HCM400: Managed Care and Health Insurance

HCM400: Managed Care and Health Insurance
Credit Hours:
3
Contact Hours:
This is a 3-credit course, offered in accelerated format. This means that 16 weeks of material is covered in 8 weeks. The exact number of hours per week that you can expect to spend on each course will vary based upon the weekly coursework, as well as your study style and preferences. You should plan to spend 10-25 hours per week in each course reading material, interacting on the discussion boards, writing papers, completing projects, and doing research.
Course Description and Outcomes
Course Description:
Managed care and health insurance covers healthcare issues surrounding management, insurances, and managed healthcare plans and discusses the new regulations from the Affordable Care Act (ACA). Students will learn about the basic foundations concerning insurance benefit plans for Medicare and Medicaid. The course will also cover fundamental ideas concerning cost-containment measures and quality of healthcare being delivered, focusing on a US-based approach to healthcare insurance plans for HMOs and other integrated insurance delivery systems.
Course Overview:
Managed Care and Health Insurance presents an overview of key concepts related to payers, providers, and consumers of public and private health plans. Students will examine the progression of the health insurance market and identify the impact of the Patient Protection and Affordable Care Act (ACA) on the administration of health plans and on the role of the health care administrator.
Course Learning Outcomes
1. Examine quality assessment and accountability in health care.
2. Summarize the historical context of the managed healthcare delivery system through present day.
3. Compare and contrast the U.S. healthcare managed system with the healthcare systems of other international developed nations.
4. Explain the medical insurance system that includes Medicare, Medicaid, and healthcare – based institutional insurances.
5. Summarize the factors that contributed to the development of health insurance and managed care in the U.S.
Participation & Attendance
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Prompt and consistent attendance in your online courses is essential for your success at CSU-Global Campus. Failure to verify your attendance within the first 7 days of this course may result in your withdrawal. If for some reason you would like to drop a course, please contact your advisor.
Online classes have deadlines, assignments, and participation requirements just like on-campus classes. Budget your time carefully and keep an open line of communication with your instructor. If you are having technical problems, problems with your assignments, or other problems that are impeding your progress, let your instructor know as soon as possible.
Course Materials
Textbook Information is located in the CSU-Global Booklist on the Student Portal.
Course Schedule
Due Dates
The Academic Week at CSU-Global begins on Monday and ends the following Sunday.
• Discussion Boards: The original post must be completed by Thursday at 11:59 p.m. MT and Peer Responses posted by Sunday 11:59 p.m. MT. Late posts may not be awarded points.
• Opening Exercises: Take the opening exercise before reading each week’s content to see which areas you will need to focus on. You may take these exercises as many times as you need. The opening exercises will not affect your final grade.
• Mastery Exercises: Students may access and retake mastery exercises through the last day of class until they achieve the scores they desire.
• Critical Thinking: Assignments are due Sunday at 11:59 p.m. MT.
• Live Classroom: Although participation is not required, Live Classroom sessions are held during Week 2 and Weeks 5 or 6. There are two total sessions.
Week #
Required Readings
Assignments
1
• Chapters 1, 2, and 3 in Essentials of Managed Health Care
• Opening Exercise (0 points)
• Discussion (25 points)
• Mastery Exercise (10 points)
2
• Chapters 4, 5, and 6 in Essentials of Managed Health Care
• Opening Exercise (0 points)
• Discussion (25 points)
• Live Classroom (0 points)
• Critical Thinking (95 points)
• Portfolio Project Milestone (10 points)
• Mastery Exercise (10 points) SAMPLE
3
• Chapters 7, 8, and 9 in Essentials of Managed Health Care
• Opening Exercise (0 points)
• Discussion (25 points)
• Critical Thinking (95 points)
• Portfolio Project Milestone (20 points)
• Mastery Exercise (10 points)
4
• Chapters 10, 11, and 12 in Essentials of Managed Health Care
• Opening Exercise (0 points)
• Discussion (25 points)
• Mastery Exercise (10 points)
5
• Chapters 13, 14, and 15 in Essentials of Managed Health Care
• Opening Exercise (0 points)
• Discussion (25 points)
• Live Classroom Option 1 (0 points)
• Critical Thinking (95 points)
• Mastery Exercise (10 points)
6
• Chapters 16, 17, 19, 21, and 23 in Essentials of Managed Health Care
• Opening Exercise (0 points)
• Discussion (25 points)
• Live Classroom Option 2 (0 points)
• Critical Thinking (85 points)
• Portfolio Project Milestone (20 points)
• Mastery Exercise (10 points)
7
• Chapters 24, 25, 26 and 27 in Essentials of Managed Health Care
• Opening Exercise (0 points)
• Discussion (25 points)
• Mastery Exercise (10 points)
8
• Chapters 28, 29 and 30 in Essentials of Managed Health Care
• Discussion (25 points)
• Opening Exercise (0 points)
• Mastery Exercise (10 points)
• Portfolio Project (350 points, including 50 points from milestones)
Assignment Details This course includes the following assignments/projects:
Module 1
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PORTFOLIO PROJECT REMINDER:
Review the Portfolio Project description and grading rubric in the Module 8 folder. Then review the Portfolio Project reminders and milestones due in Modules 2, 3, and 6. These reminders and milestones will help you prepare for the final assignment.
Module 2
CRITICAL THINKING ASSIGNMENT (95 points):
Choose one of the following two assignments to complete this week. Do not do both assignments. Identify your assignment choice in the title of your submission.
Note that while there are two options for this Critical Thinking Assignment, there is only one rubric. Review the rubric to confirm that you are meeting the assignment requirements.
Option #1: Provider Payment
Select one of the documents listed on this website: http://www.who.int/health_financing/documents/provider_payment/en/.
Provide a summary of the document, including author, countries addressed, and key facts. Explain how that document contributes to our understanding of the course concepts discussed in Chapter 5:
• Payment methodology
• Fee for Service (FFS)
• Managed care plans
• Patient Protection and Affordable Care Act (ACA)
• Pay for Performance (P4P) programs
Your paper should be 3 to 5 pages in length (not including the title and reference pages), double-spaced, and in conformance with the CSU-Global Guide to Writing and APA Requirements, and it must include a minimum of three additional sources.
Option #2: Local Healthcare Facility
Select a healthcare facility in your area and explore the facility’s website to gather information.
Discuss the type of facility and the contracting situation it is likely to have. Consider the following points in your discussion:
• Is the facility for-profit or nonprofit?
• What is its focus?
• Why is the facility likely to have the type of contract you specified?
Your paper should be 3 to 5 pages in length (not including the title and reference pages), double-spaced, and in conformance with the CSU-Global Guide to Writing and APA Requirements, and it must include a minimum of three additional sources.
PORTFOLIO PROJECT (10 points): SAMPLE
Portfolio Project Topic
This week, you should review the instructions for the Portfolio Project in the Module 8 folder and begin thinking about a topic. Identify which Portfolio Project option you will choose. Write a paragraph outlining the scope of your topic and how you plan to start your research.
Module 3
CRITICAL THINKING ASSIGNMENT (95 points):
Choose one of the following two assignments to complete this week. Do not do both assignments. Identify your assignment choice in the title of your submission.
Note that while there are two options for this Critical Thinking Assignment, there is only one rubric. Review the rubric to confirm that you are meeting the assignment requirements.
Option #1: Managing Ancillary Utilization
Kongstvedt (2013) notes that the management of utilization is one of the most important aspects of controlling overall healthcare costs. Methods used vary from weak and mechanical to tightly managed.
Develop a policy and procedure for managing ancillary utilization in a managed care plan. Be specific regarding the type of ancillary service and explain how this policy and procedure will:
• Maximize resources
• Contain costs
• Ensure that appropriate care is provided
Create a presentation for the administration outlining your proposed policy and procedure.
Your presentation should comprise 5 to 7 slides (not including the title or reference slides), and should adhere to the CSU-Global Guide to Writing and APA Requirements. A minimum of three sources should be cited and referenced. Your slideshow presentation should also be accompanied by an audio track. Images used should include the source information in parenthesis below the image. (Example – Source: http://www.website.com)
Reference
Kongstvedt, P.R. (2013). Essentials of managed health care (6th ed.). Sudbury, MA: Jones and Bartlett.
Option #2: Disease Management (DM)
Recent years have seen an increase in the use of information technology to make disease management programs more successful. These methods include:
• Free cell phones for pushing reminders to participants
• Artificial intelligence programs to predict high-cost patients
• Automated creation of care plans SAMPLE
Choose one use of information technology that you think will have a significant impact on disease management. Create a presentation for the healthcare administration explaining why purchasing this information technology product would be a worthwhile investment.
Your presentation should include:
• A discussion of what makes disease management unique
• A description of the population the product would impact
• Which component(s) of disease management would be significantly impacted:
o Recruitment
o Engagement
o Interaction
o Documentation
o Or another important component of DM
Your presentation should comprise 5 to 7 slides (not including the title or reference slides), and should adhere to the CSU-Global Guide to Writing and APA Requirements. A minimum of three sources should be cited and referenced. Your slideshow presentation should also be accompanied by an audio track. Images used should include the source information in parenthesis below the image. (Example – Source: http://www.website.com)
PORTFOLIO PROJECT (20 points)
Portfolio Project Outline:
Submit an outline of your Portfolio Project that is at least one page in length and includes a basic guide for each section of your paper.
Module 5
CRITICAL THINKING ASSIGNMENT (95 points):
Choose one of the following two assignments to complete this week. Do not do both assignments. Identify your assignment choice in the title of your submission.
Note that while there are two options for the Critical Thinking Assignment, there is only one rubric. Review the rubric to confirm that you are meeting the assignment requirements.
Option #1: Prevention of Illness
Discuss the argument for prevention of illness in this county. Consider the following questions in your paper:
• Why are some people for it and others very much against it?
• What impact does the Affordable Care Act (ACA) have on this argument?
• What is the economic value of prevention?
SAMPLE
Your paper should be 3 to 5 pages in length (not including the title and reference pages), double-spaced, and in conformance with the CSU-Global Guide to Writing and APA Requirements, and it must include a minimum of three additional sources.
Option #2: Quality Management Model
Use the Quality Management (QM) model to develop a new prevention program. Write an essay describing the following:
• How the model is applied
• How this method differs from traditional/existing quality assurance
• Why you chose specific interventions or approaches
• How effectiveness will be measured
Your paper should be 3 to 5 pages in length (not including the title and reference pages), double-spaced, and in conformance with the CSU-Global Guide to Writing and APA Requirements, and it must include a minimum of three additional sources.
Module 6
CRITICAL THINKING ASSIGNMENT (85 points):
Choose one of the following two assignments to complete this week. Do not do both assignments. Identify your assignment choice in the title of your submission.
Note that while there are two options for the Critical Thinking Assignment, there is only one rubric. Review the rubric to confirm that you are meeting the assignment requirements.
Option #1: Fraud Control
Examine Table 19-2 in your textbook and review the statutes, regulatory agencies, and organizations relevant to healthcare fraud (such as the Fraud Enforcement Recovery Act of 2009 [FERA] and the Patient Protection and Affordable Care Act [ACA]). Choose the initiative/organization that you believe has had the biggest impact on healthcare fraud control and write a paper discussing its impact. Consider the following questions:
• Does this statute/organization prevent or detect fraud?
• What type of fraud does it prevent/detect?
• How does it meet the challenges of fraud detection and prevention?
Your paper should be 3 to 5 pages in length (not including the title and reference pages), double-spaced, and in conformance with the CSU-Global Guide to Writing and APA Requirements, and it must include a minimum of three additional sources.
Option #2: Regulatory Requirements and Reporting
Research and determine which regulatory agencies/organizations govern financial reporting and solvency for different types of managed care organizations. Prepare a chart that compares/contrasts the approach of each agency. Your chart should include:
SAMPLE
• A description of each agency
• The type of healthcare organization impacted
• Different aspects of its governance
Your chart should be prepared according to CSU-Global Guide to Writing and APA Requirements and include a minimum of three sources.
PORTFOLIO PROJECT (20 points):
Portfolio Reference List
Prepare a reference list in APA format with at least four academic sources that you intend to use for your Portfolio Project. Use CSU-Global Guide to Writing and APA Requirements to help you with formatting your references. The CSU-Global Library is a good place to search for peer-reviewed sources.
Module 7
Module 8
PORTFOLIO PROJECT (300 points):
Choose one of the following two assignments to complete this week. Do not do both assignments. Identify your assignment choice in the title of your submission.
Note that while there are two options for the Portfolio Project, there is only one rubric. Review the rubric to confirm that you are meeting the assignment requirements.
Review the work you have already completed for the Portfolio Project throughout the semester:
• Week 2: Topic (10 points)
• Week 3: Outline (20 points)
• Week 6: Reference List (20 points)
Portfolio Project Option #1: Compare Insurance Plans by State
Part I Various programs provide free or low-cost coverage to millions of families with limited income. Develop a scenario in which an individual or family is currently making use of such a program, but plans to move to another state. Create a chart that compares your chosen program in three (3) different states and recommend a state to which the individual, or family, should move. Your chart should contain the following:
• A brief paragraph describing the scenario (e.g., elderly war veteran, pregnant woman, young girl who is visually impaired)
• Program features and characteristics (e.g., type, benefits, costs)
• Visual indication of the state you recommend
Part II Write a 7-8 page description of your decision-making process. Your reflection should address the following questions: SAMPLE
• What are the most important features that impacted your state choice?
• What difficulties did you face in choosing a state?
• Under what circumstances would you recommend a different state, and why?
Your paper must adhere to the following requirements:
• Be written in accordance with the CSU-Global Guide to Writing and APA Requirements
• Be 7-8 pages in length (not including the cover and reference pages); that is, approximately 3,000-3,500 words
• Include headings, per APA guidelines
• Include at least four (4) sources
Portfolio Project Option #2: Find the Right Insurance Plan
Part I Each consumer of medical services has slightly different needs. Think about your own needs with regard to medical services and those of your family. Research the plan options that are available to you and choose a plan that best meets your needs. Create a chart that compares three (3) of the plan options and indicate which option you have chosen. Your chart should contain the following:
• Plan features and characteristics (e.g., type, benefits, costs)
• Visual indication of your chosen insurance plan
Part II Write a 7-8 page description of your decision-making process. Your reflection should address the following questions:
• What are the most important features that impacted your plan choice?
• What difficulties did you face in choosing a plan?
• Under what circumstances would your plan choice be different, and why?
Your paper must adhere to the following requirements:
• Be written in accordance with the CSU-Global Guide to Writing and APA Requirements
• Be 7-8 pages in length (not including the cover and reference pages); that is, approximately 3,000-3,500 words
• Include headings, per APA guidelines
• Include at least four (4) sources
Course Policies
Course Grading
20% Discussion Participation
0% Opening Exercises
0% Live Classroom
8% Mastery Exercises
Grading Scale and Policies
A
95.0 – 100
A-
90.0 – 94.9
B+
86.7 – 89.9
B
83.3 – 86.6 SAMPLE
37% Critical Thinking Assignments 35% Final Portfolio Paper
B-
80.0 – 83.2
C+
75.0 – 79.9
C
70.0 – 74.9
D
60.0 – 69.9
F
59.9 or below
In-Classroom Policies
For information on late work and incomplete grade policies, please refer to our In-Classroom Student Policies and Guidelines or the Academic Catalog for comprehensive documentation of CSU-Global institutional policies.
Academic Integrity
Students must assume responsibility for maintaining honesty in all work submitted for credit and in any other work designated by the instructor of the course. Academic dishonesty includes cheating, fabrication, facilitating academic dishonesty, plagiarism, reusing /re-purposing your own work (see CSU-Global Guide to Writing and APA Requirements for percentage of repurposed work that can be used in an assignment), unauthorized possession of academic materials, and unauthorized collaboration. The CSU-Global Library provides information on how students can avoid plagiarism by understanding what it is and how to use the Library and Internet resources.
Citing Sources with APA Style
All students are expected to follow the CSU-Global Guide to Writing and APA Requirements when citing in APA (based on the APA Style Manual, 6th edition) for all assignments. For details on CSU-Global APA style, please review the APA resources within the CSU-Global Library under the “APA Guide & Resources” link. A link to this document should also be provided within most assignment descriptions on your course’s Assignments page.
Disability Services Statement
CSU–Global is committed to providing reasonable accommodations for all persons with disabilities. Any student with a documented disability requesting academic accommodations should contact the Disability Resource Coordinator at 720-279-0650 and/or email ada@CSUGlobal.edu for additional information to coordinate reasonable accommodations for students with documented disabilities.
Netiquette
Respect the diversity of opinions among the instructor and classmates and engage with them in a courteous, respectful, and professional manner. All posts and classroom communication must be conducted in accordance with the student code of conduct. Think before you push the Send button. Did you say just what you meant? How will the person on the other end read the words?
Maintain an environment free of harassment, stalking, threats, abuse, insults or humiliation toward the instructor and classmates. This includes, but is not limited to, demeaning written or oral comments of an ethnic, religious, age, disability, sexist (or sexual orientation), or racist nature; and the unwanted sexual advances or intimidations by email, or on discussion boards and other postings within or connected to the online classroom.
If you have concerns about something that has been said, please let your instructor know.
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