Discuss the regulatory structure used to regulate MCOs and health insurers at the state level.

Medicare Regulations

 Medicare is a federally regulated program that mandates compliance to its standards through state and federal oversight. One of the primary purposes of Medicare regulations is the protection of its recipients. Medicare Advantage is part of the Medicare Modernization Act, which was passed in 2003. Search the Internet by using the following keywords:

  • Medicare regulations
  • Centers for Medicare
  • Medicaid services

On the basis of your research, answer the following questions:

  • What are the purposes of Medicare regulations other than the one mentioned above?
  • How will the federal government enforce compliance in the Medicare Advantage program? Which two other Medicare regulations do you think are the most important for managed care organizations and why?
  • Do you think Medicare and Medicaid programs face challenges from the perspectives of providers, the government, and consumers (recipients of Medicare or Medicaid)? Why or why not?
  • What are the different services provided by the Medicare and Medicaid programs? Do you feel there is a need to have two different programs? Why or why not?
  • Discuss the advantages and disadvantages of Medicare programs such as Medicare Advantage and Medicare Part D. Do you think Medicare Advantage programs ensure the survivability of Medicare? Why or why not?

Additionally, respond to the questions given below after reading the following information in regard to control of managed care organizations at the state level.

States have a broad range of control of managed health care organizations. The main interests of the states are to protect the interest of the consumer and regulate the structure of MCOs.

  • Discuss the regulatory structure used to regulate MCOs and health insurers at the state level.
  • Discuss how states came to be the primary regulators of insurance.
  • Evaluate the most critical components of state oversight of HMO operations.
  • Review the licensing requirements for MCOs in your state and describe the specific requirements to obtain a Certificate of Authority (COA). Compare to the requirements discussed in the course textbook.
  • What are the protections available to consumers under the law in your state? Compare these protections to what is discussed in the textbook.
  • In your opinion, are the state regulations designed for the consumers, or are they designed for the MCOs? Use your course and text readings to support your answer

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