Managed Care Programs




Federal Employees Health Benefits Program (FEHBP)

  • is a system of “managed competition” through which employee benefits are provided to full-time permanent civilian employees of the United States Government. It allows insurance companies and employee associations such as labor unions to develop health, dental, and allied plans to be marketed to governmental employees.
  • These plans are available to employees during an “open enrollment” once probationary status has been passed by a new employee, during which time the employee, if accepting enrollment, will be covered fully in any plan he or she chooses without limitations regarding “pre-existing conditions”. After this, changes can be made only upon a “life-change” event such as marriage, divorce, adoption or birth of a child, or change in employment status of a spouse, or during the annual “open season”, during which employees can enroll, disenroll, or change from one plan to another. The exact dates change from year to year, but basically is from the Monday of the second full week in November through Monday, the second full week of December.

Flexible spending arrangement (FSA), or Flexible Spending Account, 

  • is one of a number of tax-advantaged financial accounts that can be set up through a cafeteria plan of an employer in the United States. An FSA allows an employee to set aside a portion of his or her earnings to pay for qualified expenses as established in the cafeteria plan, most commonly for medical expenses but often for dependent care or other expenses. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes, resulting in a substantial payroll tax savings.
  • The most common FSA, the medical expense FSA (also medical FSA or health FSA), is similar to ahealth savings account (HSA) or a health reimbursement account (HRA). However, while HSAs and HRAs are almost exclusively used as components of a consumer driven health care plan, medical FSAs are commonly offered with more traditional health plans as well. An FSA may be utilized by paper claims or an FSA debit card also known as a Flexcard.

Health insurance

  • is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government.[1] Synonyms for this usage include “health coverage,” “health care coverage” and “health benefits.” In a more technical sense, the term is used to describe any form of insurance that provides protection against injury or illness. This usage includes private insurance and social insurance programs such as Medicare, but excludes social welfare programs such as Medicaid. In addition to medical expense insurance, it also includes insurance covering disability or long-term nursing or custodial care needs.
  • The US market-based health care system relies heavily on private and not-for-profit health insurance, which is the primary source of coverage for most Americans. According to the United States Census Bureau, approximately 85% of Americans have health insurance; nearly 60% obtain it through an employer, while about 9% purchase it directly.[2] Various government agencies provide coverage to about 28% of Americans (there is some overlap in these figures).[2]

Health Reimbursement Accounts, or Health Reimbursement Arrangements, (HRAs)

  • are IRS-sanctioned arrangements that allow an employer, as agreed to in the HRA plan document, to reimburse for medical expenses paid by participating employees. HRAs reimburse only those items (copays, coinsurance, deductibles and services) agreed to by the employer which are not covered by the company’s selected standard insurance plan (any health insurance plan, not only high-deductible plans). These arrangements are described in IRS Section 105.

Health Savings Account (HSA)

  • is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a Flexible spending account (FSA), funds roll over and accumulate year over year if not spent. HSAs are owned by the individual, which differentiates them from the company-owned Health Reimbursement Arrangement(HRA) that is an alternate tax-deductible source of funds paired with HDHPs. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA account in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. These accounts are a component of consumer driven health care.

High Deductible Health Plan (HDHP)

  • is a health insurance plan with lower premiums and higherdeductibles than a traditional health plan.

HMO– health maintenance organization (HMO)

  • is a type of managed care organization (MCO) that provides a form of health care coverage in the United States that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options.[1] Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO’s guidelines and restrictions in exchange for a steady stream of customers.

Managed care

  • is used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care (“managed care techniques”), organizations that use those techniques or provide them as services to other organizations (“managed care organizations”), or systems of financing and delivering health care to enrollees organized around managed care techniques and concepts (“managed care delivery systems”). According to the National Library of Medicine, the term “managed care” encompasses programs:

…intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organization


  • is the United States health program for eligible individuals and families with low incomes and resources. It is a means-tested program that is jointly funded by the states and federal government, and is managed by the states.[1] Among the groups of people served by Medicaid are eligible low-income parents, children, seniors, and people with disabilities. Being poor, or even very poor, does not necessarily qualify an individual for Medicaid.[2] Indeed, it is estimated that approximately 60 percent of poor Americans are not covered by Medicaid.[3] Medicaid is the largest source of funding for medical and health-related services for people with limited income in the US.


  • is a social insurance program administered by the United States government, providinghealth insurance coverage to people who are aged 65 and over, or who meet other special criteria. It was originally signed into law on July 30, 1965, by President Lyndon B. Johnson as amendments toSocial Security legislation. At the bill-signing ceremony President Johnson enrolled former PresidentHarry S. Truman as the first Medicare beneficiary and presented him with the first Medicare card.[1]

Medical savings account (MSA) i

  • account, generally associated with self-employed individuals, in which tax-deferred deposits can be made for medical expenses. Withdrawals from the MSA are tax-free if used to pay for qualified medical expenses. The MSA must be coupled with a high-deductible health plan (HDHP). Withdrawals from MSA go toward paying the deductible expenses in a given year. MSA account funds can cover expenses related to most forms of medical care, disability, dental care, vision care, and long-term care, whether the expenses were billed through the qualifying insurance or otherwise.

Medical underwriting

  • is an insurance term referring to the use of medical or health status information in the evaluation of an applicant for coverage (typically for life or health insurance). As part of the underwriting process, health information may be used in making two related decisions: whether to offer or deny coverage; and what premium rate to set for the policy. The use of medical underwriting may be restricted by law in certain insurance markets. Where allowed, the criteria used should be objective, clearly related to the likely cost of providing coverage, practical to administer, consistent with applicable law, and designed to protect the long-term viability of the insurance system.[1]
  • The use of medical underwriting in the individual health insurance market has met with some controversy. While medical underwriting is designed to keep premiums as low as possible, critics say that the practice prevents some people with relatively minor and treatable pre-existing conditions from obtaining health insurance. Some states have outlawed medical underwriting as a condition for obtaining insurance; these states generally have the highest average premiums for individual insurance.

PPO preferred provider organization (or “PPO”, sometimes referred to as aparticipating provider organization)

  • managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to providehealth care at reduced rates to the insurer’s or administrator’s clients.The idea of a preferred provider organization is that the providers will provide the insured members of the group a substantial discount below their regularly-charged rates. This will be mutually beneficial in theory, as the insurer will be billed at a reduced rate when its insured utilize the services of the “preferred” provider and the provider will see an increase in its business as almost all insureds in the organization will use only providers who are members. Even the insured should benefit, as lower costs to the insurer should result in lower rates of increase in premiums. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network. They negotiate with providers to set fee schedules, and handle disputes between insurers and providers. PPOs can also contract with one another to strengthen their position in certain geographic areas without forming new relationships directly with providers.

TRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services(CHAMPUS), 

  • managed care component of the United States Department of Defense Military Health System. TRICARE provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the Reserve Component. The TRICARE program is managed by TRICARE Management Activity (TMA) under the authority of the Assistant Secretary of Defense (Health Affairs). TRICARE is the civilian care component of the Military Health System although historically, it also included health care delivered in the military medical treatment facilities.

The State Children’s Health Insurance Program (SCHIP)

  • is a United States federal government program that gives funds to states in order to provide health insurance to families with children. The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

The Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395ddEMTALA)

  • is a United States Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act. It requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment. EMTALA applies to “participating hospitals”, i.e., those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program. However, in practical terms, EMTALA applies to virtually all hospitals in the U.S., with the exception of the Shriners Hospitals for Children, Indian Health Service hospitals, and Veterans Affairs hospitals. The combined payments of Medicare and Medicaid, $602 billion in 2004,[1] or roughly 44% of all medical expenditures in the U.S., make not participating in EMTALA impractical for nearly all hospitals. EMTALA’s provisions apply to all patients, and not just to Medicare patients.[2][3]

United States Department of Veterans Affairs (VA)

  • is a government-run military veteran benefit system with Cabinet-level status. It is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors. The benefits provided include disability compensation, pension, education, home loans, life insurance, vocational rehabilitation, survivors’ benefits, medical benefits and burial benefits.[1] It is administered by the United States Secretary of Veterans Affairs.




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