Hospital EDs Seeing Sicker Medicare Patients

John Commins, for HealthLeaders Media , May 8, 2013

Hospital emergency departments are treating growing numbers of sicker Medicare patients who require more complex and expensive treatment regiments, the American Hospital Association reports [PDF].

“The drivers [are] both the aging demographic, but also just that people are getting sicker. Chronic diseases are skyrocketing,” says Caroline Steinberg, AHA’s vice president of trends analysis.

“A lot of it has to do with lifestyle factors like obesity. We did look to see if the aging of the Medicare population was driving this and we didn’t find a big change in terms of age. We did find that people are simply getting sicker. That is what a lot of the researchers say, that most of the chronic disease burden is related to lifestyle factors, exercise, weight, that sort of thing.”

The AHA says data shows that between 2006 and 2010, the severity of illness of Medicare patients in the emergency department increased, as did the rate of use, a trend that policymakers fear is leading to higher spending with inadequate reimbursements.

Steinberg says hospitals want the federal government to acknowledge what the data clearly shows.

“We would just like recognition by [the Centers for Medicare & Medicaid Services] that patients are in fact getting sicker and that it is not related to changes in the coding claims, but that we really are seeing patients getting sicker,” she says. “We have run into this problem in the inpatient setting as well, where CMS doesn’t want to pay for rising acuity levels.”

The federal government’s more stringent inpatient admissions guidelines and growing claims denials are also putting more pressure on hospitals to treat Medicare patients in the ED rather than admit them.

“We are seeing an increase by audits by the [recovery audit contractors] and other Medicare auditors that are denying admission for short stays so there is huge pressure on hospitals not to admit patients unless they are very sure that those cases can be fully justified through medical necessity,” Steinberg says.

“Nobody is questioning whether the care provided was medically necessary. They are just questioning whether or not it was provided in the right setting.”

CMS in March said it would change its policy of flatly denying any reimbursements to hospitals that provide medically necessary care determined by auditors to have been delivered inappropriately in an inpatient setting. While that will allow hospitals to re-bill Medicare for hundreds of millions of dollars in uncompensated care, Steinberg says re-billings can only date back one calendar year.

“Unfortunately most of the RAC denials are occurring beyond a one-year timeframe. You can do it, but it is not going to help because that’s when all the denials are happening,” she says.

The AHA report is limited to Medicare claims data, but Steinberg says the advent of expanded health insurance coverage in 2014 under the Affordable Care Act means that EDs will probably see an uptick in usage from other demographics “as more patients become insured and there is still limited access to primary care in many areas particularly in poor neighborhoods.”

“We haven’t looked at what is going on in terms of other populations, but we would imagine that everybody is getting sicker because it’s not like it all happens the day you enter the Medicare program. The obesity and the sedentary lifestyle and the high-stress environment—all those things are risk factors long before you enter Medicare, and a lot of that is exacerbated in the Medicaid population,” Steinberg says.

The AHA report, based on an analysis of Medicare claims data conducted by The Moran Company, also found that use of the emergency department by Medicare/Medicaid “dual-eligible” patients is rising, and; EDs are serving more Medicare patients with behavioral health diagnoses.

For Dual-Eligibles, Health Care Reform Is Already Here

Posted: 05/07/2013 11:46 am | The Huffington Post

By Emily Spitzer

Executive director, National Health Law Program

The Medicaid Expansion, which has the potential of helping 17 million people get health insurance, and the state-based Exchanges, which will offer even more the opportunity to purchase affordable health insurance at a group rate, are both set to roll out in 2014. Both the expansion and the Exchanges are an important part of expanding access to quality, affordable health care and deserve the attention they are getting.

But it would be nice to see some column inches given to another reform effort from the Affordable Care Act, one that just launched in Massachusetts: an attempt to improve care and lower costs for those who are eligible for both Medicare and Medicaid.

Known as “dual-eligible beneficiaries” (or “dual-eligibles”), this group includes roughly 10 million people nationwide who represent some of the biggest challenges for medical service providers and program administrators.

A quick recap: Medicare is a federally-run program that provides senior citizens and people with disabilities access to valuable health care services, including acute care and prescription drugs. But its coverage is often incomplete, especially for those who cannot afford to pay its premiums or share costs, or those who require long-term care.

Medicaid–a federal-state partnership that provides coverage for some low-income people–steps into this breach and, depending on the circumstances, picks up some or all of these additional expenses. And the expenses can be significant. “Dual-eligibles” comprise roughly 15 percent of the national Medicaid enrollment but account for 39 percent of its expenses.

There are at least three reasons that costs associated with dual-eligibles are so comparatively high. The ACA tackles two of these reasons directly and, in doing so, hopes to impact the third.

The first issue the ACA takes on is the inconsistencies between the Medicaid and Medicare programs. For example, Medicaid covers wheelchairs for both in-home and out-of-home use, whereas Medicare only covers wheelchairs for in-home use. Each program provides a different set of standards for evaluating the quality of care, for appealing denials of service, and for covering home health services.

Sometimes the program rules actually work against each other. As the newly-created Medicare-Medicaid Coordination Office (MMCO) recently reported, “reimbursement policies between Medicare and Medicaid incentivize nursing homes to transfer dual-eligibles to hospitals and vice versa,” resulting in less consistent care.

MMCO’s report was part of an effort by the federal government to identify points of tension between the two programs and “realign” them if possible. It proposed 29 broad areas as candidates for regulatory fixes and is seeking additional input from the public on these.

The federal re-alignment initiative will only help so much, however. Sometimes valid reasons exist for the differences between the programs–and remember, many Medicaid administrative policies are set by the individual states, not the federal government.

The difficulty–and the second reason for high costs–lies in challenges of coordinating care. Right now, it is all too easy for a program administrator to apply the incorrect standard and wrongly deny care or delay payment. Add to this the fact that more than 43 percent of all dual-eligibles have a mental or cognitive impairment and are not well-positioned to navigate the system, and you have a recipe for a daunting bureaucratic labyrinth.

This brings me to MMCO’s second initiative, and back to the state of Massachusetts: starting this year, the federal government will fund a series of demonstration, or pilot, programs across the country to better integrate Medicaid and Medicare services.

These programs will allow states and the federal government to experiment with ways to coordinate Medicaid and Medicare coverage to provide patients with quality, cost-effective care. Massachusetts’ program, which began accepting enrollees at the beginning of April, is the first of several experiments that will be launching across the country over the coming months.

Given the complexity of the programs and the vulnerability of the populations they help, advocates will be watching closely to make sure the cure isn’t worse than the disease. But if these two initiatives are effective, it will mean better care for millions of the sickest and poorest Americans, and better care will mean better health outcomes.

This leads me to the third–and biggest–reason that costs for dual eligible is so comparatively high: 60 percent of them have three or more chronic conditions–far more than the average Medicaid or Medicare enrollee.

It should come as no surprise that the oldest and sickest among us have higher medical bills than average; this would be the case even with perfect alignment and coordination. But many of these conditions, such as heart disease or diabetes, can be controlled, and costs lowered, with proper medical care.

I think you see where I’m going here. Better health care access for everyone is a win for us all.

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States Taking Initiative on Dual Eligible Cost Containment

Written by Jim McLaughlin | April 05, 2013

Becker’s Hospital Review

In an effort to control healthcare costs of the nation’s oldest, poorest and often sickest patients, 34 states have implemented or are planning integration programs within the next two years for the so-called dual eligibles who qualify for both Medicare and Medicaid, according to a report from the AARP. 

The federal government offers financial incentives for states under certain guidelines to coordinate care for dual eligibles, but some states are knowingly designing cost-cutting programs that will not fully meet the federal criteria. The AARP expressed some surprise at this finding, as the savings will likely benefit CMS more than the states’ agencies.

© Copyright ASC COMMUNICATIONS 2012.

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States Choose Managed Care to Coordinate Medicare and Medicaid

Posted By  | April 1, 2013 |

California is the latest—and of course the largest—state to join a national effort to improve health care for “dual eligibles,” low-income elderly and disabled people who qualify for both Medicare and Medicaid. That population has historically been left to navigate both programs on their own, but states are increasingly working to help coordinate care for dual-eligibles. Last week, California reached an agreement with the Centers for Medicare and Medicaid Services (CMS) on a plan to achieve that goal.

The crux of the state’s strategy is to place those people in managed care programs, in which one company oversees all of a patient’s health-care needs and is paid on a per-person basis, rather than the traditional fee-for-service model that pays per procedure, per test and so on. Any money not spent on patient care is then split between the company, CMS and the state. But the company is also liable for any costs beyond its per-person allotment.

That’s a powerful incentive for companies to keep their clients healthy and make sure they get the best possible care. By placing one entity in charge of an individual, managed care should also help eliminate the fragmentation that frequently exists between Medicare, which covers things like hospital visits and some prescription drugs, and Medicaid, which covers longer nursing home stays and in-home assistance.

California is making its move under the Affordable Care Act (ACA), which authorized CMS to oversee state demonstration projects that aim to improve coordination between Medicare and Medicaid. It is the fifth state to sign a memorandum of understanding with the Obama administration; the first four were Illinois, Massachusetts, Ohio and Washington state.

When developing their demonstration projects, states can theoretically choose between managed care, called the capitated model, or a managed fee-for-service model in which the state handles the integration of Medicare and Medicaid benefits and receives a performance payment from CMS if it meets certain targets. But managed care is winning out—four of the five approved states proposed managed-care programs; Washington state opted for managed fee-for-service. Of the 21 other states that have proposed a duals demonstration, 14 chose managed care. Five decided to try managed fee-for-service, and two are testing both models.

“We think both models can work well,” says Tim Englehardt, who is overseeing the duals demonstrations at CMS. “But many states believe there is flexibility under a capitated model that’s simply not there under fee-for-service.”

It’s easier, for example, to change how doctors are paid or what benefits are offered in managed care, where the only restriction is a flat per-person payment. Take California: it was the first state to include dental, vision and non-emergency transportation benefits in its demonstration. Those services might have been cost-prohibitive with fee-for-service, but they aren’t in managed care.

Plus, most states already have robust managed-care programs for their younger, non-duals population. In 41 states, at least 50 percent of Medicaid beneficiaries are enrolled in managed care. “That’s how most states run their programs now, so there has been broader momentum on that,” Englehardt says.

California will be the biggest testing ground yet for whether managed care can save money and improve care for dual eligibles. A little more than 450,000 Californians in eight counties will participate in the project. Enrollment will be phased in over 12 months starting in October. At first, eligible people will have to actively opt into the demonstration, then passive enrollment will begin.

Enrollees will be given a single identification card to access all of their benefits in both Medicare and Medicaid. CMS and the state Medicaid office will work jointly to contract with health plans to provide managed care, a process that will begin soon. Fragmentation will still exist—the company will receive separate checks from Medicare and Medicaid—but it should be a seamless experience for the patient.

Particular attention will be paid to Los Angeles County, where enrollment in the demonstration was capped at 200,000 people. That will leave 70,000 dual-eligibles who will not enroll in managed care. Jane Ogle, who is overseeing the project for the California Department of Health Care Services, says that will give the state a natural way to gauge how much of a difference the reforms make. The goal is 1 percent in total savings in the first year, increasing to 4 percent by the third. Success will also be measured by patients’ satisfaction with this new coordinated care.

“The real focus of this is the better care and better access,” Ogle says. “Savings are important, but not as important as getting these services integrated. If we do that, no matter what the savings, it’s worth it.”

While federal and state officials express excitement about these pending projects, expectations are notably lower than they were when the demonstrations were first announced in July 2011. Though 26 states have applied to participate, only five have been approved so far and most probably won’t begin until 2015. Some health plans reportedly boasted that they could obtain 8 or 10 percent savings on the dual-eligible population, but those estimates have been scaled back to the 1 to 4 percent projections in California.

One state, Tennessee, has actually backed out of the demonstration altogether because state officials didn’t think they could make the economics work. They concluded that not enough health plans would participate under a managed care model because companies were concerned about receiving capped payments.

That’s going to be a key metric to watch in California, says Caroline Pearson, who tracks state health reform at Avalere Health, an independent consulting firm. There are already reports of state officials clashing with health plans over the demonstration’s payment rates. In general, implementation has shown that getting two of the largest government’s bureaucracies to work well together is going to be a little messy.

“There was a lot of excitement about how many people were going to be affected. The project was extraordinarily ambitious and under not very realistic timelines,” Pearson says. “We’re kind of coming down to reality now.”

The stakes are high. The nation’s 9 million dual eligibles account for 15 percent of Medicaid’s enrollment, but nearly 40 percent of its spending. As conversations in Washington, D.C., focus on deficit reduction and entitlement reform, health officials know that the duals demonstration could play a significant role in getting government health care spending on a sustainable path.

“[Medicare-Medicaid enrollees are] one of those places we can improve,” Englehardt says. “We genuinely believe that these programs will be better for people, and we genuinely believe we’ll get some savings over time.”

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CMS Approves California’s Dual-Eligible Plan, Nation’s Largest

Becker’s Hospital Review

Written by Jim McLaughlin | March 28, 2013

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CMS approved (pdf) California’s three-year plan to better coordinate coverage for 456,000 dual-eligible patients — who qualify for both Medicare and Medicaid due to their age, disability and income status — making it the largest of the now-five states green-lighted to insure such individuals with help from private plans.

Private insurers Health Net, Molina Healthcare and WellPoint will administer the policies for dual-eligibles.

A quarter of California’s Medicaid costs comes from dual-eligibles, even though they only make up about 14 percent of the state’s 1.1 million Medicaid beneficiaries.


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Medicare-Medicaid Dual Eligibles: Measuring Quality of Special Needs Plans and State Demonstrations


Published on 21 March 2013


Medicare-Medicaid dual eligibles are often held up as a prime case for the need for better care management to reduce health costs and spending while improving quality.  But doing so can be challenging.  Most dual eligibles have multiple health conditions, whether a chronic disease, severe cognitive or physical disabilities, or some other condition or impairment that requires long-term care.  About 40 percent of dual eligibles have both a serious physical health diagnosis and a severe behavioral health condition, making care coordination and quality improvement all the more important and challenging.

Those interested in how current health insurance programs for dual eligibles measure quality can turn to a recent brief from the Center for Health Care Strategies (CHCS). You can read the full brief at the CHCS website – – but here are some highlights.


Special Needs Plans for Dual Eligibles (D-SNP):

D-SNPs, part of Medicare Advantage, account for more than 80 percent of, or 1.2 million, Special Needs Plan (SNP) enrollees. A report last year from Government Accountability Office (GAO) pointed out that the Centers for Medicare and Medicaid Services (CMS) does not require D-SNPs to report a standardized set of outcomes.

Nonetheless, the CHCS brief pulls some helpful examples of different quality measures D-SNPs use:


Most of the data come from Healthcare Effectiveness Data and Information Set (HEDIS), though some come from the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS), or from CMS directly.


Quality in Financial Alignment Demonstrations for Dual Eligibles:

The Affordable Care Act (ACA) health reform law opened the door for CMS and states to launch integrated Medicare-Medicaid health plan demonstrations. Long-term care use, mental health service use, quality of life, and care coordination are of particular importance in measuring quality of care demonstration programs provide.

Examples of quality measurements for the managed care integrated dual eligibles demonstrations include:

  • Success managing complex cases, evaluating access to case management, individualized care plans, satisfaction with case management, and identifying members who would benefit from case management.
  • Easing Care Transitions, which looks at how well health plans manage and improve care transitions from hospitals to long-term care, for example.
  • Coordination of Medicare and Medicaid benefits, which includes service coordination and network adequacy assessments.


Business Briefings for Health Plans on Integrated Care Demonstrations:

Sellers Dorsey recently hosted two helpful webinars on dual eligibles: one is a basic overview and the other describes business opportunities and risks for health plans in the large and growing dual eligibles market.

In the later, Mike Fox and Kip Piper of Sellers Dorsey provide a 90-minute briefing for health plan executives on the new demonstrations to integrate Medicare and Medicaid financing and care delivery for dual eligibles. Mike and Kip describe the current $350 billion dual eligibles marketplace, state plans to contract with health plans, steps health plans should take in assessing the business opportunities and risks of serving this market, and key considerations for entering the integrated Medicare-Medicaid health plan business. Watch the briefing online for free here on Vimeo.


Read more Piper Report posts on dual eligibles issues here.


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Ambitious Project Aims to Improve Quality, Lower Costs for Dual Eligibles

February 05, 2013 11:00
Bob Rosenblatt / The Medicare NewsGroup

The government will begin an ambitious Medicare-Medicaid coordination program next year to try to bring better care at a lower cost to some of the 9 million people who are the sickest and poorest, and thus most costly, patients in the nation’s health care system.

Their ranks include a cross section of different groups, such as residents of nursing homes, the mentally ill, and the physically or developmentally disabled. They are called “dual eligibles” because they qualify for two massive government programs: Medicare, which covers people over age 65 and the disabled of all ages, and Medicaid, which covers poor people.

As many as 2 million of dual eligibles will be enrolled in local managed care networks, or in programs with a fixed total payment for providing their care during the year. The hope is that they will get better care, and that the taxpayers will save money because there will be better oversight of the way these patients  receive care from doctors, hospitals, visiting nurses, social workers and therapists. The goal is to have one contracting organization overseeing the myriad sources of care for a group of dual eligibles.

The program will be run by the government’s new Federal Coordinated Health Care Office.

Related FAQ: Who Are Dual Eligibles?
Related FAQ: What Does the Affordable Care Act Do With Regards to Dual Eligibles?
Related FAQ: Are There Examples in the States of Novel Approaches to Managing Dual Eligibles?

The population of dual eligibles  incurs higher medical costs than any other group of patients.  They bounce in and out of hospitals, have multiple ailments, take myriad medications, and get their care through a fragmented system of public and private hospitals, local nursing agencies and county emergency mental health centers.

Of these 9 million dual eligibles, more than one-third will spend some time in a nursing home. They represent 15 percent of the Medicare population, but consume 30 percent of Medicare spending. They are also15 percent of the Medicaid population, but consume 40 percent of Medicaid dollars.

Providing care for dual eligibles is one of the most intricate tasks of the nation’s complex health care system.

The current system, in which each thing a doctor does carries a separate charge, is called fee-for-service. Dealing with this fragmented approach is very hard for dual eligibles because it is “really fend-for-yourself,” said Matt Salo, executive director of the National Association of State Medicaid Directors.

Starting in 2014, the federal government will begin a major experiment in organizing coordinated care for dual eligibles in as many as 15 states. Beneficiaries will be offered the choice to enroll in managed care plans, which have networks of doctors, hospitals and other health care providers.

This experiment will offer more expansive care than found in a traditional managed care network. In California, for example, where Kaiser Permanente has a large network of its own providers, its plan will oversee the care of mentally ill people who might otherwise be treated at a county hospital.

Kaiser is “committed to this population,” said Susan D. Fleischman, M.D., vice president for Medicaid at Kaiser, when discussing the dual eligibles who may decide to join Kaiser’s plan.  But it’s a new population and “we’re nervous,” she told a panel discussion on dual eligibles on February 1, at the annual conference of the National Academy of Social Insurance, a nonpartisan think tank working on Medicare and Social Security issues.

Despite Kaiser’s extensive experience with both the Medicare and Medicaid populations, “We have limited experience in delivering the full scope of services to the dual eligibles,” she said, adding, “If we are nervous, then other plans ought to be really nervous.”   

Kaiser presumably has a head start on its competitors in taking on this new population because it has the highest ratings for quality bestowed on managed care plans by the federal government. Only 11 Medicare Advantage Plans (Part C) have the government’s top 5-star rating, and six of them are Kaiser plans.

Nonetheless, “Our learning curve is going to be steep,” Fleischman said.

One of the new steps for Kaiser, and other plans, will be learning to coordinate care with county mental health facilities, which have always operated separately from traditional health plans.

Under the experiment, the goal will be for a dual eligible to have all of his or her care overseen and coordinated by plans like Kaiser’s. This can include if a 90-year-old in a nursing home falls and breaks a hip; a mentally ill person stops taking medication, has a psychotic episode and is taken to a county mental health emergency center; a developmentally disabled person needs a ride to a job training session; or someone is discharged from a hospital and needs a visiting nurse to provide therapy at home. The goal is that all the details for any kind of needed care will be managed by a single health plan. Not all of the services fall under the category of what might be described as traditional health care, but the goal is to give the individual as much access to self-sufficiency as possible.

Along with big health care challenges are big financial ones. The plans that will participate at the government’s invitation are supposed to show within a year’s time that they are delivering to their patients better care for less money as compared to people who don’t join such a plan.

The difficulty will be in providing quality care for a very diverse group of people. A plan might be “terrific” in providing care for the mentally ill but not for the developmentally or physically disabled, according to Brian Biles, M.D., professor in the department of health policy at the School of Public Health at George Washington University. 

Because many of the individuals have multiple physical or mental ailments, there is concern that the transition to a new method for getting care may be difficult.

CMS has stated that demonstration plan benefits packages should include “all primary, acute, behavioral health and long-term services and supports presently covered by Medicare and Medicaid.”

However, “Patient advocates around the country, and some lawmakers in Congress, warn that managed care plans – some run by for-profit, publicly traded companies – are ill-equipped to deal with the complex health needs of those who are elderly, mentally ill or disabled,” according to a story by Kaiser Health News. (MNG) original articles can be reprinted or republished with credit to The Medicare NewsGroup. To use our content, simply copy and paste text from the MNG website. Use of our content is done in compliance with our Terms and Conditions but does not extend to material from other sources that are subject to their copyright. 

Copyright the medicare newsgroup

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Changes ahead due to Patient Protection and Affordable Care Act

Posted: 01/29/2013 Last Updated: 23 hours and 9 minutes ago

By: Kristi L. Nelson, Scripps Howard News Service

The far-reaching Patient Protection and Affordable Care Act will mean myriad changes to the way health care is accessed and delivered in this country — and how it affects you could depend on your age, income, health and current insurance status, among other things.

Here’s a look at what changes could be most important to you:

If you don’t already have health insurance: You’re going to have to get coverage next year or likely face a financial penalty that starts at 1 percent of your income (or $95, whichever is more) in 2014, and rises to 2.5 percent of your income by 2016. You could be exempt if you’re American Indian, if health insurance goes against your religious beliefs or if you can show financial hardship. The good news is, thanks to other provisions of the Affordable Care Act, it should be easier and more affordable for people who are uninsured now to get insurance.  

If you are a senior citizen: You should already be seeing some benefits of the reform, including not having to pay for preventive services through Medicare and getting help paying for prescription drugs once you hit the “doughnut hole” in Medicare Part D coverage. By 2020, seniors should be paying only 25 percent of those drugs’ costs. On the other hand, some Medicare benefits are being cut — things like hearing aids, glasses and memberships to fitness centers. And you may find that some illnesses and surgeries that Medicare once would have considered appropriate for an overnight hospital stay are now considered outpatient, which means you may be billed for individual costs that once were part of the hospital “package.” If you do spend time in the hospital, you may notice your providers doing more aggressive follow-up once you are released, to try to prevent you from having to go back into the hospital.  

If you are a young adult: If you’re younger than 27 and not offered insurance through your job, you can remain on your parents’ health insurance policy until your 27th birthday. If that’s not an option for you and you’re young, in good health and don’t expect to need much medical care, you can purchase a “catastrophic” health insurance plan with low premiums but a high deductible — coverage doesn’t kick in until you’ve paid for $6,000 in care yourself.  

If you’re wealthy: You may pay a higher Medicare tax this year. Those with an annual income of more than $200,000 for one person or $250,000 for couples will pay a 2.35 percent Medicare tax, up from 1.45 percent. In five years, the government will start taxing high-dollar, high-coverage employer-sponsored “Cadillac” health plans with a 40 percent excise tax.  

If you’re low income: It’s possible that you’ll qualify for Medicaid in the future even if your income is too high to qualify now. The ACA, in its original form, intended to make it so that all Americans who earned less than 133 percent of the federal poverty line (about $14,000 for a single person, or $29,000 for a family of four) would be eligible to enroll in Medicaid, giving the states 100 percent of the extra money needed for the first three years and gradually requiring the states to fund 10 percent of the expansion in the future. But the U.S. Supreme Court ruled that the federal government could not force states to expand their Medicaid programs just to continue getting funds they were already receiving.  

If you’re middle class: If you’re self-employed or work for a smaller company, you should be able to buy insurance on the health exchange. People who make four times the federal poverty level (about $44,000 for an individual or $88,000 for a family of four) or less may be eligible for subsidies from the federal government, which would be paid to the insurance companies and appear on your bill as a discount. The idea is that people would not pay more than 10 percent of their income toward health insurance (and the lower the income, the less the percentage).  

If you’re an undocumented immigrant: There are no provisions in the ACA for you at all. You wouldn’t be eligible for Medicaid or to buy insurance on the exchange. You can still purchase a policy through a broker, if you can afford one, or pay yourself for care at clinics, hospital emergency rooms and other providers.  

If you typically claim unreimbursed medical expenses on your tax return: You may not get to do so now — they must be 10 percent of your income, up from 7.5 percent in the past.  

If you have a health insurance plan through your large employer: You’re not likely to see many changes right now. Your premiums will likely stay flat or, if the insurance company your plan is through has been making large profits, may drop as the government now regulates what percentage of profit must be funneled back into providing quality or lowering premiums.

Right now, only small businesses and individuals who don’t have insurance through their jobs can buy insurance on the exchange

— but that does mean if you lose your job, you should have an easier time finding affordable health insurance coverage for you and your family.

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In Good Hands: Adult Day Care in the US Industry Market Research Report Now Available

from IBISWorld
PRWeb – Thu, Jan 17, 2013
An aging population and an anticipated expansion in private healthcare coverage in line with the Patient Protection and Affordable Care Act are forecast to increase already growing demand for adult day-care services. For these reasons, industry research firm IBISWorld has added a report on the Adult Day Care industry to its growing industry report collection. Los Angeles, CA (PRWEB) January 17, 2013
The Adult Day Care industry has performed well over the past five years. The steadily aging population and expensive alternative long-term care options fueled demand for industry services. “Growth slowed over 2010 and 2011, though, as state and local governments faced budget shortfall stemming from the recession,” says IBISWorld industry analyst David Yang. “Households also had difficulty paying for services due to stagnant disposable income growth.” Still, other care options, like nursing homes, can cost five times more than adult day care. As a result, this industry quickly returned to strong growth in 2012 as the economy recovered and disposable income grew. In the five years to 2013, revenue is estimated to increase at an annualized rate of 2.0% to $6.2 billion.
Despite growth, profit has slightly declined since 2008 due to a slowdown in Medicaid funding for adult day care. Due to the recession, many states, such as California, attempted to cut or reduce adult day-care programs over 2010 and 2011. According to research from MetLife, government funding is estimated to contribute 55.0% of funding for industry programs. Consequently, profit declined. Despite the decline, many firms have entered this industry to meet the steadily growing demand for adult day care. In the five years to 2013, the number of enterprises increased an estimated 2.9% per year on average. “The majority of industry operators are relatively small companies,” according to Yang, “so theAdult Day Care industry is highly fragmented.” The two largest companies in the industry are Senior Care Centers of America and Easter Seals, a prominent nonprofit. Over the past five years, market share concentration has increased slightly due to Senior Care’s merger with Active Day, previously the largest company in the industry.
Over the next five years, the percentage of people aged 65 and older in the United States is projected to increase. As the population ages, the prevalence of Alzheimer’s and other physical and mental diseases will increase, bolstering demand for adult day-care services. The Patient Protection and Affordable Care Act is anticipated to increase private health insurance coverage, resulting in greater funding for this industry. Disposable income will also recover as the economy returns to growth, allowing households to better afford adult day-care services. As a result, IBISWorld forecasts that industry revenue will continue to grow in the five years to 2018. For more information, visit IBISWorld’s Adult Day Care in the US industry report page.
IBISWorld industry Report Key Topics
This industry provides social and basic health assistance, including transportation, meals, personal hygiene and therapeutic activities, to the elderly and individuals with mental or physical disabilities.
Services are typically provided during normal business hours through adult care centers. This industry does not include home care.
About IBISWorld Inc.
Recognized as the nation’s most trusted independent source of industry and market research, IBISWorld offers a comprehensive database of unique information and analysis on every US industry.
With an extensive online portfolio, valued for its depth and scope, the company equips clients with the insight necessary to make better business decisions. Headquartered in Los Angeles, IBISWorld serves a range of business, professional service and government organizations through more than 10 locations worldwide.
For more information, visit or call 1-800-330-3772.
Gavin Smith IBISWorld 310-866-5042 Email Information

11 states get extra $1.5 billion for online health insurance exchanges

11 states get extra $1.5 billion for online health insurance exchanges


By IFAwebnews Staff

Posted: January 18, 2013

The Department of Health and Human Services (HHS) has awarded an additional $1.5 billion in grants to 11 states to develop their online health insurance exchanges.

HHS Secretary Kathleen Sebelius, in announcing the grants, said the money is intended to ensure the states have the resources necessary to build online marketplaces that meets the needs of their residents.

California, Delaware, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oregon, and Vermont have all received portions of the Exchange Establishment Grants.

“These states are working to implement the health care law and we continue to support them as they build new affordable insurance marketplaces,” Sebelius said. “Starting in 2014, Americans in all states will have access to quality, affordable health insurance and these grants are helping to make that a reality.”

Beginning Jan. 1, 2014, Americans must be covered by health insurance as required by the Patient Protection and Affordable Care Act (PPACA). All exchanges must be operational by Oct. 1, 2013, to allow consumers to begin purchasing insurance online.

Delaware, Iowa, Michigan, Minnesota, North Carolina, and Vermont received awards today for Level One Exchange Establishment Grants, which are one-year grants states will use to build marketplaces.

California, Kentucky, Massachusetts, New York, and Oregon received Level Two Exchange Establishment Grants today. Level Two grants are multi-year awards to states to further develop their marketplaces.

PPACA requires all states to have an online insurance exchange.

A total of 19 states are operating their own exchanges, 25 defaulted and have passed the responsibility for creating and running their exchanges back to the federal government, and seven will operate as state-federal exchange partners.

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