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PubMed2001

A critical review of the arguments for insurance coverage for smoking-cessation therapies.

This article elucidates the reasons most insurance companies do not cover smoking-cessation therapies despite their obvious benefits. It critically reviews the arguments for and against using a universal mandate as a strategy to increase use of smoking-cessation programs to realize the associated health benefits and cost-savings. While convincing arguments exist to mandate insurance coverage for self-destructive health behaviors, their merit is tempered by several valid counter arguments. For example, insurance coverage for small, routine, and predictable events, such as smoking-cessation treatment, violates the "first principles" of what ought to be covered when considered from the traditional insurance perspective. An insurance solution to risky behaviors may be to make undesirable behaviors more undesirable to individuals by raising premiums rather than to make them less undesirable with subsidies.

Cost Savings↗
PubMed2001

Coordination of health coverage for Medicare enrollees: living with HIV/AIDS in California.

Because Medicare does not cover a large part of the health care that its enrollees living with HIV/AIDS require, they need other coverage to supplement Medicare. Medicaid is a major source of that supplemental coverage. In California, Medicare enrollees with HIV/AIDS who were also enrolled in Medi-Cal (California's Medicaid program) had total payments from both programs of $177 million, or an average of $28,956 per person in the fee-for-service-system in 1998. Of that total, Medicare paid for 38 percent, mainly for inpatient visits and ambulatory care, while Medi-Cal paid 62 percent, mainly for prescription drugs. For these dual enrollees, many of Medicare's benefit gaps--including a large share of prescription drugs, nursing facility services and home care--are being filled by Medi-Cal. Data in this Medicare Brief indicate that the incremental cost to the federal government of filling gaps in the Medicare benefits package would be considerably less than the full cost of the additional benefits. Through Medicaid and other programs, the federal government is already paying a substantial part of public program expenditures for dual enrollees with HIV/AIDS. Other issues to consider are how the dual Medicare-Medicaid funding streams affect the programs' cost efficiency, and from the perspective of Medicare enrollees and providers, how well the dual programs coordinate to meet the needs of people with HIV/AIDS and other chronic conditions.

California↗
PubMed2001

Premium subsidies for employer-sponsored health coverage: an emerging state and local strategy to reach the uninsured.

With nearly 75 percent of the uninsured living in households with at least one full-time worker, there has been renewed policy interest in strategies to expand coverage by subsidizing employer-sponsored insurance. Six of the 12 nationally representative communities that the Center for Studying Health System Change (HSC) tracks have premium assistance, or subsidy, programs planned or underway. Policy makers are enthusiastic about the potential to expand coverage through these programs, but enrollment has been modest to date. This Issue Brief examines operational challenges facing subsidy programs, such as how to structure a benefits package within budgetary and regulatory constraints and how to attract employers and employees without displacing existing private contributions to premiums. It also discusses the trade-offs policy makers may face to resolve these challenges in the context of rising premiums and a slowing economy.

Financing, Government↗
PubMed2002

Laboratory services regulations impact national coverage decisions, HIM.

This is Part 2 of a two-part article on laboratory services regulations. Part 1, which appeared in the September Journal of AHIMA, dealt with the administrative policies contained in these regulations. Part 2 addresses the specific national coverage decisions that were developed as part of this regulatory process. For more information on each coverage policy, review Addendum B of the regulations.

Aged↗
PubMed1998

Coverage decision-making in Medicaid managed care: key issues in developing managed care contracts.

Coverage provisions are the most complex part of any managed care contract. This is particularly true for Medicaid agencies, because of important differences between Medicaid and insurance. This Issue Brief identifies general issues that should be addressed by States as managed care contracts are developed and drafted, and it specifically explores the challenges faced by public purchasers when drafting managed care coverage provisions.

Contract Services↗
PubMed2004

Trends in U.S. health insurance coverage, 2001-2003.

Against the backdrop of a sluggish economy and rapidly rising health insurance premiums, the proportion of Americans under age 65 covered by employer-sponsored insurance fell dramatically from 67 percent to 63 percent between 2001 and 2003. Although the decline in employer coverage could have spurred a large increase in the uninsured, the proportion of Americans without health insurance did not increase significantly, according to findings from the Center for Studying Health System Change's (HSC) Community Tracking Study Household Survey. Expansion of public health insurance--including Medicaid and the State Children's Health Insurance Program (SCHIP)--forestalled a significant increase in the uninsured, as the proportion of the under-65 population enrolled in public coverage increased from 9 percent to 12 percent.

Adolescent↗
PubMed2004

[Intravenous immunoglobulin therapy for Guillain-Barré syndrome in Japan: changes in treatment after its inclusion in health insurance coverage].

In December 2000, health insurance in Japan was instituted for the use of intravenous immunoglobulin (IVIg) therapy for the acute phase of Guillain-Barré syndrome (GBS) that required aid to walk or worse. A nation-wide questionnaire survey was made to investigate the changes in treatment. In September 2002, a letter of inquiry was sent to experienced physicians in 620 teaching hospitals associated with the Societas Neurologica Japonica and 417 associated with the Societas Paediatrica Japonica. Totally, 356 neurologists (57%) and 223 pediatricians (53%) responded. After the introduction of IVIg health insurance coverage, more than 90% thought that GBS patients should be hospitalized and given treatment. The frequency of hospitals with an intensive care unit, however, was 70%. Before IVIg therapy's inclusion in health insurance coverage, many neurologists selected plasmapheresis (88%) rather than IVIg (4%) therapy, whereas pediatricians preferred IVIg (49%) to plasmapheresis (12%). After its inclusion, 75% of neurologists selected IVIg rather than plasmapheresis (21%), whereas pediatricians selected IVIg (86%) over plasmapheresis (5%). In March 2003, new payment system based on Diagnosis Procedure Combination was introduced into 82 large hospitals, and leads to difficulties to select IVIg in the hospitals. The payment system should be revised.

Guillain-Barre Syndrome↗
PubMed2004

MassHealth succeeds in expanding coverage for adults.

This study provides the first rigorous evaluation of the impacts of MassHealth, Massachusetts' ambitious effort in the late 1990s to expand coverage to the entire low-income population. We find clear evidence that MassHealth led to an expansion of insurance coverage relative to what was happening to similar populations in comparison states. The success of MassHealth provides support for the value of investing in ambitious new state efforts to find effective strategies to reach the remaining uninsured populations. While current budget shortfalls have forced many states, including Massachusetts, to scale back their expansion efforts, the current economic downturn is not permanent. Understanding the impacts of the expansion efforts in Massachusetts adds to the base of knowledge that will be critical for guiding states when the economy recovers and the resources needed for expansion again become available.

Adult↗
PubMed2005

Contraceptive coverage grows, but significant challenges remain.

Coverage for women's health care in general, and contraception in particular, is included in most health insurance plans. Twenty-one states mandate equal coverage between men and women, but not all Food and Drug Administration-approved approaches are reimbursed. In addition, some employers opt out, despite landmark rulings.

Contraception↗
PubMed2005

A qualitative study of insurers' coverage for mifepristone-induced abortion.

In this qualitative evaluation of 14 U.S. health insurers' coverage policies concerning mifepristone-induced medical abortion, the findings suggest that a significant proportion of health plans do not include evidence-based clinical information obtained from recent research, data, and practice. This omission may hinder the adoption of new, evidence-based protocols for medical abortion by physicians. A model coverage policy that contains comprehensive clinical information regarding appropriate clinical regimens for mifepristone is provided as an example for insurers and others in the field.

Abortion, Induced↗
PubMed2005

Local coverage initiatives: solution or band-aid for the uninsured?

This issue brief surveys health coverage expansion initiatives that are operating on the county or local level, often without the benefit of federal funding. The paper explores the circumstances that have made these initiatives possible and considers the ongoing barriers that local policymakers face in sustaining the programs. Descriptions of four initiatives illustrate the range and variety of programs in operation today and offer both best practices and lessons learned for other communities. The paper also includes a brief analysis of the key elements that make up a successful coverage initiative. Finally, this issue brief considers the role of local and county-based initiatives in the context of overall health care delivery in the national policy framework, highlighting the prospects for sustainability and replication on a broader scale.

California↗
PubMed2005

Medicare prescription drug coverage: preparing for January 1, 2006.

After many years of effort by health advocates, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (called the MMA) in December 2003. The law updates the benefits provided to Medicare beneficiaries by adding coverage for prescription drugs beginning January 1, 2006. Prescription drugs play a central role in modern health care, and extending drug coverage to Medicare beneficiaries is an important goal. The way in which Congress tackled this problem, however, has been highly contentious. This article will describe the law as it was passed, the issues that remain to be resolved, and what ia all means for people with HIV/AIDS.

Fees and Charges↗
PubMed2005

Issues related to state and employer innovations in insurance coverage.

States and employers use a number of different programs and techniques to increase rates of insurance coverage. Successful strategies--whether based on Medicaid/SCHIP expansion, strengthening employer-based coverage, or regulating the individual market--require both flexibility to tailor approaches that best serve their residents and employees and basic protections to ensure that new programs do not leave vulnerable groups behind. In addition, continued financial, regulatory, and administrative support from the federal level is crucial for states and employers to explore innovative solutions to cover the uninsured.

Child↗
PubMed2005

Limited take-up of health coverage tax credits: a challenge to future tax credit design.

The Trade Act of 2002 created federal tax credits to subsidize health coverage for certain early retirees and workers displaced by international trade. Though small, this program offers the opportunity to learn how to design future tax credits for larger groups of uninsured. During September 2004, the most recent month for which there are data about all forms of Trade Act credits, roughly 22 percent of eligible individuals received credits. The authors find that health insurance tax credits are more likely to reach their target populations if such credits: 1) limit premium costs for the low-income uninsured and do not require full premium payments while applications are pending; 2) provide access to coverage that beneficiaries value, including care for preexisting conditions; 3) are combined with outreach that uses easily understandable, multilingual materials and proactive enrollment efforts; and 4) feature a simple application process involving one form filed with one agency.

Community-Institutional Relations↗
PubMed2006

Medicare and Medicaid programs; conditions for coverage for organ procurement organizations (OPOs). Final rule.

This rule finalizes the February 4, 2005 proposed rule entitled "Medicare and Medicaid Programs; Conditions for Coverage for Organ Procurement Organizations (OPOs)." It establishes new conditions for coverage for organ procurement organizations (OPOs) that include multiple new outcome and process performance measures based on organ donor potential and other related factors in each service area of qualified OPOs. Our goal is to improve OPO performance and increase organ donation. In addition, this final rule re-certifies these 58 OPOs from August 1, 2006 through July 31, 2010 and provides an opportunity for them to sign agreements with the Secretary that will begin on August 1, 2006 and end on January 31, 2011. New agreements are needed so that the Medicare and Medicaid Programs can continue to pay them for their organ procurement activities after July 31, 2006.

Humans↗
PubMed2006

Women's health insurance coverage in California.

Health insurance coverage is a critical resource that facilitates access to the health care system and the array of health services women require across their lifespan. This policy brief provides an overview of the health insurance coverage of nonelderly women in California, based on data from the 2003 and 2001 California Health Interview Surveys (CHIS 2003, CHIS 2001).

Adolescent↗
PubMed2003

Assessment of coverage levels of single dose measles vaccine.

OBJECTIVE: To study the consequences of low coverage levels of a single dose of measles vaccine. DESIGN: Case series. PLACE AND DURATION OF STUDY: The study was conducted in the Department of Paediatrics, Rawalpindi General Hospital (RGH) from January 2001 to August 2001. PATIENTS AND METHODS: Information about 68 admitted cases of measles was collected on a structured proforma with reference to epidemiological profile, vaccination history and comorbidities. RESULTS: Mean age observed in measles cases was 2 years and 8 months with a range from 3 months to 8 years. Maximum number of cases reported were <1 year of age (n=22, 32%). Fifty percent of cases were seen among vaccinated children. Seventy-five percent (n=51) had history of contact with a measles case. Pneumonia was the commonest complication followed by acute gastroenteritis, encephalitis, febrile convulsions, oral ulcers, oral thrush, eye changes of vitamin-A deficiency and pulmonary tuberculosis (T.B.) in descending order of frequency. Fifty-four cases were successfully treated for complications of measles and discharged. Nine cases left against medical advice. Five patients died--all of them had encephalitis either alone (n=1) or in combination with pneumonia and acute gastroenteritis (n=4). CONCLUSION: There is a dire need to increase the immunization coverage to reduce the rate of vaccine failure and achieve effective control of measles.

Child↗