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In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.
Kaiser Permanente is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser Permanente is made up of three distinct but interdependent groups of entities: the Kaiser Foundation Health Plan, Inc. (KFHP) and its regional operating subsidiaries; Kaiser Foundation Hospitals; and the regional Permanente Medical Groups. As of 2017, Kaiser Permanente operates in eight states and the District of Columbia, and is the largest managed care organization in the United States.
Health insurance is an insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over numerous persons. By estimating the overall risk of health care and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity.
Self-insurance is a situation in which a person or business does not take out any third-party insurance, but rather a business that is liable for some risk, such as health costs, chooses to bear the risk itself rather than take out insurance through an insurance company.
Two-tier healthcare is a situation in which a basic government-provided healthcare system provides basic care, and a secondary tier of care exists for those who can pay for additional, better quality or faster access. Most countries have both publicly and privately funded healthcare, but the degree to which it creates a quality differential depends on the way the two systems are managed, funded, and regulated.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing for-profit health care and providing American health insurance while improving the quality of that care. It has become the essentially exclusive system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
The Commonwealth of Massachusetts in the United States passed a healthcare reform law in 2006 with the aim of providing health insurance to nearly all of its residents. The law mandated that nearly every resident of Massachusetts obtain a minimum level of insurance coverage, provided free and subsidized health care insurance for residents earning less than 150% and 300%, respectively, of the federal poverty level (FPL) and mandated employers with more than 10 full-time employees provide healthcare insurance. The law was amended significantly in 2008 and twice in 2010 to make it consistent with the federal Affordable Care Act. Major revisions related to health care industry price controls were passed in August 2012, and the employer mandate was repealed in 2013 in favor of the federal mandate. Because Mitt Romney was the governor of Massachusetts at the time, the law has colloquially been called Romneycare, a reference to the nicknaming of the Patient Protection and Affordable Care Act as "Obamacare".
Health insurance in the United States is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes private insurance and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage.
An integrated delivery system (IDS), also known as integrated delivery network (IDN), is a health system with a goal of logical integration of the delivery (provision) of health care as opposed to a fragmented system or a disorganized lack of system.
Healthcare reform in the United States has a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010, which amended the PPACA and became law on March 30, 2010.
Health insurance coverage in the United States is provided by several public and private sources. During 2019, the U.S. population overall was approximately 330 million, with 59 million people 65 years of age and over covered by the federal Medicare program. The 273 million non-institutionalized persons under age 65 either obtained their coverage from employer-based or non-employer based sources, or were uninsured. During the year 2019, 89% of the non-institutionalized population had health insurance coverage. Separately, approximately 12 million military personnel received coverage through the Veteran's Administration and Military Health System.
The Department of Managed Health Care (DMHC) is a regulatory body governing managed health care plans, sometimes referred to as Health Maintenance Organizations (HMOs) in California. The current director, Shelley Rouillard, was appointed by Governor Jerry Brown on December 2, 2013. The DMHC is part of the California Health and Human Services Agency. It was established in 2000 and is responsible for enforcing the Knox-Keene Health Care Service Plan Act of 1975, and other related laws and regulations.
Council for Affordable Quality Healthcare, Inc. is a non-profit organization incorporated in California as a mutual benefit corporation. It was first incorporated under the name Coalition for Affordable, Quality Healthcare, Inc., and then was renamed the Council for Affordable Quality Healthcare, Inc. on July 22, 1998. It is based in Washington, D.C.. Previously a 501(c)6 tax-exempt organization, CAQH changed its tax status in 2016, although it remains a non-profit. Its mission is to accelerate the transformation of business processes in healthcare through collaboration, innovation and a commitment to ensuring value across stakeholders, including healthcare providers, trade associations, and health plans.
In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection and Affordable Care Act at ACA health exchanges, where they can choose from a range of government-regulated and standardized health care plans offered by the insurers participating in the exchange.
A health insurance mandate is either an employer or individual mandate to obtain private health insurance instead of a national health insurance plan.
The Patient Protection and Affordable Care Act, also the Affordable Care Act (ACA) or colloquially known as ObamaCare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965. The Act did not create a U.S. health service, such as the United Kingdom's National Health Service.
Anthem, Inc., is a provider of health insurance in the United States. It is the largest for-profit managed health care company in the Blue Cross Blue Shield Association. As of 2018, the company had approximately 40 million members.
Health care finance in the United States discusses how Americans obtain and pay for their healthcare, and why U.S. healthcare costs are the highest in the world based on various measures.
Washington Healthplanfinder is one of the fourteen health insurance marketplaces in the United States and was created in accordance with the Patient Protection and Affordable Care Act, commonly referred to as Obamacare.
The Patient Protection and Affordable Care Act (ACA) established the health insurance rate review program in order to protect consumers from unreasonable rate increases. Through this program, proposed premium increases in the small group and individual markets that are above a threshold amount are reviewed by states or the federal government to determine whether the increases are reasonable.
References
- ↑ "Issue Brief: Estimates of Sources of Health Insurance in California for 2019" (PDF). California Health Benefits Review Program.
- 1 2 "Making Sense of Managed Care Regulation in California" (PDF). California HealthCare Foundation. 2001.
- ↑ Kelso, J. Clark (2001). "Regulatory Jurisdiction Over Health Insurance Products: The Department of Managed Health Care & The Department of Insurance" (PDF). Archived (PDF) from the original on 2015-09-09. Retrieved 2019-10-12.
- ↑ "New California Court of Appeal Decision May Impose Premium Taxes on California Health Plans". C&M Health Law. 2015-10-12. Retrieved 2019-11-29.
- ↑ Oppenheim, Charles B.; Gross, Stephanie (16 May 2019). "Changes Ahead for California's Managed Care Regulatory Scheme".
- ↑ "California's Medicaid State Plan (Title XIX)". California Department of Health Care Services.
- 1 2 3 "The Private Insurance Market in California, 2015". California Health Care Foundation. Retrieved 2019-06-13.
- ↑ "2019 Edition — California Health Insurers". California Health Care Foundation. Retrieved 2019-10-14.
- ↑ "Evolving Market Share Of Health Plans In Covered California". IMK. 2018-10-09. Retrieved 2019-06-13.
- ↑ Bartolone, Pauline; Gorman, Anna; Terhune, Chad. "Anthem's retreat leaves Californians with fewer choices, more worries". The Sacramento Bee.
- ↑ "Hospital consolidation in California linked to higher health prices". SFChronicle. 5 September 2018.
- ↑ "Suit against Sutter spawns fight with Bay Area hospitals over trade secrets". SFChronicle. 15 October 2018.
