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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 ...
Aetna Inc. (/ ˈ ɛ t n ə / ET-nə) is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare.
Hackensack Meridian Health, locked in a contract dispute with Aetna, has sent letters to the insurer's customers warning them that they may lose in-network coverage if the two sides can't reach a ...
In 2007, 87% of Californians had some form of health insurance. [47] Services in California range from private offerings: HMOs, PPOs to public programs: Medi-Cal, Medicare, and Healthy Families . Insurers can pay providers a capitation only in the case of HMOs. [48]
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Employers must disclose the value of the benefits they provided beginning in 2012 for each employee's health insurance coverage on the employee's annual Form W-2's. [46] This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 2010–69 on October 23, 2010. [ 47 ]
Concerns have also been raised about insurance carriers' efforts to limit the number of providers in their networks to reduce costs. A study of the California marketplace confirmed these concerns, but also showed that geographic access was similar and quality at times superior in marketplace-based plans. [99] "Cherry-picking"
In 1982, Blue Shield merged with The Blue Cross Association to form the Blue Cross and Blue Shield Association (BCBS). [11] Prior to 1986, organizations administering BCBS were tax exempt under 501(c)(4) as social welfare plans. The Tax Reform Act of 1986 revoked the exemption, however, because the plans sold commercial-type insurance.