HealthCare.gov, if the individual is unemployed and cannot afford any health plan and does not qualify for coverage through Medicaid and the Children’s Health Insurance Program (CHIP), he or she can get low-cost health care at a nearby community health center. These health care centers are situated in rural and urban areas for their convenience and the payment of such health care coverage depends on the individual’s income. The unemployed under this coverage is covered for prenatal care, baby shots, general primary care and referrals to specialized care, which includes mental health, HIV/AIDS and substance abuse. (HealthCare.gov, n.d.). In the U.K., NICs are compulsory contributions that are paid by employees and employers and the selfemployed to provide benefits of healthcare for the unemployed, state pensions and low-income families that fund the NHS to cover healthcare for these groups of patients. With this contribution in place, access to healthcare is at of no cost or very little cost to these groups. (Gleason, Ridic, 2012). 3
Organizational Systems and Quality Leadership Task 3 A2a. In the U.S., coverage for medications can be accessed through Medicare policy. Medicare offers drug coverage through different Medicare Prescription Drug Plan, part D, Part C, Medicare Health Plan. The U.S. healthcare system offers discounted medications through the patient’s health insurance plan. The U.K. under the NHS healthcare policy, there are almost no copayments except for small copayments for prescription medication approximately $12, including dental and eye care. U.S. patients may have a higher cost sharing of medications than the U.K.. A2b. The requirements to get a referral to see a specialist in the U.K. include having to visit the GP or family practitioner. A patient in the U.K. cannot go directly to a specialist. In the U.S., it depends on what type of coverage the patient has. For example, if the patient has a health maintenance organization (HMO) plan, the patient will have to go through his/her own PCP. If the patient goes directly to the specialist, the insurance company plan will not pay for the visit. If the patient has a point of service (POS) plan, the patient will have to pay a flat rate to be referred to a specialist through the PCP. If the patient has a preferred provider organization (PPO) plan, the patient does not necessary need to get approval from the PCP, but may cost more if the patient goes outside the network in the plan. If the patient has a fee-for-service plan, the patient has the freedom to go and see any specialist he/she prefers and does not need to go through the PCP. (Pinnacle Health, n.d.). 4 Organizational Systems and Quality Leadership Task 3 A2c. In the U.S., all marketplace plans have to cover the patient’s treatment for pre-existing medical conditions. The insurance plan cannot reject the patient or refuse to pay for essential
health benefits for any pre-existing condition. Medicaid and the Children’s Health Insurance Program (CHIP) cannot refuse to give you cover because of the pre-existing condition.
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- Fall '17