Health care cost in America is increasing. Health care insurance providers have health plans and coverage with little differences from each other. The health care system is fragmented and it leads to disconnections in insurance coverage and plans for consumers (Steven, 1999). This paper looks at TRICARE, Medicaid, Medicare, workers compensation, and commercial insurances with attention on their plans, providers, covered services, mode of payment and eligibility. Affordability and quality healthcare are essential in growing the economy as well as the nation.
Eligibility for TRICARE, Medicaid, and Medicare is based on collaboration with government institutions through its health Acts and private agencies. TRICARE is a health care program exclusive to the military, paramilitary individuals and their families. These are members of the Corps and forces who are either active in service or are retired. Medicaid is designed to cater for people who are under 65 years, children and pregnant women, and those with disabilities. In conjunction with Children's Health Insurance Program (CHIP), Medicaid covers about 72.5millions Americans being the largest provider of insurance in the U.S. The Affordable Care Act of 2010 has expanded the scope of Medicare coverage by increasing the percentage of the federal poverty level of those to be insured. Medicare is also a federal health program developed to give individuals who are 65 and above, children and people with disabilities and those with End-Stage Renal Disease opportunity to access health care. Commercial insurances such as Nationwide and Workers compensations are insurance agencies and plans between employers and employees. These are largely state-regulated insurance policies. Thus, eligibility is the employer-employee contract on a specific job offer that is determined by employers.
Delegate your assignment to our experts and they will do the rest.
Service providers under TRICARE plan and the federal-state insurance programs fall into two categories. These are the network and non-network providers. Also, the providers can be participating or non-participating providers based on the signing of a contract and acceptance of the type of claims and services that will be offered. A network provider signs a contract with a managed care support contractors (MCSCs) located in each region while the non-network provider does not sign a contract. MCSC provide verifications and certification of all providers of health care services under TRICARE and federal programs. States engage service providers and pay through the fee-for-service and the managed care support contractor systems. The workers' compensation insurance program and the commercial insurances offer services and coverage through the state-regulated compensation schemes. Employers insure their employees through insurance companies, self-insuring compensation claims and joining groups that are verified and approved by each state.
Payment methods are essentially deductibles and reimbursements according to the health plan chosen and the work status of an individual. Those with social security or railroad retirement board benefits get a deduction for the insurance services. Civil service retiree without social security gets their deductions from the annuity. Individuals living in certain states and have low financial background can have their bills defrayed by the states through their eligibility status. Some service providers have payment plans that are automatic. An example is the Medicare Easy pay. And there are online, mobile, billing systems available. The use of debit and credit cards is another method of making payments for services.
All insurance companies have elaborate and challenging rules and regulations. However, the commercial insurances have the most rules and regulations. This is possible because of the profitability margin that is set by each insurance service provider. And the stringent nature of these rules and regulation means that any deviation means termination and forfeiture of coverage benefits. Policyholders are expected to follow the rules and regulations accordingly. Individuals with low SES appear to have more care compliance gaps and poor health literacy (Sherman, Lynch, and Addy, 2016). Thus, proper attention may not be given to a policy by a policyholder.
References
Sherman, B. W., Wendy D. Lynch, W. D., & Addy, C. (2016). Lost in Translation: Healthcare Utilization by Low-Income Workers Receiving Employer-Sponsored Health Insurance. American Journal of Managed Care, vol. 22 (4): 286-290.
Stevens, R. (1999). In sickness and wealth, American hospitals in the twentieth century.
Baltimore, MD: The Johns Hopkins University Press.
