Metal-Tiered System: The Basic Metal Tier System

The Patient Protection and Affordable Care Act (Obamacare) had mame dramatic changes in the field of the health care system, especially in Medicare, that will seriously take effect in American seniors. Indeed, much of the health law’s new spending is financed by spending reductions in the Medicare program. In addition to the provider payment reductions, Obamacare significantly reduces payments to Medicare Advantage (MA) plans by an estimated $156 billion from 2013 to 2022.( Elmendorf, letter to Speaker Boehner). About 27 percent of all Medicare beneficiaries are enrolled in MA plans, a system of regulated and private plans competing against each other as an alternative to traditional Medicare. MA plans are attractive to beneficiaries because they offer more generous and comprehensive coverage than traditional Medicare by capping out-of-pocket costs and offering drug coverage to a rasonable

The dysfunction of the American health care system implies that not everyone has access to the right medication and medical treatment. Middle-class families and chronically ill patients do not always have access to health care, and when they do they do not receive adequate treatment with regards to hospitalization and medical services or quality of service. The lack of payment reform results in

A mixed payment system combined with physician monitoring, will provide physicians with incentives to consider costs and benefits of different treatment options, which will lead to an efficient level and quality of care. (1,2)

H. (04/2015). Comprehensive Health Insurance: Billing, Coding & Reimbursement, VitalSource for Allen School of Health Sciences, 1st Edition. [Bookshelf Online]. Retrieved from https://online.vitalsource.com/#/books/9781323131503/

Within the formulary the drugs are divided into tiers. Co-payments are based on the tier that the drug is in and range from tier 1, the least expensive drugs, to tier 3 the most expensive drugs. Each insurance company plan is allowed to add or drop drugs from their formularies and move drugs from one tier level to another throughout the year. An insurance company can also drop a drug in the middle of the year, but must continue covering the drug for anyone taking it until the next reenrollment period, at which time a new plan will have to be chosen that covers that drug (Gustaitis, 2007). Although not used a lot there is a fourth tier that is for specialty drugs only. Some plans use a flat-rate or assign a percentage co-pay to the higher tier drugs (Gustaitis, 2007). Other characteristics of the insurance company plans that they have control over are requiring prior authorization for a drug, using step therapy, limiting the quantity, participating at certain pharmacies, and having preferred pharmacies (Gustaitis, 2007).

tier, they can ask the patient’s plan for an allowance for a lower co-payment. Mrs. Zwicks’s part

Closing out the meeting was John Connolly who serves as Associate Director of Insure the Uninsured. Connolly detailed the Covered California healthcare exchange as a commercial insurance provider. Connolly spent the majority of his time speaking addressing the improvements to coverage, and eligibility changes to applicable California residents. Making a repeated and substantial effort to state how the commercial insurance exchange would work, Connolly showed the various healthcare providers that would be available to certain individuals, and an estimation of the average cost per provider. The most significant aspect of Connolly’s presentation was his outline of the new health insurance plan tier levels, ranging from “Bronze” to “Platinum”. Bronze tier coverage represented the tier with the smallest amount of payment made by the plan and highest amount of payment made by the consumer, and Platinum tier coverage representing the highest amount of payment made by the plan and lowest amount paid by consumer.

Healthcare is essential to the nature of our well- being, it provides some financial relief to individuals or families during doctor or hospital visits. Medical care is very expensive, and without health insurance it can be even more of a financial burden. However, being able to afford health insurance has been a challenge for a lot of family’s. For some, they must choose whether to feed their families, pay utility bills or make monthly health insurance payments; so, they allow the insurance to laps. The

In the current U.S. system the free market prevails and companies, in this case, major insurance providers “compete” for business. This competitive business approach should in theory drive costs down. For some reason, however, an argument can be made that it has produced the opposite result in profiteering. The nation’s largest insurer, UnitedHealth, boasted over a 10 percent revenue increase in 2013 according to Forbes (2013). Health insurance affordability contributes to the disparity in access to health care, as evidenced by the fact that there are millions that are still uncovered. A greater majority of certain minorities lack both health insurance and the financial resource to seek out either health care or insurance. While insurance companies reap huge profits the percent of private sector companies offering health insurance has dropped to less than 50 percent (Kaiser, 2013). There is decidedly a lack of coordination of care for this at risk population as well, since treatment is rendered sporadically and with continuously changing providers. The last major challenge is that of improving the quality of health care. According to a 2010 report by the U.S. Department of Health and Human Services, Office of Inspector General (OIG), an estimated 13.5 percent of Medicare beneficiaries experienced adverse events during their hospital stay and an additional 13.5 percent experienced a temporary

Perhaps the saddest part about these high prices are the people who will most feel the effects of the impossible costs. For the average healthy citizen, it is relatively easy to switch plans or providers in an effort to receive an optimal rate. Those who are already sick and injured, however, won’t have as easy a time of it. These people have

The Medicare beneficiaries’ contribution to the coverage gap decreases each year, with the majority of cost absorbed by the government and the drug manufacturers. Drug manufacturers also agreed to pay a fee to the federal government health care programs on branded prescription drugs (BPD), based on its sales of BPD’s. There was an expansion of the Public Health Service Act (PHSA), that required drug manufactures to provide eligible entities with significantly reduced drug price. The PHSA, also expanded those entities such as free-standing cancer centers and critical access hospitals (CAH), that were eligible to participate in the 340B program In, addition they also agreed to increase rebates on sales of prescription drugs to the Medicaid program (Spats, 2010). The rebate was increased from 15.1 percent to 23.1 percent. In addition, drugs, such as those used for pediatric care and clotting factor drugs there was a 17.1% rebate. Perhaps, most importantly, the firms extended the rebates to Medicaid patients enrolled in Managed Care Organizations (MCO). This new agreement allows plans to negotiate rebates in addition to the new ones

The metal tiers deliver basic understanding for consumers of health coverage categories such as Bronze, Silver, Gold, and Platinum that will greater or lesser cover health care costs, but not include quality of care. In other words, the higher the metal level, the highest payment from health plan will be received for users care overall. On the other hand, the lower the metal level the more users have to pay for provided care. Out of four categories Platinum and Gold (higher premium) compensate higher costs of health care than Bronze and Silver (lower premium). Bronze and Silver categories have lowest monthly insurance bill for users, however highest deductibles and out-of-pocket costs. In opposite site Platinum and Gold categories offered highest monthly payment and lowest deductible and out-of-pocket costs. Based on the consumer income after enrolling in a Silver plan user could qualified for cost-sharing reductions benefits of that is fairly low premium, lower deductible, and pay lower from out-of-pocket costs when care needed.

Patient financial services in managed care environments are now challenged with gauging the patient’s ability to pay with the increase of liability on high-deductible health plans. “The inability of many consumers to pay high deductibles is projected to produce outcomes that damage bottom lines of healthcare businesses” (Boland, PhD; Gibson, PhD; 2014).

The U.S. spends more resources on healthcare than any other nation. Yet, the The Commonwealth Fund (2014, para. 1) claim the U.S. health system consistently ranks last or near last relative to other industrialized nations regarding health outcomes. Consequently, insurance companies are adopting a value-based reimbursement system aimed at containing costs and improving clinical outcomes (U.S. Department of Health and Human Services, n.d., para. 35).

HR-101 proposes a cap on “Out of pocket” expenses. The cost of medical treatment can skyrocket quickly. Currently, even those with adequate insurance coverage can be left financially devastated if faced with a long-term critical illness. Private insurance companies often have a lifetime maximum payout amount. The consumer may then be left with a catastrophic amount of debt related to the treatment received and the unforeseen notion of the concept of a maximum lifetime payout figure.