Dewonkify – Overseas Contingency Operations

Term: Overseas Contingency Operations (OCO)

Definition: OCO funding is money set aside in the federal budget for expenses connected to overseas operations such as: crisis response, infrastructure and coalition support for operations in Iraq/Afghanistan, humanitarian assistance in the Middle East and North Africa, and embassy security among other needs abroad.

Used in Sentence: “‘I have received some questions about the willingness to do OCO as a pay-for,” Fisher wrote. “Chairman Wyden is VERY OPEN to considering OCO as a pay-for. If that is the position of your organization, please include that in your support letters … [and] convey this sentiment in your meetings with senators.’ The email sheds light on the status of negotiations over a permanent “doc fix.” Lawmakers are closer than ever to repealing the SGR, but deciding how to offset the reform is proving a major challenge.

Wyden, the Finance Committee’s newly installed chief, is hardly the first lawmaker to suggest war spending as a way to fund an SGR fix. The idea has been proposed by House Democrats and has support from major players in the medical community.             -The Hill

History: Following the terror attacks of 2011, President George W. Bush’s administration requested Congress provide specific funds to pursue the “Global War on Terror.” Beginning in 2009 the administration of President Barack Obama changed from using the “Global War on Terror” terminology to instead employing the nomenclature of “Overseas Contingency Operations” and the funds to support the effort became known as OCO.  Due to the reduced U.S. military presence in Iraq and Afghanistan, the need for OCO funding is declining.  In Fiscal Year (FY) 2013 OCO outlays/expenditures were $93 billion and the President’s request for OCO in FY 2015 has decreased to $85 billion.  Currently, there is a debate in Congress about the possibility of using the OCO funds as “savings” to pay-for other expenses (i.e. SGR)—Democrats contend that reallocating OCO funds would account for actual savings, while Republicans claim that since the monies have not actually been spent it is not real savings, just money the nation no longer needs to spend.

Dewonkify – Risk Corridors

The Patient Protection and Affordable Care Act –commonly referred to as “the ACA”—is a law that reformed nearly twenty-percent of the economy through modifications to regulations and changes to existing law. Its primary goals were to expand health care coverage and control rising costs. Among a number of reforms, the ACA mandated that all citizens have health insurance for a minimum of nine months of the year (or face a penalty); allowed children to remain on their parents plan until the age of 26; created health insurance market places where anyone can shop for health insurance; and banned insurance companies from denying coverage on the basis of pre-existing conditions.

Word: Risk Corridors

Used in a sentence:Risk corridors, a provision of the ACA, limits both the amount of money that a health-insurance plan can make and lose during the first three years it is sold on the new health-care exchanges. Related programs that mitigate risk for insurance companies are also being targeted by conservative Republicans.” –Rep. Tom Cole quoted in The Washington Post.

Definition: Risk corridors are a component of the ACA that limit the risk borne by qualified health plans on the insurance marketplaces. Risk Corridors are a mechanism to minimize the year-end losses of insurers who covered a disproportionate share of sicker, often older, insured customers. The federal government, through the Department of Health and Human Services, agrees to cover 50% of the excess costs borne by insurers if those costs exceeded premiums by 3-8%. In the event those losses amount to greater than 8%, the government will defray 80% of those losses. However, if insurance companies see similar gains then the situation is reversed and the federal government is the beneficiary of those excess funds. This is the risk adjustment portion of the ACA where “healthier” insurance companies help ones shouldering more expensive populations.

History: Ideally, insurance is a system whereby a company manages risk by distributing moneys from a sizeable portion of healthy participants—needing minimal to moderate medical services—to a much smaller portion of sicker participants that need a lot more medical services. This results in a margin or profit where premiums exceed the medical costs of the consumers participating in a given plan. This is a simplified way of explaining what actuaries do every year. They take consumers in a given plan and compare their likelihood to use medical services with the expected revenues from monthly insurance premiums and other out-of-pocket costs like yearly deductibles. However, the advent of the ACA brought on this new frontier of health insurance marketplaces where no one could be denied care due to pre-existing conditions: previous surgery, diabetes, HIV, cancers, benign tumors, hypertension, etc.

Although, risk was managed by mandating that everyone be covered, this did not completely allay the fears of private insurers. Actuaries remained nervous. Anyone from the individual market—usually those not eligible for Medicaid/Medicare or employer sponsored coverage—could enter the exchanges and purchase insurance coverage. This uncertainty could have resulted in excessive premiums to consumers. To mitigate that risk and help with the possibility that consumers would be sicker and older—and thus more likely to use many costly medical procedures—the authors of the law created risk corridors. This would be a temporary program to help insurers on the insurance market places for three years.

 

Dewonkify – Manager’s Amendment

Word: Manager’s Amendment

Meaning: A manager’s amendment is a big amendment containing a number of individual amendments to a piece of legislation offered by the majority or minority Member of Congress managing the debate on the bill. A manager’s amendment is almost always agreed to by both sides in advance.

Used in a sentence: After much political pressure, House Ways and Means Chair David Camp (R-MI) determined that it was best to amend his Medicare physician pay reform legislation to include a .5 percent temporary pay increase in the manager’s amendment that was considered and passed by the committee in December.

What it really means: When legislation actually starts moving in Congress, be in committee or on the House or Senate floor, often many Members of Congress have amendments to offer. Sometimes these amendments are debated and voted on individually because they are substantial, controversial, or there is a political need to do so. Other times, however, there may be a number of amendments that both sides can agree to or that are technical fixes in drafting. In order to keep the process moving and not draw out the debate those amendments will be packaged together and offered as one amendment called a manager’s amendment. Since both sides have agreed to what is in the manager’s amendment, the amendment usually passes by voice vote or unanimous consent. Manager’s amendments are especially, but not exclusively, used for large pieces of legislation. Why is it is called the manager’s amendment? The person offering in the amendment is the majority or minority Member of Congress in charge of the debate on the bill, the “manager” of the bill.

Dewonkify – Markup

The Meaning:  A legislative process for considering and making any recommended adjustments to a piece of legislation prior to moving the legislation forward for a committee vote of passage or defeat.

Used in a Sentence: On December 12, 2013, the Senate Finance Committee will markup legislation that aims to provide a permanent fix to the Medicare Sustainable Growth Rate (SGR) formula, and several amendments are expected to the text of the bill.

What It Means:  A markup may be the most critical part of the congressional legislative process, as it provides a true test of whether a bill can ultimately pass the House or Senate.  It is during the markup process where one can truly learn of a legislator’s position (for or against) a bill and what adjustments would be needed to ensure the support of individual committee members.  It is also where most consensus can be achieved for a piece of legislation, as it typically results in a negotiation between political parties.

During a Congressional markup, members of the Committee may ask questions to Committee staff regarding technical provisions of the pending legislation.  In addition, Members of the Committee also may offer amendments to the underlying legislation.  At the conclusion of the markup the Committee will “report out” legislation (assuming passage) and legislation is then ready to be moved to the floor of the respective Congressional chamber.

History: In many cases, when a bill comes before a committee for markup, negotiations have already occurred behind the scenes between members of Congress and interested external organizations, and the chairman of the Committee will introduce a manager’s package (an amended version of the original bill set to be marked up) or a bill in the nature of a substitute for the Committee to consider and “markup.”  When this is the situation, a markup can be brief and primarily offer an opportunity for opening statements for Committee members to be recognized and to explain their position on the legislation.

Dewonkify – Medicare Part D

Medicare is a federal program that provides health insurance coverage for people who are age 65 or older.  Individuals younger than 65 may qualify if they have certain disabilities or have End-Stage Renal Disease (ESRD).  Medicare is comprised of four parts—Parts A, B, C, and D.  Over the past few weeks, Capitol Health Record has dewonkified each of the four parts.

Definition:  Medicare Part D is a voluntary benefit that provides outpatient prescription drug coverage to beneficiaries.  The Part D benefit is operated through private plans; beneficiaries have the option of choosing either prescription drug coverage as part of their Medicare Advantage plan (more information is available here) or as a stand-alone prescription drug plan (PDP) which can be purchased in addition to traditional Medicare (Part A and Part B).

Used in a Sentence: “The Medicare Part D benefit provides seniors a way to afford their medications when they do not have other affordable drug coverage options.”

History:  The Medicare prescription drug benefit was added to Medicare as part of the Medicare Modernization Act of 2003 (MMA).  Prior to the passage of the MMA, many Medicare beneficiaries lacked access to prescription drug coverage.

When it was enacted, the standard benefit structure was as follows:  the beneficiary paid a deductible.  Once the deductible was met, the beneficiary paid 25 percent of the costs of his/her drugs and the plan paid the other 75 percent of the costs, up to the initial coverage limit (which, in 2010, was $2830 in total drug costs).  At this point, the plan stopped covering the costs of the beneficiary’s drugs (otherwise known as the “doughnut hole” or “coverage gap”) until the beneficiary’s drug costs exceeded the catastrophic coverage limit (which was $6440 in total drug costs in 2010).  At this point, the beneficiary would pay 5 percent, the plan would pay 15 percent, and Medicare would pay 80 percent of the costs for medications.  This unusual benefit design was meant to provide some drug coverage for all beneficiaries.

Many beneficiaries were very frustrated with the gap in coverage (doughnut hole).  The Affordable Care Act (“ACA”) contained provisions to incrementally address the gap in coverage, and by the year 2020, beneficiaries will no longer experience such a gap.  More information about the doughnut hole and the ACA provisions is available here.

More information about the 2014 Medicare Part D program is available here.  An overview of the Medicare Part D payment system is available here.

When the benefit first launched in 2005, the then-Bush Administration encountered some initial issues related to the launch of the website and enrollment.  While much different in scope, some politicians have compared problems with the launch of the Part D program to the problems currently being experienced with the ACA rollout (more information is available here).

Premiums:  Medicare Part D premiums vary depending on the beneficiary’s plan choice and geography.  Some plans, called “enhanced plans” provide greater coverage for prescription drugs, but usually have a higher premium.  In 2014, the standard average Medicare Part D monthly premium is estimated to be $31.

Like Medicare Part B, individuals who lack prescription drug coverage either through a former employer, Medicaid, or some other source, will face a late enrollment penalty if they delay signing up for Part D.  (More information on the Part D late enrollment penalty is available here.)

Dewonkify — Medicare Part C

Medicare is a federal program that provides health insurance coverage for people who are age 65 or older.  Individuals younger than 65 may qualify if they have certain disabilities or have End-Stage Renal Disease (ESRD).  Medicare is comprised of four parts — Parts A, B, C, and D.  Over the next few weeks, Capitol Health Record will dewonkify each of the four parts.

Definition:  Medicare Part C is otherwise known as “Medicare Advantage” (formerly “Medicare+Choice”).  These are private plans that are approved by Medicare to cover all of the services provided by Part A and Part B.  Some Medicare Advantage plans offer coverage for items not otherwise covered by Medicare (like hearing aids and eyeglasses).

Used in a Sentence:  “The premiums of Americans enrolled in Medicare Part C (Medicare Advantage) have fallen by 16 percent since 2010, Health and Human Services Secretary Kathleen Sebelius has said.” From “Where is Republican anger over Obama’s health care law?” by Juan Williams, Washington Post, September 27, 2012

History:  Medicare Advantage began as an alternative to traditional Medicare.  Some policymakers believed that private insurance companies would be able to provide beneficiaries with better, more coordinated care at a lower cost to beneficiaries and the federal government.  Medicare Advantage plans operated by private insurance companies and are available in almost every county in the country.  Medicare Advantage plans can be either health maintenance organization (HMO) plans, private fee-for-service (PFFS) plans, or regional or local preferred provider organizations (PPOs).  (More information is available here.)

Premiums:  Medicare beneficiaries pay a premium to enroll in Medicare Advantage plans; premiums vary depending on the plan offerings in the area.  Most Medicare Advantage plans also offer prescription drug coverage (called MA-PD plans).  In 2012, the average premium charged for a Medicare Advantage plan offering drug coverage was $51.43 per month.  Approximately 87 percent of Medicare beneficiaries can choose an MA-PAD plan with a $0 premium (though beneficiaries would still have to pay their Medicare Part B premium).  More information is available here.

Enrollment:  In 2012, approximately 27 percent of Medicare beneficiaries chose to enroll in a Medicare Advantage plan.

Dewonkify – Medicare Part B

Medicare is a federal program that provides health insurance coverage for people who are age 65 or older.  Individuals younger than 65 may qualify if they have certain disabilities or have End-Stage Renal Disease (ESRD).  Medicare is comprised of four parts — Parts A, B, C, and D.  Over the next few weeks, Capitol Health Record will dewonkify each of the four parts.

Definition:  Medicare Part B primarily pays for care provided by doctors and other health care professionals (like nurse practitioners), outpatient services, durable medical equipment (DME), home health, and some preventive services.

Used in a Sentence:  “The premiums for Medicare Part B will remain flat in 2014 and seniors have saved $8.3 billion on Part D prescriptions since the Affordable Care Act was enacted in 2010, the Department of Health and Human Services announced Monday. Medicare Part B covers medically necessary services, as well as preventive services.” From “Medicare Part B Premiums Won’t Go Up in 2014,” by Kelly Kennedy, USA Today, October 28, 2013

History:  Medicare Part B began in 1965 under the same legislation that enacted Medicare Part A and the Medicaid program.

Enrollment:  In 2012, 46.4 million Americans were enrolled in Medicare Part B.

Financing:  Medicare Part B is financed through general revenues and premiums collected from beneficiaries.  Because of the way it is financed, technically Medicare Part B can never be insolvent.  However, because the federal government pays 75 percent of the cost of Part B, many policymakers have begun to grow concerned about the increased cost of the program and have proposed ways to reduce these federal expenditures.

Sustainable Growth Rate (SGR):  Medicare Part B pays for services provided by physicians and other health care professionals using the SGR formula.  Unless Congress acts by the end of this year, physicians who treat Medicare beneficiaries will see their reimbursement cut by approximately 24 percent (the exact amount will be determined when the Centers for Medicare and Medicaid Services (CMS) releases its final rule implementing the Physician Fee Schedule).

Over the past decade, Congress has enacted more than 15 short-term fixes to address the SGR (see infographic).  In July the House Energy and Commerce Committee passed legislation to permanently address the SGR.  Last week, the House Ways and Means Committee and Senate Finance Committee jointly released a draft discussion guide which closely follows the Energy and Commerce proposal.

Premiums:  Medicare beneficiaries pay monthly premiums, which are adjusted each year and account for roughly 25 percent of Part B costs.  Currently most beneficiaries pay a monthly premium of $104.90 per month.  Individuals with higher incomes pay a higher monthly premium.  (More information on Medicare Part B premiums is available here.)  Individuals who lack other coverage (generally through a current or former employer) who delay signing up for Part B may be assessed a permanent late enrollment penalty.  (More information on the late enrollment penalty is available here.)

Out-of-Pocket Costs:  In addition to the monthly premium, beneficiaries have an annual deductible of $147 for 2013.  Beneficiaries also are assessed a copayment of 20 percent of the Medicare-approved cost of the service.  (More information is available here.) 

Dewonkify – Medicare Part A

Medicare is a federal program that provides health insurance coverage for people who are age 65 or older.  Individuals younger than 65 may qualify if they have certain disabilities or have End-Stage Renal Disease (ESRD).  Medicare is comprised of four parts — Parts A, B, C, and D.  Over the next few weeks, Capitol Health Record will dewonkify each of the four parts.

Definition:  Medicare Part A pays primarily for inpatient hospital stays, care in skilled nursing facilities, home health care, and hospice care.

Used in a Sentence: “Republicans have suggested a push to reduce the deficit with entitlement cuts, such as means testing for Medicare and a possible merger of Medicare parts A and B for hospitals and doctor services.” From “GOP Senators Ready Entitlement, Tax Proposals for Budget Conference” by Alan K. Ota, published in CQ (subscription required).We also have a program called the Seal of Recognition that may be worth your time and consideration.  You could submit your materials supporting the Trigen SureShot and our nursing team would evaluate the content to make sure it is consistent with the AORN Recommended Practices.  If approved, you would receive the AORN Seal of Recognition logo to use on your documents for one year (can be renewed annually).

History:  Medicare Part A began in 1965 and was enacted at the same time as Part B and Medicaid.  At the time, older Americans who did not have health care coverage through their employers, had to either purchase health insurance on their own (which could be expensive) or rely on their families to help pay for their medical care.  More information on the history of the Medicare program can be found here.

Financing:  Medicare Part A is financed through a payroll tax paid by employers and employees.  Part A currently pays out more in claims than it collects in revenue and is projected to become insolvent by the year 2026.  In 2012, total expenditures (costs) for the Medicare program were $574.2 billion and total income was $536.9 billion.  Each year the independent Medicare Trustees releases a report projecting the solvency of the program.  Information on the most recent Trustees’ report is available here.

Enrollment:  Currently 50.7 million Americans are enrolled in Medicare Part A.

Eligibility:  In order to be eligible for Medicare Part A, you (or your spouse) must have worked at least 10 years (40 quarters) in Medicare-covered employment.  Some individuals under age 65 may be eligible for Medicare Part A if they are entitled to Social Security (or railroad retirement) disability benefits for at least the previous 25 months or qualify for ESRD benefits.  More information on eligibility requirements can be found here.

Out-of-Pocket Costs:  Beneficiaries enrolled in Part A pay a deductible when they are admitted to the hospital.  The amount of the deductible varies from year to year and is calculated to be $1,216 in 2014.  This deductible covers beneficiaries’ costs for the first 60 days of care within a benefit period.  Beneficiaries pay additional fees for hospitalizations longer than 60 days (for more information, see here).

Premiums:  About 99 percent of individuals who have Part A do not pay a premium.  However, some individuals may be able to enroll in Part A and pay a monthly premium:  individuals (and spouses) with fewer than 30 quarters (7.5 years) of Medicare-covered employment pay a premium of $426 and individuals (and spouses) with between 30 and 39 quarters of Medicare-covered employment pay $234.  (More information is available here.)

Dewonkify – Boehner Rule

The Word: Boehner Rule

Definition: The “Boehner Rule” is not a formal rule of the House of Representatives, but rather a procedural technique used by the Speaker of the House to bring legislation to the floor for a vote.

History: The “Hastert Rule,” named for former Speaker of the House Dennis Hastert, is a procedural technique that Republicans have used to bring legislation to floor only if it has the support of the majority of House Republicans. The current Speaker of the House, John Boehner, has at times abandoned the Hastert Rule in order to pass legislation that a majority of his Republican caucus would not support.  On at least three occasions (2012 fiscal cliff vote, Hurricane Sandy Relief bill, and the Violence Against Women Act), Speaker Boehner has used a new procedural technique that has been dubbed the “Boehner Rule” which basically allows the Senate to pass their bill first. Once the bill is passed by the Senate, Speaker Boehner calls the bill up for a vote in the House. Usually this technique can muster up the needed votes by both House Democrats and Republicans to pass the measure.

Used in a Sentence: “Mainly, what they seem to want is solved by the `Boehner Rule’ that involves having the Senate act first on most things.” From “Hastert Rule/Boehner Rule,”  by Jonathan Bernstein, Washington Post, April 11, 2013.

Why It’s Relevant: With the continued fraction within the House Republican Caucus Speaker Boehner may have to use the “Boehner Rule” to pass a clean continuing resolution (CR) to end the government shutdown and/or to raise the debt ceiling set to expire on October 17th.

**The Boehner Rule may also refer to Speaker Boehner’s insistence of “at least one dollar in spending cuts for every dollar of debt increase”:  “As Boehner put it, from now on `any increase debt limit has to be accompanied by spending reductions that meet or exceed it.’ It became known as the Boehner Rule.” From “Why did the GOP surrender the spending fight?” by Marc A. Thiessen, Washington Post, October 7, 2013.

Dewonkify – Hastert Rule

Term: Hastert Rule

Definition: An informal governing principle used by Republican Speakers of the House of Representatives since the 1990s to only allow bills to come up for a vote on the House floor that have support from the “the majority of the majority” of Members of Congress. In practice, if Speaker Boehner follows the Hastert Rule it would mean that he would not bring legislation for a vote unless it would have the support of the majority of the current House majority party, the Republicans.

Used In a Sentence:  “That’s what the Hastert rule is really about, Feehery, now a lobbyist and consultant, told me recently — political survival. It’s just common sense: The speaker is elected by a majority vote of his caucus; if he does things a majority of his caucus doesn’t like, they can vote him out.” From “Even the Aide Who Coined the Hastert Rule Says the Hastert Rule Isn’t Working,” by Molly Ball, The Atlantic, July 21, 2013

History: According to John Feehery, the staffer who coined the phrase, former Speaker Dennis Hastert is often credited with inventing the rule but Newt Gingrich, who preceded him as Speaker, followed it as well.

Why It’s Relevant: Following the Hastert Rule makes it is very difficult to have legislative successes if the majority caucus is divided. Speaker Boehner has invoked the Hastert Rule during the recent fiscal debates leading up to the current government shutdown.  Some suggest that the House of Representatives could pass clean (no added legislative language or provisions) legislation to reopen the government or raise the debt ceiling because most of the Democrats and 20 or so of the Republicans would vote for it, giving it enough votes to pass.  However, bringing that legislation up would violate the Hastert Rule since at this point it would not have the support of the majority of the Republicans (the majority party).