WK5A2: Please use APA format and list and site all sources and references: 5- to
ID: 122517 • Letter: W
Question
WK5A2:
Please use APA format and list and site all sources and references:
5- to 7 -page Microsoft Word document
Assess the differences in benefits and costs which are available to Medicare patients based upon the patent selecting either the “Traditional” Medicare program or Medicare Part C (Advantage Plan). Once a patient makes a choice, is he or she locked into the choice?
Evaluated at least two valuable elements to both programs and two negative elements to both programs.
Demonstrate which program would be more attractive to a physician and to a hospital as well as why.
Discuss Capitation and evaluate if either program reimburses using a capitation model.
Please use APA format and list and site all sources and references: cite your sources in your work and provide references for the citations in APA format.
At least 5- to 7-page in Microsoft Word document APA format.
Explanation / Answer
If the client is eligible for Medicare they can chose between getting the Medicare benefits through traditional Medicare (also commonly referred to as original Medicare) or a Medicare Advantage (MA) plan. Making this choice is personal and requires that they consider their circumstances, including health, desire for flexibility, budget and tolerance for financial risk. Before deciding how to receive Medicare benefits it is important to understand the different parts of Medicare and how they work together as well as the key differences between traditional Medicare and Medicare Advantage. It is also important to ask questions and gather information before deciding whether to enroll in a Medicare Advantage plan.
Understanding the Parts of Medicare
Before discussing the differences between traditional Medicare and Medicare Advantage, it is important to understand the different parts of Medicare and how they work together. Medicare has 4 parts: Part A, Part B, Part C and Part D.
Traditional Medicare, Part A and Part B, are administered and run by the federal government. Part A covers hospital care (hospital care, skilled nursing facility care, home health care and hospice care) and Part B covers medical insurance (e.g. doctor visits, medical equipment, outpatient procedures, lab tests, x-rays, ambulance services and some preventive services).
Part C, also known as Medicare Advantage, is administered and run by private insurers. It is simply a different way of getting Medicare Part A and Part B coverage. Part C may be chosen in place of traditional Medicare. The private Medicare Advantage health plans are regulated by the federal government. MA plans combine Part A and Part B and often Part D, into one plan so the entire package of benefits comes from a private insurance company.
Part D is the part of the Medicare program that provides outpatient prescription drug coverage. Part D is administered and run by private insurance companies that have contracts with the federal government. If you have traditional Medicare or a Medicare Advantage plan that does not include prescription drug coverage and you want Part D coverage, you must purchase it separately. This is called a “stand-alone” Prescription Drug Plan (PDP). A Medicare Advantage plan that includes both health and drug coverage is referred to as a Medicare Advantage Prescription Drug (MA-PD) Plan.
Medicare Supplement Insurance (Medigap)
Some beneficiaries have employer or union coverage that pays costs that traditional Medicare does not. Those who do not may need to buy Medicare Supplement Insurance (also known as Medigap). Medigap plans are private health insurance plans that help pay for the "gaps" in coverage left by traditional Medicare including copayments, coinsurance, and deductibles. In many cases, someone with traditional Medicare must purchase a separate Part D drug plan as well as a Medigap plan to supplement their Medicare benefits. Medigap policies do not work with MA plans and it is illegal for anyone to sell an MA enrollee a Medigap policy unless they are switching to traditional Medicare.
Key Differences between Traditional Medicare and a Medicare Advantage Plan
Access to Services
Traditional Medicare
If you are enrolled in traditional Medicare you can go to any doctor or hospital in the United States that accepts Medicare. Traditional Medicare does not have a “network.” Referrals are not needed to see specialists and there is no prior authorization required to obtain services.
Medicare Advantage
If you are enrolled in a Medicare Advantage plan you may be limited by the MA plan to using a network of specific providers in order for the plan to cover your care. You may have to choose a primary care physician, obtain referrals to see specialists, and get prior authorization for certain services. Certain MA plans may cover care you get outside of the network, but you will likely have to pay more. Plans may only cover emergency and urgent care if you are out of the service area; you must return to the service area for follow up or routine care. Network providers can join or leave a plan’s provider network anytime during the year but, generally, you must wait until the next year’s open enrollment period to opt to leave the plan. The MA plan can also change the providers in the network anytime during the year.
Costs
Traditional Medicare
In traditional Medicare, Part A is free if you have worked and paid Social Security taxes for at least 40 calendar quarters (10 years). If you are in traditional Medicare you owe a monthly premium for Part B coverage. You may also have to pay for deductibles, coinsurance and copays. Traditional Medicare has no out-of-pocket maximum or cap on what you may spend on health care. With traditional Medicare, you will have to purchase Part D drug coverage and a Medigap plan separately.
Medicare Advantage
Costs in MA plans vary. You must pay the same monthly premium as those enrolled in traditional Medicare Part B. Additional out-of-pocket costs in an MA plan depend on what type of MA plan you choose and may include the following: whether the plan charges an extra monthly premium; whether the plan has a yearly deductible; how much you pay for each visit or service (copayments or coinsurance); the type of health care services needed and how often; and, whether network providers are used. MA plans may charge cost-sharing for a service that is above or below the traditional Medicare cost-sharing for that service. However, MA plans cannot impose cost-sharing for chemotherapy administration services, renal dialysis services, and skilled nursing care services that exceed the cost-sharing for those services under traditional Medicare. All MA plans must have a maximum allowable out-of-pocket (MOOP) limit on the amount of cost-sharing they can charge for all Part A and Part B services, after which you will pay nothing for the rest of the year. MA plans may also change benefits, premiums, and copays every year.
Benefits
Traditional Medicare
Traditional Medicare has a standard benefit package that covers medically necessary health care services. Traditional Medicare does not offer coverage for prescription drugs. In traditional Medicare you may have to buy a Medigap plan as well as a separate Part D prescription drug plan.
Medicare Advantage
MA plans must offer a benefit package that is at least equal to traditional Medicare's and covers everything traditional Medicare covers. Some MA plans may cover services which are not covered by traditional Medicare such as dental, hearing and vision care, and health club memberships. Many MA plans have prescription drug coverage built into the benefit package.
Capitation Systems
Under a capitation system, healthcare service providers (physicians) are paid a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care, per period of time. For example, a pediatrician may be paid $30 for each of the 120 children under his/her care, per month, even though the doctor may end up seeing only 35-40 of them (35-40 visits) in an average month. In other words, the doctor receives an average of about $90 per each child's visit in an average month.
The amount of remuneration is based on the average expected healthcare utilization of that patient (more remuneration is paid for patients with extensive or complicated medical histories). Other factors considered include age, race, sex, type of employment, and geographical location.
The capitation system provides financial certainty to both providers (doctors, hospitals) and payers (insurance companies) in the aspects of care delivery. Providers assume the risk of more patients than expected falling sick and needing care. In the case of the pediatric example, if a flu breaks out amongst the doctor's patients, he/she may end up seeing 55-60 children three or four times in that month, a total of over 200 visits, for the same payment, averaging about $18 per visit.
Evaluation of capitation model
By combining capitation for basic services and payments for less-required health care needs, the either above said programs is able to reduce operational costs and absorb the growing number of patients that have risen from the Baby Boomer generation (the largest population growth period in U.S. history). Capitation incentivizes preventive health care, including in-home services, while the limited treatments allow for cost analysis and adjustments between doctors, service providers, and health programs.
Over the past decade, capitation has become the preferred form of providing health care payments for medical and health plans. The heath programs are been using capitation as its base system since the 1970s, though aspects of the plan, such as mental health treatments and dental care. Large insurance companies moved away from systems because the rising costs of lab tests, diagnostic procedures, and medication were severely curtailing profits.
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