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Managed Health Care
Significant managed care federal legislation
Question | Answer: |
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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 |