Please add a few more sentences to each question.
1. ACA requires HMOs to achieve a certain “medical loss ratio”. What is a “medical loss ratio” and why is this an important issue?
The medical loss ratio is understood as the percentage of premium insurance spends on claims and expenses that are incurred to improve the health care quality. Computation of the ratio is important so that the insurance companies can know whether they are within the stipulated Affordable Care Act. The act requires that the insurance companies spend between 80% and 85% of premium dollars on medical care. Therefore, the calculation of the ratio will help highlight whether or not they are within the act. Moreover, they can come up with ways to reduce any deficit.
2. After the passage of Medicare, the federal government has played a major role in setting health policy. Identify and briefly discuss three federal laws regulating health care which have had a material impact on HMOs and the health care industry in general.
Various laws enacted by the federal government and affect he health care industry include the Health Insurance Accountability and Portability Act of 2013. It expands protection of patient’s health information through the strengthening of protection and privacy rules. The Patient’s Protection and Affordable Care Act provides for comprehensive health reforms in the industry. It impacts on the patient, the provider and the insurance cover and how they coordinate in the managed care. The American with Disability Amendment Act impacts on the health sector as it helps ensure that there is no discrimination of any case when it comes to the people living with disabilities.
3. Over a dozen years ago, California established the Department of Managed Health Care, one of the first in the nation to recognize that HMOs were different from other forms of health care insurance. Please identify and discuss three major functions of this Department.
The California department of managed health care is a creational department of the Health Maintenance Organization. It was initially developed to handle and enforce the Knox-Keene Healthcare Service Plan ACT of 1975. The act was to ensure that the healthcare service plans in the county were thoroughly revisited and ensure there smooth transition. However, in recent years, the activities done by the department have evolved. It, nevertheless, still handles some of the related regulations and laws regarding the enforcement of the act. The department can also help out in the case of disasters such as floods.
4. Incurred But Not Reported (IBNR) in claims processing can (and has) led to insolvency on the part of some medical group. Discuss IBNR and identify several ways capitated medical groups try to address this issue.
The incurred but not reported aspect is described as the amount owed by an insurer to all the claims which have had a loss covered but not yet reported it. The insurer does not always know the exact number of the losses covered, hence, making the sum a mere estimate. Medical groups usually try to address the issue and discourage it from gaining ground through various methods. The groups usually try to encourage the patients to report any amount owed in time to avoid the issue. Moreover, the groups can also rely on estimates from methods such as actuarial reserving to ensure that the loss is covered.
5. There are two basic methods HMOs (and other insurance companies) use to rate the risk of providing insurance to employers: experience rating and community rating. Briefly discuss each method and explain the merits and problems associated with each method.
Community rating is used when the insurer wants to charge all the clients covered by the same type of health policy and the same premium. It does not regard aspects of age, gender, health status or occupation. Premiums are, consequently, determined through basing on health and demographic profile. In this type of rating, the higher groups such as those comprising, the older people are averaged out by, the lower groups comprising young and energetic people. The expenses are pooled together and then equally spread out across all the participants involved.
Experience rating, on the other hand, is used by insurance companies when predicting the future medical cost of a group by its past experiences. In this case, the calculation of the premiums by the insurer is based on the insurer’s history rather than the community’s experience. Past experiences, in this case, include aspects of actual cost of providing healthcare coverage to the given group at a specific period and the group’s claim history in the insurance.

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Please add a few more sentences to each question.
1. ACA requires HMOs to achieve a certain “medical loss ratio”. What is a “medical loss ratio” and why is this an important issue?
The medical loss ratio is understood as the percentage of premium insurance spends on claims and expenses that are incurred to improve the health care quality. Computation of the ratio is important so that the insurance companies can know whether they are within the stipulated Affordable Care Act. The act requires that the insurance companies spend between 80% and 85% of premium dollars on medical care. Therefore, the calculation of the ratio will help highlight whether or not they are within the act. Moreover, they can come up with ways to reduce any deficit.
2. After the passage of Medicare, the federal government has played a major role in setting health policy. Identify and briefly discuss three federal laws regulating health care which have had a material impact on HMOs and the health care industry in general.
Various laws enacted by the federal government and affect he health care industry include the Health Insurance Accountability and Portability Act of 2013. It expands protection of patient’s health information through the strengthening of protection and privacy rules. The Patient’s Protection and Affordable Care Act provides for comprehensive health reforms in the industry. It impacts on the patient, the provider and the insurance cover and how they coordinate in the managed care. The American with Disability Amendment Act impacts on the health sector as it helps ensure that there is no discrimination of any case when it comes to the people living with disabilities.
3. Over a dozen years ago, California established the Department of Managed Health Care, one of the first in the nation to recognize that HMOs were different from other forms of health care insurance. Please identify and discuss three major functions of this Department.
The California department of managed health care is a creational department of the Health Maintenance Organization. It was initially developed to handle and enforce the Knox-Keene Healthcare Service Plan ACT of 1975. The act was to ensure that the healthcare service plans in the county were thoroughly revisited and ensure there smooth transition. However, in recent years, the activities done by the department have evolved. It, nevertheless, still handles some of the related regulations and laws regarding the enforcement of the act. The department can also help out in the case of disasters such as floods.
4. Incurred But Not Reported (IBNR) in claims processing can (and has) led to insolvency on the part of some medical group. Discuss IBNR and identify several ways capitated medical groups try to address this issue.
The incurred but not reported aspect is described as the amount owed by an insurer to all the claims which have had a loss covered but not yet reported it. The insurer does not always know the exact number of the losses covered, hence, making the sum a mere estimate. Medical groups usually try to address the issue and discourage it from gaining ground through various methods. The groups usually try to encourage the patients to report any amount owed in time to avoid the issue. Moreover, the groups can also rely on estimates from methods such as actuarial reserving to ensure that the loss is covered.
5. There are two basic methods HMOs (and other insurance companies) use to rate the risk of providing insurance to employers: experience rating and community rating. Briefly discuss each method and explain the merits and problems associated with each method.
Community rating is used when the insurer wants to charge all the clients covered by the same type of health policy and the same premium. It does not regard aspects of age, gender, health status or occupation. Premiums are, consequently, determined through basing on health and demographic profile. In this type of rating, the higher groups such as those comprising, the older people are averaged out by, the lower groups comprising young and energetic people. The expenses are pooled together and then equally spread out across all the participants involved.
Experience rating, on the other hand, is used by insurance companies when predicting the future medical cost of a group by its past experiences. In this case, the calculation of the premiums by the insurer is based on the insurer’s history rather than the community’s experience. Past experiences, in this case, include aspects of actual cost of providing healthcare coverage to the given group at a specific period and the group’s claim history in the insurance.

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Your email address will not be published. Required fields are marked *