Managed Care State Laws and Regulations - 1225 Words

420 Week 7 DQ 1. What are the most critical components of state regulation for managed care organizations? Which federal regulations also bring specific requirements for the operation of such entities? Discuss state and federal regulation of MCOs. State oversight of managed care generally focuses on two aspects: the techniques and processes used by a payer, and in particular an HMO, to deliver or arrange for the delivery of health care services to enrollees, and the organizational structure of the payer. (Kongstvedt 596) Much of the state regulation of managed care is based on the Health Maintenance Organization Model Act released by the National Association of Insurance Commissioners (NAIC) in 1972. The NAIC is the national†¦show more content†¦The Act has a significant impact on how MCOs operate in the individual and group insurance markets and with respect to the administration of self-funded group health plans. 1998 – The Women’s Health and Cancer Rights Act (WHCRA) – law enacted to make sure that women who had breast cancer for their health insurers and group health plans to provide coverage for reconstructive breast surgery after a mastectomy (Kongstvedt 608) 2008 - The Genetic Information Nondiscrimination Act (GINA) - prohibits insurances to discriminate against genetic makeup The Mental Health Parity and Addiction Equity Act (MHPAEA) -The law amended the 1996 Mental Health Parity Act by extending the parity requirements to include substance use disorder benefits. In addition, the MHPAEA requires parity with respect to all financial requirements (cost-sharing such as deductibles, copayments, and co-insurance) and treatment limitations (day or visit limits) between medical and surgical benefits and benefits for mental health and substance use disorder services (Kongstvedt 608-609) Michelle’s Law – requires health insurers and group health plans to provide medical coverage 12 months after a child leaves school for a medically necessary leave of absence. 2009 –Show MoreRelatedStaffing Models : Meeting The Needs Of Patients And Families1632 Words   |  7 Pagescontinue to provide adequate patient care (Porter-O’Grady Malloch, 2013). Patients are the most important priority in healthcare. They enter healthcare facilities with a problem that needs to be treated, and they expect the best care available. Having proper nurse-to-patient staffing ratios is one way in which patient needs are met. Staffing models have yet to catch up with the change, only one state has mandated patient ratios. It was thought other states would follow in their footsteps butRead MoreHealthcare Services : A Healthcare Specialist1262 Words   |  6 PagesManaged care is a healthcare specialist brought together to deliver services to improve quality and costs. The main functions are assembling, bringing together providers to deliver services, evaluating suppliers, and services. The normal way providers are paid for services, managed care users per diem, per case and per capita. Managed care combines health insurance, care and administration. The Health care system is hospitals, physicians and other providers that provide other, health care servicesRead MoreKey Elements Of The Policymaking Process816 Words   |  4 Pages It likewise determines policies on matters of taxes, debts, provisions for the general welfare, regulation of commerce, and more, in numerous areas of American society, including healthcare (of course). Regarding healthcare policy making, in specific, Congress may form a number of committees to focus on particular healthcare-related issues, such as the Finance Committe’s Subcommittee on Health Care, or the Subcommittee on Labor, Health, and Human Services, or more. ================3.The key elementsRead MoreUnderstanding the Future of Managed Care1671 Words   |  7 PagesUnderstanding the Future of Managed Care Saida Ali Holyfield Abstract At one point, managed care was the viewed as a resourceful tool in efforts to help assist employee, physicians and hospitals with quality health care, while controlling the cost of medical care in the United States. Over the past 30 years, managed care has been in the limelight of health insurance, as a dictator of how it will pay for medical bills. There have been many factors playing a role with managed care over the years. ForRead MoreManage Care and How It Has Affected and Changed Health Care Essay1161 Words   |  5 PagesManage Care and How It Has Affected and Changed Health Care Manage Care and how it has affected and changed Health Care â€Å"Managed care embodies an effort by employers, the insurance industry, and some elements of the medical profession to establish priorities and decide who gets what from the health care system.† (JAMA.2001; pg. 285:2622-2628). Manage Care is part of the Health Care system since 1973 is known as the system that finances and delivers health care to individuals enrolled underRead MoreProblems with HMOs Essay1147 Words   |  5 Pagesmaintenance organizations) and managed care plans continue to proliferate, that means a choice between bad and worse. As employees line up in the lunch-room for a process called open enrollment, they may be surprised to learn that managed care rates have gone up — again. The mirage that managed care is cheaper care is finally fading. And, for the first time in years, employees may also have the promise of free choice in medicine in the form of a new method of financing health care. Consumers are alreadyRead MoreHca Case Analysis : Hca830 Words   |  4 PagesHospital Corporation of America (HCA), it is of paramount importance that they provide a diverse range of healthcare services through the most cost-effective means available. Although, one of the largest health care services companies in the United States, HCA must take on the challenges of health care finance and reform through a strong and stable business strategy. In an attempt to combat the many challenges being faced, HCA has committed their resources by promising to establish a strong presence inRead MoreBeing An American Guarantees The Right And Responsibility1370 Words   |  6 Pagessponsored healthcare plans begin to expand. Thus, in the year 1977, U.S government over turned the power to the Health Care Financing Administration (HCFA), but is now referred to as Centers for Medicare and Medicaid Services (CMS). The CMS was developed in prospect to the growing number of people, as well as children who were uninsured. This began the rise of laws and re gulations towards the billing aspects of insurance and the information contained in the healthcare field. One requirement of theRead MoreManaged Care Programs Defined By Merriam Webster.com Essay1540 Words   |  7 PagesManaged Care Programs Defined Managed care as defined by Merriam-Webster.com is â€Å"a system of providing health  care  (as by an HMO  or a PPO) that is designed to control costs through  managed  programs in which the physician accepts constraints on the amount charged for  medical care and the patient is limited in the choice of a physician.† While the definition is appropriate for health plans, physicians and government entities focused on cost control and utilization reduction; it does not includeRead MoreThe And Its Effect On The People Of Colberia979 Words   |  4 Pagescompliant with the Utilitarianism principles, as they do not care about the indigenous people working for them. b) Deontology principle says that â€Å" A person should not lie, even when lying seems to produce a good result† (Halbert/Ingulli 2012). Based on this theory PharmaCare is not ethical. They lie about their initiative by using the slogan we care about your health while supporting the PAC to block any environmental protection laws and regulations. They preach one thing and doing something that is contrary