Coverage for medication in the U.S. varies among each available health plan (U.S. Centers for Medicare & Medicaid Services [CMS], n.d.). U.S. health plans have their own list of approved prescription medications that will be less expensive for beneficiaries to purchase, and some health plans also have lists of in-network pharmacies that beneficiaries must use in order for their medications to be covered (CMS, n.d.). Medicare beneficiaries have to be enrolled in an approved plan that offers Medicare prescription coverage (CMS, n.d.). Referral to See a Specialist Unless a person’s insurance plan explicitly states otherwise, Swiss residents have open access to specialists without a referral or restriction of which doctor they choose (Mossialos et al., 2016). Similar to medication coverage, referral requirements in the U.S. for specialists differs by health plan as do restrictions on choice of specialist (Mossialos et al., 2016). Some plans require referrals and limit patients’ choice of specialist while others allow more choices of specialists and do not require a referral (Mossialos et al., 2016). Coverage for Pre-existing Conditions Current U.S. health law prevents any insurance companies from refusing coverage or charging a patient more who has a pre-existing condition (U.S. Department of Health & Human Services [HHS], n.d.). Similarly, Swiss MHI coverage cannot be refused based on a person’s health (Mossialos et al., 2016). Swiss supplemental voluntary insurance providers, however, are allowed to ask about a patient’s health and can reject coverage (Federal Office of Public Health, 2018).
TASK THREE 6 Financial Implications for Healthcare Delivery One financial implication that applies to patients in both the U.S. and Switzerland relates to prescription medication coverage. Although the coinsurance in Switzerland is 10% for generic medications and 20% for brand-name medications that have generic alternatives, the prices of generic medications in Switzerland are comparatively higher than other countries (The Organisation for Economic Co-operation and Development [OECD], 2017). This means that Swiss residents are paying a higher cost for generic medications than residents in other countries. Since medication coverage in the U.S. differs by health plan, patients may have to pay more for medications that are not on their insurance plan’s approved medication list. Another financial implication for patients in the U.S. relates to eligibility for income- based subsidies. While Marketplace health plans are offered at a reduced cost based on income and Medicaid and CHIP are in place for those who cannot afford a private health plan through the Marketplace, there are still residents with incomes too low for a Marketplace plan and too high to be eligible for Medicaid or CHIP (Mossialos et al., 2016). Those residents could incur the tax penalty for being uninsured. One other financial implication for Swiss residents relates to the minimum MHI deductibles. While the minimum required yearly deductible for adults is CHF300 and zero for children age 18 and under, beneficiaries have the option to choose a higher deductible that can range from CHF300 to CHF2,500 for adults and zero to CHF600 for children 18 and under in exchange for a lower monthly premium (Mossialos et al., 2016).
- Fall '17
- Task 3, C489, Swiss Vs. US Health System, Health System Comparison