Medicare Advantage Plans, QHPs, And Medicaid MCOs: The Pro’s And Con’s

Medicare Advantage Plans

The three plans that I will discuss are Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations. Medicare Advantage is for those that have Medicare. Medicare Advantage plans provides a combination of benefits from Medicare Parts A, Medicare B and Medicare Part D prescription drug benefits. The Medicare is “a federal program” (Lipschutz 2015) Qualified Health Plans are available on the Marketplace and cover ten essential health benefits. These plans are funded by federal and state partnerships.  Medicaid Managed Care Organizations is a plan that a Managed Care Organization administers health benefits by using Medicaid benefits for people that have Medicaid.  The Medicaid plans are funded jointly by state and federal. The three plans have different types of medical coverages that I will discuss below.

Prescription drug coverage for Medicare Advantage must cover drugs in six protected classes. The Qualified Health Plans must cover the largest number of drugs in a class. The Medicaid MCO must cover all FDA drugs that have rebate agreements.

There is an out of pocket limit on Medicare Advantage and Qualified Health Plans. The Medicaid MCO Plans limit is 5% of monthly /annual income.  The people with Medicaid MCO’s pays the least out of pocket. This is helpful for the Medicaid MCO population.

The is no balance billing for Medicaid MCO Plans and Medicare Advantage. The Qualified Health Plans don’t have a restriction for balance billing.  The balance billing policy is helpful for the Medicare Advantage and Medicaid MCO policy holders. They can’t be billed by medical providers for balances left after the insurance pays their portion.  The people with Qualified Health Plans can be billed after the insurance pays the medical provider.

Switching the plan mid-year is an option for Medicare Advantage and Medicaid MCO Plans. This is helpful if providers terminate their contract with the plan. This is not an option for Qualified Health Plans.

alisha Adams posted

Analysis of Medicare Advantage Plans, QHPs and Medicaid MCOs

American healthcare insurance system is basically comprised of publicly funded plans as well as privately administered covers. Lack of universal health care in America encourages the adoption and prevalence of private health insurance covers to people under publicly funded Medicare and Medicaid. Medicare Advantage Plans, Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations (MCOs) constitute the most popular privately administered plans available in the marketplace (Lipschutz et al., 2015). The plans have distinctive offers to clients, implementation strategies and different targets therefore exhibiting their specific advantages and disadvantages.

Medicare Advantage Plans

Medicare Advantage plans provide for coverage benefits stipulated by the traditional Medicare in the sense that clients cannot substitute benefits other those provided by general Medicare plans. The programs fundamentally cater to senior citizens without healthcare coverage as well as a defined set of people with disabilities (Lipschutz et al., 2015).

Pros: Covers for virtually all prescription drugs in protected classes defined by 6 categories, additional two drugs for all protected drug classes, pharmacy and therapeutics.

-Plans are subject to asset test which determines the cost-sharing subsidies available for specified categories of client’s income ratio to Federal Poverty Level.

Cons: Confined to time and distances stipulated by the regulations and, terms and conditions.

Qualified Health Plans (QHPs)

QHPs are subject to consumer protection standards enforced at state levels irrespective of the establishing minimums and standards set by the federal government. QHPs mostly provide coverage for non-elderly citizens without other coverage options and all plans must meet the Affordable Care Act minimum requirements (Lipschutz et al., 2015).

Pros: Covers benefits in 10 essential health insurance categories and allows for substitution of benefits within categories, unlike Medicare Advantage.

Cons: The plan does not allow policyholders to change plans mid-years in case the plan terminates providers from the network.

The absence of drugs’ protected classes other than requirements on covering a greater number of drugs as covered by the benchmark plan.

Medicaid Managed Care Organizations (Medicaid MCOs)

Medicaid MCOs caters for low-income individuals and provide coverage to disabled people. The program is funded by both federal and state governments and administered jointly or by either of the governments (Lipschutz et al., 2015).

Pros: Covers all Medicaid benefits stated by the federal government and additional benefits set by the regulations of the state.

Covers all FDA approved drugs and prescription drugs according to state regulations.

Cons: Does not provide for federal or state requirement on minimum revenues to be spent on healthcare expenses.



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