Category: MAOTD (Medicaid Acronym of the Day)

Qualified Health Plan – Under the ACA, the designation of qualified health plan (QHP) is given to health insurance plans that are sold in the marketplace (exchange).  The same basic rules apply to plans sold both in and out of the exchanges:  they must be guaranteed issue, follow the ACA’s cost-sharing guidelines, and cover “essential health benefits” with no lifetime or annual maximums.

But in order to be sold in the exchanges, a health plan must also be certified by the exchange as a qualified health plan.  In the spring of 2013, health insurance carriers in each state submitted plan designs and pricing to the exchanges – the ones that were approved are considered QHPs.  The QHP label is basically an extra layer of consumer protection, one that makes shopping in the exchanges a good idea even for people who don’t qualify for subsidies.

Further reading –

https://obamacarefacts.com/insurance-exchange/qualified-health-plan/

 

The Association for Community Affiliated Plans (ACAP) is a national trade association representing 57 Medicaid-focused health plans in 26 states. Headquartered in Washington, D.C., ACAP advocates on behalf of its community-affiliated member health plans operating throughout the United States. ACAP’s advocacy work focuses on representing publicly sponsored programs and health care providers who serve vulnerable populations. ACAP also promotes universal access to quality and cost-efficient care.

ACAP members are nonprofit plans that serve public insurance programs and the safety net. Collectively, ACAP plans serve more than 17 million enrollees, which is over 50 percent of individuals enrolled in Medicaid-focused health plans.[1]

Further reading –

https://www.communityplans.net/

 

Alternative Benefit Plan – States have the option to provide alternative benefits specifically tailored to meet the needs of certain Medicaid population groups, target residents in certain areas of the state, or provide services through specific delivery systems instead of following the traditional Medicaid benefit plan. Key Requirements of the Rule Include:

The term 1937 Medicaid Benchmark or Benchmark Equivalent Plan has been retitled to Alternative Benefit Plans.
ABPs must cover the 10 Essential Health Benefits (EHB) as described in section 1302(b) of the Affordable Care Act whether the state uses an ABP for Medicaid expansion or coverage of any other groups of individuals.
Individuals in the new adult VIII eligibility group will receive benefits through an ABP.

Further reading –

https://www.medicaid.gov/State-Resource-Center/Eligibility-Enrollment-Final-Rule/Alternative-Benefit-Plans-and-Essential-Health-Benefits.pdf

https://www.federalregister.gov/documents/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit#h-14

 

Applied Behavioral Analysis – ABA is an empirically validated approach to improve behavior and skills related to core impairments associated with autism and a number of other developmental disabilities. ABA involves the systematic application of scientifically validated principles of human behavior to change inappropriate behaviors. ABA uses scientific methods to reliably demonstrate that behavioral improvements are caused by the prescribed interventions. ABA is presently considered the gold standard of autism interventions.

ABA’s focus on social significance promotes a family-centered and whole-life approach to intervention. Common methods used include: assessment of behavior, caregiver interviews, direct observation, and collection of data on targeted behaviors.

A single-case design is used to demonstrate the relationship between the environment and behavior as a means to implement client-specific ABA therapy treatment plans with specific goals and promote lasting change. ABA also includes the implementation of a functional behavior assessment to identify environmental variables that maintain challenging behaviors and allow for more effective interventions to be developed that reduce challenging behaviors and teach appropriate replacement behaviors.

Further reading –

https://www.hca.wa.gov/assets/billers-and-providers/ABA-services-20161001.pdf

Actual Acquisition Cost – In accordance with the Affordable Care Act and requirements of §447.512(b) of the final regulation, states’ reimbursement for ingredient costs for brand and certain multiple source drugs (that do not have a FUL calculated), will be established as an aggregate upper limit based on AAC, as opposed to an estimated acquisition cost. AAC is defined at §447.502 of the final regulation as the agency’s determination of the pharmacy providers’ actual prices paid to acquire drugs marketed or sold by specific manufacturers. CMS believes that changing this definition of
ingredient cost reimbursement to AAC will provide a reference price consistent with the dictates of section 1902(a)(30)(A) of the Act.

Further reading –

https://www.medicaid.gov/federal-policy-guidance/downloads/smd16001.pdf

Comprehensive Medicaid Integrity Plan – Section 1936(d) of the Social Security Act directs the Secretary of Health and Human Services (HHS) to establish, on a recurring 5-fiscal year basis, a comprehensive plan for ensuring the integrity of the Medicaid program by combatting fraud, waste, and abuse. This Comprehensive Medicaid Integrity Plan sets forth the strategy of the Centers for Medicare & Medicaid Services (CMS) to safeguard the integrity of the Medicaid program.

Further reading –

https://www.cms.gov/Regulations-and-Guidance/Legislation/DeficitReductionAct/Downloads/cmip2014.pdf

The Office of Management and Policy (OMP) mission is to provide management, guidance, and resources in support of OIG. Our vision is to be the best at what we do. OMP is focused on customer satisfaction, reliability, innovation, and continuous improvement. We oversee a diverse portfolio, which includes:
budget formulation, execution, and funding of the State Medicaid Fraud Control Unit grant program; human capital planning, including recruiting, staffing, training, and performance management; information technology solutions, including the complete life cycle for each solution from project initiation, implementation, security, support, policy, maintenance, and decommissioning; and administrative services, including space management, acquisitions/procurement, travel, policies, and emergency preparedness.

Further reading –

https://oig.hhs.gov/about-oig/about-us/office-of-management-and-policy.asp

The Office of Audit Services (OAS) conducts independent audits of HHS programs and/or HHS grantees and contractors. These audits examine the performance of HHS programs and/or grantees in carrying out their responsibilities and provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. OAS conducts audits using its own resources and oversees audit work performed by others. OAS is the largest civilian audit agency in the Federal Government. OAS conducts its work in accordance with Government Auditing Standards issued by the Comptroller General of the United States; the Single Audit Act Amendments of 1996; applicable Office of Management and Budget circulars; and other legal, regulatory, and administrative requirements.

Further reading –

https://oig.hhs.gov/about-oig/about-us/office-of-audit-services.asp

Organ Procurement Organization – OPOs play a crucial role in ensuring that an immensely valuable, but scarce resource—transplantable human
organs—becomes available to seriously ill patients who are on a waiting list for an organ transplant. OPOs are responsible for identifying potential organ donors and for obtaining as many organs as possible from those donors. They are also responsible for ensuring that the organs they obtain are properly preserved and quickly delivered to a suitable recipient awaiting transplantation. Therefore, OPO performance is a critical element of the organ transplantation system in the United States. An OPO that is efficient in procuring organs and delivering them to recipients will save more lives  than an ineffective OPO.

The nation’s 58 OPOs are responsible for all organ recovery from deceased donors in the United States; without OPOs, organs from deceased donors  will not be recovered. Without recovery of organs from deceased donors, only organs from living donors will be recovered and transplanted, and many
patients waiting for organs will die.

Further reading –

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/downloads/cms3064f.pdf

The Health Care Fraud Prevention and Enforcement Action Team – In May 2009, the Department of Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder pledged to fight waste, fraud, and abuse in Medicare with the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). With the creation of HEAT, fighting Medicare fraud has become a top priority for both Department of Justice (DOJ) and HHS. Its Mission was to assemble and strengthen significant resources across government entities to prevent waste, fraud and abuse in the Medicare and Medicaid programs and crack down on the fraud perpetrators who are abusing the system and stealing billions of dollars.

To reduce skyrocketing health care costs and improve the quality of care by ridding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries and harming the short-term and long-term solvency of these essential programs.

Further reading –

https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/heat-taskforce/!ut/p/z1/tZRRU-