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Two state-based health insurance regulators is unusual in the United States, and has led to various additional work to synchronize laws. [3] This dual regulation arose due for historical reasons, and when the DMHC was created in 2000, the California legislature requested a report on merging the health insurer responsibilities with the CDI. [4 ...
The California Medical Assistance Program (Medi-Cal or MediCal) is the California implementation of the federal Medicaid program serving low-income individuals, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults with incomes below 138% of federal poverty level.
Jointly operated by Blue Shield of California Promise Health Plan and L.A. Care Health Plan, community resource centers offer member support services, enrolment in local and state assistance programs and other community services. Centers are currently located in Pomona, Lynwood, East Los Angeles and Palmdale.
In the context of a health insurer or health plan it is defined as: [5] A method of managing the provision of health care to members with high-cost medical conditions. The goal is to coordinate the care so as to both improve continuity and quality of care and lower costs.
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards.
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.
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Medical underwriting is a health insurance term referring to the use of medical or health information in the evaluation of an applicant for coverage, typically for life or health insurance. As part of the underwriting process, an individual's health information may be used in making two decisions: whether to offer or deny coverage and what ...
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