Conventional Health Insurance Case Study

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

Medicare and Medicaid are programs that have been developed to assist Americans in attainment of quality health care. Both programs were established in 1965 and are federally supported to provide health care coverage to vulnerable populations such as the elderly, the disabled, and people with low incomes. Both Medicare and Medicaid are federally mandated and determine coverage under each program; both are run by the Centers for Medicare & Medicaid Services, a federal agency ("What is Medicare? What is Medicaid?” 2008).

Medicaid is a social health care program that covers nearly 60 million Americans, including children, pregnant women, seniors, parents and individuals suffering with disabilities. Medicaid is the biggest source of funding for health related services and medical needs for the people with low income in the United States. This program is funded jointly by the state and federal level governments, but it is the state’s responsibility to manage this program. The Medicaid program is not a required program that states have to use, but all 50 states have implemented this program. With the introduction of the Affordable Care Act (ACA), and its passing in 2010, the ACA unveiled its plans to expand Medicaid eligibility to nearly all low-income adults as an addition to the other groups that fall into the Medicaid eligibility. The Medicaid program had “many gaps in coverage for adults” because it was only restricted to the low income individuals and other people with needs in their own specific category. In the past, the majority of the states who had adults that did not have children dependent on those parents were not eligible for Medicaid. These low income adults without dependent children would be without medical insurance assistance before the ACA was introduced. Medicaid is now available to all Americans under the age of 65 whose family income is at or below the federal poverty guideline of “133 percent or $14,484 for an individual and $29,726 for a family of four in 2011” (NSCL).

Medicaid, which is a separate federal funded insurance was intended to cover low-income, aged, blind, disabled individuals, parents, and their dependent children on welfare. However, the senior citizens are the population group most likely to be living in poverty, and only about half of these individuals have insurance coverage. The difference between 1965 and now, of course, is costs. Years ago spending more on health care in result covering more people were the whole point. The administration wants to broaden coverage, but cut spending.

As result, the Social Security Amendments (Medicare/Medicaid) has shaped our healthcare system by providing health insurance to elderly adults and those who have low income. Everyone had health insurance for their physicians, hospital care, and other medical

In 1965, President Johnson signed Title XIX of the Social Security Amendments, which enacted Medicare and Medicaid (CMS, n.d.). Now, Medicaid is the single largest publically funded health coverage in the United States. The Medicaid program is federally and state funded. Currently, Medicaid covers 70 million Americans. Over 33 million children, 19 million low-income adults, and 16 million elderly or disabled persons are insured through the program. Medicaid also provides assistance to select Medicare beneficiaries, which is currently about 10 million individuals. Long-term care assistance is also a role of Medicaid, with 1.5 million institutional and 2.9 million community-based residents assisted. As visualized in Figure 1, of the almost 70

Medicaid, Medicare, and CHIP’s healthcare coverage is usually used in the typical American household. Though they serve different people they all have the same goal: To provide health coverage for lower costs and better care. They all have many ways they are funded. Medicare is funded through taxes, trust funds, premiums from members of Part A,B, and D, and funds from Congress. Medicaid and CHIP is funded by the government. The federal government pays states for a specific percentage of program expenditures or costs for a specific group. The percentage for Medicaid is 15% higher than CHIP’s. If you want to be a member of medicaid, you have to have a limited income, be 65 or older, a child under 19, be pregnant, be living with a disability,

There are some problems that must be addressed in the expansion of the Medicaid policy to include; social, economic, ethical, legal and political. First, the social impact of having health insurance removes the burden off of parents, people with chronic diseases, children and the disabled. If access to health insurance is unavailable our nation’s health care costs will continue to rise,

Managed care has been adopted into the government funded care organizations. Medicare managed care plans provide all coverage themselves, including basic Medicare coverage. Managed care plans cover above and beyond the basic benefits of Medicare, the size of premiums and copayments, and the decisions about paying for treatment are controlled by the managed care plan. The basic premise of managed care is that the member/patient agrees to receive care from only a specific doctors and hospitals, in exchange for reduced healthcare costs. Medicare, like other insurance companies offer plans that give Medicare beneficiaries more choices in coverage, like HMO or PPO. Managed care has been used since the mid 1990’s in order to provide healthcare to beneficiaries with serious or life long illnesses. Today, managed care has become a way for states to provide quality care to both Medicaid and Medicare patients.

Medicaid and Medicare are two different government programs. Both programs were created in 1965 to help older and low-income families be able to buy their own private health insurance. These programs were part of President Lyndon Johnson’s “Great Society” plan, a commitment to helping meet the needs of individual health care. They are social insurance programs, which allow the financial load of patient’s illnesses to be shared by other healthy, sick, wealthy, and lower income individuals and families.

ACA estimating 25 to 30 millions uninsured because of health service financing (Shi and Singh, 2015). That a large portion of our population that lives in one of the industrialized country and has the best technology yet cant figure out the finances. I didn’t realize that insurance will lower out of pocket cost for uninsured simply because they will be paying more in the because of their medical needs. ACA coming into play was an idea that everyone will be insured, kinda like “universal” insurance such as other countries but it doesn’t seem as such. Christical part is that out of pocket is not the only option, working for a company that provides medical benefits is an option for all. I understand that not everyone is a doctor nor everyone wants

I chose to search for a health insurance plan that would serve well for myself, my spouse, and my child that would be considered a minor. I chose to look throughout the gold plans due to the possible income from both my spouse and I within the future. My listed income between my spouse and I would be around $110,000 10 years from now, considering where I know I am going in life as of right now. The two insurance plans that caught my eye were the AmeriHealth New Jersey: IHC Gold EPO Community Advantage $10/$20, that consisted of $950 monthly premium, a $2000 deductible, and a $8,500 out of pocket maximum; the AmeriHealth New Jersey: IHC Gold HMO

I think you should review the patient account b/c on PM shows that the patient is active with BCBS effective 04/01/2016 .The receptionist should be see that and verify insurance coverage at the moment the patient was registered. If the insurance was inactive the receptionist should be expired the Insurance.

Government started the Medicare and Medicaid so that the ageing and low income population would get health insurance and to reduce disparities related to socio economic status. Now due to Affordable Care Act there is decrease in uninsured population as it has helped the population by reducing the premium the pay for the health insurance, which has allowed the underinsured, uninsured population and small business employers

Private health Insurance is a $1.42 billion (before tax) industry in Australia (Seah, 2012) and has played a prominent role in the country’s health system for over 60 years. As of 2009, 51per cent of the Australian population was covered by some form of private health insurance. Private health insurance is a regulated industry; this means it is controlled by government legislation under the Private Health Insurance Act (2007). Private health insurers are required to register under this Act, and the policies they sell must adhere to these regulations (Shamsullah, 2011). Due to the size and regulation of the industry managers in the sector may face many complex challenges.