ESSENTIALS OF MANAGED HEALTH CARE - PART 5: MEDICARE AND MEDICAID

Course overview

OUTLINE SECTION 1: Medicare and Managed Care A. INTRODUCTION B. ORGANIZATION OF THIS SECTION C. WHO IS ELIGIBLE FOR A MEDICARE RISK CONTRACT? 1. State Licensure 2. Repeal of 50/50 3. Minimum Enrollment: Waiver of Requirement D. THE EXCEPTION IN STATE LICENSURE: PROVIDER-SPONSORED ORGANIZATIONS E. OTHER NEW OPTIONS 1. Medical Savings Account Plans (MSAs) 2. Preferred Provider Organizations 3. Private Fee-for-Service Plans 4. Point of Service: Old Wine in New Bottles 5. Repeal of the Cost Plan Option F. MUDDYING THE WATERS: PLANS VERSUS ORGANIZATIONS 1. Service Area: Flexible Benefits 2. Continuation Areas: Service beyond the Service Area 3. Payment, or the Art of Phasing In and Phasing Out 4. Minimum Payments and Increases 5. Blended Rate 6. Removal of Medical Education 7. Risk Adjustment 8. New Entrant Bonus 9. User Fees 10. Announcement of Rates: Computation of Rates 11. Limits on Charges for Medicare Services 12. Supplemental Benefits: Waiving of Charges 13. Benefit Information Form and Its Successors 14. Mid-Year Benefit Changes 15. Special Treatment of Employer Group Retirees G. FEDERAL PREEMPTION H. WHAT THE CONTRACT REQUIRES (FINALLY!) 1. Some Basic Requirements 2. Quality Standards 3. Reporting and Surveying 4. External Review 5. Evolving Quality Standards 6. Deemed Compliance with Quality Requirements I. LIMITATIONS ON PHYSICIAN INCENTIVE PLANS J. CONSUMER PROTECTIONS 1. Access Standards Information on Advance Directives 2. Member Appeals and Grievances 3. Grievances 4. Avoiding Speed Traps K. PROVIDER PROTECTIONS AND RIGHTS: CONSCIENCE PROTECTION L. INFORMATION DISSEMINATION 1. Coordinated Open Enrollment 2. Information on Plan Performance M. ENROLLMENT 1. Who May Enroll? 2. Open Enrollment: Coordinated Open Enrollment 3. Capacity Waivers N. MARKETING RULES 1. Basic Requirement 2. Prohibited Marketing 3. Prior Approval 4. Description of Plan (Evidence of Coverage) 5. Notifications to Enrollees O. INTERACTIONS WITH YOUR GOVERNMENT P. THE CONTRACTING PROCESS Q. WEB RESOURCES AND OTHER CONTACTS R. FUTURE DIRECTION OF THE PROGRAM SECTION 2: Medicaid Managed Care by Robert E. Hurley and Stephen A. Somers A. INTRODUCTION B. MEDICAID: ORIGINS AND EVOLUTION C. MEDICAID MANAGED CARE: BACKGROUND AND MODELS D. OPERATIONAL FEATURES 1. Design, Planning, and Implementation 2. Program Models 3. Eligibility, Enrollment, and Choice 4. Buying Value: It's All in the Contract 5. Compensation and Rates 6. Quality Monitoring and Oversight E. SUCCESSES OF MEDICAID MANAGED CARE 1. Access 2. Cost 3. Quality/Outcomes 4. Consumer Satisfaction and Responsiveness 5. Accountability 6. Devolution F. SHORTFALLS OF MEDICAID MANAGED CARE 1. Lack of Data/Evidence of Impact 2. Administrative Capacity and Performance 3. Adversarial Contracting Environment 4. Serving Special Need Groups G. THE CHALLENGING CONTEMPORARY CONTEXT H. LONGER TERM QUESTIONS AND CONCERNS I. CONCLUSION