Unformatted Attachment Preview
Running head: MANAGED CARE PLANS
Medicare/Medicaid Managed Care Plans
1
MANAGED CARE PLANS
2
Medicare/Medicaid Managed Care Plans
Distinguish the roles of Medicare and Medicaid managed care plans in the healthcare
delivery system.
To control cost and raise the bar when it comes to innovation in health care delivery states
are turning to Medicaid managed care and looking to it as a key strategy more than ever
before. This data looks at the health care providers' ideas on the role of managed care and
how it is improving health services for low-income adults in several communities. Even
though this report is looking at a few communities, there is evidence of this data being true
for more than just these four areas. These states include Milwaukee, Wisconsin, Oakland,
Seattle, and Washington, D.C. these locations don't see managed Medicaid as an important
piece of the puzzle for the delivery system reform. It is these types of broken delivery
systems such as these that put limits on the kinds of services for which managed care
organizations are at risk, the frivolity in such markets all reveal challenges to making the care
delivery better. While looking at the types of results, the providers in these areas had a
change of heart when it comes whether managed care systems are designed to improve
quality and control cost by suggesting a competitive atmosphere among MCO's.
Assess the similarities and differences between Medicare and Medicaid managed care
plans by comparing (a) strengths, weaknesses, and incentives; (b) commitment to
access; and (c) risks to the consumers.
MANAGED CARE PLANS
3
Let's begin with the Medicare program which has quite a bit of strength one being that it
provides insurance for those that are 65 or older, disabled, and this is without any regard to
the income of these individuals. Also, it covers the cost of hospital stays, doctor visits, tests,
and medications. Medicaid has some strengths that mirror Medicare simply by providing
health insurance to families the far below the poverty level or are at that level. Medicaid is
funded by taxes and hospital taxes, and on the other hand, Medicare which is financed by
payroll taxes, interest on trust funds and Medicare premiums (Medicare vs. Medicaid, 2016).
Weaknesses that has identified in Medicare is that depending on the person's status; they
must pay for which part they are also receiving if they have a working spouse for ten years or
more of their life. If not then they must pay a small premium one more about Medicare they
don't cover dental or vision they can for an extra fee so again the person is paying.
Commitment to Access to Both Plans
Federal regulation requires that when it comes to Medicaid Managed Care access states have
a written strategy for assessing and improving the quality of health care services offered by
all Managed Care Organizations (Levinson, 2014). These set of standards exist to make sure
that each MCO maintains a sufficient and adequate network of providers. For instance,
things that are being considered is that should be an anticipated Medicaid enrollment,
secondly expected utilization of services, number, and types of providers, some network
providers who are not accepting new Medicaid patients, locations of provider and Medicaid
enrollees. Lastly, States are required to make sure that if the MCO can't provide the services
that are needed by a person, they must cover the cost of an out of network provider.
Medicare managed care plans commitment to access is somewhat like that of Medicaid since
MANAGED CARE PLANS
4
the same unit operates them. Achieving a reasonable balance among multiple goals for
Medicare programs including keeping Medicare fiscally secure, setting adequate payments to
private plans, and meeting beneficiaries health care needs will continue to be a critical issue
for policymakers in the future which can affect the accessibility (Kaiser family foundation,
2016).
Risk to the Consumer Associated with Either Plan
The risk to the consumer is that with Medicare the rates keep going up on an annual basis
and it could end up costing the consumer more than they could afford. The idea is to provide
affordable care to the consumer whose income is low. On the other hand, Medicaid already
charges some individuals a small premium could start charging more people premiums.
Another risk for Medicare benefits could start to go down, and the cost sharing could
increase. Medicaid consumers have an issue if they want to switch providers because of
there not being enough providers for the number of users on this program.
Synthesize two recommendations for improvement, including your justification, of each
managed care plan. (You should have a total of four recommendations for both
Medicare and Medicaid managed care plans.)
Some suggestions for improvements with the Medicare program would be to offer the
programs already including dental, vision, and provide better coverage for long-term care.
Secondly for Medicare is to make these plans more affordable instead of annually increasing
the cost try making plans better and instead of growth put some provisions. Such as if a
person can't afford the premiums then decrease the premium or take it away altogether. For
MANAGED CARE PLANS
5
the Medicaid program make the reimbursements a little bit more then possibly more provider
would be willing to accept Medicaid. Let there be accountability when it comes to financial
information like making sure that the funds are used the way they should.
References
Kongstvedt, P. R. (2012). Essentials of managed health care (6th ed.). Sudbury, MA: Jones and Bartlett
Publishers.
Martino, SC., Elliot, Mn., Haviland, AM., Saliba, D., Burkhart, Q., Kanous, DE. (2016). Comparing the
health care experiences of medicare beneficiaries. Health service research, Volume 51 (3), pp.
1002-20 doi:#10.1111/1475-6773.12359
Summer, L., Hoadley, J. (2014, April 10th). The Role of Medicaid managed care in health
delivery system. The commonwealth fund. Retrieved from
MANAGED CARE PLANS
6
http://www.commonwealthfund.org/publications/fund-reports/2014/apr/role-of-medicaid-managed-carein-health-delivery-system-innovation
Diffen (2014, April, 14th). Medicare vs. Medicaid. Retrieved from
http://www.diffen.com/difference/Medicaid_vs_Medicare
Kaiser Family Foundation (2016, May, 11th). Medicare Advantage. Retrieved from
http://kff.org/medicare/fact-sheet/medicare-advantage/