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Market segments and distribution channels for the MCOs Essay Paper

Market segments and distribution channels for the MCOs Essay PaperMarket segments and distribution channels for the MCOs Essay PaperThis week’s chapter discusses the various market segments and distribution channels for the MCOs. Outline the market segments and identify the most successful distribution channels for those markets. Use some outside research to support your statements. Why do you believe each distribution channel successfully reaches the targeted market?Discussion Board Requirements: 250 word count One original post and two reply posts, APA Format, please include referencesDeadline: Saturday, March 2nd at 11:50 pm.Market segments and distribution channels for the MCOs Essay PaperChapter 6: Sales, Governance and AdministrationORDER A PLAGIARISM-FREE PAPER HERELearning ObjectivesUnderstand the basic structure of governance and management in payer organizationsUnderstand the basic elements of the internal operations of payer organizations, including:Information technology (IT)Marketing and sales, including insurance exchangesUnderwriting and premium rate developmentEligibility, enrollment and billingClaims and benefits administrationMember services, including appeal rightsStatutory accounting and statutory net worthFinancial management2   2Board of DirectorsMay be specific to a plan, may be pro-forma for a subsidiary of a larger company, etc.Responsibilities:Final approval of corporate bylawsGeneral oversight of the profitability or reserve statusOversight and approval of significant fiscal eventsReview of reports and document signingSetting and approving policyOversight of the quality management programIn for-profit plans, responsibility to protect shareholders’ interestsIn free-standing plans, hiring the CEO and reviewing CEO’s performance3Market segments and distribution channels for the MCOs Essay Paper Typical Key Management PositionsChief Executive Officer/Executive DirectorChief Operating Officer/Operations DirectorMay be a separate position from CEO in large companiesIf separate from CEO, the COO may also be the PresidentChief Medical Officer/Medical DirectorVice President (or SVP or EVP) of Network ManagementChief Financial Officer/Finance DirectorTreasurerChief Marketing Officer/Marketing DirectorChief Underwriting OfficerChief Information Officer/Director of Information SystemsCorporate Compliance Officer4 Typical Key Operational CommitteesQuality Management CommitteeCredentialing CommitteeUtilization Review CommitteePharmacy and Therapeutics CommitteeMedical Grievance Review and Appeals Committee 5 Foundational Information Technology (IT) SystemsKey software functionality includes:Benefit configurationEmployer group and member enrollmentPremium managementProvider enrollment, contracting and credentialingClaims paymentDocument Imaging and WorkflowCustomer ServicingMedical ManagementAbility for two-way EDI with insurance exchanges, employers, state and federal government, members, providers, etc.6Market segments and distribution channels for the MCOs Essay PaperHIPAA Mandated Electronic Transaction StandardsHIPAA requires covered entities that conduct certain electronic transactions to use only ANSI X12N 5010 defined standardsACA is creating new standards and requiring more standardization of implementation7Transaction StandardProvider Claims submission ANSI X12 – 837 (different versions exist for institutional, professional, and dental)Pharmacy claims NCPDPEligibility ANSI X12 – 270 (inquiry) ANSI X12 – 271 (response)Claim status ANSI X12 – 276 (inquiry) ANSI X12 – 277 (response)Provider Referral certification and authorization ANSI X12 – 278Health care payment to provider, with remittance advice ANSI X12 – 835Enrollment and Disenrollment in health plan* ANSI X12 – 834Claims attachment (additional clinical information from provider to health plan, used for claims adjudication) ANSI X12 – 275 (not finalized at the time of publication), and HL7 CDAPremium payment to health plan* ANSI X12 – 820First report of injury ANSI X12 – 148 (not yet issued)* These are for voluntarily but not mandatory use by employers, unions, or associations that pay premiums to the health plan on behalf of members. Source: Compiled by author based on 45 CFR §160.920 and other sources at the Center for Medicare and Medicaid Services (CMS);Accessible at http://www.cms.govMarket segments and distribution channels for the MCOs Essay Paper HIPAA Mandated Privacy and Security RequirementsHIPAA requires high levels of privacy and security for electronic information, to:ensure the confidentiality, integrity, and availability of electronic PHI;protect against any reasonably anticipated threats or hazards to the security and integrity of electronic PHI;protect against any reasonably anticipated uses or disclosures of electronic PHI not permitted by the HIPAA privacy rules; andensure compliance with the above by its workforce (Source: Federal Register, 45 CFR § 164.308)There are eighteen standards for HIPAA security rules:8Security Management Process Assigned Security Responsibility Workforce SecurityInformation Access Management Security Awareness and Training Security Incident ProceduresContingency Plan Evaluation Business Associate ContractsFacility Access Controls Workstation Use Workstation SecurityDevice and Media Controls Access Control Audit ControlsIntegrity Person or Identity Authentication Transmission SecuritySource: Federal Register, 45 CFR § 164.308(a & b), 45 CFR § 164.310(a-d); 45 CFR § 164.312(a-e)  Standardized SBC/SOCACA requires all health plans, including self-funded, must provide a standardized Summary of Benefits and Coverage (SBC), also called a Summary of Coverage (SOC) to all current and prospective enrolleesThe SBC/SOC to be done in a uniform and common format that defines the number of pages, the exact information that must be provided, and even the size of the fontThe SBC does not replace the far more detailed Evidence of Coverage (EOC), sometimes called a Certificate of Coverage or Certificate of Insurance9Market segments and distribution channels for the MCOs Essay PaperMarketing vs. SalesMarketing and sales are related but distinct activitiesMarketingFocus is on overall growth goals, strategies and tactics, management of the processCompensation combination of salary and overall growth goalsRole in Insurance Exchange as well as outside exchangeSalesThe actual process of selling the plan’s offerings in the marketplace through any distribution channelCompensation usually heavily weighted towards achievement of sales goalsNo real role in the insurance exchange10© P.R. Kongstvedt Fundamental Elements of MarketingBrand ManagementExternal Communications and Public RelationsAdvertisingEmployer versus consumer advertisingCollateral texts: outdoor, directMarket ResearchLead GenerationSales Campaign SupportHeavily regulated for individual and small group market through the Exchange11 Distribution Channels by Market Segment12 Health Insurance Exchanges…ACA created state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which small businesses with up to 100 employees can purchase qualified coverageSeparate exchanges for individuals to access coveragePermit states to allow businesses with more than 100 employees to purchase coverage in the SHOP Exchange beginning in 2017States may form regional Exchanges or allow more than one Exchange to operate in a stateFeds operate exchanges in states that refused to build themOffice of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entityCreation of plan rating systems similar to that used in Medicare Advantage13Market segments and distribution channels for the MCOs Essay PaperHealth Insurance Exchanges (cont.)Brokers still allowed to operate in this market segment for healthExchanges do not prohibit a non-Exchange market for individual and group coverage, but rates must be the same if sold both in and outside of the ExchangeRequire the Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entityEach multi-state plan must be licensed in each state and must meet the qualifications of a qualified health planMembers of Congress and congressional staff may only enroll in either plans created under ACA (e.g., CO-OPs) or in plans offered in Exchange – but this also required a “fix” because ACA as written did not allow of an employer contribution to coverage purchased through the individual exchangesTwo-way data exchange requirements are huge© P.R. Kongstvedt14 Actuarial ServicesActuaries analyze the data and predict costs, adjusted forTrendUtilizationCostsBenefits designBehavioral shiftDistribution amongst different providers with different cost profilesActuaries generally do not create the rates, but only model costsLarge payers have their own, smaller and mid-sized plans use actuarial consulting firms15 Rating and UnderwritingUnderwriting has had two distinct but related meanings:Medical underwriting referred to using an individual’s or small group’s medical history to determine whether to offer coverage at allGeneral underwriting includes gathering of information to assist in the development of premium ratesUnderwriters use the actuarial data and other factors to calculate ratesThree types of premium rating:Community ratingExperience ratingPremium equivalent or imputed premium ratesType of rating only affects the calculation of the base rate, not the mechanics of creating actual premium ratesCommunity rating requires the same base rate for all, though may be different for all individuals vs. all small groupsExperience rating uses base rate from actual costs of the groupPremium equivalent is calculated just like experience rating for the base rate16Market segments and distribution channels for the MCOs Essay PaperRating and Underwriting in the Individual and Small Group Markets under the ACAExtension of dependent coverage to age 26Prohibition on rescissions except in cases of outright fraudProhibition of preexisting condition exclusions and coverage rescissionsLifetime and annual policy coverage limits prohibitedRequire first-dollar coverage for preventive servicesMinimum medical loss ratio (MLR) of 85% for large group and 80% for individuals and small groups – applies only to insured business, not self-funded (no premiums)Insurers required to guarantee availability and renewability to individuals and groups.Insurers not allowed to use health status as a rating variableOnly the following will be allowed:Age related pricing variations are limited to a maximum of 3 to 1.The number of people covered under the policy (e.g., “single” vs. “family” coverage).Tobacco use (except rates may not vary by more than a ratio of 1.5 to 1)Other provisions such as out-of-pocket cost limitations based on income, etc.Requirement to include Essential Health Benefits at one of four different coverage levelsPremium risk-adjustment mechanism for individual and small group marketsBeginning in 2018, impose an excise tax of plans with premiums that exceed a certain level17© P.R. Kongstvedt The ACA’s Four Coverage Tiers What’s in Your Wallet?Allows for 40% swing in cost sharing between Platinum and Bronze plan designsCoverage levels based on in-network costs for all but emergency care (defined via “prudent layperson), not billed chargesCoverage based on actuarial equivalency, so may be spread around benefits, except cannot have different cost-sharing for MH/BH than for Med/Surg.Room to futz with benefits as long as cost sharing ends up where it’s supposed to18High deductible plan with preventive services and limited office visit coverage for the under-30s   18Eligibility in the Commercial MarketEligibility in the commercial (non-Medicare/Medicaid) market may be thought of in four categories:Eligibility in Employer Sponsored Group Benefits PlansEligibility changes based on life eventsIndividual eligibilityEligibility for subsidized coverageEmployer sponsored coverageMust be full timeDependent coverage through employeeMust first enroll during defined periods such as upon employment following a defined number of days after they start working 19 Life Events and Eligibility Options[Put Table 6 – 2 here]20Market segments and distribution channels for the MCOs Essay Paper Life Events and Eligibility Options (cont’d)[Put Table 6 – 2 here]21 Elements of Claims Complexity Multiple Lines of BusinessProvider Payment RulesSophiscated Px & Dx CodingUnbundled ClaimsReferral/Authorization RulesGovernment MandatesMedicare/Medicaid StandardsOther Party LiabilityCost Sharing FeaturesBenefit Plan VariationsMultiple Lines of BusinessRules and Regulations of ExchangeTracking MLR for Groups and IndividualsValue Based BenefitsNew Payment Models22 Claims Operational FunctionsThe modern claims capability is the set of operational functions within the payer organization that together process claims from receipt to issuance of payment and/or Explanation of Benefits (EOB).23© PR Kongstvedt Determination of Eligibility & LiabilityBenefit plan in force on the date of serviceProvider network and/or PCP on date of serviceCoordination of Benefits (COB), Other Party Liability (OPL), and SubrogationBenefits AdministrationApplying the applicable schedule of benefits in force on the date of serviceRequires CPT codes, Hospital Revenue Codes, HCPCS codes, ICD-10Computation of cost sharing amountsApplication of appropriate medical policiesApplication of appropriate provider payment schedules based on specific network at time of service, in vs. out of network, etc.Management of pended claims, resubmissions, and duplicate claimsAdjustments and appealsDetection of fraud and abuse24Core Claims Determinations in the Adjudication ProcessMarket segments and distribution channels for the MCOs Essay PaperRole of Member Services and Consumer AffairsHelp members understand how to use the planHelp resolve members’ problems or questionsMeasure and monitor member satisfaction, administer surveysMonitor and track the nature of member contactsAllow members to express dissatisfaction with their careHelp members seek review of claims that have been denied or covered at a lower than expected level of benefitsManage member problems with paymentsHelp address routine business issuesState health insurance exchanges may play a similar function, but unclear at this point25 Formal Internal Appeals Process Requirements[Put Table 6 – 3 here]26 Formal External Appeals Process Requirements[Put Table 6 – 4 here]27© P.R. Kongstvedt Financial ManagementFour primary responsibilitiesOperational financeBudgetingTreasury function (managing cash and investments)ReportingKey conceptsAccrual accountingStatutory Accounting Principles (SAP) vs. Generally Accepted Accounting Principles (GAAP)Only cash and cash equivalents can be counted as assets, not things like IT systems, buildings, long-term investments, etc.Statutory Net Worth requirements, using SAPCalculation and management of claims reserves, including Incurred But Not Reported (IBNR)28. Market segments and distribution channels for the MCOs Essay Paper

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