plans do not cover expensive, rare, or alternative treatments. Also, the out of pocket co-pays is either nothing or just a few dollars per prescription. Retired individuals qualify for Medicare however it does not include prescription coverage so they must buy one of two types of supplements. The first is called Medicare Prescription Drug Plan (Part D), and the second is called Medicare Advantage Plan (Part C). Both parts follow the same formulary and tier system as the other types of insurance plans previously described (Medicare, 2019). The National Health System of England does not charge for medications received as in inpatient at a hospital, however there is a co-payment charge for each outpatient prescription. The NHS does provide a safety net for certain populations that are exempt from paying the
ORGANIZATIONAL SYSTEMS TASK 3 4 copay. Children aged 15 and younger, children aged 16-18 if a full-time student, individuals 60 years and older, and those who are low income (such as the unemployed) fall into the safety net (Thorlby & Anora, 2016). A2B. Referral to See a Specialist The healthcare system of the United States requires a referral from your primary care provider (PCP) to see a specialist, regardless of age or employment status, if you want to use your insurance plan benefits. The PCP will provide written or verbal authorization to a specialist that is in your insurance plan network. If you want to see a specialist that is out of network or if you do not obtain a referral prior to going, you will have to pay most or all the cost out of pocket (Montgomery, 2019). The NHS of Great Britain also requires a referral from your general practitioner for specialty treatment. A General Practitioner (GP) is essentially the gate keeper for all medical care. The NHS suffers from a shortage of GP’s and specialty physicians, effectively leaving patients with little to no choice in providers and a long wait list to see them. Services will only be ordered if the GP feels it is clinically necessary, and usually only after several alternative treatments are attempted (NHS, 2019). A2C. Coverage for Preexisting Conditions When the US government enacted the Affordable Healthcare Act in 2010 a law was created, and went into effect on January 1, 2014, that prevented health insurance companies from not providing coverage due to a pre-existing condition, or for charging the consumer more money due to the pre-existing condition. They also can not limit benefits for any pre-existing conditions. The one exception to this rule is any “grandfathered” individual health insurance
ORGANIZATIONAL SYSTEMS TASK 3 5 policies purchased prior to March 23, 2010 that has not been changed in any specific way since the date of purchase (US Dept of Health, 2017).
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