Managed Care State Laws and Regulations

Good Essays

420 Week 7 DQ 1. What are the most critical components of state regulation for managed care organizations? Which federal regulations also bring specific requirements for the operation of such entities? Discuss state and federal regulation of MCOs. State oversight of managed care generally focuses on two aspects: the techniques and processes used by a payer, and in particular an HMO, to deliver or arrange for the delivery of health care services to enrollees, and the organizational structure of the payer. (Kongstvedt 596) Much of the state regulation of managed care is based on the Health Maintenance Organization Model Act released by the National Association of Insurance Commissioners (NAIC) in 1972. The NAIC is the national …show more content…

The Act has a significant impact on how MCOs operate in the individual and group insurance markets and with respect to the administration of self-funded group health plans. 1998 – The Women’s Health and Cancer Rights Act (WHCRA) – law enacted to make sure that women who had breast cancer for their health insurers and group health plans to provide coverage for reconstructive breast surgery after a mastectomy (Kongstvedt 608) 2008 - The Genetic Information Nondiscrimination Act (GINA) - prohibits insurances to discriminate against genetic makeup The Mental Health Parity and Addiction Equity Act (MHPAEA) -The law amended the 1996 Mental Health Parity Act by extending the parity requirements to include substance use disorder benefits. In addition, the MHPAEA requires parity with respect to all financial requirements (cost-sharing such as deductibles, copayments, and co-insurance) and treatment limitations (day or visit limits) between medical and surgical benefits and benefits for mental health and substance use disorder services (Kongstvedt 608-609) Michelle’s Law – requires health insurers and group health plans to provide medical coverage 12 months after a child leaves school for a medically necessary leave of absence. 2009 –

Get Access