AHM 250- INTRODUCTION TO HEALTH MANAGEMENT
(25-27)
NAIC HMO Model Act regulates HMO operations in two critical areas: - Answers -
financial responsibility and healthcare delivery
addresses financial responsibility through licensing requirements and financial
standards. It addresses healthcare delivery by establishing requirements for network
adequacy, quality assurance
Insolvency - Answers - occurs when an organization's assets or resources are not
adequate to cover its debts and obligations.
Receivership - Answers - is a situation in which the commissioner, acting for a state
court, takes control of and administers an HMO's assets and liabilities
The HMO Model Act focuses on three key aspects of healthcare delivery: - Answers - •
Network adequacy
• Quality assurance requirements focus on an HMO's procedures for facilitating the
delivery of healthcare services to plan enrollees.
• Grievance procedures.
requires HMOs to maintain records of all complaints received by the organization and to
make these records available to the appropriate regulatory authority for review. internal
process created
Quality assurance - Answers - requirements focus on an HMO's procedures for
facilitating the delivery of healthcare services to plan enrollees. HMO's quality
assurance program must include a statement of the HMO's goals and objectives for
evaluating and improving enrollees' health status; documentation of all quality
assurance activities; and a system for periodically reporting program results to the
HMO's board of directors, its providers, and regulators.
preferred provider arrangement (PPA) - Answers - PPOs-Preferred provider org
EPOS- exclusive provider organizations health plans that include a preferred provider
arrangement.
as a contract between a healthcare insurer and a healthcare provider or group of
providers who agree to provide services to persons covered under the contract.
Preferred Provider Arrangement Model Act (PPA Model Act). - Answers - This model
requires PPAs to:
• clearly identify any differences in benefit levels for services of preferred providers and
non-preferred providers,
• establish the amount and manner of payment to preferred providers,
• include mechanisms for minimizing the cost of the health plan, and
, • provide plan members with reasonable access to covered services.
Third-party administrators (TPAs - Answers - are companies that provide administrative
services to health plans, employers, or other plan sponsors. Some of these
administrative services, such as underwriting and claims, are classified as insurance
activities and as such are
-subject to state regulation
NAIC's Health Care Professional Credentialing Verification Model Act - Answers -
specifies requirements that health plans must satisfy to ensure that network providers
meet minimum standards of professional qualification. These requirements include the
following:
• verification of the credentials of all contracted healthcare professionals in accordance
with written procedures that must be disclosed, on written request, to any applying
healthcare professional;
• collection of a minimum set of credentialing information by either primary or secondary
verification, with recredentialing required every three years; and
• establishment of a process by which providers can review and correct credentialing
information.
Quality Assessment and Improvement Model Act. - Answers - This model requires
health plans to establish and report on systems for assessing the quality of care and
services they provide. In particular, quality assessment laws require health plans to:
• establish an appropriate system for assessing the quality of healthcare services
provided by each type of network,
• report to the appropriate licensing authorities any problems that would offer grounds
for provider termination,
• file a written description of quality assessment programs with the state insurance
commissioner or the secretary of the state health department,
• describe quality programs to consumers through marketing and educational materials,
and
• meet specified data confidentiality requirements.
Health Plan Network Adequacy Model Act - Answers - requires all health plans to:
• meet specified adequacy and accessibility standards;
• hold covered persons harmless against provider collections and provide continued
coverage for uncompleted treatment in the event of plan insolvency;
• develop standards to be used in the selection of providers;
• adhere to specified disclosure requirements, including 60-day written notice to
providers before terminating a contract without cause and 15-day notice to patients of a
provider's contract termination; and
• file written access plans and sample contract forms with the state insurance
commissioner
(25-27)
NAIC HMO Model Act regulates HMO operations in two critical areas: - Answers -
financial responsibility and healthcare delivery
addresses financial responsibility through licensing requirements and financial
standards. It addresses healthcare delivery by establishing requirements for network
adequacy, quality assurance
Insolvency - Answers - occurs when an organization's assets or resources are not
adequate to cover its debts and obligations.
Receivership - Answers - is a situation in which the commissioner, acting for a state
court, takes control of and administers an HMO's assets and liabilities
The HMO Model Act focuses on three key aspects of healthcare delivery: - Answers - •
Network adequacy
• Quality assurance requirements focus on an HMO's procedures for facilitating the
delivery of healthcare services to plan enrollees.
• Grievance procedures.
requires HMOs to maintain records of all complaints received by the organization and to
make these records available to the appropriate regulatory authority for review. internal
process created
Quality assurance - Answers - requirements focus on an HMO's procedures for
facilitating the delivery of healthcare services to plan enrollees. HMO's quality
assurance program must include a statement of the HMO's goals and objectives for
evaluating and improving enrollees' health status; documentation of all quality
assurance activities; and a system for periodically reporting program results to the
HMO's board of directors, its providers, and regulators.
preferred provider arrangement (PPA) - Answers - PPOs-Preferred provider org
EPOS- exclusive provider organizations health plans that include a preferred provider
arrangement.
as a contract between a healthcare insurer and a healthcare provider or group of
providers who agree to provide services to persons covered under the contract.
Preferred Provider Arrangement Model Act (PPA Model Act). - Answers - This model
requires PPAs to:
• clearly identify any differences in benefit levels for services of preferred providers and
non-preferred providers,
• establish the amount and manner of payment to preferred providers,
• include mechanisms for minimizing the cost of the health plan, and
, • provide plan members with reasonable access to covered services.
Third-party administrators (TPAs - Answers - are companies that provide administrative
services to health plans, employers, or other plan sponsors. Some of these
administrative services, such as underwriting and claims, are classified as insurance
activities and as such are
-subject to state regulation
NAIC's Health Care Professional Credentialing Verification Model Act - Answers -
specifies requirements that health plans must satisfy to ensure that network providers
meet minimum standards of professional qualification. These requirements include the
following:
• verification of the credentials of all contracted healthcare professionals in accordance
with written procedures that must be disclosed, on written request, to any applying
healthcare professional;
• collection of a minimum set of credentialing information by either primary or secondary
verification, with recredentialing required every three years; and
• establishment of a process by which providers can review and correct credentialing
information.
Quality Assessment and Improvement Model Act. - Answers - This model requires
health plans to establish and report on systems for assessing the quality of care and
services they provide. In particular, quality assessment laws require health plans to:
• establish an appropriate system for assessing the quality of healthcare services
provided by each type of network,
• report to the appropriate licensing authorities any problems that would offer grounds
for provider termination,
• file a written description of quality assessment programs with the state insurance
commissioner or the secretary of the state health department,
• describe quality programs to consumers through marketing and educational materials,
and
• meet specified data confidentiality requirements.
Health Plan Network Adequacy Model Act - Answers - requires all health plans to:
• meet specified adequacy and accessibility standards;
• hold covered persons harmless against provider collections and provide continued
coverage for uncompleted treatment in the event of plan insolvency;
• develop standards to be used in the selection of providers;
• adhere to specified disclosure requirements, including 60-day written notice to
providers before terminating a contract without cause and 15-day notice to patients of a
provider's contract termination; and
• file written access plans and sample contract forms with the state insurance
commissioner
