Topic
payers
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From HMOs to Homerooms: What Managed Care 101 Teaches Us About California’s Youth Behavioral Health Reform
HMO, PPO, EPO, capitation, value-based care — see how these managed care basics play out in real life through California’s CYBHI Fee Schedule program and its Evaluation Hub…
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Business · Innovations · Leadership · Managed Care · MCO · Medical Loss Ratio · Medicare · Medicare Advantage · Payers · Providers · Startups · Value Based CareThe 2025 Healthcare Perfect Storm: How Rising Costs and Increased Scrutiny Impact Insurers
The blog post examines the health insurance industry’s challenges in 2025, highlighting rising healthcare costs, increased patient demand, and heightened government scrutiny. Insurers, particularly those focused on Medicare…
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Business · HMO · Innovations · Managed Care · Maternity · Maternity Kick Payments · MCO · Medicaid · PayersUnderstanding State-Level Variation in Medicaid Managed Care Maternity Kick Payments
Understanding State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care Introduction Today, we’re exploring an intriguing study on the state-level variation in supplemental maternity kick payments…
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California · California Advancing and Innovating Medi-Cal (CalAIM) · Care Coordination · CHIP · CMS · Justice-Involved · Medicaid · Substance Use Disorders · Value Based Care · YouthMedicaid Coverage for Incarcerated Youth: California’s Initiative
What is the Justice-Involved Initiative? The Justice-Involved Initiative is a pioneering program under California’s Medicaid reforms, specifically designed to extend Medicaid coverage to incarcerated individuals. Historically, under the…
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Business · California · California Advancing and Innovating Medi-Cal (CalAIM) · Medicaid · Population Needs Assessment (PNA) · Quality Improvement · Resource · SDoHAddressing Critical Health Needs: Partnership HealthPlan of California Strategic Response to the 2024 Population Needs Assessment
Business Brief: Addressing Critical Needs in Population Health Partnership’s membership remained relatively stable in 2023. The member redetermination process, resulting from the winding down of the COVID-19 Public…
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Alabama · Arkansas · Colorado · Connecticut · Data Tools · Databank · Delaware · Florida · Georgia · Hawaii · Idaho · Illinois · Indiana · Iowa · Kentucky · Louisiana · Maine · Managed Care · Massachusetts · Mississippi · Missouri · Montana · Nebraska · Network Management · New Jersey · North Carolina · North Dakota · Oklahoma · Payers · Policies & Procedures · Regulation · Resource · Rhode Island · South Carolina · South Dakota · Tennessee · texas · Utah · Virginia · Wisconsin · Wyoming35 States with Any Willing Provider laws
As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.
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Eligibility: Contract Language (Payer v Provider) and Sample to Use
Eligibility: Contract Language (Payer v Provider) and Sample to Use.
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Business · Connected Care · Contracting · Databank · Digital Therapeutics · Funding · HEDIS · Managed Care · Payers · Press · Reimbursement · Startups · Subcontracting · Value Based Care · virtual health · Virtual Specialty CareHealth Insurance Providers’ Actions Concerning Mental Health
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New Jersey Health Care Quality Act (HCQA) and Provider Bill of Rights
The New Jersey Health Care Quality Act (HCQA), N.J.S.A. 26:2S-1 et seq. and rules establish certain rights AND responsibilities for health care providers that contract with carriers for…
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Managed Care Contracts and Health System Operational Alignment
CASE EXAMPLE of how we breakdown contracts and tie the terms to operational alignment Because the business of healthcare is to deliver the highest quality care to patients,…
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Medical Loss Ratio
The medical loss ratio (MLR) is the percentage of premium that health insurers spend on medical care and quality improvement activities. Prior to the Affordable Care Act (ACA),…
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Health Net, Carenodes, and Insight Choices Expand Access to Telehealthcare
Health Net has grant funded a proposal by Insight Choices, in partnership with Carenodes, to expand virtual healthcare delivery capacity and accessibility. In response to the ongoing COVID-19…
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Strong Networks Begin with Strong Healthcare Provider Relationships
As Medicare Advantage plans already know, many factors go into building a robust CMS-compliant network. One focal point should be strong provider relationships. Carenodes is committed to cultivating…