Market and Distribution Channels for MCOs.

NOW F OR AN ORIGINAL PAPER ASSIGNMENT: Market and Distribution Channels for MCOs.

This week’s chapter discusses the various market segments and distribution channels for the MCOs. Outline the market segments and identify the most successful distribution channels for those markets. Use some outside research to support your statements. Why do you believe each distribution channel successfully reaches the targeted market?

Discussion Board Requirements: 250 word count One original post and two reply posts, APA Format, please include references

Chapter 6: Sales, Governance and Administration

Learning Objectives

Understand the basic structure of governance and management in payer organizations

Understand the basic elements of the internal operations of payer organizations, including:

Information technology (IT)

Marketing and sales, including insurance exchanges

Underwriting and premium rate development

Eligibility, enrollment and billing

Claims and benefits administration

Member services, including appeal rights

Statutory accounting and statutory net worth

Financial management

Board of Directors

May be specific to a plan, may be pro-forma for a subsidiary of a larger company, etc.

Responsibilities:

Final approval of corporate bylaws

General oversight of the profitability or reserve status

Oversight and approval of significant fiscal events

Review of reports and document signing

Setting and approving policy

Oversight of the quality management program

In for-profit plans, responsibility to protect shareholders’ interests

In free-standing plans, hiring the CEO and reviewing CEO’s performance

Typical Key Management Positions

Chief Executive Officer/Executive Director

Chief Operating Officer/Operations Director

May be a separate position from CEO in large companies

If separate from CEO, the COO may also be the President

Chief Medical Officer/Medical Director

Vice President (or SVP or EVP) of Network Management

Chief Financial Officer/Finance Director

Treasurer

Chief Marketing Officer/Marketing Director

Chief Underwriting Officer

Chief Information Officer/Director of Information Systems

Corporate Compliance Officer

Typical Key Operational Committees

Quality Management Committee

Credentialing Committee

Utilization Review Committee

Pharmacy and Therapeutics Committee

Medical Grievance Review and Appeals Committee

Foundational Information Technology (IT) Systems

Key software functionality includes:

Benefit configuration

Employer group and member enrollment

Premium management

Provider enrollment, contracting and credentialing

Claims payment

Document Imaging and Workflow

Customer Servicing

Medical Management

Ability for two-way EDI with insurance exchanges, employers, state and federal government, members, providers, etc.

HIPAA Mandated Electronic Transaction Standards

HIPAA requires covered entities that conduct certain electronic transactions to use only ANSI X12N 5010 defined standards

ACA is creating new standards and requiring more standardization of implementation

7
Transaction Standard
Provider Claims submission ANSI X12 – 837 (different versions exist for institutional, professional, and dental)
Pharmacy claims NCPDP
Eligibility ANSI X12 – 270 (inquiry) ANSI X12 – 271 (response)
Claim status ANSI X12 – 276 (inquiry) ANSI X12 – 277 (response)
Provider Referral certification and authorization ANSI X12 – 278
Health care payment to provider, with remittance advice ANSI X12 – 835
Enrollment and Disenrollment in health plan* ANSI X12 – 834
Claims attachment (additional clinical information from provider to health plan, used for claims adjudication) ANSI X12 – 275 (not finalized at the time of publication), and HL7 CDA
Premium payment to health plan* ANSI X12 – 820
First report of injury ANSI X12 – 148 (not yet issued)
* These are for voluntarily but not mandatory use by employers, unions, or associations that pay premiums to the health plan on behalf of members.

Source: Compiled by author based on 45 CFR §160.920 and other sources at the Center for Medicare and Medicaid Services (CMS);

Accessible at http://www.cms.gov

HIPAA Mandated Privacy and Security Requirements

HIPAA requires high levels of privacy and security for electronic information, to:

ensure the confidentiality, integrity, and availability of electronic PHI;

protect against any reasonably anticipated threats or hazards to the security and integrity of electronic PHI;

protect against any reasonably anticipated uses or disclosures of electronic PHI not permitted by the HIPAA privacy rules; and

ensure compliance with the above by its workforce (Source: Federal Register, 45 CFR § 164.308)

There are eighteen standards for HIPAA security rules:

8
Security Management Process Assigned Security Responsibility Workforce Security
Information Access Management Security Awareness and Training Security Incident Procedures
Contingency Plan Evaluation Business Associate Contracts
Facility Access Controls Workstation Use Workstation Security
Device and Media Controls Access Control Audit Controls
Integrity Person or Identity Authentication Transmission Security
Source: Federal Register, 45 CFR § 164.308(a & b), 45 CFR § 164.310(a-d); 45 CFR § 164.312(a-e)

Standardized SBC/SOC

ACA requires all health plans, including self-funded, must provide a standardized Summary of Benefits and Coverage (SBC), also called a Summary of Coverage (SOC) to all current and prospective enrollees

The SBC/SOC to be done in a uniform and common format that defines the number of pages, the exact information that must be provided, and even the size of the font

The SBC does not replace the far more detailed Evidence of Coverage (EOC), sometimes called a Certificate of Coverage or Certificate of Insurance

Marketing vs. Sales

Marketing and sales are related but distinct activities

Marketing

Focus is on overall growth goals, strategies and tactics, management of the process

Compensation combination of salary and overall growth goals

Role in Insurance Exchange as well as outside exchange

Sales

The actual process of selling the plan’s offerings in the marketplace through any distribution channel

Compensation usually heavily weighted towards achievement of sales goals

No real role in the insurance exchange

Fundamental Elements of Marketing

Brand Management

External Communications and Public Relations

Advertising

Employer versus consumer advertising

Collateral texts: outdoor, direct

Market Research

Lead Generation

Sales Campaign Support

Heavily regulated for individual and small group market through the Exchange

Distribution Channels by Market Segment

Health Insurance Exchanges…

ACA created state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which small businesses with up to 100 employees can purchase qualified coverage

Separate exchanges for individuals to access coverage

Permit states to allow businesses with more than 100 employees to purchase coverage in the SHOP Exchange beginning in 2017

States may form regional Exchanges or allow more than one Exchange to operate in a state

Feds operate exchanges in states that refused to build them

Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entity

Creation of plan rating systems similar to that used in Medicare Advantage

Health Insurance Exchanges (cont.)

Brokers still allowed to operate in this market segment for health

Exchanges do not prohibit a non-Exchange market for individual and group coverage, but rates must be the same if sold both in and outside of the Exchange

Require the Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entity

Each multi-state plan must be licensed in each state and must meet the qualifications of a qualified health plan

Members of Congress and congressional staff may only enroll in either plans created under ACA (e.g., CO-OPs) or in plans offered in Exchange – but this also required a “fix” because ACA as written did not allow of an employer contribution to coverage purchased through the individual exchanges

Two-way data exchange requirements are huge

Actuarial Services

Actuaries analyze the data and predict costs, adjusted for

Trend

Utilization

Costs

Benefits design

Behavioral shift

Distribution amongst different providers with different cost profiles

Actuaries generally do not create the rates, but only model costs

Large payers have their own, smaller and mid-sized plans use actuarial consulting firms

Rating and Underwriting

Underwriting has had two distinct but related meanings:

Medical underwriting referred to using an individual’s or small group’s medical history to determine whether to offer coverage at all

General underwriting includes gathering of information to assist in the development of premium rates

Underwriters use the actuarial data and other factors to calculate rates

Three types of premium rating:

Community rating

Experience rating

Premium equivalent or imputed premium rates

Type of rating only affects the calculation of the base rate, not the mechanics of creating actual premium rates

Community rating requires the same base rate for all, though may be different for all individuals vs. all small groups

Experience rating uses base rate from actual costs of the group

Premium equivalent is calculated just like experience rating for the base rate

Excellent	Good	Fair	Poor
RESPONSIVENESS TO DISCUSSION QUESTION Discussion post minimum requirements: *The original posting must be completed by Wednesday, Day 3, at 11:59pm MST. Two response postings to two different peer original posts, on two different days, are required by Saturday, Day 6, at 11:59pm MST. Faculty member inquiries require responses, which are not included in the minimum number of posts. Your Discussion Board postings should be written in standard edited English and follow APA style for format and grammar as closely as possible given the constraints of the online platform. Be sure to support the postings with specific citations from this week’s Learning Resources as well as resources available through the Walden University online databases. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct.	8 (26.67%) – 8 (26.67%) Discussion postings and responses exceed the requirements of the Discussion instructions. They: Respond to the question being asked or the prompt provided; – Go beyond what is required in some meaningful way (e.g., the post contributes a new dimension, unearths something unanticipated); -Are substantive, reflective, with critical analysis and synthesis representative of knowledge gained from the course readings and current credible evidence. – Demonstrate significant ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Demonstrate that the student has read, viewed, and considered the Learning -Resources as well as additional resources and has read, viewed, or considered a sampling of colleagues’ postings; -Exceed the minimum requirements for discussion posts*.	7 (23.33%) – 7 (23.33%) Discussion postings and responses meet the requirements of the Discussion instructions. They: -Respond to the question being asked or the prompt provided; -Are substantive, reflective, with critical analysis and synthesis representative of knowledge gained from the course readings and current credible evidence.re -Demonstrate ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Demonstrate that the student has read, viewed, and considered the Learning Resources and has read, viewed, or considered a sampling of colleagues’ postings -Meet the minimum requirements for discussion posts*.	6 (20%) – 6 (20%) Discussion postings and responses are minimally responsive to the requirements of the Discussion instructions. They: – do not clearly address the objectives of the discussion or the question or prompt; and/or -May (lack) lack in depth, reflection, analysis, or synthesis but rely more on anecdotal than scholarly evidence; and/or -Do not adequately demonstrate that the student has read, viewed, and considered the Learning -Resources and/or a sampling of colleagues’ postings; and/or has posted by the due date at least in part. – Lack ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Do not meet the minimum requirements for discussion posts*.	0 (0%) – 5 (16.67%) Discussion postings and responses are unresponsive to the requirements of the Discussion instructions. They: – do not clearly address the objectives of the discussion or the question or prompt; and/or – Lack in substance, reflection, analysis, or synthesis but rely more on anecdotal than scholarly evidence. – Lack ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Do not demonstrate that the student has read, viewed, and considered the Learning Resources and/or a sampling of colleagues’ postings; and/or does not meet the minimum requirements for discussion posts*.
CONTENT KNOWLEDGE	8 (26.67%) – 8 (26.67%) Discussion postings and responses: -demonstrate in-depth understanding and application of concepts and issues presented in the course (e.g., insightful interpretations including analysis, synthesis and/or evaluation of topic; – are well supported by pertinent research/evidence from a variety of and multiple peer- reviewed books and journals, where appropriate; -Demonstrate significant mastery and thoughtful/accurate application of content, applicable skills or strategies presented in the course.	7 (23.33%) – 7 (23.33%) Discussion postings and responses: -demonstrate understanding and application of the concepts and issues presented in the course, presented with some understanding and application of concepts and issues presented in the course (e.g., insightful interpretations including analysis, synthesis and/or evaluation of topic; -are supported by research/evidence from peer-reviewed books and journals, where appropriate; and · demonstrate some mastery and application of content, applicable skills, or strategies presented in the course.	6 (20%) – 6 (20%) Discussion postings and responses: – demonstrate minimal understanding of concepts and issues presented in the course, and, although generally accurate, display some omissions and/or errors; –lack support by research/evidence and/or the research/evidence is inappropriate or marginal in quality; and/or lack of analysis, synthesis or evaluation of topic – demonstrate minimal content, skills or strategies presented in the course. ——-Contain numerous errors when using the skills or strategies presented in the course	0 (0%) – 5 (16.67%) Discussion postings and responses demonstrate: -A lack of understanding of the concepts and issues presented in the course; and/or are inaccurate, contain many omissions and/or errors; and/or are not supported by research/evidence; and/or lack of analysis, synthesis or evaluation of topic -Many critical errors when discussing content, applicable skills or strategies presented in the course.
CONTRIBUTION TO THE DISCUSSION	8 (26.67%) – 8 (26.67%) Discussion postings and responses significantly contribute to the quality of the discussion/interaction and thinking and learning by: -providing Rich and relevant examples; discerning and thought-provoking ideas; and stimulating thoughts and probes; – -demonstrating original thinking, new perspectives, and extensive synthesis of ideas supported by the literature.	7 (23.33%) – 7 (23.33%) Discussion postings and responses contribute to the quality of the discussion/interaction and thinking and learning by -providing relevant examples; thought-provoking ideas – Demonstrating synthesis of ideas supported by the literature	6 (20%) – 6 (20%) Discussion postings and responses minimally contribute to the quality of discussion/interaction and thinking and learning by: – providing few and/or irrelevant examples; and/or – providing few if any thought- provoking ideas; and/or -. Information that is restated from the literature with no/little demonstration of critical thinking or synthesis of ideas.	0 (0%) – 5 (16.67%) Discussion postings and responses do not contribute to the quality of interaction/discussion and thinking and learning as they do not: -Provide examples (or examples are irrelevant); and/or -Include interesting thoughts or ideas; and/or – Demonstrate of critical thinking or synthesis of ideas
QUALITY OF WRITING	6 (20%) – 6 (20%) Discussion postings and responses exceed doctoral -level writing expectations. They: · Use grammar and syntax that is clear, concise, and appropriate to doctoral level writing; · Make few if any errors in spelling, grammar, and syntax; · Use original language and refrain from directly quoting original source materials; -provide correct APA · Are positive, courteous, and respectful when offering suggestions, constructive feedback, or opposing viewpoints.	5 (16.67%) – 5 (16.67%) Discussion postings and responses meet doctoral -level writing expectations. They: ·Use grammar and syntax that is clear and appropriate to doctoral level writing; ; · Make a few errors in spelling, grammar, and syntax; · paraphrase but refrain from directly quoting original source materials; Provide correct APA format · Are courteous and respectful when offering suggestions, constructive feedback, or opposing viewpoints;.	4 (13.33%) – 4 (13.33%) Discussion postings and responses are minimally below doctoral-level writing expectations. They: · Make more than occasional errors in spelling, grammar, and syntax; · Directly quote from original source materials and/or paraphrase rather than use original language; lack correct APA format; and/or · Are less than courteous and respectful when offering suggestions, feedback, or opposing viewpoints.	0 (0%) – 3 (10%) Discussion postings and responses are well below doctoral -level writing expectations. They: · Use grammar and syntax that is that is unclear · Make many errors in spelling, grammar, and syntax; and –use incorrect APA format · Are discourteous and disrespectful when offering suggestions, feedback, or opposing viewpoints.
Total Points: 30

Excellent

Good

Fair

Poor

RESPONSIVENESS TO DISCUSSION QUESTION

Discussion post minimum requirements:

*The original posting must be completed by Wednesday, Day 3, at 11:59pm MST. Two response postings to two different peer original posts, on two different days, are required by Saturday, Day 6, at 11:59pm MST. Faculty member inquiries require responses, which are not included in the minimum number of posts. Your Discussion Board postings should be written in standard edited English and follow APA style for format and grammar as closely as possible given the constraints of the online platform. Be sure to support the postings with specific citations from this week’s Learning Resources as well as resources available through the Walden University online databases. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct.

8 (26.67%) – 8 (26.67%)

Discussion postings and responses exceed the requirements of the Discussion instructions. They: Respond to the question being asked or the prompt provided; – Go beyond what is required in some meaningful way (e.g., the post contributes a new dimension, unearths something unanticipated); -Are substantive, reflective, with critical analysis and synthesis representative of knowledge gained from the course readings and current credible evidence. – Demonstrate significant ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Demonstrate that the student has read, viewed, and considered the Learning -Resources as well as additional resources and has read, viewed, or considered a sampling of colleagues’ postings; -Exceed the minimum requirements for discussion posts*.

7 (23.33%) – 7 (23.33%)

Discussion postings and responses meet the requirements of the Discussion instructions. They: -Respond to the question being asked or the prompt provided; -Are substantive, reflective, with critical analysis and synthesis representative of knowledge gained from the course readings and current credible evidence.re -Demonstrate ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Demonstrate that the student has read, viewed, and considered the Learning Resources and has read, viewed, or considered a sampling of colleagues’ postings -Meet the minimum requirements for discussion posts*.

6 (20%) – 6 (20%)

Discussion postings and responses are minimally responsive to the requirements of the Discussion instructions. They: – do not clearly address the objectives of the discussion or the question or prompt; and/or -May (lack) lack in depth, reflection, analysis, or synthesis but rely more on anecdotal than scholarly evidence; and/or -Do not adequately demonstrate that the student has read, viewed, and considered the Learning -Resources and/or a sampling of colleagues’ postings; and/or has posted by the due date at least in part. – Lack ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Do not meet the minimum requirements for discussion posts*.

0 (0%) – 5 (16.67%)

Discussion postings and responses are unresponsive to the requirements of the Discussion instructions. They: – do not clearly address the objectives of the discussion or the question or prompt; and/or – Lack in substance, reflection, analysis, or synthesis but rely more on anecdotal than scholarly evidence. – Lack ability to generalize and extend thinking and evaluate theories or concepts within the topic or context of the discussion. -Do not demonstrate that the student has read, viewed, and considered the Learning Resources and/or a sampling of colleagues’ postings; and/or does not meet the minimum requirements for discussion posts*.

CONTENT KNOWLEDGE

8 (26.67%) – 8 (26.67%)

Discussion postings and responses: -demonstrate in-depth understanding and application of concepts and issues presented in the course (e.g., insightful interpretations including analysis, synthesis and/or evaluation of topic; – are well supported by pertinent research/evidence from a variety of and multiple peer- reviewed books and journals, where appropriate; -Demonstrate significant mastery and thoughtful/accurate application of content, applicable skills or strategies presented in the course.

7 (23.33%) – 7 (23.33%)

Discussion postings and responses: -demonstrate understanding and application of the concepts and issues presented in the course, presented with some understanding and application of concepts and issues presented in the course (e.g., insightful interpretations including analysis, synthesis and/or evaluation of topic; -are supported by research/evidence from peer-reviewed books and journals, where appropriate; and · demonstrate some mastery and application of content, applicable skills, or strategies presented in the course.

6 (20%) – 6 (20%)

Discussion postings and responses: – demonstrate minimal understanding of concepts and issues presented in the course, and, although generally accurate, display some omissions and/or errors; –lack support by research/evidence and/or the research/evidence is inappropriate or marginal in quality; and/or lack of analysis, synthesis or evaluation of topic – demonstrate minimal content, skills or strategies presented in the course. ——-Contain numerous errors when using the skills or strategies presented in the course

0 (0%) – 5 (16.67%)

Discussion postings and responses demonstrate: -A lack of understanding of the concepts and issues presented in the course; and/or are inaccurate, contain many omissions and/or errors; and/or are not supported by research/evidence; and/or lack of analysis, synthesis or evaluation of topic -Many critical errors when discussing content, applicable skills or strategies presented in the course.

CONTRIBUTION TO THE DISCUSSION

8 (26.67%) – 8 (26.67%)

Discussion postings and responses significantly contribute to the quality of the discussion/interaction and thinking and learning by: -providing Rich and relevant examples; discerning and thought-provoking ideas; and stimulating thoughts and probes; – -demonstrating original thinking, new perspectives, and extensive synthesis of ideas supported by the literature.

7 (23.33%) – 7 (23.33%)

Discussion postings and responses contribute to the quality of the discussion/interaction and thinking and learning by -providing relevant examples; thought-provoking ideas – Demonstrating synthesis of ideas supported by the literature

6 (20%) – 6 (20%)

Discussion postings and responses minimally contribute to the quality of discussion/interaction and thinking and learning by: – providing few and/or irrelevant examples; and/or – providing few if any thought- provoking ideas; and/or -. Information that is restated from the literature with no/little demonstration of critical thinking or synthesis of ideas.

0 (0%) – 5 (16.67%)

Discussion postings and responses do not contribute to the quality of interaction/discussion and thinking and learning as they do not: -Provide examples (or examples are irrelevant); and/or -Include interesting thoughts or ideas; and/or – Demonstrate of critical thinking or synthesis of ideas

QUALITY OF WRITING

6 (20%) – 6 (20%)

Discussion postings and responses exceed doctoral -level writing expectations. They: · Use grammar and syntax that is clear, concise, and appropriate to doctoral level writing; · Make few if any errors in spelling, grammar, and syntax; · Use original language and refrain from directly quoting original source materials; -provide correct APA · Are positive, courteous, and respectful when offering suggestions, constructive feedback, or opposing viewpoints.

5 (16.67%) – 5 (16.67%)

Discussion postings and responses meet doctoral -level writing expectations. They: ·Use grammar and syntax that is clear and appropriate to doctoral level writing; ; · Make a few errors in spelling, grammar, and syntax; · paraphrase but refrain from directly quoting original source materials; Provide correct APA format · Are courteous and respectful when offering suggestions, constructive feedback, or opposing viewpoints;.

4 (13.33%) – 4 (13.33%)

Discussion postings and responses are minimally below doctoral-level writing expectations. They: · Make more than occasional errors in spelling, grammar, and syntax; · Directly quote from original source materials and/or paraphrase rather than use original language; lack correct APA format; and/or · Are less than courteous and respectful when offering suggestions, feedback, or opposing viewpoints.

0 (0%) – 3 (10%)

Discussion postings and responses are well below doctoral -level writing expectations. They: · Use grammar and syntax that is that is unclear · Make many errors in spelling, grammar, and syntax; and –use incorrect APA format · Are discourteous and disrespectful when offering suggestions, feedback, or opposing viewpoints.

Total Points: 30