Question

LP6 Assignment: Employer RFP

The assignment assesses competency 4. Examine the principles, structure, and operation of health insurance programs in relationship to managed care organizations, 13. Critique the managed care concept in the workplace.

The paper is due at the end of this two week learning plan. The paper should be 6 to 12 pages in length. The paper is due by Sunday midnight at the end of the second week of Learning Plan Six.

Directions: Employer RFP Paper: (Read Chapter 5 and 7.)

SCENARIO: You are responsible for the request for proposal (RFP) department in an MCO. Several employers have come to you looking for health insurance benefit offerings to its employees. You are to provide a package of health care insurance benefit coverage recommendations based on the size of each company: small group, medium group, and large group.

For each company size, recommend the services you would offer that sized company. Include how those services would be organized. You may assume anything you want about the employer. Incorporate your assumptions into your paper.

Be sure to include such things as what payment systems would be implemented (fee-for-service? capitation? deduction? and so forth).

How would you incorporate inpatient and outpatient services? How would you handle behavioral health services?

For each company size, your paper should be about 2 to 4 pages in length. Double space and use 1 inch margins all around in 12 point Times New Roman font.

Use headers freely to help outline your various recommendations for structure and content

There is no one correct answer to this. Your task is to demonstrate through this assignment that you understand the structure, internal operations of MCOs and health care options as presented in the text.

When writing, consider these questions:

What might a small/medium/large group employer look like?

What sort of financial structure would you recommend?

What would be the physician relations and so forth?

Use the text as a guide as to other factors that should be included in your paper. Details are good here.

Consider the reader in how you structure each of your employer recommendations. Do not write paragraphs that are 50 lines long. Break up your content into paragraphs that reflect changes in topic or thought. As stated above, use headers freely. Proper grammar is important. Proof read your assignment for spelling and grammar before you submit it.

Answer 1

A health care delivery system consisting of affiliatedand/or owned hospitals, physicians and others which provide a wide range of coordinated health services; an umbrella termfor health plans that provide health care in return for a predetermined monthly fee and coordinate care through a definednetwork of physicians and hospitals

Principle

Direct access to emergency services should be a covered benefit for patients enrolled in health care plans, using the prudent layperson standard for claims adjudication and reimbursement. Managed care organizations have an obligation to promptly reimburse physicians and other providers for these services.

Types of managed care organizations
There are three primary types of managed care organizations: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans. PPOs are by far the most common form of managed care in the U.S.

HMOs tend to be the most restrictive type of managed care. They frequently require members to select a primary care physician, from whom a referral is typically required before receiving care from a specialist or other physician. HMOs usually only pay for care within the provider network.

PPOs allow members more flexibility than HMOs do. These types of plans usually allow members to receive care out of network, but the member must pay more than if they use a network provider. This flexibility has made PPOs popular, although premiums for PPOs are typically higher than those for HMOs.

POS plans offer a middle ground between an HMO and a PPO. Like HMOs, POS plans usually require members to have primary care physicians. Like PPOs, POS plans allow members to go out of network for care -- although they must pay more than they would for a network provider. Premiums for POS plans are usually higher than those for HMO plans.

Does managed care work?
Opinions vary greatly about just how effective managed care actually is. Opponents point to high overhead costs at large HMOs and lower quality scores as signs that managed care doesn't work well.