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Key Topics
Requirement
Case scenario:
Pt age:32
Family income:80500
Number of male adult:1
Number of female adult:1
Any disabled:yes
Any pregnant:yes
Drug to be covered: Abilify(psychosis, depression)and Crestor(cholesterol)
Provide this household member advice to help their family to select an affordable health insurance plan for the next year
1) A brief description of the case and health care needs, 1 paragraph for this
2) A summary table for eligible plans. If there are too many options, you may only pick a representative for each category. Be very concise and only include key information that will be need for the person to make a decision. You may also need this table to explain to the person. It is suggested to create a own table.(1 table for this ) Key information includes, but not limits to(1)costs, premium, deductible, copay, coinsurance, out of packet limit, (2)type(HMO,PPO,etc), in or out of network also (3)medication coverage:formulary, copay, drugs needed by the familycovered or not.(4)additional services covered other than the 10 required areas, if any (5) access to care (eg.available facilities, distance, convenience) (6)indicating the benchmark plan and other important consideration related to the case.
3) Calculate or estimate tax subsidies: determine whether the household income in the case is eligible for a tax subsidy(table of federal poverty level vs household size, expected contribution to insurance costs)
4) You advice to the person as if you would consult the patient. You may need to briefly explain your rationale why this is the best option among all eligible plans.
Solution
CASE STUDY
There are a number of health insurance plans which can be suggested to the family. There are many conditions with the family members which need to be taken care of before selecting an insurance plan. The family can opt for more than one insurance plan to support their condition .
In this, we will first take a look at the plans mentioned in the table. Then discuss them one by one and find out which plan is most suitable for the family member. The plan is for a young person. Also, there is a pregnant female in the family. Along with this, there is a medication for psychosis , depression and cholesterol.
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Plan Main Benefits
Maternity benefits are one of 10 essential benefits that are covered by most of the insurance plans. It was not a granted benefit before 2014. Only about 12% plans in the market had maternity benefits. But now there are many special riders which insurers can opt for along with the maternity plan. Earlier it was only viable to the women who are not pregnant and was not available to the one who had already conceived. But now the maternity benefits can be taken by the women who are pregnant. There are various services covered for the mother and the baby. The outpatient services which will include antenatal and postnatal care. The lab checkups for various diseases like gestation diabetes, screening and medications are also included. There are services like Inpatient hospitalization during delivery and the fees of the treating physician are also included in the insurance plan. There are a lot of expenses of newborn babies in the hospital itself. The newborn baby care has also been included in the insurance. As the new mothers required much counseling regarding baby care. Hence in this, the counseling with the physician on lactation is also included. Insurance also provides coverage for rental breast pumps. Maternity Insurance is a mandatory benefit. Maternal care includes a broad spectrum. It includes regular medical visits to the physician, prenatal testing, nutrition, exercise and test for diagnosis of infections. All these should be there during the pregnancy phase. It is very important to have good nutrition as this supplies directly the child directly food and nutrition through mother. This also helps in having a healthy lactating phase.
There are lot of inequalities in healthcare when it comes to mentally ill patients. The main factor contributing to their ill health is lack of proper treatment and care. There are two laws that are passed in 2008 that created equality for mental health services in Medicare and private insurance. These laws especially meant that coverage for mental health services will have the same benefits as per the other general insurance. It includes the cost-sharing arrangements such as deductibles and co-payments and limits on coverage. The people suffering from mental illness have increased protection since 2008. The plans now offer a series of health insurance exchanges in parity with the general insurance cover. There is a broad improvement in health insurance coverage. Now the people need not depend on the public mental health systems or charity care. Through insurance, they can take care of their mental health. There is also a focus on particular clinic care in early detection and intervention and diagnosis of mental illness. There is increased coverage on pharmaceuticals. There is also the elimination of exclusion. There are still many challenges. Now with the reforms, we require evidence-based practice. There is also a requirement of better coverage. But currently, the system is far better than what is was earlier. The plans now cover the disease without exclusion. There might not be any rider or tax benefit provided.
People with high cholesterol get health plans easily as it is not termed as a disease. There is some extra premium charged on the base amount. In these diseases like stroke is covered. Almost all health insurance plans cover high cholesterol. There are many riders also available. It can be added without any further cost. Also, there is tax befits offered by Medicare under this category. Along with this, there are many community health care centres which provide various exercise plan and diet modification plan under the insurance cover. This saves the further worsening of the future condition. Also, there is counseling and regular session and also health checkups under the insurance plan. The main complication of high cholesterol is a stroke. In the case of Medicaid, depending on family income there is coverages post-stroke. Insurance plans are available in market to inspire of various diseases and complications.
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Place Your OrderFederal Poverty Level Guidelines & Tax Implications
The family income is $80500 which is 505% of the Federal Poverty Level (FPL) which does not qualify for the premium tax credit. The criterion for availing tax subsidy is met only if the annual income is within 400% of FPL. However, extra savings known as Cost-Sharing Reductions (CSR) can accrue by paying less out of pocket expenses “which is only available if enrolled in a Silver Plan”. The Silver Plan pays 70% of the covered medical costs and are the only ones offering CSR. The remaining 30% premium to be paid by the policyholder excludes the monthly premium and can vary with different insurance companies. An illustrative Silver Plan showing average out of pocket expenses is as given below.
It is to be noted that the monthly premium depends on the insurer, the number of people, age, whether you smoke and the region you live. The average monthly premium for a person aged 30 comes to about $312.
References
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Knox, C. A., Delaney, J. A., & Winterstein, A. G. (2014). Anti-diabetic drug utilization of pregnant diabetic women in us managed care. BMC pregnancy and childbirth, 14(1), 1.
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Anderson, M., Dobkin, C., & Gross, T. (2012). The effect of health insurance coverage on the use of medical services. American Economic Journal: Economic Policy, 4(1), 1-27.
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Bartlett, J., & Manderscheid, R. (2016). What Does Mental Health Parity Really Mean for the Care of People with Serious Mental Illness?. Psychiatric Clinics of North America, 39(2), 331-342.
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Levine, D. A., Morgenstern, L. B., Langa, K. M., Piette, J. D., Rogers, M. A., & Karve, S. J. (2013). Recent trends in cost?related medication nonadherence among stroke survivors in the United States. Annals of neurology, 73(2), 180-188.
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