Health insurance in the United States

Question

This piglix contains articles or sub-piglix about Health insurance in the United States

Answer 1

Universal American

Universal American (: UAM) is a Fortune 1000 company with offices throughout the United States, and headquarters in Rye Brook, New York. The company offers health insurance, and also deals in Medicare managed care plans, and Medicare prescription drug benefits. Subsidiaries include Heritage Health Systems, Inc.. Its CEO is Richard A. Barasch.

Universal American Corporation (UA) is an insurance, Finance and administrative services company that specializes in offering products to the senior and self-employed markets. UA Corp has targeted the senior market in particular because it is the fastest growing demographic segment in the country. UAC contracts with the federal government to offer Medicare Advantages with Prescription Drug Plans. Universal American is currently the 3rd largest Medicare Prescription Drug Plan organization and the Fifth largest Medicare Advantage Private-Fee-for-Service organization in the U.S. Universal American is traded on the New York Stock Exchange (NYSE) under the ticker symbol UAM.

As of November 17, 2016, WellCare, Inc., has agreed to acquire Universal American for ~$600M.

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Wikipedia

Answer 2

URAC

URAC

URAC is a non-profit organization that helps promote health care quality through the accreditation of organizations involved in medical care services.

URAC accreditation is given to an organization for a period of up to three years. An organization must go through a review again after this period expires in order to maintain their accredited status.

It is noted that “[t]he amount of time it takes for an organization to prepare an application… may vary depending on whether the appropriate work processes, policies, and procedures are in place” and “the type of accreditation you are seeking.” The website states that it “usually takes four to six months to complete an accreditation review once URAC receives your completed application.”

Accreditation standards for URAC programs are developed by independent experts, relying on advisory committees of experts in health care delivery. After internal discussion, the organization makes them available for public comment, refines them further based on comments, then passes them to URAC's independent advisory group for approval. URAC's board of directors gives final approval of accreditation standards.

Founded under the name Utilization Review Accreditation Commission in 1990, the name “was shortened to the acronym URAC in 1996 when it began accrediting other types of organizations such as health plans, pharmacies, and provider organizations.”

As of January 2016, the URAC website listed that it offered the following accreditation programs:

Educational programs include workshops, conferences, webinars and audio conferences open to individuals and companies in the health care industry. These programs cover best practices in URAC accreditation, and news on issues in health care presented by industry professionals and URAC staff.

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Answer 3

Usual, customary and reasonable

Usual, customary and reasonable (UCR) was and is an American method of generating health care prices, described as "more or less whatever doctors decided to charge." According to Steven Schroeder, Wilbur Cohen inserted UCR into the Social Security Act of 1965 "in an unsuccessful attempt to placate the American Medical Association." Health insurers determine what they deem to be "usual, customary and reasonable" and pay only a percentage of that.

Under an early version of this system bases on Resource-Based Relative Value Units, physician services were largely considered to be misvalued, with evaluation and management services being undervalued and procedures overvalued. Third-party payers (public and private health insurance) advocated for an improved model instead of the UCR fees that led to "some egregious distortions". In the mid-1980s, U.S. health care "payments for doing procedures had far outstripped payments for diagnosis". For example, "doctors who spent an hour making a complex and lifesaving diagnosis were paid forty dollars; for spending an hour doing a colonoscopy and excising a polyp, they received more than six hundred dollars". Costs for cataract surgery, which could be as high as $6,000 in 1985, "grew to consume 4% of Medicare's budget". And despite technology that reduced the time required for the surgery by a factor of 4 to 6, costs did not decrease.

The US government healthcare website defines usual, customary and reasonable as being "The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount." Often it is used by insurance companies and plan administrators when participants go out of network for services where typically the maximum the plan will pay for a claim is based on the prevailing rates in the area or UCR. These statistics are available from private and commercial sources.

In the context of prescription costs, the Government Accountability Office has stated that "The U&C price is the price an individual without prescription drug coverage would pay at a retail pharmacy."

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Answer 4

Vaccines for Children Program

The Vaccines for Children Program (VFC) is a federally funded program in the United States providing no-cost vaccines to children who lack health insurance or who otherwise cannot afford the cost of the vaccination. The VFC program was created by the Omnibus Budget Reconciliation Act of 1993 and is required to be a new entitlement of each state's Medicaid plan. The program was officially implemented in October 1994.

From 1989 through 1991, a measles epidemic in the United States resulted in several tens of thousands of cases of measles and hundreds of deaths. Upon investigation, CDC found that more than half of the children who had measles had not been immunized, despite seeing a health care provider.

In partial response to that epidemic, Congress passed the Omnibus Budget Reconciliation Act (OBRA) on August 10, 1993, creating the VFC Program. It became operational October 1, 1994 and is known as section 1928 of the Social Security Act, the VFC program is an entitlement for eligible children, age 18 and below.

Aiming to address the barrier of cost to families, the Vaccines for Children program represented a major vaccine finance reform, working as a state-operated federal entitlement program that supplied both public and private providers with federally purchased vaccines. This integration of both the public and private sector benefitted all providers. Because private providers now had a role in the nation's immunization program, they, along with the public health sector, benefitted from the supply of vaccines at no cost, educational opportunities, and the ability to provide immunization services to patients without a need for referral.

The VFC program is funded through an approval by the Office of Management and Budget (OMB), and the funds are allocated to the Centers for Disease Control and Prevention (CDC). The CDC buys vaccines at a discount directly from manufacturers and distributes them to state health departments and certain local and territorial public health agencies. The agencies then redistribute the vaccines at no cost to those private physicians' offices and public health clinics that are registered as VFC program providers.

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Wikipedia

Answer 5

Wellmark Blue Cross Blue Shield

Wellmark Blue Cross Blue Shield

Wellmark Blue Cross Blue Shield is a mutual insurance in the United States with more than two million members in Iowa and South Dakota. It is the dominant health insurance in Iowa. It is an independent licensee of the Blue Cross Blue Shield Association. Founded in 1939, Wellmark offers dental and health insurance as well as life insurance. It will begin participating in the health care exchange for 2017.

In 1939, 'Hospital Service Incorporated of Iowa' (later known as Blue Cross of Iowa) began business in Des Moines, Iowa. That same year, 'Associated Hospital Services Incorporated' (later known as Blue Cross of Western Iowa and South Dakota) was established in Sioux City, Iowa. In 1945, Iowa Medical Service (later known as Blue Shield of Iowa) was formed. In 1948, Associated Hospital Services began doing business in South Dakota and marketing activities as Blue Cross. In 1956 'South Dakota Medical Service' began doing business in South Dakota as South Dakota Blue Shield. In 1986, Blue Cross and Blue Shield of Iowa purchased Benefit Administrators of America, Inc., a third-party administrator, which was the plans' first for-profit venture. Benefit Administrators of America was renamed Wellmark Administrators, Inc. in 1997.

In 1989, Blue Cross of Iowa, Blue Shield of Iowa and Blue Cross of Western Iowa and South Dakota merged to form 'IASD Health Services Corporation'. In 1991, IASD Health Services Corporation became a mutual insurance. In 1994, Blue Cross Blue Shield (BCBS) allowed its licensees to be for-profit corporations, and the joint service agreement of Blue Cross of South Dakota and South Dakota Blue Shield expired, putting the two plans in competition with one another.

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Answer 6

Wisconsin Physicians Service

Wisconsin Physicians Service Insurance Corporation (WPS Health Solutions) is a not-for-profit service insurance corporation based in Madison, Wisconsin. WPS offers health insurance plans for groups and individuals and benefit plan administration for businesses. WPS also provides insurance claims processing services under various U.S. government contracts and has a subsidiary corporation, EPIC Specialty Benefits, offering dental and other nonmedical benefits.

In 1946, the State Medical Society of Wisconsin formed the WPS division in Milwaukee to market and administer the Wisconsin Plan, a non-profit insurance plan intended to help those having difficulty paying for health care.

Charles Crownhart became WPS’ first chief executive officer in 1946, and WPS was awarded the American Medical Association (AMA) Seal of Acceptance in 1948.

WPS relocated from Milwaukee to Madison in 1950. WPS expanded across the state over the next decade, opening sales offices in Kenosha, Green Bay, Eau Claire, Milwaukee, and Wausau. Later, offices were opened in Appleton and La Crosse. WPS moved its Madison headquarters to 1717 W. Broadway in November 1973. In 1998, WPS consolidated its three major lines of business—Medicare, TRICARE, and WPS Health Insurance—on its Monona campus.

In 1975, the Wisconsin legislature passed a law requiring that service insurance corporations be legally separate from the parent professional society.

In order to comply with the legislation, on April 27, 1977, WPS ended its relationship with the Wisconsin Medical Society, becoming an independent not-for-profit corporation.

Ray Koenig was named the first president of WPS.

On June 11, 2012, Mike Hamerlik succeeded Jim Riordan as WPS president and chief executive officer. Hamerlik was formerly the CEO of Noridian Administrative Services, LLC.

In 2016, the International Ethisphere Institute® named WPS one of the World’s Most Ethical Companies^® for the seventh straight year.

The WPS Military and Veterans Health (MVH) business unit serves members of the U.S. military and their families through TRICARE and Veterans Administration programs.

Since 1956, WPS has continually served the Military Health System as a claims administrator. WPS managed the first regional plan for Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

WPS MVH provides claims administration, customer service, and related activities for the TRICARE Overseas Program and TRICARE For Life Program. WPS MVH also does contract work for the Veterans Choice program, which is operated by the Department of Veterans Affairs.

On July 21, 2016, the U.S. Department of Defense awarded Humana Government Business the TRICARE 2017 contract for the East Region, with WPS MVH as a subcontractor. WPS will provide information technology support, claims processing, and customer service functions. The East Region includes 30 states and approximately 6 million TRICARE beneficiaries.

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