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Managed Care Organization Essay

USLegal.com

A managed care organization (MCO) is a health care provider or a group or organization of medical service providers who offers managed care health plans. It is a health organization that contracts with insurers or self-insured employers and finances and delivers health care using a specific provider network and specific services and products. They provide a wide variety of quality and managed health care services to enrolled workers keeping medical costs down through preventative medicine, patient education, and in other ways.

These organizations are certified by the director of the Department of Consumer and Business Services (DCBS). MCOs vary in their constitution as some organizations are made of physicians, while others are combinations of physicians, hospitals, and other providers. For instance, a group practice without walls, independent practice association, management services organization, and a physician practice management company are the common MCO’s. Patient Advocate Foundation

Providers of care, such as hospitals, physicians, laboratories, clinics, etc., make up a “managed care organization” delivery system often known as an “MCO.” Seven common MCO models are:

1. Preferred Provider Organization (PPO) An arrangement whereby a third-party payer (health plan) contracts with a group of medical-care providers who furnish services at agreed-upon rates in return for prompt payment and a certain volume of patients, perhaps under contract with a private insurer. The services may be furnished at discounted rates, and the insured population may incur out-of-pocket expenses for covered services received outside the PPO if the outside charge exceeds the PPO payment rate.

2. Point-of-Service Plan (POS) Also known as an open-ended HMO, POS plans encourage, but do not require, members to choose a primary care physician. As in traditional HMOs, the primary care physician may act as a “gatekeeper” when making referrals; plan members may, however, opt to visit out-of-network providers at their discretion. Subscribers choosing not to use a network physician must pay higher deductibles and co-payments than those using network physicians.

3. Exclusive Provider Organization (EPO) A network of providers that have agreed to provide services on a discounted basis. Enrollees typically do not need referrals for services from network providers (including specialists), but if a patient elects to seek care outside of the network, then he or she will not be reimbursed for the cost of the treatment. An EPO typically does not provide the preventive benefits and quality assurance monitor.

4. Physician-Hospital Organization (PHO) A contracted arrangement among physicians and hospital wherein a single entity, the Physician Hospital Organization, contracts to provide services to insurers’ subscribers.

5. Individual Practice Association (IPA) A formal organization of physicians or other providers through which they may enter into contractual relationships with health plans or employers to provide certain benefits or services.

6. Managed Indemnity Program A program in which the insurer pays for the cost of covered services after services have been rendered and uses various tools to monitor cost-effectiveness, such as precertification, second surgical opinion, case management, and utilization review. Also called managed fee-for-service programs.

7. Health Maintenance Organization (HMO) HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. An HMO contracts with health care providers, e.g., physicians, hospitals, and other health professionals, and members are required to use participating providers for all health services. Model types include staff, group practice, network, and IPA. They differ in their financial and organizational arrangements between the HMO and its physicians. Some HMOs combine various attributes of the four principal models.

WISCONSIN DEPARTMENT OF HEALTH SERVICES

When a person decides to enroll in Family Care, they become a member of a managed care organization (MCO). MCOs operate the Family Care program and provide or coordinate services in the Family Care benefit. The Family Care benefit combines funding and services from a variety of existing programs into one flexible long-term care benefit, tailored to each individual’s needs, circumstances and preferences. View a list of items covered in the Family Care benefit package.

In order to assure access to services, MCOs develop and manage a comprehensive network of long-term care services and support, either through purchase of service contracts with providers, or by direct service provision by MCO employees. MCOs are responsible for assuring and continually improving the quality of care and services consumers receive. MCOs receive a per person per month payment to manage care for their members, who may be living in their own homes, group living situations, or nursing facilities.

Some highlights of the Family Care benefit are:

When a person decides to enroll in Family Care, they become a member of a managed care organization (MCO). MCOs operate the Family Care program and provide or coordinate services in the Family Care benefit. The Family Care benefit combines funding and services from a variety of existing programs into one flexible long-term care benefit, tailored to each individual’s needs, circumstances and preferences. View a list of items covered in the Family Care benefit package.

In order to assure access to services, MCOs develop and manage a comprehensive network of long-term care services and support, either through purchase of service contracts with providers, or by direct service provision by MCO employees. MCOs are responsible for assuring and continually improving the quality of care and services consumers receive. MCOs receive a per person per month payment to manage care for their members, who may be living in their own homes, group living situations, or nursing facilities.

Some highlights of the Family Care benefit are:

People Receive Services Where They Live. MCO members receive Family Care services where they live, which may be in their own home or supported apartment, or in alternative residential settings such as Residential Care Apartment Complexes, Community-Based Residential Facilities, Adult Family Homes, Nursing Homes, or Intermediate Care Facilities for Individuals with Intellectual Disabilities. People Receive Interdisciplinary Case Management. Each member has support from an interdisciplinary team that consists of, at a minimum, a social worker/care manager and a Registered Nurse. Other professionals, as appropriate, also participate as members of the interdisciplinary team.

The interdisciplinary team conducts a comprehensive assessment of the member’s needs, abilities, preferences and values with the consumer and his or her representative, if any. The assessment looks at areas such as activities of daily living, physical health, nutrition, autonomy and self-determination, communication, and mental health and cognition. People Participate in Determining the Services They Receive. Members or their authorized representatives take an active role with the interdisciplinary team in developing their care plans. MCOs provide support and information to assure members are making informed decisions about their needs and the services they receive. Members may also participate in the Self-Directed Supports component of Family Care, in which they have increased control over their long-term care budgets and providers.

People Receive Family Care Services that Include:

Long-Term Care Services that have traditionally been part of the Medicaid Waiver programs or the Community Options Program. These include services such as adult day care, home modifications, home delivered meals and supportive home care. Health Care Services that help people achieve their long-term care outcomes. These services include home health, skilled nursing, mental health services, and occupational, physical and speech therapy. For Medicaid recipients, health care services not included in Family Care are available through the Medicaid fee-for-service program. People Receive Help Coordinating Their Primary Health Care. In addition to assuring that people get the health and long-term care services in the Family Care benefit package, the MCO interdisciplinary teams also help members coordinate all their health care, including, if needed, helping members get to and communicate with their physicians and helping them manage their treatments and medications.

People Receive Services to Help Achieve Their Employment Objectives. Services such as daily living skills training, day treatment, pre-vocational services and supported employment are included in the Family Care benefit package. Other Family Care services such as transportation and personal care also help people meet their employment goals. People Receive the Services that Best Achieve Their Outcomes. The MCO is not restricted to providing only the specific services listed in the Family Care benefit package. The MCO interdisciplinary care management team and the member may decide that other services, treatments or supports are more likely to help the member achieve his or her outcomes, and the MCO would then authorize those services in the member’s care plan. For a complete list of the services that must be offered by MCOs, refer to the description of the long-term care benefit package in the Health and Community Supports Contract.

People Receive Services Where They Live. MCO members receive Family Care services where they live, which may be in their own home or supported apartment, or in alternative residential settings such as Residential Care Apartment Complexes, Community-Based Residential Facilities, Adult Family Homes, Nursing Homes, or Intermediate Care Facilities for Individuals with Intellectual Disabilities. People Receive Interdisciplinary Case Management. Each member has support from an interdisciplinary team that consists of, at a minimum, a social worker/care manager and a Registered Nurse. Other professionals, as appropriate, also participate as members of the interdisciplinary team. The interdisciplinary team conducts a comprehensive assessment of the member’s needs, abilities, preferences and values with the consumer and his or her representative, if any.

The assessment looks at areas such as activities of daily living, physical health, nutrition, autonomy and self-determination, communication, and mental health and cognition. People Participate in Determining the Services They Receive. Members or their authorized representatives take an active role with the interdisciplinary team in developing their care plans. MCOs provide support and information to assure members are making informed decisions about their needs and the services they receive. Members may also participate in the Self-Directed Supports component of Family Care, in which they have increased control over their long-term care budgets and providers.

People Receive Family Care Services that Include:

Long-Term Care Services that have traditionally been part of the Medicaid Waiver programs or the Community Options Program. These include services such as adult day care, home modifications, home delivered meals and supportive home care. Health Care Services that help people achieve their long-term care outcomes. These services include home health, skilled nursing, mental health services, and occupational, physical and speech therapy. For Medicaid recipients, health care services not included in Family Care are available through the Medicaid fee-for-service program.

People Receive Help Coordinating Their Primary Health Care. In addition to assuring that people get the health and long-term care services in the Family Care benefit package, the MCO interdisciplinary teams also help members coordinate all their health care, including, if needed, helping members get to and communicate with their physicians and helping them manage their treatments and medications. People Receive Services to Help Achieve Their Employment Objectives. Services such as daily living skills training, day treatment, pre-vocational services and supported employment are included in the Family Care benefit package. Other Family Care services such as transportation and personal care also help people meet their employment goals. People Receive the Services that Best Achieve Their Outcomes. The MCO is not restricted to providing only the specific services listed in the Family Care benefit package.

The MCO interdisciplinary care management team and the member may decide that other services, treatments or supports are more likely to help the member achieve his or her outcomes, and the MCO would then authorize those services in the member’s care plan. For a complete list of the services that must be offered by MCOs, refer to the description of the long-term care benefit package in the Health and Community Supports Contract. A managed care organization (MCO) is a health care provider or a group of association of medical examination providers who proposes accomplished health plans. It is a health group that bonds with insurers or self-insured employers and funds and provides health care by means of a definite provider system and precise facilities and products. An MCO is an insurer that delivers both healthcare amenities and payment on behalf of services.

They offer a comprehensive range of quality and managed health care services to the joined employees by keeping medical charges down through preventive medicine, patient teaching, and in additional ways. These organizations are certified by the director of the Department of Consumer and Business Services (DCBS). MCOs vary in their constitution as some organizations are made of physicians, while others are combinations of physicians, hospitals, and other providers. For instance, a group practice without walls, independent practice association, management services organization, and a physician practice management company are the common MCO’s.


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