Hospital Outpatient Prospective Payment System
1. Insurance Plan Review: Refer to the figure 5.4 in the online Harrington text on the Insurance Plan Option one. Answer the following questions
a. What is the difference between the out-of-pocket limits for participating providers per person and per family versus non-participating providers per person per family?
b. What are the copay/coinsurance costs for the various levels (tiers) of prescription drugs available with the plan? Are there are limitations & exceptions?
c. In the coverage example on Managing Type 2 Diabetes, what is the listed total out of pocket costs for the patient assuming they are participating wellness program? Does participating in a diabetes wellness program make any difference?
2. Comparison Table regarding Government-Sponsored Health Plans including:
Using this template complete a comparison table of government sponsored health plans. The comparison table should include the name of the plan, the population it covers, and one important aspect regarding the plan. After completing the comparison table summarizes the similarities and differences of the government sponsored plans presented. The list of the Government-Sponsored plans are listed here, each must be represented on the template:
A. Medicare
B. Medicaid
C. TRICARE
D. CHIP
E. PACE
F. TANF
G. CHAMPVA
H. Worker’s Compensation
I. Indian Health Services
3. Managed Care Organizations: Review any Managed Care Insurance plan via the Internet.
a. What type of managed care organization is it?
b. What does the plan cover and what does it not cover?
c. What kind of physician provider panel does it include?
d. Are there different options available for coverage (percentages)?
e. Is coverage for a specific population or is it open to the general public?
d. Provide a APA reference link to the site that you reviewed here:
4. Managed Medicaid:
Medicaid managed care organizations (MCOs) vary from state to state. Moreover, like all third-party payers, the MCOs operate in healthcare’s constantly changing environment. Kaiser Family Foundation tracks and reports sociodemographic and third-party payer data.
Go to the organization’s website: http://kff.org/state-category/
You may need to review various links and pages in the website to answer the questions.
Answer the following questions:
1. What is the percentage of HMO penetration of your state?
2. What is the percentage of HMO penetration of a neighboring state?
3. What is the percentage of HMO penetration for the United States?
4. How do these percentages compare?
5. How does one enroll in the MCO in the state you reviewed?
