Assume you are a Maryland resident and Medicaid recipient looking to enroll in a managed care plan, review the Maryland Managed Care Website at:https://mmcp.dhmh.maryland.gov/healthchoice/SitePages/Home.aspx.
Assess and evaluate HealthChoice, Maryland’s statewide mandatory managed care program. You will be evaluating HealthChoice overall, not one of the 8 participating plans. Your evaluation should be based on the following criteria. Answer the questions that appear in bold type:
Benefits Offered or Covered Services
You want a plan that offers a comprehensive benefits package including preventive care as well as treatment programs for chronic disease management. Also, you may need emergency care and/or care away from home. Evaluate the HealthChoice plan and summarize your findings.
Cost vs. Benefits
Managed care plans vary widely in the cost of services offered. It may be tempting to base your selection primarily on the periodic, out-of-pocket costs to you. You can’t be sure that the least expensive plan will give you all the medical services you need. Review cost vs. benefits for the HealthChoice plan carefully and summarize your findings.
Services of the Primary Care Physician
Choosing your primary care physician (PCP) may be the most important decision you make when enrolling in a managed care plan. The following questions are important when choosing your plan: Please use the answers to each question to provide a critical analysis of the program. DO NOT SIMPLY ANSWER THE QUESTIONS.
- Can you choose more than one PCP for your family?
- Is there a large choice of primary care doctors and specialists?
- How long is the average wait to get an appointment with the chosen PCP?
- Can you see the same doctor consistently?
- When and how can you change doctors if you are dissatisfied?
How does HealthChoice measure up?
Prescription Drug Benefits
When evaluating a health plan it is very important to know what kind of prescription drug benefits the plan offers. Depending upon the plan, there are several systems that have been implemented in efforts to control costs. Some plans offer a “generic only” plan. Use the following questions to guide your analysis in an academic response. DO NOT SIMPLY ANSWER THE QUESTIONS.
What prescription drug benefits does HealthChoice offer? Are they beneficial to your current drug regimen? (if you don’t take any prescription drugs, ask your instructor for a “list”). Would this be a good program for someone with chronic illnesses, multiple family members, pediatrics, geriatrics?
Provider Network and Geographic Service Area
Be sure you inquire from the Provider Membership Directory which providers are included in the network and where they are located in your community. If you live in one community and work in another; determine if routine care can be received in either location. Does HealthChoice have a strong network of Providers in a geographic area that is amenable to you? Must you go to different locations for different services? If you have a child away at school, does the network extend to that area? These are just a few questions you may ask when deciding whether the HealthChoice Provider Network is suitable to you. Compile the provider flexibility of these questions into a comprehensive paragraph or two response. Why are these important – use scholarly literature to identify why patient’s need access to a primary care physician.
Commitment to Quality of Care and Service
What measures of quality care and satisfaction of service are available? It is worthwhile to find out if the plan has been accredited by the National Committee for Quality Assurance (NCQA). NCQA is the most common accrediting body for network plans. Review and analyze what measures of quality care and satisfaction are available for HealthChoice. Are these standards in the industry? Is anything missing?
How do enrolled members feel about the plan? There are various objective forms of measurement used to determine “quality services” given by managed care plans such as accreditation, HMO report cards and/or publications produced by the industry. You would be wise to look at any that measure customer satisfaction.The National Committee for Quality Assurance (NCQA) mission is to provide information that enables purchasers and consumers of managed health care to compare plans based on quality. Their web site may be reached at http://www.ncqa.org/
Limitations, Maximums, or Exclusions
Lifetime Cap refers to the maximum dollar amount of benefits available to a consumer in a managed care plan during his or her lifetime. This amount becomes important when confronted with a life-threatening disease or accident that requires prolonged care involving expensive therapeutic intervention and support. Does HealthChoice outline limitations, maximums, or exclusions? Analyze the limitations that might negatively impact an individual or family and the reasons behind these boundaries. How might these change with new laws and future health care changes?