New Health Care Act titled the American Health Care Act

The House Republicans released the bill for a new Health Care Act titled the American Health Care Act on Monday night(March 6, 2017). The new health care law will repeal and replace major portions of the Affordable Care Act popularly known as Obamacare.

The bill repeals major portions of the Affordable Care Act which included individual mandate and most of the taxes that Obamacare imposed. The new legislation calls for providing refundable tax credits based on a person's age and income. But the new law did not repeal two popular features of Obamacare. One of them is that insurance companies need to insure people with pre-existing conditions, and another allowing young adults to remain on their parents’ insurance plans until they are 26 years old.

American Health Care Act  VS Affordable Care Act
Both Obamacare and the proposed GOP plan help people afford policies by providing refundable tax credits that are paid in advance to insurers. Those buying plans on the individual market are eligible, but those covered through their jobs or the government are not.
There are some significant differences. Obamacare's subsidies are based on enrollees' incomes and cost of coverage in their areas. The Republican tax credits vary with age, ranging from $2,000 for 20-somethings to $4,000 for those in their early 60s.


But Obamacare and the Republican plan both have income caps. An enrollee making more than $47,500 does not qualify for assistance under Obamacare. If the GOP plan becomes law, those making more than $75,000 would see their tax credits start to phase out, and an enrollee making more than $215,000 would no longer be eligible.

Unpopular Provision of the Affordable Care Act or ObamaCare

Perhaps the most unpopular provision of the Affordable Care Act popularly known as ObamaCare is the Individual Mandate. ObamaCare’s individual mandate requires that most Americans obtain and maintain health insurance, or an exemption, each month or pay a tax penalty. The mandate's purpose is to draw young and healthy Americans into healthcare market. Without this provision, they might be unwilling to buy any health plan, thinking that they do not need any health coverage. But their participation is very important to balance out the higher costs of older and sicker enrollees, whom insurers are required to cover under Obamacare.

The individual mandate went into effect at the beginning of January 2014 and continues each year. The penalty for not having coverage will be paid on your Federal Income Tax Returns for each full month you, or a family member doesn’t have health insurance or an exemption and is based on your Modified Adjusted Gross Income (MAGI).

Depending on your coverage, income, and family size, you will either pay a flat dollar amount or a percentage of income above the tax return filing threshold for your filing status. The fee is capped at the national average for a Bronze health plan available in the marketplace, and it is only paid for full months you or a family member went without coverage. The fee went up each year from 2014–2016 making it more important to look into coverage and exemptions options each year.

For the 2014 tax year, you'll pay the greater of these two numbers: A. 1 percent of your household income above $10,000, up to a maximum of $2,448 per person; or B. $95 per adult and $47.50 per child, up to a family maximum of $285. For 2015, the penalty for no health insurance is $325 per person or 2% of your annual household income – whichever is higher.

The annual fee for not having insurance in 2016 is $695 per adult and $347.50 per child (up to $2,085 for a family), or it’s 2.5% of your household income above the tax return filing threshold for your filing status – whichever is greater. You’ll pay 1/12 of the total fee for each full month in which a family member went without coverage or an exemption. The fee for 2017 hasn’t been published yet.

Managed Care Health Plans

Managed Care health plans are types of health plans that are quite opposite to Indemnity Health plans or Open Choice health plans. In case of Managed Care Health plans, individuals  do not have complete freedom in choosing their physicians but must select from a list of in-network/participating providers.  Managed Care plans mean controlled access to doctors, clinics, hospitals, procedures, and medicines. These plans can called Defined Benefit Health programs.

In spite of so many limitations, Managed Care Health plans are very popular. In general, managed care plans are better suited for the average individuals because these types of health plans are more cost effective in the long run. In fact, this is an age of Managed Care Health plans in the world of health insurance plans. This is because maximum benefits are available in Managed Care Health plans at minimum costs. Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans are known as Managed Care Health plans.  

Preferred Provider Organization

Preferred Provider Organization (PPO) plans are an affordable and popular option for family health insurance because they are comprehensive and flexible. Subscribers will save money covering their family when they use preferred network physicians but a PPO also provides them with coverage on out-of-network doctors as well.

PPO health insurance allows substantial discounts from providers who are within the network. Deductibles must be paid before the insurance companies start giving benefits. That is, after annual deductible amount are paid, insurance company will start cost sharing of medical expenses of the subscribers. For example, if the medical cost is $100 and cost sharing rate is 80%/20%, the insurance company will give 80 dollars and the subscriber will pay 20 dollars from his pocket.

PPO health insurance is usually the least expensive of managed care health insurance because the patient picks up a substantial portion of the “first dollars” coverage with a higher deductible.  The higher the deductible is,  the lower is  the premium.

Health Maintenance Organization

A Health Maintenance Organization (HMO) is one of the more affordable individual health insurance alternatives. HMOs usually have an extensive network of doctors, specialists, hospitals, and clinics. HMO networks often encompass a wide and varying range of healthcare professionals. Subscribers will have convenient access to all their healthcare needs.

Each subscriber/member  chooses a primary care physician (PCP) who sees to the overall care of that member. Specialists and non-emergency hospital admissions usually require a referral from a PCP.

Point of Service

Point of Service (POS) plans are essentially a mixture of the HMO and PPO. Like an HMO subscriber can pick a primary care physician but as in a PPO,  they can seek help from any medical professional in or out-of-network and they will still be covered.

POS plans are still managed care resulting in lowered medical costs in return for more limited choices. Point of Service health insurance is sometimes called an open ended HMO or PPO. The major difference though is policyholders are allowed to seek help outside the POS network though there is more of an incentive to choose providers within the network.

POS members choose a primary care physician (PCP) as they would in other managed care health care plans. From there the doctor becomes the insured’s “point of service” and will refer the insured to other healthcare providers.

Indemnity Health Plans

Health insurance plans can be categorized into larger divisions. One of them is Indemnity plans or Fee-for-service plans or Reimbursement plans , and the other is Managed Care plans. Indemnity plans are the types of health plans that primarily existed before the rise of Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans.

Indemnity health insurance plans allow the subscriber to choose the doctor, healthcare professional, hospital or service provider of his choice and allow the greatest amount of flexibility and freedom in a health insurance plan. Under an Indemnity plan, a subscriber may visit any doctor or specialist he likes. He does not need any referral for visiting a specialist. Though he may choose to get the majority of his basic care from a single doctor, his insurance company will not require him to choose a primary care physician.

An indemnity plan reimburses him for his medical expenses regardless of who gives him medical services. It may be that in some cases his reimbursement amount may be limited.  An Indemnity plan may sometimes require that the subscriber pay up front for services and then submit a claim to his insurance company for reimbursement.

The subscriber will have to pay his annual deductible amount first. After that the insurance company will begin to reimburse him. Once his deductible has been met, the insurance company will typically pay his claims at a set percentage of the "usual, customary and reasonable (UCR) rate" for the service. The UCR rate is the amount that healthcare providers in his area typically charge for any given service.

In general, managed care plans are better suited for the average individuals because these types of health plans are more cost effective in the long run. In contrast, Indemnity plans or Fee-for-service plans or Reimbursement plans usually hit the subscriber with more out-of-pocket charges (in the form of deductibles and co-payments) and often place caps on the amount of benefits individuals can receive over their lifetime.

There are subscribers who want highest level of freedom in choosing doctors, clinics and hospitals.  They do not want to designate primary care physicians or get referrals to visit specialists. They want to freely visit any physician they like. Treatment costs are  not any factors for them. As Indemnity health plans offer individuals all these benefits including highest level of flexibility in choosing health care professionals or hospitals, so indemnity plans are best  suited for these types of people.

Body Mass Index or BMI

Obesity has become a serious health problem in the United States. Currently, one in three U.S. adults is obese, bringing forth a possible health toll, including high blood pressure, Type 2 diabetes, heart disease and stroke. Another third of Americans are overweight. Affordable Care Act has come into being as a blessing to prevent and address this fatal threat from USA. As part of regulatory requirements, almost every quality health plan covers the following obesity related diseases:

1. Morbid Obesity

2. Bariatric Surgery

3. CVD Counseling for obesity

4. Child Obesity

5. Adult Obesity

Generally, doctors and nutritionists classify people as either underweight, healthy weight, overweight, or obese. These different classifications are determined by body mass index popularly known as BMI. By losing weight or maintaining a healthy weight, people may experience:

·         Fewer joint and muscle pains

·         More energy and greater ability to join in desired activities

·         Better regulation of bodily fluids and blood pressure

·         Reduced burden on heart and circulatory system

·         Better sleep patterns

·    Reductions in blood triglycerides, blood glucose, and risk of developing type 2 diabetes

·         Reduced risk for heart disease and certain cancers

BMI is a useful measure of overweight and obesity. Body Mass Index (BMI) is a person's weight in kilograms divided by the square of height in meters. For instance, a person's height is 5’3" and weight is 125 lbs . Let us calculate his BMI by performing the following steps:

Step 1: Multiply the weight in pounds by 0.45 (the metric conversion factor)

125 X 0.45 = 56.25 kg

Step 2:  Multiply the height in inches by 0.025 (the metric conversion factor)

63 X 0.025 = 1.575 m

Step 3:  Square the answer from step 2

1.575 X 1.575 = 2.480625

Step 4:  Divide the answer from step 1 by the answer from step 3

56.25 / 2.480625 = 22.7

Step 5: The BMI for a person who is 5’3" and weighs 125 lbs is 22.7 or practically,

23.

A healthy BMI ranges between 19 and 25. A BMI of 30.0 or greater is classified as obese, a BMI between 25.0 and 29.9 is classified as overweight and a BMI less than 18.5 is classified as underweight.

The higher a person's  BMI is, the higher will be  his risk for certain diseases such as heart disease, high blood pressure, type 2 diabetes, gallstones, breathing problems, and certain cancers.

Processing an INN Inpatient Hospital Claim in Facets

Today I am giving an example of INN Inpatient Hospital claim. These are the steps that you are supposed to perform to process an INN  Inpatient Hospital  claim in Facets under medical plan.

Step 1: Open Test Lab Module of ALM, you will see the following test case in test lab module of ALM/QC.

Test Case description: 

Process a claim for INN Inpatient Hospital claim using following data: INN Provider 000011113333 (Hospital);Type of Bill: Type-class 011, Frequency 01; Statement Covers Period: 01/01/2017 To 01/03/2017; Admission date 01/01/2017 and Discharged date 01/03/2017; Revenue codes 0110, 0250, 0272, 0636, diagnosis code ICD10  K5732, Subscriber ID-100500700, Charges (Hospital Fee) $2500, Unit 1(One Time Visit).

Expected Result: Claim should process at 80% of the allowable.

Step 2: Open Facets Claims Processing application group and scroll down to Hospital Claims processing application.

Step 3: In the Indicative page of Medical Claims processing application, enter the following data: Subscriber ID and select a member from the drop down menu, Claim Received Date(suppose Jan 25, 2017), Provider ID and Diagnosis code, Type of Bill: Type-class 013, Frequency 01; Statement Covers Period:01/01/2017 To 01/03/2017; Admission date and Discharged date (01/01/2017)

Step 4: Now double click on Line Item page and when you are in Line Item page, enter the following data: Date of service (01/01/2017 to 01/03/2017), Revenue codes, Charges(suppose $2500), Unit(suppose 1 per revenue code), Total charges(Suppose $2500).

Step 5: Press F3 on your keyboard to process the claim. Now check the claim pricing.

Step 6:  Claim should process at 80% of the allowable. if the expected result matches with the actual result, save the claim by pressing F4 on your keyboard. Facets will generate a claim ID automatically. Suppose the claim ID is 000011115555

Step7: Open Lab module of ALM, take required screenshots and type as follows in actual result edit box:

Claim processed as expected and write the claim ID and pass the test case. 

Note: Revenue code is a unique 4 digit Numbers code which tells an insurance company whether the procedure was performed in the emergency room, operating room or another department.

Product Enhancements 2016

Product enhancement means adding some benefits to existing health plans. Different insurance companies offer different types of health plans having different benefits including terms and conditions. Health plans are the marketing names of insurance companies. But in reality, at the root of every health plan, there is a product and it is known by its Product Id. Benefits including terms and conditions of the health plans are tagged to this product id.

In Facets, there are different application groups to manage the product ids and add benefits as well restrictions to these product ids. The application groups are Dental Plan application group, FSA Plan application group , ITS Plan application group, Medical Plan application group and  Vision Plan application group. Under each application group, their are different applications. Developers and  Configuration analysts will use specific application or database table to perform specific task.

In order to meet regulatory requirements and sometimes for their own reasons, insurance companies need to enhance their products. For example, Insurance companies are required to implement USPSTF Grade A & B recommendations as part of regulatory requirements. On the other hand, some insurance companies need to increase copayment and deductible amount in their existing products. Sometimes they also put cap on some benefits. So, in order to perform these types of changes, insurance companies start special projects known as Product Enhancement projects.

As part of ACA requirements, Health Insurance companies implemented product enhancements in 2016. Major areas of Product Enhancement 2016 are:

Ø  Cardiovascular Disease Counseling

Ø  Childhood Obesity

Ø  Mental Health & Autism

Ø  Non Transport Ground Ambulance

Ø  Telemedicine

Ø  Victim of Sex Crimes Mandate

Among these benefits, Cardiovascular Disease Counseling for adult 18 & older having  overweight and additional risk factors and Childhood Obesity(age 6-18) are mandatory for NGF Self-Funded Groups. It may be mentioned that Affordable care Act requires Preventive and Wellness Service coverage per US Preventive Services Task Force(USPSTF)recommendation levels 'A' & 'B'. These preventive and wellness services will be covered at first dollar when provided by Network Provider.