code encourages employees who receive health insurance as part of their benefits package to choose more costly coverage than they would buy with their own money. The authors propose an approach that corrects this problem as well as the inequities experienced by self-employed and unemployed people.

Medical savings accounts: in the spotlight on Capitol Hill

Medical savings accounts (MSAs) have emerged as one of the key health care proposals under consideration in the 104th Congress. These tax-free accounts, which are viewed as an alternative to traditional "comprehensive" health care coverage, would allow individuals and their employers to set aside money to pay for major health care expenses. Depending on how they are designed, MSAs could have significant implications for HMOs and other managed care arrangements.

Patients' rights after health care reform: who decides what is medically necessary?

President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health insurance plans will retain the primary authority to decide what is medically necessary for their patient subscribers.

The success and repeal of the Medicare Catastrophic Coverage Act: a paradoxical lesson for health care reform

Congress intended the Medicare Catastrophic Coverage Act (MCCA) of 1988 to reduce the risk for illness-related catastrophic financial losses in the elderly. The act was short-lived, facing repeal just one year after passage. Many elderly persons were convinced that the costs of the program outweighed the benefits. However nursing home payment provisions of the MCCA may have affected out-of-pocket expenses paid by the elderly for long-term care more than consumers realized at the time of repeal. A transmittal memorandum, issued by the Health Care Financing Administration independent of Congressional action, enhanced consumers' ability to qualify for Medicare nursing home benefits. We investigated the effects of the Medicare policy change on nursing home payer mix and out-of-pocket expenses in 489 Pennsylvania nursing homes. We found that substantial shifts in payer mix from self-pay to Medicare payment sources occurred, reducing out-of-pocket expenses. Unfortunately the debate over the MCCA's repeal did not include discussion of the improved nursing home benefit structure. These findings, and the fate of the MCCA legislation, reinforce the importance of comprehensive information and clear communication in promoting health care reform.

The print media and aging policy: how differential coverage of Medicare Catastrophic led congress astray

This article examines the role of the print media in covering complex policy issues. Two models of journalism are considered. "Pack journalism" predicts that print media coverage will be highly consistent in content due to the reliance by those in the media on the same sources of information. In this article, another model--"Beltway journalism"--is proposed. It implies that coverage by the print media indigenous to the Washington, D.C. area (inside the Beltway) will diverge from that of other print media, presenting a potentially distorted view of the world to policymakers in Washington. Using the Washington Post and the Los Angeles Times as possible indicators of the two models, aging policy is addressed through a case study of newspaper coverage during passage and repeal of the Medicare Catastrophic Coverage Act of 1988. Findings suggest that Congress was unduly influenced by the way that Medicare Catastrophic was framed in the Washington Post, lending credence to the Beltway journalism model. By paying insufficient attention to the way Medicare Catastrophic was being framed by sources of print outside the Beltway area, lawmakers allowed themselves to assume a grassroots-level understanding of the issue and support for the bill, both of which turned out to be illusory.

Catastrophic acute and long-term care costs: risks faced by disabled elderly persons

This article presents an empirical analysis of the extent to which acute and long-term care cause disabled elderly persons to incur catastrophic costs. We found that the proportion of those people whose out-of-pocket costs exceed 20% of income rises from 20% (when only acute care costs are measured) to 30% (when long-term care costs are included).

The short life and painful death of the Medicare Catastrophic Coverage Act

This article draws upon a combined political and moral economy theoretical framework to explicate the rise and fall of the Medicare Catastrophic Coverage Act (CHI). Underlying factors, including the legacy of Medicare, the politics of austerity, and the declining political legitimacy of the aged in the 1970s and 1980s, are seen to have heavily shaped the unique characteristics of the legislation, such as its unpopular self-financing mechanism. Moral economy concerns with reciprocity, fairness, and just taxation are used to help explain the intensity of the "senior revolt" against CHI, which ultimately led to the legislation's repeal. The "Catastrophic catastrophe" is seen as having further eroded the political legitimacy of the old, while at the same time demonstrating the raw political muscle of this population group. Implications of the repeal of CHI for future health coverage legislation, and the impact of repeal on the states and other stakeholders, also are discussed.

An interview with Senator John D. Rockefeller IV. Interview by Carmella Bocchino

Congress is faced with moving forward a pressing health care agenda while the federal deficit demands major budget cuts in Medicare. A pivotal player in this chess game is Senator John D. Rockefeller IV (D-WV). In this interview with Nursing Economic+, Sen. Rockefeller discusses catastrophic health insurance, Medicare, long-term care, and other health care issues.

Fiscal catastrophe

The revolt against the catastrophic care law may be less important for what it says about a troubled program than for what it may mean for financing of unmet needs.

Overview of the Medicare Catastrophic Coverage Act of 1988 and its impact on health-care delivery

The Medicare Catastrophic Coverage Act of 1988 is described, and its impact on health-care delivery is discussed. The act will expand Medicare coverage of inpatient hospital care and will also provide payment for outpatient prescription drugs and home i.v. therapy. For the prescription drug benefit, deductible and coinsurance payments will be phased in, and Medicare will establish payment limits. A per diem fee schedule will be established to pay for the supplies and services used in home i.v. therapy. Providers of home therapy must have qualifications specified by the act. Pharmacists will have an important role in ensuring that patients understand and comply with their drug therapy once they leave the hospital. As members of the home health-care team, pharmacists will be involved in identifying candidates for home care, instructing patients in the use of sophisticated medical equipment, and monitoring the safety and efficacy of therapy. Medicare beneficiaries will help finance the new coverage by paying a flat premium; in addition, all individuals eligible for Medicare will pay supplemental premiums based on their federal income tax liability. Congress, however, will come under pressure to lower or freeze these premiums. Hospitals and pharmacists should cooperate in urging Congress to provide adequate funding for services specified by the catastrophic coverage act.

Pharmacist's role in home i.v. therapy

The pharmacist's role in home i.v. therapy is described, and its relationship to the Medicare Catastrophic Coverage Act is discussed. Congress, in enacting the catastrophic coverage act, has recognized the need for pharmaceutical services in the provision of home i.v. therapy. Pharmacists must recognize their responsibilities in providing these services. These responsibilities include ensuring the quality of drug therapy, monitoring patient progress, advocating cost-effective therapy, and communicating with local health-care providers. Pharmacists should also educate hospital administrators about the effects of the act, suggest how the hospital can best provide home i.v. therapy, assume responsibility for overseeing the home i.v. therapy process, and help ensure compliance with the interpretive regulations of the act. Other responsibilities of pharmacists include educating potential beneficiaries about the need to pay the coinsurance and premiums for catastrophic coverage and advocating home i.v. therapy as a reasonable alternative to hospitalization. Pharmacists should become familiar with the Standards for the Accreditation of Home Care adopted by the Joint Commission on Accreditation of Healthcare Organizations because these standards may be considered when the conditions for provider participation are established by the Department of Health and Human Services. The home i.v. therapy provision of the catastrophic coverage act presents challenges for pharmacists. Appropriate pharmacist involvement should help reduce costs and ensure optimal health care.