insurance 1

• prospective payment system
• made medicare secondary payer for some pts
• groundwork for peer review organizations to reduce inappropriate admissions

• five new prospective payment systems for Medicare rehab services
• (for inpatient rehabilitation hospital or unit services, skilled nursing
• facility services, home health services, hospital outpatient department
• services, and outpatient rehabilitation services)

implementation of pay for performance

• establishes standards for employee benefit plans established or maintained by an employer or an employee
• organization (i.e., a union)

• addresses several areas, including:
• preexisting condition exclusions and
• portability;
• access to coverage;
• renewability; 
• nondiscrimination.

• state level
• establish how much money an insurance company must have on hand

• established under state law
• pays claims of insurers that become insolvent.

• The funds to pay claims
• generally are provided by assessing other insurers that provide coverage
• in the state.

• state laws mandating that insurance cover certain services,
• stuff like -- mental health services, substance abuse treatment, and
• breast reconstruction following mastectomy. The number and type of these
• mandates varies considerably across states. Federal law also includes
• certain mandated benefits

laws limiting the diffs between highest and lowest premiums for one type of coverage in one insurance company

The rate bands may limit all factors by which rates vary (e.g., age, gender), or may apply only to specified factors, such as health status or claims experience.

• a rating method under which all policyholders are charged the same
• premium for the same coverage.

• "Modified community rating" -- a rating method under which health insuring organizations are permitted to vary premiums for coverage based on specified demographic characteristics (e.g., age, gender, location) but cannot vary premiums
• based on the health status or claims history of policyholders.

ratio of benefits paid to premiums

insurance must let you renew, but they do have the right to change your premium

• A - hospital insurance (paid by taxes)
• B - medical insurance (pay a monthly premium)
• C - medicare advantage plans (like PPO or HMO)
• D - prescription drugs (pay monthly premium)

Services are not covered if not reasonable and necessary for the diagnosis or  treatment of illness or injury or to improve function.There must be potential for restoration or improvement of lost or impaired functions. For example, treatments involving repetitive exercises (i.e., maintenance programs, general conditioning or ambulation) that do not require the skilled services of therapists or other professional rehabilitation practitioners are not covered.

Percentage (FMAP) is computed from a formula that takes into account the average per capita income for each State relative to the national average. By law, the FMAP cannot be less than 50%.

• "Payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally
• misrepresented facts to obtain payment."

Prohibits individuals/entities from knowingly and willfully offering, paying soliciting or receiving remuneration or induce referrals of items or services covered by federally funded programs. A violation of this law can result in fines up to $25,000 and imprisonment up to five years.

Parties who knowingly present fraudulent claims for payment to the government can be fined as much as $10,000 per violation.

permit private individuals to initiate false claims actions on the government's behalf.

Whistleblowers may share a percentage of recovery.