Dhhs Issues Letter to Take Over State-contracted Managed Care
MANAGED CARE, MARKET REPORTS AND THE STATES
material added 7/1//2017
ARCHIVE FEATURES - This web report was compiled and maintained between 2008 and 2013. Other than individual state market reports for 2015-17, It no longer contains updates or current information. Use as an historical reference only, pending a future edition. For current health insurance material, see http://www.ncsl.org/default.aspx?tabid=21388
Overview
Managed care is a term used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care for organizations that use those techniques or provide them as services to other organizations. It is also used to describe systems of financing and delivering health care to enrollees organized around managed care techniques and concepts.
Over the past 20 years, managed care has become the predominant form of health care in most parts of the United States. More than 70 million Americans have been enrolled in HMOs (health maintenance organizations) and almost 90 million have been part of PPOs (preferred provider organizations). Overall enrollment numbers in HMOs peaked in 2001 and are declining substantially in almost every area, but managed care generally remains a dominant type of health care and coverage.
According to Kaiser Family Foundation's Employer Health Benefits 2010 Annual Survey, 58 percent of covered workers are enrolled in PPOs, followed by HMOs (19 percent), HDHP/SOs (13 percent), POS plans (8 percent), and conventional indemnity plans (1 percent). Enrollment in HDHP/SOs rose to 13 percent of covered workers in 2010, up from 8 percent in 2009.
- Plan enrollment patterns vary by firm size. Workers in large firms (200 or more workers) are more likely than workers in small firms (3-199 workers) to enroll in PPOs (63 percent vs. 51 percent). Workers in small firms are more likely than workers in large firms to enroll in POS plans (15 percent vs. 5 percent.
- Managed Care Digest Series - The HMO-PPORx Digest provides comprehensive overviews of the medical and pharmacy benefits—along with extensive retail pharmacy data by chronic disease category—at managed care plans, including HMOs, PPOs and point-of-service plans. This Digest features long-term trends and analyses of key industry measures, as well as information pertaining to the impact of health care reform legislation. Updated 2017
Managed Care in Medicaid
Medicaid managed care grew rapidly in the 1990s. In 1991, 2.7 million beneficiaries were enrolled in some form of managed care. By 2004, that number had grown to 27 million, an increase of 900 percent. Of the total Medicaid enrollment in the United States in 2009, almost 72 percent were receiving Medicaid benefits through managed care. All states except Alaska and Wyoming have all, or a portion of their Medicaid population enrolled in an MCO (Managed Care Organization). States can make managed care enrollment voluntary, or seek a waiver of section 1915(b) of the Social Security Act from the Centers for Medicare and Medicaid Services to require certain populations to enroll in an MCO.
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Medicaid Managed Care: 2016 Trends in Federal Spending and State Oversight of Costs and Enrollment . GAO-16-77: Publicly Released: Jan 19, 2016. | Highlights | View Report (PDF, 49 pages)
Medicaid Managed Care State Contracts- The George Washington University's Department of Health Policy published a series of unique studies of managed care contracts. State-by-state profiles are included on their webpage. These state profiles show the various components of each state's contract with health plans, including performance standards, reporting requirements, definition of actuarially sound rates, conditions under which money must be returned, etc. Contact GWU for access to this material at http://www.gwumc.edu/sphhs.
"Medicare Advantage" managed care plans saw a surge in enrollment as a result of the launch of "Part D" prescription drug coverage in 2006.
The State Legislative Role- Over the years, state legislatures have responded by passing numerous laws on the subject of managed care - over 900 in the past 15 years, in all 50 states. NCSL has a variety of print and web-based resources describing these efforts - see below.
In 2001-2002, the U.S. House of Representatives passed an amended Patients' Rights bill; the U.S. Senate passed a somewhat different bill. However, at the end of the congressional session the bills died in a House-Senate conference committee, primarily on issues related to liability and the right to sue. Similar federal measures were filed for 2003-06, but were not voted on.
Managed Care Resources
These are selected research, academic and advocacy publications. NCSL is not responsible for the contents or opinions expressed within these pages.
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STATE HEALTH MARKET REPORTS & MATERIAL (written and released by Allan Baumgarten):
Full reports are available for purchase from http://www.AllanBaumgarten.com.
ADDITIONAL ARCHIVE REPORTS AND LINKS
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NCSL Research and Articles
- Managed Care State Laws for Ombudsman, Report Cards and Provider Profiles- Updated 2008.
- State Insurance & Managed Care Mandated Coverage- Updated 2008-10.
- Childhood Immunizations - 2015
- Clinical Trials Coverage
- Colorectal Cancer Screening
- Contraceptives
- Dependent Coverage
- Diabetes
- Genetics and Health Insurance: State Anti-Discrimination Laws
- Infertility Treatment
- Mental Health Benefits
- Newborn Hearing Screening
- Newborn Genetic & Metabolic Disease Screening
- Making the Best of Managed Care- State Legislatures article, June 2001.
- U.S. Supreme Court Strikes Down State HMO Liability Laws- On June 21, 2004 the Supreme Court ruled unanimously that patients cannot sue their HMO under state laws for failing to pay for doctor recommended care. Experts describe the decision as ruling that the federal ERISA law "completely pre-empted such lawsuits brought in state court." This ruling against the states will have substantial adverse legal impact on the enacted laws in the ten states listed below, plus two additional states, although the number of active cases brought under these state laws evidently is not large. Also, note that some of the "right to sue" provisions are part of broader laws, affecting rights to independent appeals and other managed care procedures. Summary and Full Text of Court Opinion - Aetna Health v. Davila (02-1845) and Cigna v. Calad et al. (03-83)-23 pages.
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"Managed Care Magazine"- provides timely updates useful to policymakers, researchers and professionals. NCSL is cited periodically. 6/04
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Managed Care State Laws for Report Cards - NCSL report, updated 2009.
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Managed Care State Laws and Regulations, Including Consumer and Provider Protections- NCSL 50-state tables of laws, 1990-2005. Updated 2008. (Offline-members only file:GO 14320)
NCSL staff contact: Richard Cauchi - Health Program, Denver.
Dhhs Issues Letter to Take Over State-contracted Managed Care
Source: https://www.ncsl.org/research/health/managed-care-and-the-states.aspx
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