Health Insurance and Managed Care What They Are and How They Work

Health Insurance and Managed Care: What They Are and How They Work (formerly titled Managed Care: What It Is and How It Works) is a concise introduction to the foundations of the American managed health care system. Written in clear and accessible language, this handy guide offers an historical overview of managed care and then walks the reader through the organizational structures, concepts, and practices of the managed care industry.
The Fourth Edition is a thorough update that addresses the impact of the Affordable Care Act throughout the industry including:
- New underwriting requirements
- New marketing and sales channels
- Limitations on sales, governance, and administrative (SG&A) costs and profits
- New provider organizations such as Patient Centered Medical Homes (PCHMs) and Accountable Care Organizations (ACO’s)
- New payment mechanisms such as shared savings with ACOs, and severity-adjusted diagnosis related groups
- Changes to Medicare Advantage
- Medicaid expansion and reliance on Medicaid managed care

Preface
Acknowledgments
About the Author
Keeping Current
Chapter1 A History of Managed Health Care and Health Insurance in the United States
Chapter2 Health Benefits Coverage and Types of Health Plans
Chapter3 The Provider Network
Chapter4 Provider Payment
Chapter5 Utilization Management, Quality Management, and Accreditation
Chapter6 Sales, Governance and Administration
Chapter7 Medicare and Medicaid
Chapter8 Laws and Regulations in Managed Care
Glossary