Managed Care Compliance

Health Maintenance Organization Act of 1973

·       Also known as the HMO Act of 1973, 42 U.S.C. § 300e

·       Provides grants and loans for HMO

·      Removes certain state restrictions for federally qualified

HMOs

·         Requires employers with 25 or more employees to offer federally certified HMO options if they offered traditional health insurance to employees

Health Insurance Portability and Accountability Act (HIPAA)

·         Title I protects health insurance coverage for workers and their families when they change or lose their jobs.

·         Title II requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.

HIPAA Privacy Rule

·         Regulates the use and disclosure of certain information held by "covered entities" (generally, health care clearinghouses, employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions.)

HIPAA Security Rule

·         Protects the confidentiality, integrity and availability of electronic protected health information

Employee Retirement Income Security Act of 1974

(ERISA)

·         Preempts all state laws that “relate to” employee benefits plans, allowing states to continue to regulate insurance products but not employee benefits, including health insurance, provided by firms that self-insure

Health Maintenance Organizations (HMO)

·         Provide healthcare coverage through hospitals, doctors, and other providers with which the HMO has a contract

·         Provide quality healthcare services at a lower cost.

·         Benefit is the reduction of healthcare costs for the plan members

Preferred Provider Organizations (PPO)

·         Organization of medical doctors, hospitals, and other healthcare providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

·         Combines features of traditional Indemnity Health Insurance plan (Fee-for-Service) with Managed Care

Point-of-Service (POS) plans

·         Based on the basic managed care foundation

·         Lower medical costs in exchange for more limited choice

·         Combines characteristics of both the HMO and the PPO

·         More flexibility than in the HMO plans and less than in a PPO

Independent Practice Association (IPA)

Type of HMO that contracts with a group of physicians to provide service to the HMO's members

Contract is not usually exclusive, allowing individual doctors or the group to sign contracts with multiple HMOs.

Participating physicians usually also serve fee-for-service patients not associated with managed care.