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Similarities and differences between Medicare and Medicaid managed care plans
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Medicare Advantage: A Case Study
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Medicare Part C is also known as Medicare Advantage. Medicare Part C allows Medicare recipients obtain a private health insurance plan. The plans the induvial enrolled in must be Medicare approved. These individuals must pay the Medicare Part B premium. Other health care packages such as vision, dental, hearing, and prescription coverage may be included. The same networking restrictions apply to the Medicare Advantage plan as it does to regular private insurance plans. If the individual wants to upgrade to Medicare Advantage they can only do so October 15th- December 7th. If the individual wants to go back to the Original Medicare they can only do so January 1st – February 14th. To qualify you must have both Medicare Parts A and Part B. There is one restriction on an individual cannot have end stage renal failure. Parts C and D are completely optional. The eligibility requirements are they must have Medicare Parts A and B and enroll during …show more content…
Individuals can enroll in Part D, October 15th –December 7th. There is a coverage gap with Medicare Part D, this is also known as the Donut Hole. Each year the coverage gap limit is set ($3,310.00 in 2016). Medicare recipients who receive “extra help” from Medicare are exempted from the gap and do not have to pay. When the individual has entered the Medicare Gap, they are responsible for paying a portion of their medication. If the individual buys name brand medication, they have to pay 45% of their medication cost out of pocket. This money is added to their out of pocket costs. When the individual is purchasing generic medications, in 2016 the generic prescription 42% if covered by Medicare and the individual pays 58% of the cost. Each year Medicare decreases the amount the individual is required to pay. Once the decrease reaches the 25% cut off in the year 2020. Again the percentage of what the individual pays helps get them out of the Medicare
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Kaiser Permanente Case Study
1708 Words | 4 PagesMembership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
The Balanced Budget Act of 1997
938 Words | 2 PagesAccording to Medicare’s WebPage Medicare is a Health Insurance Program for people 65 years of age and older, some disabled people under 65 years of age, and people with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant). Medicare has two parts, Part A which is for basically hospital insurance. Most people do not have to pay for Part A. In addition it has a Part B, which is basically medical insurance. Most people pay a small monthly fee for Part B. Medicare first went into effect in 1966 and was originally administered by the Social Security Administration. In 1977 the control of it was switched over to the newly formed Health Care Financing Administration. Beginning in July 1973 Medicare was extended to persons under the age of 65 with certain disabling conditions. In 1988 Congress passed legislation to expand the program to cover health care costs of catastrophic illnesses.
Kaiser Permanente Case Study
957 Words | 2 PagesIntegrated Managed Care Organization- The organization is properly aligned for the primary driver being cost cutting services. Since all entities within the organization are responsible and affected by any expenses endured on any entity being unfavorable or favorable, the foundation serves as a primary motivator to reduce costs at all levels. This alignment eliminates any financial gains from driving high utilization of services or higher intensity services within the organization. Ultimately, this system allows the physician medical group to drive patient care, being responsible for the clinical care decisions as opposed to health plan making those decisions as designed in other organizations. This is the preferable model for Medicaid
Health Care Case Study
1406 Words | 3 PagesHealth Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
Medicare Part D
1800 Words | 4 Pages(II) The enacting of Medicare Part D in 2006 only helped to fuel America’s hunger for prescription medication. In 2003, President George W. Bush announced and signed the Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Medicare Modernization Act, or MMA) on December 8th. The roughly $400 billion dollar measure was marketed to the American public as something that will provide care for the millions of senior citizens who, at the time, were struggling to afford prescription medication. This was the largest development of Medicare since 1965, which is when the program was initially created, and gave hope to those wishing for positive medical reform. According to title XI of the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003”, the most significant change will be the affordability of prescription drugs by implementing the importation of drugs from Canada, along with necessary safety measures, in order to lessen the cost (United States Congress, 832). For those who were in retirement homes and lacked a steady income, the affordability of drugs was often a deciding factor in the decision to seek medical attention and the idea that those individuals ceased to live simply because they lacked the funds tugged at the heartstrings of many Americans.
Medicare: Cost and Implications for the Future
1965 Words | 4 PagesMedicare Part A now includes any person aged sixty-five or older who has been employed for
Medicare/Medicaid Summary
1020 Words | 3 PagesMedicare is a Federal health insurance program which consists of hospital insurance, medical insurance, customizable plans, and prescription drug coverage. Eligibility requirements for Medicare include individuals who are at least 65 years old, disabled individuals who are under the age of 65, and individuals at any age who have End-Stage Renal Disease. End-Stage Renal Disease is defined as permanent kidney failure that requires dialysis or a transplant. To be eligible for Medicare, an individual must be a U.S. citizen or permanent legal resident for five continuous years. Individuals must also be eligible for Social Security benefits with at least ten years of contribution payments. (Crosta)
Expanding Medicare to Include Prescription Drug Coverage
2103 Words | 5 PagesMany people argue that the lack of a prescription-drug benefit is the major shortcoming of the Medicare program. But are Medicare recipients really in need of such a benefit? According to a study done by the AARP Public Policy Institute, about 25.6 million, or 65 percent, of noninstitutionalized Medicare beneficiaries already receive some type of prescription-drug coverage, whether it is through employer-sponsored health plans or individually purchased private health policies. This leaves about 13.5 million Medicare beneficiaries who are without prescription-drug coverage.
The Reluctant Welfare State
2100 Words | 5 PagesPart D is the prescription plan for enrollees. Centers for Medicare and Medicaid Services, 2010. Medicare Part A is meant to be a major medical hospitalization plan that is offered to every US citizen that has turned 65 years old. It covers inpatient care in hospitals and skilled nursing facilities, hospice care, some home health care services, a semi-private room, meals and nursing services while in the hospital.... ...
Medicare Essay
1043 Words | 3 PagesThere are four components to the Medicare program, part A, B, C and D. Part A of Medicare covers in patient hospital services; patients have a financial responsibility to cover a deductible that is equivalent to 1 day of hospitalization, thereafter cost is covered at 100 percent for a maximum of 60 days. This also includes nursing facilities, home and hospice care. Part B covers outpatient surgery and physician office visits. This is an elective component of Medicare in that there is a premium associated with this plan that is paid for directly through social security payments. Part C is know as Medicare Advantage and is a supplemental policy that is purchased directly from employers; one may be denied for health reasons depending one when the plan is acquired. Part D is prescription drug coverage that is eligible to all individuals that qualify for Medicare. Beneficiaries of the Medicare choose which prescription plan they want and pay a corresponding monthly premium.
Medicare Pros And Cons
872 Words | 2 PagesMedicare has four parts A, B, C, and D. Medicare Part A covers inpatient hospitalization, skilled nursing centers, hospice and some home health services. Medicare Part B covers some services not covered by Part A. Typically there is a premium charged for this coverage. Part B Covers medical supplies and outpatient visits. Medicare Part C, also known as Medicare Advantage plans are offered by private insurance companies which are in contract with Medicare. Medicare Part C provides you benefits from Part A, Part B and usually covers prescription drugs. This plan will cover most services. Last is Medicare Part D, Part D is a prescription drug program offered by private insurance companies. Part D allows drug coverage to the original Medicare plan. (Medicare.gov, 2016)
The Medicare Problem
2703 Words | 6 PagesMedicare is the nation’s largest health insurance program. Generally, you are eligible for Medicare if you or your spouse worked for at least ten years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. Medicare-covered services include hospital insurance, inpatient hospital care, skilled nursing facility care, home health care, hospice care, and medical insurance (Medicare U.S.) With such an encompassing effect on the health insurance field, Medicare provides a haven for older individuals, and end-stage renal disease (ESRD) patients who require the best medical care for whatever possible reason. The only problem with this scenario is that doctors are turning many older patients away because they have Medicare. Why do doctors turn away Medicare patients? Is there a reason why certain doctors turn away certain patients?
Medicare and Medicaid
2099 Words | 5 PagesThese requirements overlap between the two and some beneficiaries do qualify for both benefits. This means that Medicaid is sometimes used to help pay for Medicare premiums and those who do quality for both programs are considered to be “dual eligible” and will usually enroll in both programs in order to cut personal costs. Medicare and Medicaid both have their financial woes, each have their burdens, a...
Medicare Essay
1253 Words | 3 PagesMedicare is a federal health insurance program for people, who are age sixty five or older, or people that have End Stage Renal Disease and permanent disabilities. There are four different entities of Medicare to include; Medicare Part A which is the Hospital Benefit that covers inpatient hospital services, hospice treatment, skilled nursing facilities and other home health services. Medicare Part B that covers the Professional component of the physicians' services, preventive services and medical supplies then there is Medicare Part C which is considered a Medicare Advantage Plans that is offered by a private company that has a contract with Medicare to provide the patient with both Part A and Part B benefits. A Medicare Advantage Plans consist of Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Private Fee for Special Needs Plans, Service Plans, and Medicare Medical Savings Account Plans.
Medicare and Medicaid
1303 Words | 3 PagesMedicare is a federally governed insurance program, primarily serving Americans over the age of 65, younger disabled meeting specific disability criteria, and dialysis patients having permanent kidney failure. Medicare is linked to Social Security, is not income based, and is available to every American meeting the requirements of the program. Those entitled to Medicare can select Original Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) paying co-insurance and deductibles or opt to add Part C (Medicare Advantage Plans) paying a monthly premium and co-payments normally less than the out-of-pocket expenses for Original Medicare.
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