The Affordable Care Act (2010) was enacted to standardize benefit packages for healthcare coverage and ensure universal health coverage, a gap that existed in the Medicaid and Medicare programs. However, the Act did not streamline healthcare affordability as was initially anticipated. There are significant differences in some aspects of coverage that still exist from one policy to another. This paper explores the comparison and contrast that exists between the traditional Medicare and other programs such as Health Maintenance Organization, preferred provider organizations, and fee-for-service.
There are a number of considerations a healthcare provider or manager should take when working with patient enrollees in various coverage programs. Under the original Medicare, patients are allowed to see any provider/healthcare facility that accepts Medicare and visit physicians anywhere within the United States whereas Health Maintenance Organization (HMO) require a patient to only see providers within their network and those doctors within the plan’s service area except for urgent and emergency care requirements (Medicareinteractive.org, n.d ) . Elsewhere, fee-for-service and preferred provider organization (PPO) plans allow patients to see any provider/physician but are likely to pay more in the case of out-of-network providers and physicians. Also, original Medicare, preferred provider organizations, and fee-for-service do not require patients to have referrals for specialists, unlike HMOs that typically require enrollees to have referrals from their primary care physicians in order to see specialists.
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Medicare does not cover additional services including dental, vision and hearing whilst fee-for-service, PPO, and HMO may cover such additional services but such cover increases one’s premium and out-of-pocket costs. In addition, Medicare Part D requires enrollees to sign up for a stand-alone prescription drug plan, while fee-for-service gives prescription drug coverage or stand-alone plan option where the prescription drug coverage is absent (Medicareinteractive.org, n.d ) . HMO and PPO plans, on the other hand, offer prescription drug coverage but the patient bears the cost for a higher premium. While original Medicare has both Part A and Part B costs standardized and varying costs for premiums and Part D, it does not have a limit for out-of-pocket expenditure for its enrollees. On the other hand, HMO and fee-for-service provide for cost-sharing that is dependent on the plan and have an annual out-of-pocket limit. PPO plan charges monthly premiums that involve co-payment for care provided in-network and co-insurance for care provided out-of-network and their corresponding out-of-pocket limits. HMO, PPO, and fee-for-service plans require patients to make their share of payment to a provider/physician often referred to as co-payments and a set amount for medical care before the insurer starts to pay, also known as a deductible (Medicareinteractive.org, n.d ) .
The changes to Medicare under the Affordable Care Act, in my opinion, have consequences on the quality and availability of home care for patients. Under ACA, budget cuts in Medicare payments caused a corresponding reduction of Medicare payments to home health care providers and agencies, and the resulting effect is the reduction of skilled nursing staff and home health caregivers as well as a greater patient load per home health worker ( Manchester Specialty, 2017) . Originally, Medicare Part A and B covered home healthcare services including skilled nursing care, medical social services, medical supplies for home care use, home-based physical therapy, and durable medical equipment which may be limited now due to Medicare budget cuts caused by the changes under health reform ( Medicare.gov., n.d.) . Under Obama’s administration, it was proposed in the 2017 budget that Medicare co-payment be re-imposed on home health beneficiaries. These changes are likely to deny the elderly access to quality home health care and cause errors and lapses in treatment, thus leading to illness, injury, or death ( Manchester Specialty, 2017) .
In conclusion, a healthcare provider cannot consider a single option as the best for all patients because of the differences that exist in costs, coverage, and availability (Medicareinteractive.org , n.d ) . Patients also have the freedom to choose which plan fits them the most relative to their financial abilities, especially when it comes to out-of-pocket costs. In the US, healthcare continues to undergo reforms and so it is important that any changes to healthcare program are adequately analyzed to ensure proper understanding of the impacts such changes may have to the populations they serve.
References
Manchester Specialty (2017). The ACA's potential impact on quality of care in Medicare home health care. Retrieved from https://www.manchesterspecialty.com/acas-impact-quality-care/
Medicareinteractive.org (n.d). Comparison: PFFS, HMOs, and Original Medicare - Medicare Interactive. Retrieved from https://www.medicareinteractive.org/get-answers/types-of-medicare-advantage-coverage/medicare-private-fee-for-service-pffs-plans/comparison-pffs-hmos-and-original-medicare
