expenses related to being seen by a specialist out of the network, and POS may only cover a small portion of the out of pocket expenses (Montgomery, 2018). However, there are other private insurances that allow members to select specialist without the need for a primary care physicians referral. Private insurances like the preferred provider organization (PPO) and the exclusive provider organization (EPO) allow members to select physicians from a broad range of services in network or out of network without the requirement of a primary care providers script. If a member is insured with an EPO plan, out of network coverage is not provided by the insurance. Although some of the private insurance plans allow flexibility to see specialist without a referral, members are still responsible for co-payments and deductibles. Medicaid and Medicare are government assisted insurance programs for individuals or families with low-income. Both government provided insurances cover a large array of services, however the services provided are required to be deemed necessary services. For individuals with Medicaid or Medicare, referrals are required from the primary care physicians with approval by Medicaid. If the approval is denied, members are required to appeal the decision. Updated on 6/15/2018
ORGANIZATIONAL SYSTEMS TASK 3 7 Depending on how busy Medicaid is, the appeal may take from 3-6 months or more to process (Medicaid-help.org). A2C. Coverage for Preexisting Conditions Coverage for residents living outside of their native country residing in Japan, preexisting conditions are somewhat difficult to be covered. Some insurers are reluctant to provide coverage to those with preexisting conditions. A period of 24 months from the start of the plan is usually offered to the policyholder and if, during this time, no treatment is sought for the condition then the insurer may reconsider it for cover. Treatment includes any check-ups, medications prescribed, or symptoms displayed (JMI,2018). Higher premiums are offered at times to policy applicants for some preexisting conditions. There are cases in which an insurance company will offer coverage to the individual but exclude the pre-existing condition and "all consequences" of that condition. If a policyholder enters a plan with an exclusion on a pre-existing condition, the insurance company will refuse cover of any treatment related to that condition (JMI,2018). This is known as exclusion insurance coverage. The mandatory health insurance plans in Japan allows coverage for all medical, dental, and prescription drug needs, and individuals cannot be denied coverage for any preexisting conditions (Pacific Century Ventures, LLC). In the US, any plan included on the Marketplace must cover treatment for preexisting conditions. Members cannot be rejected, charged more, or have payments refused for any preexisting conditions. The Medicaid or the CHIP insurance programs also can’t refuse to provide coverage due to preexisting conditions. However, any plan purchased before the initiation of the affordable care act are not included. “Grand-fathered plans” are not obligated to
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- Spring '19
- Organizational Systems Task