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Health Insurance and Managed Care: What They Are and How They Work is a concise introduction to the workings of health insurance and managed care within the American health care system. Written in clear and accessible language, this text offers an historical overview of managed care before walking the reader through the organizational structures, concepts, and practices of the health insurance and managed care industry. The Fifth Edition is a thorough update that addresses the current status of The Patient Protection and Affordable Care Act (ACA), including political pressures that have been partially successful in implementing changes. This new edition also explores the changes in provider payment models and medical management methodologies that can affect managed care plans and health insurer. The Fifth Edition also offers new or expanded coverage of: • “Moral hazard,” and its application in health insurance and managed care • The ever expanding and evolving payment systems and methodologies used in the U.S. Healthcare System • The role of benefits design along with discussion about medical necessity and its impact on benefits coverage • The impact of limitations on sales, governance and administrative (SG&A) costs and profits • Continued changes in payment mechanisms such as value-based payment under the Medicare Improvement for Patients and Providers Act (MIPPA) • Medicare Part D, the drug benefit and the plans that offer it, as well as the complexities of Medicare Advantage payment plans, Medicaid expansion under ACA, and more.
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