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 association representing state insurance regulatory agencies.
States have also enacted other NAIC model laws and regulations affecting managed care and payers including requirements for the individual and small group insurance markets, utilization review provisions, standards for health care provider networks, and consumer protections such as procedures for resolving claims appeals and grievances. (Kongstvedt 597) 1973-HMO Act -established conditions for the operation of federally qualified HMOs and provided loans and loan guarantees for HMO startup costs.
Federally qualified HMOs were required to provide “basic” and “supplemental” health services to their enrollees, including inpatient, outpatient, home health, laboratory, preventive, and emergency care. 8 The Act required federally qualified HMOs to meet solvency standards, provide procedures for handling member grievances, and establish programs for quality assurance. 9 In addition, the HMO Act required employers that offered health benefits to their employees through a federally qualified HMO to not financially discriminate against employees that choose the HMO option.
The Term Paper on Health Care 6
Under indemnity insurance, the insurers guarantee payment to any licensed health care provider for all covered services. In recent years, fee-for-service indemnity plans also have grown more similar to man- aged care plans. Traditionally, fee-for-service indemnity plans gave individuals an unrestricted choice of licensed health care professionals. Care providers were free to determine which ...
The employer’s contribution toward the cost of coverage had to be reasonable and designed to ensure the employee had a fair choice among benefit plan options).
(Kongstvedt 607) 1974 – The Employee Retirement Income Security Act – provides comprehensive standards for group health plans offered to workers and their family me.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) – included provisions on a variety of subjects including Title X, which established rules for the continuation of health coverage to employees and qualified family members because of certain qualifying life events such as termination of employment or where an individual loses coverage because of the death of, or divorce from, a covered spouse. Another aspect of it enacted the EMTALA, which requires hospitals to provide services to patients with emergency medical conditions. 14 EMTALA affects decisions by MCOs to pay medical services at hospital facilities.
The Americans with Disabilities Act (ADA) – prohibits discrimination against individuals on the basis of a disability in employment and public services and accommodations (Kongstvedt 608) 1993 – The Family and Medical Leave Act (FMLA) – requires certain employers with 50 or more employees to allow workers to take unpaid leave of up to 12 weeks a year for recovery from a serious health condition, for the birth or adoption of a child, or for care of a sick family member.
Upon returning to work, the individual must be restored to their old job or an equivalent position, including all benefits such as health coverage. The Act affects how MCOs provide coverage to individuals both during their leave and after return to work. (Kongstvedt 608) 1994 – The Uniform Services Employment and Reemployment Rights Act (USERRA) – protects the employment and benefit rights of service personnel. The law requires, among other protections, that individuals have the right to return to their jobs and to reenroll in the employer’s health coverage without penalty.
The Essay on The Community Mental Health Act of 1963
The Community Mental Health Act of 1963 Introduction Community mental health center act of 1963 was a significant milestone in America’s record of mental health rights. On 31st October 1963, the act was signed into a regulation by President John F. Kennedy. The law was the pioneer among other many federal policy alterations that helped ignite a significant transformation of the ...
The Health Insurance Portability and Accountability Act – establishes requirements for the guarantee availability and renewability of health coverage, prohibits the use of health status factors in setting premium rates, sets out safeguards for health information privacy and the security of electronic data, and provides standards for the exchange of electronic health information. 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 – The Health Information Technology for Economic and Clinical Health Act (HITECH) – amended the privacy protections and data security standards contained in HIPAA. It established new requirements for notifying individuals if their health information has been wrongfully disclosed due to a data breach and increases the penalties for violations of the HIPAA privacy rule.
In addition, it provided funding to states and public entities for health information technology (IT) initiatives, created a new federal office to coordinate health IT programs, and established a process to develop standards for electronic health records (EHRs) and interoperability standards to facilitate data-sharing between health information systems. (Kongstvedt 609) 2010 – The Patient Protection and Affordable Care Act (ACA)- the ACA is the most comprehensive federal law affecting MCOs and other entities providing health coverage since the passage of HIPAA in 1996.
The Essay on Mental Health Parity Act of 1996
The law allowed an increased cost exemption, which stated that employers that can demonstrate a one percent or more rise in costs due to parity implementation will be allowed to exempt themselves from the law. The Mental Health Parity Act did not include rules for service charges, designations for the number of inpatient hospital days or outpatient visits that must be covered, coverage in ...
Immediate insurance market reforms (including requirements to cover preventive and emergency services, the extension of health coverage for dependents up to age 26, and restrictions on annual and lifetime benefit limits) and imposes additional requirements with respect to health insurers and group health plans beginning in 2014, including guaranteed issue of coverage and restrictions on the use of age and other rating factors. The ACA also establishes new mechanisms to expand access to health coverage, including the creation of state health insurance exchanges and mandates for employers to offer and individuals to maintain health coverage.
