Key Features, Differences, and Disadvantages of Health Care Consumer Plans

MANAGED CARE, ACCOUNTABLE CARE ORGANIZATIONS, HEALTH CARE CONSUMER PLANS/MODELS

Assignment Overview

There are various types of plans consumers can select. MCOs, HMOs, PPOs, POSs, or ACOs are the most common ones; however they all supply various benefits and drawbacks. Consumers (patients) have the right to choose the type of plan that best fits their needs. As a health care leader, it is vital that you understand the differences in these plans. In addition, in a health care environment where there are plenty of options for consumers (e.g., providers, medical offices, location, consumer plans etc.), ideally making the “choice” is left up to the consumer’s determination.

Case Assignment

For the Module 3 Case Assignment, conduct additional research as needed and complete the following:



Comparative Chart:



Prepare a detailed comparative chart (see example at the following source: https://philsblogspace(dot)files(dot)wordpress(dot)com/2012/10/eco-chart.jpg?w=1400). In your comparative chart, evaluate and discuss the key features, differences, and disadvantages between MCOs, HMOs, PPOs, POSs, and ACOs.



Please review the below scenarios and respond to the closing questions in complete sentences advising how you determined the outcome.



Marjorie has a Point of Service (POS) plan that has a yearly deductible of $500 that is effective January 1 of every coverage year. Marjorie’s plan also requires her to pay 25% of the charges each time she visits her primary care doctor until she reaches her out-of-pocket maximum. Marjorie is visiting her PCP next week. The contracted rate, as she is seeing an in-network doctor, charges for her visit will be $382. What will be Marjorie’s out of pocket?



Ted has a Preferred Provider Option (PPO) plan that has a yearly deductible of $1,000 that is effective January 1 of every coverage year. Ted’s plan allows him to see in-network and out-of- network doctors. If Ted sees an out-of-network physician, his plan will cover 50% of the charges after his deductible is met. If Ted sees an in-network physician, his plan will cover 80% of the charges after his deductible is met. Ted has been seeing his Primary Care Physician for over 20 years and wants to continue treating with the same doctor. However, his PCP is out-of-network. Ted has a visit coming up that will total $750 .and his deductible is satisfied. What will Ted’s out of pocket be?



Jonathan has a HMO plan that does not have a deductible. However, Jonathan has a copay for office visits, inpatient stays, diagnostic testing, and prescriptions. PCP office visits are $30, Specialists are $50, Diagnostic testing is $25, and inpatient is $100 per day. On Monday, Jonathan had an office visit with a specialist. The specialist referred Jonathon for diagnostic testing on Tuesday. The specialist received the results on Thursday and admitted Jonathan for emergency surgery on Friday. Jonathan was in the hospital for five days. What was Jonathan’s total out of pocket cost for this course of treatment?



Suzane has selected an Accountable Care Organization to be responsible for her care, Kaiser Permanente. Kaiser Permanente houses all physicians, lab services, specialty services, diagnostic care, and pharmacy services in one building. Suzane is charged a co-pay each time she sees a different physician, but does not have to pay for lab or diagnostic services. Suzane has decided that she wants to have plastic surgery and use a doctor that is not under Kaiser’s ACO umbrella. Does Suzanne have any options for coverage for any of her care?



Roseanne recently qualified for Medicare because she was diagnosed with ESRD. Roseanne is still working full time and still does have a private POS plan in place. Roseanne does have a deductible that must be met on her private plan. Roseanne has been undergoing dialysis and visits a Nephrologist weekly.



Which insurance would be primary? At what point does Medicare begin to pay? Does Roseanne still have to meet her deductible?



Bailey was admitted to the hospital with preterm labor and is covered by a Consumer Driven Health Plan. Bailey also has an HSA account where she has had pre-taxed money taken by payroll deduction to fund this account. This account currently has $1500 that can be applied to health care costs. Bailey’s inpatient copay is $1000 per stay and her deductible is $1000.00, that she has not met yet. Bailey delivered and her and baby were discharged. Two weeks later Bailey returned to the hospital ER with the newborn not feeling well and the baby was readmitted. The newborn has been added to Bailey’s plan and the same deductible rules and copay apply. How much is Bailey out of pocket for this series of events with the application of monies in her HSA?





In your scholarly paper, you should include an introduction and conclusion paragraph.



Assignment Expectations

Conduct additional research to gather sufficient information to justify/support your thoughts and analysis.

Limit your response to a maximum of 4 pages.

Support your report with peer-reviewed articles, with at least 3 references. Use the following link for additional information on how to recognize peer-reviewed journals. Angelo State University Library (n.d.) Library guide: How to recognize peer reviewed (refereed journals). Retrieved from: https://www(dot)angelo(dot)edu/services/library/handouts/peerrev.php

You may use the following source to assist in formatting your assignment. Purdue Online Writing Lab. (n.d.). General APA guidelines. Retrieved from: https://owl(dot)english(dot)purdue(dot)edu/owl/resource/560/01/.

For additional information on reliability of sources review the following source. Georgetown University Library (n.d.) Evaluating internet resources. Retrieved from https://www(dot)library(dot)georgetown(dot)edu/tutorials/research-guides/evaluating-internet-content