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Managed Health Care

Significant managed care federal legislation

What is ERISA and when was it enacted? The Employee Retirement Income Security Act of 1974 (ERISA): 1. Mandated rptg and discl req for grp life/hlth plns (incl mngd care plns). 2. Prmitted lrg empl to self-insr emplyee hc bnfts. 3. exmptd lrg emply frm taxes on HI prms.
What does OBRA stand for, when was it enacted and for what purpose? The Omnibus Budget Reconciliation Act of 1981: 1. Provided states w/flx to est HMOs for Medicare/Medicaid prgrms. 2. Increased managed care enrollement resulted. (Meaning of Omnibus: providing for many things at once; "an omnibus law")
What is TEFRA? When was it enacted and for what purpose? The Tax Exquity and Fiscal Resp Act of 1982: 1. Mod HMO Act of 1973. 2. Allowed HMOs to contract Medicare. 3. Defined risk contract & competitive med pln (using capitated (fixed,prepaid basis)
What is the “Preferred Provider Health Care Act of 1985”? •Eased restrictions on preferred provider organizations (PPOs) •Allowed subscribers to seek HC from providers outside of the PPO
What is COBRA spelled out, when was it enacted and for what purpose? The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) established an employee’s right to continue HC coverage beyond the scheduled benefit termination date (including HMO coverage)
What is the “Amendment to the HMO Act of 1973”? Allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed.
What is HEDIS, when was it enacted and for what purpose? The Healthcare Effectiveness Data and Information Set (HEDIS) 1989: •Developed by (NCQA) •Create std to assess mngd care systms in terms of membship,utilization of svcs, qlty, access,health plan mgmt actvts, and fin indctrs.
What was Office of Managed Care and what is it now? Established as an office of HCFA “Health Care Financing Administration” (now called CMS – Centers for Medicare and Medicaid Services effective 6/14/2001) to facilitate innovation and competition among Medicare HMOs.
What is HIPPA, when was it created and why? The H Ins Portability & Accntblty Act of 1996(HIPPA)MANDATED nat’l stnd for the elec xchg of admn & fin HC trans to impv effcy effct of HC sys. Majr goal of prvcy pol to assure indv H info is prply prtctd while allwig flow of HI ndd to prvd high qual HC.
How does a “Medical Savings Accounts” work? A MSA (est 1997) allows ind to withdraw tax-free fnds for HC exp hat are not cov by a qual high-ded HP. HC exp that may be reimbursed from the MSA. In 2003 MSA replaced by (HSAs) Health Savings Accounts. Exstng MSAs are “grandfathered.
What is the BBA, when enacted and for what purpose? The Balncd Budget Act of 1997(BBA:•Encrged frmation of PSNs PSOs.•Mndtd rsk-basd mgd care orgs to sbmt enctr data reltd to inptnt hosp stays of mbrs•Est Medcare +Choice whch expl Medicre cov optns by crtng mgd care plns to incl HMOs,PPOs&MSAs (Now Medcre
How does “State Managed Care Legislation” impact consumers? •In 1997, Texas first enact leg allwng consms to sue an HMO for med mal prct•Other state-enacted legstn since 1997 incl that relating to mandated benefits, high-risk pools, method, philosophy of trtmnt for Alz, Mdcaid elig, bnng fin inctvs, & othe items.
How does MMA impact Medicare The Medicare Prscrptn Drug,Imprvmnt,& Modzn Act or Medicare Modz Act)2003:•AmndIRScode of 1986 to allow ded to ind for $ contrbtd to HSS, HSAs,to prvde for dispstn of unused H benfts in caftria plns,flxble spndg argmts•TitleI of Act est volpgrm for RX cov
What is the HMO Assistance Act purpose and when was it enacted? The HMO Assistance Act of 1973: 1. Auth $ to dvlp HMOs under pvt spnsp 2. Defined what a fdlly qualfd HMO as one that has appld for and met fed stds est in the HMO Act of 1973. 3. Req most empl w/25+ emplyees to offer HMO cov if lcl plns were available
Created by: rsavalza