Medicare
What are the purposes of Medicare regulations other than the one mentioned above?
Medicare was signed into law in 1965 with the intention of providing better healthcare to the citizen through medical insurance. It provides protection to its recipients, and it is a government program intended to provide insurance to the aged and people living with certain disabilities (Moon, 2006). It is mandated by the law to provide hospital insurance, medical insurance and cover drug prescription for its recipients. How will the federal government enforce compliance in the Medicare Advantage program? Which two other Medicare regulations do you think are the most important for managed care organizations and why?
The administration and enforcement of the Medicare Advantage program is the responsibility of a government agency by the name the Health Care Financing Administration. Medicare regulations are critical in the management of managed care organizations. Affordable Care Act Section 1557 rules against discrimination in these organizations (Hoffman, 2012). Managed care organizations operate under prepaid inpatient and ambulatory plans and primary care case management. These two regulations are critical in the management of managed care organizations. Do you think Medicare and Medicaid programs face challenges from the perspectives of providers, the government, and consumers (recipients of Medicare or Medicaid)? Why or why not?
Customers face both challenges of affordability and delivery of the services provided under the program. Customers under this program find it difficult to access dentists and specialists willing to treat them (Ketler, 2008). Providers, on the other hand, face the challenge of meeting the ever growing demand. Nursing homes and care centers are increasingly facing the challenge of the increasing long-term demand for their services. What are the different services provided by the Medicare and Medicaid programs? Do you feel there is a need to have two different programs? Why or why not?
Medicaid provides services that are fundamental in providing social protection and social welfare. It is a means-tested welfare and based on the social welfare needs of the client. It is both funded at the state and federal level. Medicare, on the other hand, is a social insurance that is funded by the federal government, and its primary focus is the provision of healthcare insurance to the older generation (Ketler, 2008). There is a need to have the two different programs. Each program is designed to provide services different to the other. This allows for the better implementation of both programs. Social protection and provision of healthcare are improved by having the two different interrelated programs. Discuss the advantages and disadvantages of Medicare programs such as Medicare Advantage and Medicare Part D. Do you think Medicare Advantage programs ensure the survivability of Medicare?
Medicare provides medical insurance to the elderly and people living with disabilities or chronic diseases. Medicare part D provides for coverage of prescription drug. They both offer extra coverage. They may provide for coverage beyond the normal program coverage. This may include coverage for vision, dental and hearing conditions
Medicare Advantage program ensures the survival of Medicare. It ensures that clients are fully covered for Medicare services and other related services such as emergencies and special care needed urgently. It may offer better or more coverage in terms of patient services. The disadvantage of Medicare advantage is that it is costly sometimes to the client especially when a client needs a service that is not medically necessary (Kongstvedt, 2007). In addition, it does not cover hospice care. Discuss the regulatory structure used to regulate MCOs and health insurers at the state level
Managed care organizations are used in the delivery of Medicaid. They are useful in delivering care to the clients through a well-managed system where costs are minimized, and quality delivered. They provide the needed care and medical services to the patients under the program.
There are several state and federal regulatory structure that are used in regulating managed care organizations and health insurers. At the state level, Affordable Care Act and prepaid inpatient health plan are the critical regulations in managed care organizations.
Discuss how states came to be the primary regulators of insurance
States are the key players in insurance regulation. They are contributors to the funds used in Medicare programs. They have implemented initiatives that have integrated care that is more advanced than the traditional care. Further, the law passed in 1994 as the McCarran-Ferguson Act provided superior powers to the state on matters of insurance (Kongstvedt, 2007). Evaluate the most critical components of state oversight of HMO operations
Processes and procedures are important in the state’s role of oversight in the operations of the HMO. The state ensures that all procedures and processes under several regulations are followed. Review the licensing requirements for MCOs in your state and describe the specific requirements to obtain a Certificate of Authority (COA). Compare to the requirements discussed in the course textbook.
The state of Washington provides that the provider must meet the requirements under the Affordable Care Act. Further, the state has passed patient protection laws that must be adhered to buy the provider. The regulations set up under the department of labor must also be met by the applicant.
The state provides that for one to obtain a certificate of authority to operate a managed care organization, one has to comply with provisions of Public Health Law. In addition, one has to apply to the commissioner on prescribed forms. The applicant must prove the capability to operate MCO and assume all financial risks associated with services covered (Kongstvedt, 2007).
What are the protections available to consumers under the law in your state? Compare these protections to what is discussed in the textbook. In your opinion, are the state regulations designed for the consumers, or are they designed for the MCOs? Use your course and text readings to support your answer
Consumers’ protection provisions in the state of Washington are spelled out under the consumer protection and quality requirement for managed care organization. The state regulations are designed for both the consumers, or and the Managed Care Organizations (Kongstvedt, 2007). They provide a balance between the exploitation of the consumer by the provider and the provision of quality services from the provider to the client.
References
Moon, M. (2006). Medicare: A policy primer. Washington, D.C: Urban Institute Press.
Ketler, S. R. (2008). Medicaid: Services, costs and future. New York: Nova Science.
Kongstvedt, P. R. (2007). Essentials of managed health care. Sudbury, Mass: Jones and Bartlett
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