Provision of a healthcare insurance policy that requires policy holders to pay for a portion of their healthcare services; A cost-control mechanism.
Healthcare payment method in which providers retrospectively receive payment for each service rendered.
1. Based on average income perperson living in that state
2. Low income families with children
3. Including families that qualify for TANF (Temporary Assistance for Needy Families)
1. Manage costs
2. Manage outcomes
3. Integrate finaancing & delivery of healthcare services.
a. Foundational Principles of Care for certain conditions.
b. Developed from scientific evidence & clinical expertise.
1. Suggestions for improvements.
2. Intentions regarding re-enrollment.
3. Satisfaction with administrative, clinical and customer services.
1. Initial Clinical Review
2. Peer Clinical Review
3. Appeals Consideration
1. Method of Reimbursement
2. Service Management Tools
3. Financial Incentives
a. Staff Model is the most controlled of the HMOs.
b. Primary care physicians control the referrals to specialists within the HMO.
c. Members who recieve care out of the HMO network will not receive compensation for their healthcare costs.
1. Long-term Management
3. Managed by one group specialists
4. Not usually managed by primary care providers
5. Sub-capitation = a common payment for specialist services.
Medicare Modernizaiton Act of 2003
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