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Analyzing Medicare, Essay Example

Pages: 5

Words: 1366

Essay

Consider the following situation.

Your son has taken the job at Costco and made friends with a colleague who is retiring at age 65. She is impressed by your son’s knowledge of the Costco health plan. At 65, she will sign up for Medicare Parts A and B. She wants help deciding whether to buy a supplemental Medigap policy, a Medicare Advantage plan, and/or Part D. Your son needs help from you again to help his friend.

Part One: In 300 words or less, explain how this woman’s health insurance coverage will be different under basic Medicare Parts A and B from her Costco plan. Be sure to consider cost— you may assume she has been paying $79/month for health insurance

under Costco. You may use lists to compare but be sure to include some commentary.

 

In addition to Medicare Parts A and B, the client has the option of purchasing Medicare Part C, also known as Medicare Advantage, which is provided by a private insurer and includes Parts A and B, Part D, plus other options such as dental and vision coverage (Medicare.gov, 2012). However, each plan establishes its own premiums and out-of-pocket costs, depending on specific requirements (Medicare.gov). It would be up to the client to research the options and to determine whether or not the premiums are within her price range (Medicare.gov). A Medigap policy is in addition to Parts A and B and is similar to Medicare Advantage in many ways. Furthermore, Part D, known as prescription drug coverage, is largely provided by many insurers to better manage the costs associated with prescription drug needs. Medicare Part D is essential for any patient who requires prescription drugs for a variety of reasons, and covers both brand name and generic formulas (AARP, 2012). Based upon these alternatives, perhaps the best choice for her specific needs is Medicare Advantage, which includes Part D benefits, coupled with additional offerings (AARP, 2012). However, this also depends upon her specific needs and what might be required as a result of preexisting conditions or other issues that might be prevalent in the client’s medical history. In order to keep the premiums as close as possible to her rate at Costco, the client must make a decision that will provide her with maximum coverage at an affordable rate. Therefore, the client must make these comparisons and decide how to best approach the circumstances to achieve maximum savings.

Part Two: Assume your son’s friend will continue to live in Columbus, Ohio (zip code 43221, Franklin County). She has a preretirement income of about $55,000 and will have a retirement income of about $45,000 per year (She does not qualify for any subsidies.), is in “good” health, and has no pharmacy preferences. She will be signing up for Medicare for the year for which you are exploring premiums – be sure to use the latest year available. She takes no medications at this time. Her family has a history of high blood pressure and cardiovascular problems, but she has exercised and eaten well to avoid these. She has specified that she does not want to pay more than $155 per month in premiums (including her Part B premium) for health coverage and would prefer to be able to see her current doctor. She is not sure about the drug coverage since she takes no drugs currently. She also travels in the U.S. to visit grandchildren, so would be concerned about coverage while she is away from home.

  1. Using the table provided, please consider the four options we have selected for your son’s friend. (These are not necessarily the best, but are good for comparison purposes.) Consider what the potential impact of each provision in each plan is for this person. Except for the premium box, you should not just enter numbers. Rather, explain how the options compare on each feature. Remember, this woman can change plans at the end of any year (but will need to do this analysis again!).

Assume hospital stays of less than five days (notice the rules about benefit periods), outpatient preferred generic and preferred brand drugs from retail pharmacy only, all services as considered Medicare-covered, and billed charges within Medicare limits. Please figure out what the “gap” in Part D coverage is, but disregard it in your answers in the table.

 

MHA Module 1: Context of Leadership in the U.S. Health Care System

Week Seven Assignment One: Analyzing Medicare

 

Names  

 

Part Two: Given the friend’s scenario and your study of the Medicare Web site, complete this table.

 

Feature

Original Medicare
H0001-001-0
Original Medicare with

First Health Part D-Premier (PDP)
(S5768-137-D)

Humana Gold Plus H8953-005 (HMO)
[S5768-005-0]
Blue Medicare Access Value (Regional PPO)
(R5941-008-0)

 

Which of these plans is best for each feature – in some cases you will need to mention the conditions under which a feature would be better? (Eg, if she is happy with the doctor choices.)
Total monthly premium (including Part B premium) $0 $25.10 monthly/$301.20 annually $0 $0 Blue Medicare Access Value is the optimal choice
Out-of-pocket limit Not Available After $2,700 up to $4,350 $3,950 in network $4,800 Original Medicare is the optimal choice
Relevant deductibles Not Applicable $0 in network

 

Annual Drug Deductible: $320 $60 Original Medicare with First Health Part D-Premier is the optimal choice
Ability to choose doctors Any Doctor Yes Yes within the network; authorization rules apply

 

Yes within the network; no referral required; additional costs apply for out-of-network Original Medicare is the optimal choice
Doctor visit costs – Primary Not Available Not Listed $10 in network $20 per visit Humana Gold is the optimal choice
-specialist Not Available Not Listed $40 in network $35 per visit Blue Medicare is the optimal choice
Hospital costs (per day in stay of less than 5 days) Not Listed Not Listed $225 per day $270 per day for days 1-5 in network Humana Gold Plus is the optimal choice
Diagnostic X-ray costs Not Listed Not Listed $10 to $50 for x-rays $0 copay for Medicare-covered x-rays Blue Medicare is the optimal choice
Outpatient Prescription drug costs (consider whether gap coverage is important).  Consider preferred generic and preferred brand drugs from retail pharmacy for one month supply.

 

 

Not Listed

 

Drug Restrictions: Not Applicable

No Gap Coverage

0% to 20% of Part B drugs, not including chemotherapy drugs

20% for chemotherapy drugs

Formulary drugs depend upon type

Part B: 20% of Part B-covered chemotherapy drugs and Part-B covered drugs

Formulary drugs dependent upon individual cost

Humana Gold Plus is the optimal choice

 

 

 

 

Coverage while traveling in the U.S. Not Listed Not Listed National in-network prescription coverage Yes Blue Medicare and Humana Gold Plus are the optimal choices
Mammogram cost Not Listed Not Listed Not Listed $0 copay Blue Medicare is the optimal choice
Which of these plans do you think is best for her now and why? Overall, in reviewing the options, Blue Medicare appears to be the most effective choice for the client, as long as her doctor is within the established network. This would provide the client with most optimal level of coverage, combined with maximum cost savings across different categories.
What would be the pros and cons of a Medigap supplmenetal policy (type A) instead of Medicare Advantage Under the appropriate conditions, a Medigap supplemental policy might be an effective choice in order to supplement a client’s existing Medicare coverage. However, in the case of the client in question who does not face any particularly difficult health challenges, this type of policy is not likely to provide any real benefits beyond what is already received, and the client will be required to pay an additional premium for coverage that is not necessary.
How easy is it to use the Medicare site? The Medicare website has a number of user-friendly features, including the areas where there are options to narrow down the search for different types of coverage within the geographic area where a person lives. However, once the plans are identified, there is some confusion regarding how to view the specific benefits for the plans being offered, other than those provided by General Medicare.

 

References

First Health Premier (2009).  2009 Summary of Benefits. Retrieved from http://www.firsthealthpremier.com/content/items/13507/FH09SB23_91311. Pdf Medicare (2012). Retrieved from www.medicare.gov

Medicare.gov (2012). Medicare Advantage (Part C). Retrieved from http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx

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