Your Source for Health Reform

Browse content
by topic

 

Our resources arranged by subject matter.


  • 1115 Waivers Section 1115 waivers give States the flexibility to try out ways of improving their Medicaid system. The Illinois demo is being used to focus on population health management, build up the healthcare workforce, and improve long term services and supports infrastructure, choice, and coordination.
  • ABE The Application for Benefits Eligibility, or ABE, is the State of Illinois’ online application for Medicaid and other public assistance. Note that there is not a specific open enrollment period for Medicaid, as there is for the Health Insurance Marketplace; application can be made at any time during the year.
  • ACA Outreach The chronically uninsured tend to face significant barriers to enrollment. The newly insured can also experience challenges keeping coverage. Lack of experience with insurance, language barriers and deficits of information regarding the Affordable Care Act are examples of the potential barriers. Enrollment events, special materials and a variety of outreach efforts are required to connect these target populations with health coverage.
  • Affordable Care Act The Patient Protection and Affordable Care Act is the most sweeping reform of the healthcare system in the United States since Medicare. The ACA was signed into law in March 2010, and was upheld by the U.S. Supreme Court in June 2012.
  • All Kids All Kids is a state-run program in Illinois that provides comprehensive healthcare benefits for children in lower-income households. Some families pay monthly premiums for the coverage, but rates for middle-income families are significantly lower than on the private market.
  • Behavioral Health Historically, health insurance had limited coverage of behavioral health services related to behavioral health, overall well-being, and substance abuse disorder treatment. Under the ACA, all new small-group and individual-market plans must cover behavioral health and substance use disorder services as one of the ten essential health benefits, and cover them at parity with medical and surgical benefits.
  • Benchmark Plan To improve the adequacy of private health insurance, the Affordable Care Act requires insurers to cover a minimum set of medical benefits, known as essential health benefits. In implementing this requirement, states were asked to select a “benchmark plan” to serve as a reference point for designing health plans that meet ACA rules.
  • Brokers and Agents Brokers and agents are licensed professionals who act as intermediaries between customers and insurers, and can help you find a plan. While both receive a commission on plans sold, an agent represents specific companies. The federal government now certifies agents and brokers who have received training in the details of ACA plans. (The DOI refers to brokers and agents as “insurance producers.”)
  • Business Health insurance for working people and their dependents in the United States has primarily been provided by employers, and critics of health reform efforts have claimed that reform represented a threat to business and the economy. The ACA requires that employers with 50 or more FTEs provide affordable health insurance to their employees.
  • CHIP The Children’s Health Insurance Program provides health insurance for uninsured children in low-income families that do not qualify for Medicaid. States receive federal matching funds to coverage children in families with income under 300% of the federal poverty level. The ACA extends authorization for CHIP through FY 2019 and funding through FY 2015.
  • Chicago Prior to the ACA, about 30% of Illinois’ uninsured lived in Chicago, the majority of them Black or Latino. The city also has the state’s largest concentrations of immigrant populations, with more than 100 languages spoken, and more than a third of residents speaking a language other than English at home.
  • Children Most Illinois children in lower-income families qualify for free or low-cost health coverage through Medicaid and/or All Kids. Under the ACA, many privately run health insurance companies also offer similar benefits to parents and kids, including preventive services and “essential health benefits,” and medical, dental, and vision coverage for children with a disability.
  • Chronic Conditions Health or medical problems persist or have long-lasting effects, such diabetes, kidney disease, and heart disease, require monitoring, coordinated treatment, and patient education. Chronic conditions can also place undue stress on family caregivers.
  • Consumer Info All informational resources are not alike. Some analyze the effects of reform on the nation or the economy, or give detailed guidance to lawyers, brokers and navigators on the fine points of the law and the regulations surrounding it. But there are many valuable resources like charts and fact sheets that explain in simple language what you need to know to make the best decisions for yourself, your family, or your small business.
  • Consumer Protections The ACA requires insurance companies to cover people with pre-existing health conditions, makes it illegal for cancel your policy just because you get sick, and does away with lifetime and yearly dollar limits on coverage of essential health benefits, among other protections.
  • CountyCare CountyCare is a provider-operated Medicaid program for adults in Cook County. To be eligible, a person age 19-64 with income up to 133% of the federal poverty level must be a U.S. citizen or legal permanent residentfor 5 years or more. The program serves clients via “medical homes” where each member has a primary care physician to help them get the care they need.
  • Culture of Coverage Employer-based insurance and its automatic disenrollment at job loss, or when a child reached age 18, created many barriers to continued coverage; and for many, continuation of coverage was not attainable or affordable. A key tenet of health reform is to shift the culture to one where being covered, and making effective use of health services, is not only affordable, but also the expectation and the norm for all.
  • Data Digitally presenting data helps us understand who the uninsured are and where they live, or find the locations of facilities and services. Such visualizations allow governments and communities to discover how well needs are being met, and they can serve to inform future programs, outreach, and policy.
  • Dept of Healthcare & Family Services The Illinois HFS is the state agency responsible for providing healthcare coverage for adults and children who qualify for Medicaid, and for providing child support services to help ensure that Illinois children receive financial support from both parents.
  • Dept of Insurance The DOI is the Illinois agency charged with regulating the insurance industry’s market behavior and financial solvency. As such, it implements ACA safeguards through insurer oversight, coordinates Illinois-specific training for ACA assisters and navigators, and licenses insurance agents and brokers.
  • Disabilities Because of the ACA, private insurance is an option for some people with disabilities. At the same time, the ACA, along with reforms at the state level, has sometimes narrowed the healthcare choices for this population. To receive necessary specialty care and live a healthy lifestyle, people with disabilities must have access to healthcare that meets their unique needs.
  • Dual Eligibles Dual-eligible beneficiaries are those qualifying for both Medicare and Medicaid. About 9 million people fall into this category, including low-income seniors and younger people with disabilities. They tend to have complex and costly health care needs.
  • Employee Health Benefits Although 70% of working-age people work for an employer that offers health insurance, the actual benefits offered to employees vary. The ACA now requires large employers to offer employees affordable, minimum essential coverage. Meanwhile, the type of coverage employers offer has evolved, with some now providing wellness programs and health incentives.
  • Employers Health insurance through one’s job has traditionally been the main way for working-age people to obtain coverage for themselves and their families. The ACA now requires large employers to offer their employees affordable minimum essential coverage, and provides a penalty for those who fail to do so.
  • Enrollment Assisters People can help consumers look and apply for health coverage through the marketplace and Medicaid. They may be referred to as navigators or in-person-counselors and must have special training, be unbiased and offer assistance for free.
  • Essential Health Benefits The ACA requires health plans offered in the individual and small-group markets to cover 10 categories of essential health benefits needed to prevent and treat illness, including outpatient and emergency care, hospitalization and prescription drugs.
  • FTE Employees The ACA categorizes employers as large or small based on the number of full-time equivalent employees they have. In general, this means finding how many full-time workers the part-timers’ hours would have added up to. The IRS has developed an exact formula to make this calculation.
  • Families Healthcare is often a family affair, and family caregivers are the most important source of support for older people and adults with chronic conditions. The ACA helps families pay their health insurance premiums and gives them affordable new coverage options.
  • Financial Assistance Financial assistance is available to lower- and middle-income people buying plans on the Marketplace in the form of tax credits and cost-sharing reductions. People with income up to four times the federal poverty level can pay reduced premiums, and those with income below 250% can have lower out-of-pocket costs, such as deductibles and copays. About 80% of people enrolling in first round qualified for assistance.
  • Get Covered Illinois GetCoveredIllinois.gov is the website of the Illinois Health Insurance Marketplace. As one of the federally facilitated marketplaces, the site directs visitors to either the the Medicaid application, at ABE, or to Healthcare.gov, depending on their eligibility. It also provides information on health insurance, allows visitors to compare plans, and helps them locate trained navigators in their area.
  • Getting Coverage The health insurance marketplace is new, and it can be a little daunting – especially if you have only had health insurer from your employer, or have not had insurance for a while. Fortunately, there are many helpful materials.
  • Gov Quinn Governor Pat Quinn created the Illinois Healthcare Reform Implementation Council by executive order in 2010 to help the state implement provisions of the ACA. In July 2013, he signed SB 26 into law, implementing Medicaid expansion in Illinois.
  • HHS The U.S. Department of Health and Human Services is the cabinet-level federal agency responsible for health-related programs. Medicare and Medicaid – the nation’s two largest public health programs – as well as the Children’s Health Insurance Program and implementation of the Affordable Care Act, are managed by HHS’ Centers for Medicare & Medicaid Services, or CMS.
  • Health Insurance Exchange A key concept of the reform model adopted by the ACA is that states would have centralized markets offering a variety of qualified health plans to consumers, along the lines established in Massachusetts in 2006. Although the term was common during the campaign to enact reform, the exchanges are now more often called health insurance marketplaces.
  • Health Insurance Literacy Getting coverage is just the first step, consumers must also know how to use it. When consumers can understand the jargon, how to be smart health insurance shoppers and what to expect when visiting the doctor, they can benefit from their new coverage.
  • Health Policy While a great deal of information is available to help consumers and companies deal with health reform and understand how it will affect them, there is at the same time an effort to understand how well it is meeting its goals, and how it will affect communities and the nation as a whole.
  • Health Reform As far back as 1948, President Truman drew attention to the need to make healthcare more accessible, stating that “most of our people cannot afford to pay for the care they need.” In recent decades this has been a growing national issue, which came to a boil during the enactment of, and subsequent constitutional challenges to, the Affordable Care Act.
  • Healthcare.gov HealthCare.gov is the federal ACA website, which serves as the online health insurance exchange for states that have not set up their own. The site was overhauled after a troubled launch, and as of March 2014, 36 states relied on HealthCare.gov as their online Health Insurance Marketplace.
  • Immigrants Health reforms and programs have special rules for immigrants in regards to eligibility. Immigrants also have a unique experience within the healthcare system.
  • Individual Mandate The ACA requires that everyone have health coverage in some form. Those who not have insurance, and do not fall into one of the exemption categories, are subject to a penalty. The penalty fee is $95 or prorated 1% of income for 2014, and increases in later years. The constitutionality of this part of the law was challenged, and was upheld by the U.S. Supreme Court.
  • IRS The tax provisions of the Affordable Care Act are overseen by the IRS. From verifying that consumers complied with the individual mandate to confirming the income reported for premium tax credits, the IRS is a major player in implementing healthcare reform.
  • Keeping Coverage The steps you need to take in order to keep the insurance you purchased on the health insurance marketplace include paying premiums, keeping information up to date, and renewing coverage every year.
  • Marketplace The ACA created health insurance marketplaces where people can purchase health plans available in their state. Consumers and small businesses can purchase insurance online at GetCoveredIllinois.gov or through other means, such as insurance companies or brokers.
  • Medicaid Medicaid is a state-run program that provides medical coverage for low-income populations. Traditionally, families with children, pregnant women, children, seniors, and persons with disabilities have been eligible. The Affordable Care Act broadened eligibility to low-income adults without children in states that chose to implement the expansion.
  • Medicaid Care Coordination Illinois law requires 50% of Medicaid beneficiaries to be enrolled in coordinated care by 2015. Coordinated care plans include a choice of primary care physician, a care coordinator, and a provider network. They are available through managed care organizations or health provider groups. The plans vary by how they are reimbursed and designed, and some may offer some extra benefits, but all traditional Medicaid benefits are guaranteed.
  • Medicaid Eligibility In general, eligibility for Medicaid benefits is based on income and family size, but there are different categories of eligibility, and it can be complicated. Some Medicaid programs are designed for people in specific age groups or with specific medical needs.
  • Medicaid Expansion The Affordable Care Act provides states with additional federal funding if they expand their Medicaid programs to cover low-income adults. As of February 2015, 28 states and the District of Columbia had opted to expand their Medicaid programs. Illinois expanded Medicaid in July 2013.
  • Medical Loss Ratio The ACA’s MLR provisions require insurance companies to spend at least 80% to 85% of premium dollars on medical care, and to provide rebates to consumers when they fail to do this. Insurers are required to report data to the government to show that they are not spending too much on administrative costs.
  • Medicare Medicare is the federal health insurance program for people 65 and older. It also covers younger people with certain disabilities. It is administered by the CMS and is America’s largest health insurance program. Medicare beneficiaries are largely unaffected by health reform, although some provisions of the ACA strengthen the program.
  • Network Adequacy The extent to which a health insurance plan comprehensively meets the health care needs of its enrollees. A health plan with a satisfactory number of doctors, specialists and suppliers—all within a reasonable traveling distance to its enrollees— is considered adequate. To ensure a prospective health plan will address all their medical needs, consumers need to double check the plan’s network.
  • Older Adults While most seniors over 65 are covered by Medicare, some haven’t completed the work requirements for coverage. And people age 50-64 – who are not yet eligible for Medicare – have often had limited access to public or private health insurance, especially if they were low income. And yet this age group has greater healthcare needs on average than younger individuals.
  • Open Enrollment For both traditional employer-based insurance and plans purchased on the Marketplace, there is a period each year when people can freely purchase plans or make changes in their coverage. Outside of this open enrollment period, a major life event qualifies a person for a special enrollment period.
  • Out Of Pocket Costs When visiting the doctor or filling a prescription, consumers may have to pay a percentage or set dollar amount of the costs. Health insurance plans identify out of pocket costs with their explanation of benefits, often using terms such as deductibles, coinsurance and copayments. Evaluating a potential health plan’s out of pocket costs is an important consideration for health insurance consumers, especially for those with existing medical needs.
  • Patient Engagement Navigating the health system, understanding medical jargon, and incorporating healthy behaviors into everyday life can be difficult for patients to do on their own. Healthcare providers can be a source of information and support for patients seeking care. By interacting with patients in a responsive and understanding manner, providers can ensure that patients have positive experiences with the healthcare system and will want to return with future questions or concerns.
  • Patient Info Physicians, nurses and others who perform healthcare services are the connecting link between health reform and the patient. In addition to providing care, healthcare providers are often the only ones in a position to advise or help a patient find their way through the healthcare system in a time of need.
  • Penalty The ACA stipulates that people who do not have coverage must pay a penalty, which is done via their tax return the following year. The penalty started at $95 or 1% of income, whichever is greater, for 2014 and increases every year. There is also a penalty for employers with 50 or more FTE employees who fail to offer affordable coverage to their workers.
  • Pre-Existing Condition A key provision of the ACA outlaws discrimination based on health status. Starting in 2014, no one can be denied coverage, charged a higher premium, or sold a policy that excludes coverage of important health services simply because of a pre-existing condition.
  • Premiums The amount that a person, family or company pays for their health insurance plan, usually monthly, is the premium. Workers covered through their employer normally have the premium deducted from their paycheck. Medicare patients typically have their medical insurance premium deducted from their Social Security benefit.
  • Preventive Services The ACA requires that insurance plans provide important preventive healthcare services – such as vaccines, screening, counseling, and annual checkups – at no out-of-pocket charge. This provision went into effect in 2011.
  • Qualified Health Plans QHPs are plans sold on the health insurance marketplace. They must meet certain standards as established by the ACA.
  • SHOP The Small Business Health Options Program, or SHOP, is a marketplace that helps small businesses provide health coverage to their employees. Employers with 50 or fewer full-time-equivalent employees can buy employee coverage on the SHOP through a broker or agent, and those with fewer than 25 employees may qualify for tax credits.
  • Safety Net Hospitals A general term for the hospitals and health centers that provide a substantial share of their care to low-income, uninsured, and vulnerable populations. These facilities have long served as a “safety net” for those with no other access to care, and they remain so for undocumented non-citizens and others who still lack health insurance.
  • Small Business The ACA defines a small business as one with fewer than 50 FTE employees. Small employers, although they are the prime drivers of job creation and economic growth, have faced barriers to providing health insurance for their workers. They can now buy insurance on the SHOP, and may qualify for tax credits to help them provide employee coverage.
  • Small Business Tax Credits Tax credits are available under the ACA to help small business owners provide coverage for their employees. To be eligible, the business must have fewer than 25 FTE employees and cover at least 50% of employee premiums.
  • Special Enrollment Period You can sign up for coverage outside of open enrollment if you have certain life events, such as changes in your income or your family size. If you marry, divorce, have a baby or a serious illness, you qualify for a special enrollment period.
  • Special Populations Special populations such as immigrants, the uninsured, the unbanked, and people with low English skills require special outreach efforts to connect them with the benefits the ACA is intended to provide. Some groups, such as refugees and Pacific Islanders, have special provisions for them in the law. And certain demographic groups, such as the young people and healthy people, are important to the the program’s success. The ACA also particularly impacts the LGBTQ community, populations affected by chronic disease, and people impacted by circumstances like domestic violence.
  • Supreme Court After the enactment of the Affordable Care Act in 2010, a number of states filed suit claiming the law was unconstitutional. On June 28, 2012, the U.S. Supreme Court upheld the ACA, finding that the penalty for failing to have health insurance was a tax. It struck down the law’s original requirement that the states must expand Medicaid coverage to poor adults, and by 2014 half the states had not implemented expansion.
  • Undocumented Non-Citizens People who do not have legal status to be in the United States are distinct from legally present immigrants. Undocumented non-citizens are not currently eligible for health insurance under the law. Illinois is home to more than 500,000 undocumented non-citizens.
  • Uninsured Health reform targets people who do not have insurance. In 2013, there were about 1.8 million people in Illinois without health insurance.
  • Veterans While veterans often have significant healthcare needs, not all are eligible for services via the Veterans Administration. Uninsured veterans have a disproportionate amount and complexity of health issues.
  • Women The ACA guarantees women’s access to preventive services, and prohibits female gender from being treated as a pre-existing condition. Women make 80% of healthcare decisions for their families and are likely to be the caregivers for family members.
  • Young Adults People age 19-26 have the highest uninsured rate of any age group and the lowest access to employer-based insurance. Covering young adults is important to health reform, as insurance depends up on people at less risk being in the risk pool to balance those with greater health needs, and also because an unexpected illness or injury can be catastrophic to a person without insurance.