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Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its medical appropriateness before it is provided, by using evidence-based criteria or guidelines.
An Indiana health insurance plan used by hundreds of thousands could be in danger after a Washington, D.C. judge ruled in favor of a lawsuit against the Department of Health and Human Services and ...
As initially passed, the ACA was designed to provide universal health care in the U.S.: those with employer-sponsored health insurance would keep their plans, those with middle-income and lacking employer-sponsored health insurance could purchase subsidized insurance via newly established health insurance marketplaces, and those with low-income would be covered by the expansion of Medicaid.
All private health insurance plans offered in the Marketplace must offer the following essential health benefits: ambulatory care, emergency services, hospitalization (such as surgery), maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitative and habilitative services (services to help people ...
The Affordable Care Act (ACA) established the health insurance rate review program in order to protect consumers from unreasonable rate increases. [1] Through this program, proposed premium increases in the small group and individual markets that are above a threshold amount (ten percent or more, as of February 2014) are reviewed by states or the federal government to determine whether the ...
Health insurance coverage is provided by several public and private sources in the United States. Analyzing these statistics is challenging due to multiple survey methods [12] and persons with multiple sources of insurance, such as those with coverage under both an employer plan and Medicaid. [1]
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