The Department of Managed Health Care (DMHC) administers and evaluates healthcare laws and regulations. The following sections outline these laws, including The Knox-Keene Health Care Service Plan Act, regulations, and issues. Show
You will find additional topics relating to DMHC jurisdiction, administrative actions and opportunities for public participation in rulemaking proceedings.
Knox-Keene Health Care Service Plan Act of 1975These are the laws administered by the Department. The Knox-Keene Health Care Service Plan Act of 1975, as amended, is the set of laws or statutes passed by the State Legislature to regulate health care service plans, including health maintenance organizations (HMOs) within the State. The Knox-Keene Act is in the California Health & Safety Code, section 1340 et seq. In addition to statutes, the DMHC develops regulations with the help of our stakeholders: consumers, health plans, and providers, pursuant to the Administrative Procedures Act. These regulations are codified under title 28 of the California Code of Regulations. Regulations are used by the DMHC to implement, interpret, or make specific the laws enforced by the Department.
Newly Effective RegulationsRegulations become effective on a quarterly basis after filing with the Secretary of State. An emergency regulation becomes effective when filed with the Secretary of State. The text of the regulation is available within each regulation. Newly Effective Regulations Open Pending RegulationsThese are the draft regulations in which the Department is asking for public comments. Open Pending Regulations Closed Pending RegulationsThese are the draft regulation in which the comment period is closed. The Department is now reviewing the comments. Closed Pending Regulations Approved Pending RegulationsThe formal rulemaking process is completed and the office of Administrative Law has issued an approval. These regulations will become effective. Approved Pending Regulations Issues and RegulationsThis section lists the topics the Department is currently considering and evaluating and where you can submit comments on those topics. Issues and Regulations for the Upcoming Year Additional information about this website and the Office of Legal Services role in the rulemaking process is available by clicking the following link: Office of Legal Services Information The laws by which the Department regulates health plans come in two varieties: those statutes enacted by the Legislature and those regulations developed by the Department. The California Legislature has enacted a body of statutes collectively known as the Knox-Keene Health Care Service Plan Act of 1975, as amended. Managed health care (managed care) Combines health care delivery with the financing of services provided Consumer-directed health plans (CDHPs) Employer contributions and ask employees to be more responsible for health care decisions and cost-sharing Enrollees, subscribers, policyholders Employees and dependents who join a managed care plan and are also known as beneficiaries in private insurance plan Managed care organization (MCO) Responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system Reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services Provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year) Health maintenance organization (HMO) assistance Act of 1973 Authorized grants and loans to develop HMOs under private sponsorship, defined a federally qualified HMO as one that has applied for, and met, federal standards established in the HMO Act of 1973, required most employers with more than 25 employees to offer HMO coverage if local plans were available Federally qualified (HMO) Certified to provide health care services to Medicare and Medicaid enrollees Federally qualified HMOs and competitive medical plans (CMPs) that meet specified Medicare requirements provide Medicare-covered services under a risk contract An arrangement among providers to provide capitated (fixed,prepaid basis) health care services to Medicare beneficiaries Competitive medical plan (CMP) An HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan Preferred provider health care act of 1985 Eased restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO Amendment of the HMO Act of 1973 Legislation that allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed Healthcare effectiveness data and information set (HEDIS) Created standards to assess managed-care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans CMS agency that facilitates innovation and competition among Medicare HMOs Quality assessment and performance improvement (QAPI) Program implemented so that quality assurance activities are performed to improve the functioning of Medicare advantage organizations Primary care provider (PCP) Responsible for supervising and coordinating health care services for enrollees and approves referrals to specialist and inpatient hospital admissions (except in emergencies) Primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists Quality assurance program Activities that access the quality of care provided in a health care setting External quality review Organization (EQRO) Responsible for reviewing health care provided by managed care organizations Quality improvement system for managed care (QISMC) Established by Medicare to ensure the accountability of managed care plans in terms of objective, measurable standards Contains data regarding a managed care plans quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control Utilization review Organization (URO) Entity that establishes a utilization management program and performs external utilization review services Submits written confirmation, authorizing treatment, to the provider Second Surgical Opinion (SSO) Second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement of services Include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services (discharge an inpatient from the hospital more quickly) to save money for the managed care plan Requires managed care plans that contract with Medicare or Medicaid to disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval Exclusive provider organization (EPO) Managed care plan that provides benefits to subscribers if they receive services from network providers Physician, other health care practitioner, or health care facility under contract to the managed care plan Integrated delivery system (IDS) Organization of affiliated provider sites that offer joint health care services to subscribers Physician-hospital Organization (PHO) Owned by hospital(s) and physician groups that obtain managed care plan contracts; physicians maintain their own practices and provide health care services to plan members Management service organization (MSO) Usually owed by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices Group practice without walls (GPWW) Contract that allows providers to maintain their own offices and share services (appointment scheduling and billing) Integrated provider organization (IPO) Manages the delivery of health care services offered by hospitals, physicians employed by the IPO, and other health care organizations (an ambulatory surgery clinic and a nursing facility) Nonprofit organization that contracts with and acquired the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practices business Health maintenance organization (HMO) Responsible for providing health services to subscribers in a given geographical area for a fixed fee Point-of-service plan (POS) Delivers health care services using both managed care network and traditional indemnity coverage so patient can seek care outside the managed care network Health care is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO Contracted healthcare services are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice. The HMO reimburses the physician group, which is then responsible for reimbursing physician members and contacted healthcare facilities. The physician group can be owned or managed by the HMO, or it can simply contract with the HMO. Health care services are provided to subscribers by physicians employed by the HMO. Premiums and other revenue are paid to the HMO. Usually, all ambulatory services are provided within HMO corporate buildings Health care is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO. Contracted health care services are delivered to subscribers by individual physicians in the community Individual practice association (IPA) HMO Also called independent practice association (IPA) HMO, contracted health services are delivered to subscribers by physicians who remain in their independence office settings. The IPA is an intermediary that negotiates the HMO contract and receives and manages the capitation payment from the HMO, so that physicians are paid on either a fee-for-service or capitation basis. Contracted health care services are provided to subscribers by two or more physician multispecialty group practices Enrollee who sees a non-HMO panel specialist without a referral from the primary care physician Preferred provider organization (PPO) Network of physicians, other health care practitioners, and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee
Usually offered by either a single insurance plan or as a joint venture among two or more third-party payers, and provide subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans. Also called cafeteria plan or flexible benefit plan Cafeteria plan (or flexible benefit plan) Also called triple option plan, provides different health benefit plans and extra coverage options through insurer or third-party administrator Covering members who are sicker than the general population Created when a number of people are grouped for insurance purposes, the cost of healthcare coverage is determined by employees health status, age, sex and occupation Customized sub-capitation plan (CSCP) Managed care plan in which health care expenses are funded by insurance coverage, the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium, each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider Each provider is paid a fixed amount per month to provide only the care that an individual needs from that provider Flexible spending account (FSA) Tax-exempt account offered by employers with any number of employees, which individuals use to pay health care bills, participants enroll in a relatively inexpensive, high-deductible insurance plan, and a tax-deductible savings account is open to cover current and future medical expenses; money deposited (and earnings) is tax-deferred, and money is withdrawn to cover qualified medical expenses tax–free money can be withdrawn for purposes other than healthcare expenses after payment of income tax plus a 15 day penalty; unused balances “roll over” from year to year, and if an employee changes jobs, the FSA can continue to be used to pay for qualified healthcare expenses; also called health savings account (HSA) or health savings security account (HSSA) Health care reimbursement account (HCRA) Tax exempt account used to pay for healthcare expenses, Individual decides, in advance, how much money to deposit in an (and unused funds are lost) Health reimbursement arrangement (HRA) Tax exempt accounts offered by employers with 50 or more employees; individuals use to pay healthcare bills; must be used for qualified healthcare expenses, require enrollment in the high-deductible insurance policy, and can accumulate unspent money for future years; if an employee changes jobs, the can continue to be used to pay for qualified healthcare expenses Voluntary process that a health care facility or organization under goes to demonstrate that it has met standards beyond those required by law Conducted by accreditation organizations and/or regulatory agencies to evaluate a facility’s compliance with standards and/or regulations National committee for quality assurance (NCQA) A private, not for profit organization that assesses the quality of managed care plans in the United States and regulates the data to the public for its consideration when selecting a managed care plan Which is responsible for reviewing health care provided by managed care organizations?CMS is responsible for reviewing and approving state requests to implement managed care under these authorities. All Medicaid managed care programs, regardless of authority, are subject to the provisions of Section 1932 and 42 CFR 438 unless specifically waived.
What is the role of a managed care organization quizlet?Organization that delivers health care services without using an insurance company to manage risk and without a third party administrator to make payments. Most MCOs arrange medical services through contracts with physicians, clinics, and hospitals operating independently.
Which of the following is responsible for supervising and coordinating health care services for enrollees?Chapter 3 Insurance. Which administration procedure should a medical practice follow when it contracts with a managed care organization?Which administrative procedure should a medical practice follow when it contracts with a managed care organization (MCO)? Maintain separate bookkeeping systems for each capitated plan.
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Which of these is responsible for reviewing health care provided by managed care organizations?
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