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CHAPTER 7

CHAPTER 7. Regulation and Accreditation in Managed Care. Learning Objectives. Understand the basic issues involved with state regulation of managed care Understand the limited continuation of coverage benefit under COBRA

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CHAPTER 7

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  1. CHAPTER 7 Regulation and Accreditation in Managed Care

  2. Learning Objectives • Understand the basic issues involved with state regulation of managed care • Understand the limited continuation of coverage benefit under COBRA • Understand the key components of the Health Insurance Portability and Accountability Act • Understand the key components of the Employee Retirement Income Security Act • Understand the key components of external accreditation of managed care organizations

  3. State Regulation • Licensure • Any Willing Provider • Regulation of Insured Business • Benefits Plans and Premium Rates • Mandated Benefits • Provider-MCO Relationships • Provider Access

  4. State Regulation (cont’d) • Regulation of Insured Business (cont’d) • External Appeals • Privacy • Solvency Standards and Insolvency Protections • Health Plan Liability • Multistate Operations

  5. The Health Insurance PortabilityAnd Accountability Act (HIPAA) • To be eligible for individual coverage under HIPAA, a person must: • have 18 or more months of aggregate creditable coverage (the most recent coverage must have come from a group health plan, government plan, or church plan or have been health insurance coverage linked to any such plan); • be ineligible for group health coverage, Medicare, or Medicaid; • lack other health insurance coverage; • have not been terminated from his or her most recent prior coverage for nonpayment of premiums or fraud; • and have elected and exhausted COBRA coverage or similar state-mandated continuation coverage if he or she was eligible for it.

  6. HIPAA (cont’d) • Specific Clinical Conditions Addressed in HIPAA • Administrative Simplification • Transactions and Code Sets • Electronic Transaction Standards • Code Set Standards • National Identifiers

  7. HIPAA (cont’d) • Administrative Simplification (cont’d) • Privacy • Consumer control over health information • Limits on medical record use and release • Administrative requirements • Security Standards Applicable to Electronic Protected Health Information

  8. The Employee Retirement IncomeSecurity Act • General Provisions • Grievances and Appeals • Timeliness of response • Who will review the grievance or appeal • Limitations on how long a member has to file a grievance or appeal • What recourse a member has

  9. Accreditation of Managed Care Organizations • Accreditation Organizations • NCQA • URAC • AAAHC • Accreditation by Type of MCO

  10. HEDIS • HEDIS Measures • Effectiveness of Care • Access/Availability of Care • Satisfaction with the Experience • Health Plan Stability • Use of Services • Health Plan Descriptive Information • Consumer Assessment of Healthcare Providers and Systems

  11. Conclusion • All MCOs are subject to federal and state laws and regulations. • In addition, private nonprofit accreditation agencies are increasingly reviewing the operations of MCOs to assure consumers, employers, and government agencies that they are meeting quality and performance criteria. • Finally, information collected through these various channels is increasingly being made available to consumers.

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