8 questions
almutlaq
chapter19.ppt
Chapter 19
National Health Insurance
& Managed Care
LEARNING OBJECTIVES
- Discuss the purpose and various titles of the Patient Protection and Affordable Care Act of 2010 (PPACA).
- Discuss the Supreme Court’s ruling on the constitutionality of the PPACA.
- Describe the common models of managed care organizations.
- Explain what can happen if a state fails to comply with the PPACA.
PPACA Purpose
- Increase # of Americans covered by health insurance
- Decrease cost of insurance
- Make more affordable through shared responsibility
- Eliminate discriminatory acts
- Exclusion due to pre-existing conditions, health status, & gender.
PPACA Reforms Health Care – I
- Eliminate lifetime & unreasonable annual limits on benefits
- Prohibit recessions of health insurance policies
- Assistance for uninsured due to pre-existing conditions
- Require coverage: preventative services & immunizations
- Extend dependent coverage up to age 26
PPACA Reforms Health Care - II
- Develop uniform coverage documents so consumers can make equal insurance comparisons
- Cap insurance company
- nonmedical & administrative expenditures
- Ensure consumers have access to an effective appeals process
- provide a place to turn for help
- navigating the appeals process & assessing coverage
Supreme Court 6/28/12
- Agreed that the requirement for nearly all Americans to buy health insurance.
- Court excised part of law requiring states to expand their Medicaid coverage in a joint federal–state effort, to families with incomes up to 133% of the Federal Poverty Level (FPL).
PPACA Titles
Title I. Quality Affordable Health Care for All Americans
Title II. The Role of Public Programs
Title III. Improving the Quality and Efficiency of Health Care
Title IV. Prevention of Chronic Disease and Improving Public Health
Title V. Health Care Workforce
PPACA Titles – II
Title VI. Transparency and Program Integrity
Title VII. Improving Access to Innovative Medical Therapies
Title VIII. CLASS Act
Title IX. Revenue Provisions
Title IX. Strengthening Quality, Affordable Health Care for All Americans
Models of Managed Care Organizations (MCO’s)
- Health Maintenance Organizations
- Preferred Provider Organizations
- Exclusive Provider Organizations
- Point of Service Plans
- Experience-Rated HMOs
- Specialty HMO’s
- Independent Practice Associations
- Physician Group Practice
Models of MCOs – II
- Group Practice without Walls
- Physician-Hospital Organizations
- Medical Foundations
- Managed Service Organizations
- Vertically Integrated Delivery System
- Horizontal Consolidations
- Federally Qualified
Federally Qualified MCOs
- Strictly Voluntary
- Must Meet Federal Standards
- Less flexibility in
- benefits packages
- setting premium rates
- Must Provide Basic Package of Health Services
State HMO Laws – I
- Specify what types on entities may operate an MCO.
- Require the provision of basic care services
- ED
- Inpatient care
- Physician care
- Outpatient care
State Laws – II
- Generally require
- continued coverage if enrollee’s health status changes
- ability of enrollee to convert to a direct payment plan
- grievance procedure for enrollees
Case Management Firms
- Assist employers & insurers in managing in managing catastrophic cases.
- Negotiate services & reimbursement with provider’s who treat patient’s condition.
- Develop a treatment protocol & monitor treatment.
Third Party Administrators (TPAs)
- Provides services for employers & associations that have group insurance policies.
- Acts as a liaison between employer & insurer.
- Provides administrative activities
- Claims processing
- Certifying eligibility
- Preparation of reports
Utilization Review
- 3rd party evaluates medical necessity of care
- Process of Reviews of patient care conducted either by
- Prospective Review
- Concurrent Review
- Retrospective Review
- Utilization Management Firms
- perform utilization management activities for managed care entities, insurers, or employers
Liability for Nonemployee Participating Physicians
- Patient must reasonably view the entity & not the physician as the source of care.
- Patient reasonably believes the physician to be an employee of the entity.
Employee Retirement
Income Security Act
- Designed to ensure employee welfare & benefit plans conform to a uniform body of benefits law.
- Requires plans to provide participants with plan information.
- Requires fiduciary responsibilities for those who manage & control plan assets.
- Establish appeals & grievance process.
- Provide participants with rights to to sue for benefits & breaches of fiduciary responsibility.
Health Care Quality
Improvement Act of 1986
- The purpose of the HCQIA is to provide those persons providing information to professional review bodies & those assisting in review activities limited immunity from damages that may result as a result of adverse decisions that affect a physician’s medical staff privileges.
- Immunity does not extend to
- civil rights litigation suits.
- suits filed by U.S. Attorney General.
Managed Care & Legal Actions – I
- Open enrollment
- Emergency Care
- Market Power
- Product Market
- Geographic Market
- Ethics and the Denial of Services
Review Questions
1. Describe some of the more common models of MCOs.
2. What are the advantages and disadvantages of HMOs?
3. What is the purpose of utilization review?
4. Discuss the various reforms included in the Patient Protection and Affordable Care Act.
