LEGAL ISSUES IN HEALTH CARE DELIVERY RESEARCH
INSURANCE MEDICARE AND MEDICAID ISSUES
A course paper presented to the School for Arts and Sciences and Distance Learning
in partial fulfillment of the requirements for the degree of
Health Care Law
TABLE OF CONTENTS
Insurance is hard to come by if you are unemployed, self-employed, or working part-time or for a small business that do not offer insurance. In some cases you may qualify for Medicare if you are sixty-five and older or disability. Otherwise your best bet is seeing if you’re eligible for Medicaid. President Obama signed the Affordable Care Act (ACA) on March 23, 2010, into law putting in place comprehensive reforms that improve access to affordable health coverage for everyone and protect consumers from abusive insurance company practices. (Reform) This new health care law is suppose to stop insurance companies from taking advantage of you, by adding new benefits, fighting fraud, cutting costs and improving care for patients.
In our country there are about 45 million uninsured Americans, insurance is the one thing you don’t want to be without. Most are uninsured due to unemployed, lost of job, self-employed, or working part-time that don’t supply insurance. So who’s paying for the medical bills, most working class people cannot afford their own medical bill, that why we have insurance to pick up the coverage. People in despared times will get creative at getting out of paying that bill. A friend told me a story once of this girl who got her husband into urgent care using their son Medicaid number and everything was paid for. I sure it was caught eventually, but that was just one case, how many others are out there. Insurance fraud is a big problem that causes our premiums and co-pays to increase. The issues with insurance is coverage, what type of coverage does the patient have, what will it cover and is it a plan that we support. INSURANCE
The number one insurance company in America today is Blue Cross and Blue Shield (BCBS). They currently insure about 3 million people with very low and affordable plans. (BCBS) BCBS of Arkansas is my plan through Wal-Mart Corporation and BCBS of Kansas City is what most patients bring to my pharmacy. Now the issues with insurance in the pharmacy, most people do not know what type of coverage they have, wether it is medical, dental, prescription or all is covered. For prescription coverage, the processor is Express Script through Medco. (Wire) There is a difference co-pay for patents, which depends on the plan the patient chooses, but most co-pay range five dollars for generic and ten dollars for name brand. One of the biggest issues is patient that wants a ninety day supply for medication; this plan will only allow a thirty day supply at retail and a ninety day supply through mail-order. Another issue is prior authorizations claims, most are for medications that are not on the patient formulary or they need to try a less costly drug first before the insurance will pay. Under no circumstances can we override this type of rejection without the physician speaking to the insurance first, to do so would be fraud, and then pharmacy is liable for the charges. Sometimes it is just a product that they just will not cover, like over-the-counter (OTC) products. Most if not all insurances will not covered OTC products, they are usually cheaper to get OTC anyway. MEDICAID
The most common state and federally funded health insurance is Medicaid. It currently provides health coverage to about 60 million Americans. (Medicaid) This free or low cost program you usually hear that it is for...
References: Blue Cross and Blue Shield of Kansas City, Retrieved from http://www.bluekc.com/Home.aspx
Healthcare Reform in Action, Retrieved from http://www.whitehouse.gov/healthreform
Medicaid.gov. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/missouri.html
Medicare.gov. Retrieved from http://www.medicare.gov/
Social Security.gov, Retrieved from http://www.socialsecurity.gov/pubs/EN-05-10043.pdf
Wal-Mart wire portal. Retrieved from www.wireportal.walt-mart.com
This site you will not have access to, because it’s for Wal-Mart employees only. I had to site it, because some of my research came from that site that I printed off from work.
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