The following glossary is not an exhaustive list of terms describing the Affordable Care Act but covers key elements of the law that pertain to health care reform as it relates to behavioral health in New Jersey. The definitions are taken from the website Healthcare.gov.
Accountable Care Organization:
A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost savings.
Affordable Care Act:
The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
The organization of your treatment across several health care providers. Medical homes (defined below and Accountable Care Organizations (defined above) are two common ways to coordinate care.
Chronic Disease Management:
An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve a patient’s quality of life while reducing health care costs in cases of chronic disease by preventing or minimizing the effects of a disease.
Essential Health Benefits:
A set of health care service categories that must be covered by certain plans, starting in 2014.
The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Affordable Insurance Exchanges (Exchanges), offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Insurance policies must cover these benefits in order to be certified and offered in Exchanges, and all Medicaid state plans must cover these services by 2014.
· Fact Sheet: Essential Health Benefits: HHS Informational Bulletin
· Fact Sheet: Individual Market Coverage
· Fact Sheet: Comparing Benefits in Small Group Products and State and Federal Employee Plans
Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, must phase out annual dollar spending limits for these services by 2014.
In the fall of 2011, the Department of Health and Human Services launched an effort to collect public comment and hear directly from all Americans who are interested in sharing their thoughts on this important issue.
Federal Poverty Level (FPL):
A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits. The current poverty level for a family of four is $23, 050.
Federally Qualified Health Center (FQHC):
Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee based on your ability to pay.
Fee for Service:
A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits.
Health Insurance Exchanges
Affordable Insurance Exchanges are designed to make buying health coverage easier and more affordable. Starting in 2014, Exchanges will allow individuals and small businesses to compare health plans, get answers to questions, find out if they are eligible for tax credits for private insurance or health programs like the Children’s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs.
An Exchange Can Help You:
Ø Look for and compare private health plans.
Ø Get answers to questions about your health coverage options.
Ø Find out if you’re eligible for health programs or tax credits that make coverage more affordable.
Ø Enroll in a health plan that meets your needs.
Ø States across the country are working to implement the health care law. States can apply for Exchange grants through the end of 2014.
What This Means for You
Ø For individuals and families, the Exchange is a single place where you can enroll in private or public health insurance coverage.
Ø For small employers, the Exchange is a way to level the playing field, where you have better choice of plans and insurers at a lower cost, the way larger employers do now.
Health Maintenance Organization (HMO):
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state.
Patient-Centered Outcomes Research:
Research that compares different medical treatments and interventions to provide evidence on which strategies are most effective in different populations and situations. The goal is to empower you and your doctor with additional information to make sound health care decisions.
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Qualified Health Plan:
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Exchange in which it is sold.
A program intended to improve and promote health and fitness that's usually offered through the work place, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.