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An important aspect of self-funded group health plans lies in the requirement that the employer remain liable for funding of plan claims regardless of the purchase of stop-loss insurance. What this means, in turn, is a fund or company's own bank account creates a pool of their employees and is managed & distributed to claim payouts.
If individuals or anyone in their families claim an exemption from minimum essential coverage, individuals are not required to make a shared responsibility payment. If individuals have a gross income below the tax return filing threshold for a certain year, they are automatically exempt from the shared responsibility provision for that year.
Unlike capitation, bundled payment does not penalize providers for caring for sicker patients. [ 5 ] Considering the advantages and disadvantages of fee-for-service, pay for performance , bundled payment for episodes of care, and global payment such as capitation, Mechanic and Altman concluded that "episode payments are the most immediately ...
Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
A prospective payment system (PPS) is a term used to refer to several payment methodologies for which means of determining insurance reimbursement is based on a predetermined payment regardless of the intensity of the actual service provided.
Health Insurance Portability and Accountability Act of 1996; Other short titles: Kassebaum–Kennedy Act, Kennedy–Kassebaum Act: Long title: An Act To amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use ...
Underwriting requirements even for voluntary group life cover are far less onerous than for similar insurance on individual lives. However, the assessment criteria for group life insurance cover is more strict in comparison to individual coverage. It is easier to qualify for benefits under individual cover than group cover at claim stage.
But, "for people in poor or fair health, the chances of losing coverage are much greater for people who had small-group insurance than for those who had individual insurance." The authors attribute these results to the combination in the individual market of high costs and guaranteed renewability of coverage.