Managed Care Essay

The types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

Managed care plan is another significant health care plan that gives options that may either make it easy or limit medical care services by the patients. This is the type that most people embrace. It covers a wide spectrum of health services in a cheaper and most convenient way. Costs are relatively lower when patients utilize the doctors and other stake holders. Mostly this cover does not require one to fill out any insurance forms or give out any claims to the company that has given you the cover when one uses the in-network providers. One pays a co pay each time he visits the doctor or any hospital. This co pay varies depending on who you visit and whether you receive brand name or generic prescription drug. Various managed care plans adopt a mail-order pharmacy alternative. In this alternative, one sends for the doctor’s prescription for

To decide on whether or not an issue is considered ethical or moral we need the hard cold facts. Facts expose or explain what is to be decided upon—not what the outcome should be. Decisions regarding health care and mental health issues represent a major portion of ethical and moral choices. As individuals we are not always able to understand the justice, or fairness, behind the decisions supposedly based on hard cold facts.

The protection and privacy of HIPAA (Health Insurance Portability and Accountability Act) which became law in ,1996. Subtitle F of Title II of HIPAA, entitled "Administrative Simplification, "requires the Secretary of Health and Human Services to adopt national standards for certain information- related activities of the health care industry. This law works to make the efficiency and effectiveness of the health care system by mandating the development of standards and requirements to enable

Health Insurance Portability and Accountability Act or HIPAA is a statute endorsed by the U.S. Congress in 1996. It offers protections for many American workers which improves portability and continuity of health insurance coverage. The seven titles of the final law are Title I - Health care Access , Portability, Title II - Preventing Health Care Fraud and Abuse; administrative simplification; Medical Liability Reform; Title III – Tax-related Health Provisions; Title IV – Application and

The Health Insurance Portability and Accountability Act, HIPAA was passed by Congress in 1996 to provide the ability to transfer and continue health insurance coverage for workers as well as their families after changing or losing their jobs. As a result, new patients are required to fill HIPAA compliant forms while existing patients should update their information on a regular basis. Documenting and maintaining the HIPAA forms properly ensures that healthcare providers focus more on other aspects of their practice.

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

For example an x-ray machine could be leased and the organization would a fee depending on how many x-rays they take per month or year.

Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially accountable for the long-term care of the members that she/he has been assigned and any specialists that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser Permanente and Humana. HMOs have been licensed at the state level, under a license that is known as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their insurance being authorized; A member may benefit from this because there would be little to no treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow provider networks; A member may not benefit if in an emergency because their “in-network” emergency room might be far or there are “quick-care” in their area.

HIPAA, (Health Insurance and Portability Act of 1996) outlines rules and regulations and the rights of patients to access their healthcare information such as notifications of privacy practices, copying and viewing medical records, and amendments. This paper explains why confidentiality is important today and discusses recourses patients can use if they believe their privacy has been violated. This paper will also discuss criminal and civil penalties’ that can occur for breaking HIPAA privacy rules.

HIPAA law is for the protection of patient’s private health information. All covered entities must abide by HIPAA regulations in regards to all protect health information. HIPAA out line privacy and security rules in regards to the use and disclosure of all health information. This helps prevent abuse of protected information and allows patients to understand a covered entities responsibility to protect the information that is within the medical record. HIPAA was enacted in 1996 and has been followed by all covered entities since.

An HMO provides comprehensive health-care services to the insured for a fixed periodic payment. There may also be a nominal fee paid for each visit to a health-care provider. Unlike traditional insurance, HMOs actually provide the health care rather than just making payments to health-care providers. HMOs can have a variety of relationships with hospitals and physicians. Plan physicians may be salaried employees, members of an independent multi-specialty group, of a network of independent multi-specialty groups, or part of an individual practice association.

Today, there are several types of managed care plans including Preferred Provider Organizations (PPOs), HMOs, and Point-of-Service (POS) plans. There are many types of HMOs that offer members a variety of health benefits. An HMO plan requires the member to use health care providers and facilities within the HMO network in order receive coverage, unless it is an emergency (Andrews, 2014, p. 1). A PPO is a form of managed care that most resembles a fee-for-service type situation. The plan members can generally refer themselves to doctors, including doctors outside the plan, although they typically will pay a higher percentage of the cost if the doctor is out of the network (Andrews, 2014, p. 1). A POS plan allows members to refer themselves outside the HMO network and still get some coverage (Andrews, 2014, p. 1). While these

Managed care has been adopted into the government funded care organizations. Medicare managed care plans provide all coverage themselves, including basic Medicare coverage. Managed care plans cover above and beyond the basic benefits of Medicare, the size of premiums and copayments, and the decisions about paying for treatment are controlled by the managed care plan. The basic premise of managed care is that the member/patient agrees to receive care from only a specific doctors and hospitals, in exchange for reduced healthcare costs. Medicare, like other insurance companies offer plans that give Medicare beneficiaries more choices in coverage, like HMO or PPO. Managed care has been used since the mid 1990’s in order to provide healthcare to beneficiaries with serious or life long illnesses. Today, managed care has become a way for states to provide quality care to both Medicaid and Medicare patients.

A health plan is a contractual arrangement between the MCO and the members; it includes a list of covered health services to which members are entitled