Medicare for Medicare (Berenson, 2015). Additionally, individuals who

Medicare is the nationwide
health insurance program that qualifies all Social Security beneficiaries who
are either over 65 years of age or permanently disabled (Medicare Advocacy,
2018). . For those individuals who are over the age of 65 and have paid 10
years of social security taxes, automatically qualifies for Medicare (Berenson,
2015). Additionally, individuals who receive railroad
retirement benefits and those that suffer from renal disease are also qualified
to receive Medicare benefits (Medicare Advocacy, 2018). Medicare should not be confused
with Medicaid as it does not have the same criteria as welfare. In terms of
determining eligibility, income and assets of a Medicare recipient is not an issue
(Afendulis, 2012). Medicare procedures should not vary significantly from state
to state (Medicare Advocacy, 2018).

 Medicare coverage is like the coverage
provided by private insurance companies. Just like a private insurance carrier,
deductibles and co-insurance are required from the beneficiary (Berenson, 2015).
 If an individual is eligible for
Medicare they can chose between getting their benefits through traditional
Medicare or getting benefits through Medicare Advantage (Berenson, 2015).
Before deciding on which program to enroll, the individual must consider their
circumstances which include their health, budget, desire for flexibility, and
tolerance for financial risk (Medicare Advocacy, 2018). It’s important to know
the different portions of Medicare and how they work collectively before
deciding if this is the right program. Also, its important to identify the main
differences between the two, traditional Medicare and Medicare Advantage. Asking
questions and gathering information is the most important thing before
enrolling in either of the two plans (Medicare Advocacy, 2018).

We Will Write a Custom Essay Specifically
For You For Only $13.90/page!

order now

has four coverage components Part A, Part B, Part C, and Part D.  Traditional Medicare, which consists of Part A
and Part B, is managed, and run by the federal government (Medicare Advocacy,
2018). Part A covers the overall hospitalization expenses such as skilled
nursing facility care, home health, and hospice care whereas Part B covers the
medical expenses such as doctor visits, medical equipment, lab tests,
ambulatory services, and outpatient procedures (J Oncol, 2009).  Medicare Advantage, which consists of Part C,
is managed, and run by private insurers (Medicare Advocacy, 2018). It
is basically a different way of getting Medicare Part A and Part B coverage. However,
Part C may be chosen in place of traditional Medicare. There are some
additional programs as well which is included in the Medicare part c.

 Part C Medicare is also called Medicare
advantage. “This specific Medicare plan is run by private insurance companies, but
they are curated and regulated by the federal government” (Medicare Advocacy,
2018). Medicare part C plans are mandatory to offer the overall coverage what
Medicare plans A and B offers. Most of the Medicare C plans include the
prescription coverage and therefore can be upgraded to a Medicare part D plan.
Medicare advantage plans combine Part A and Part B and often Part D, into one
plan so the entire package of benefits comes from a private insurance company
(J Oncol, 2009).

“Part D is the part of the Medicare program that provides
outpatient prescription drug coverage” (Medicare Advocacy, 2018). Similarly, Part
D is administered and run by private insurance companies that have contracts
with the federal government (J Oncol, 2009). Part D coverage must be purchased
separately if you have traditional Medicare or a Medicare Advantage plan that
does not include prescription drug coverage (Medicare Advocacy, 2018). Another
term for this is “stand-alone” Prescription Drug Plan (Medicare Advocacy, 2018).
However, a Medicare Advantage plan that includes health and drug coverage is
referred to as a Medicare Advantage Prescription Drug plan (J Oncol, 2009).


recipients have union coverage that pays costs that traditional Medicare does not
cover (Berenson, 2015). Those who do not may need to buy Medicare Supplement
Insurance (also known as Medigap) (Medicare Advocacy, 2018). Any co pays,
coinsurances, or deductibles left by traditional Medicare, Medigap plans help
pay for those gaps (J Oncol, 2009).
In certain situations, recipient with traditional Medicare must purchase a
separate Part D drug plan as well as a Medigap plan to supplement their
Medicare benefits (Afendulis, 2012). Because Medigap guidelines do not work
with Medicare Advantage, it is against the law to sell a Medicare Advantage
recipient a Medigap policy (Medicare Advocacy, 2018). Nevertheless, the only
way for that to take place is if the recipient is switching over to traditional

are a few key differences between Traditional Medicare and Medicare Advantage
Plan. Some of those differences between the two include access to services,
cost, and benefits (Berenson, 2015). Traditional Medicare allows the enrollee
to go to any doctor or hospital in the US that will accept Medicare.
Traditional Medicare does not have a network so referrals and prior
authorization to obtain services are not required (J Oncol, 2009). However, any
Medicare Advantage enrollees are limited to the network of providers for the
plan to cover their care (Berenson, 2015). These enrollees must obtain
referrals and have prior authorization before the services are provided
(Afendulis, 2012). Additionally, they may be required to choose a Primary Care
Provider (PCP). 

Although there are
certain Medicare Advantage plans that could cover the services provided outside
of the network, it’s more likely for that enrollee to have to pay more out of
pocket (Berenson, 2015). Being that emergency and urgent care might only be covered
by this plan if you are outside of the service area, it’s important to schedule
a follow up appointment (Medicare Advocacy, 2018). In the Medicare Advantage
plan, network providers have the ability to join or leave at any time during
the year as well as the Medicare Advantage plan have the advantage of changing
the providers in the network (Berenson, 2015). However,
the enrollee must wait until the following year, during open enrollment period,
to leave the plan (J Oncol, 2009).

Again in traditional Medicare,
any individual who have worked and paid social security taxes for at least 10
years qualifies for Part A coverage (Berenson, 2015). With traditional
Medicare, there is a monthly premium for Part B coverage that has to be paid as
well as deductibles, coinsurance, and co pays (J Oncol, 2009). There are no out
of pocket limit on what the individual could spend on healthcare. Part D drug
coverage and Medigap plan must be purchased separately with traditional
Medicare (Medicare Advocacy, 2018).

            Similar to traditional Medicare,
Medicare Advantage enrollees must pay the same monthly premium for Part B
coverage (J Oncol, 2009). However, the cost in Medicare Advantage plans varies.
Out of pocket expenses depends on the plan chosen and may include the following:
whether the plan charges an extra monthly premium and what network providers
are used, if the plan has a yearly deductible, the co pay or coinsurance for
each visit, and the type of services the individual is seeking (Medicare
Advocacy, 2018)

Medicare Advantage plans could possibly change their
benefits, co pays, and premiums yearly (Afendulis, 2012). In terms of cost-
sharing, Medicare Advantage plans may charge for a service that is above or
below the traditional Medicare cost-sharing for that service (Medicare
Advocacy, 2018). However, Medicare plan can not surpass the cost-sharing for
those services under traditional Medicare (Berenson, 2015). Some of those
services include chemotherapy administration, renal dialysis, and skilled
nursing care (Medicare Advocacy, n.d). For Part A and Part B coverage, Medicare
Advantage plans have a maximum out of pocket limit on the amount of
cost-sharing they can charge (J Oncol, 2009). The good thing about that is that
the individual would not be required to pay anything for the remainder of the

In terms of benefits, traditional
Medicare and Medicare Advantage have a standard benefit package that covers
medically required health care services (Afendulis, 2012). However, the
difference between the two is that traditional Medicare do not cover
prescription drug whereas Medicare Advantage does. The traditional Medicare
enrollee must purchase a Medigap plan and Part D coverage in order to receive
prescription drugs (J Oncol, 2009).  
Another difference is that Medicare Advantage covers services such as
vision, dental, and hearing whereas traditional Medicare does not cover those


With traditional Medicare, there are better selections
of doctors and freedom of choice to select your preferred healthcare organization
(Afendulis, 2012). Many individuals usually support and remain loyal to the
traditional Medicare system as oppose to the privately insured Medicare
Advantage. Medicare Advantage plans have the ability to change at any given
time whereas traditional Medicare plans pretty much stay consistent but there
are several protocols that have to be taken in order to make changes in the
traditional Medicare plans (Medicare Advocacy, 2018).

Some of the perks with having Medicare Advantage plans
are that they provide a wide coverage of different Medicare options.  The enrollees have the option to select the
services they want and don’t want. 
Hence, they could possibly see a lower premium based upon their selection
(Berenson, 2015).   Medicare Advantage plans can be extended and
offer additional coverage such as vision, dental, etc. Some Medicare programs
can be expensive and doesn’t cover as much as shown in the Medicare Advantage
programs (J Oncol, 2009). Some of the downfalls with Medicare Advantage plans
are that they can change at anytime without giving notice to the individual and
there is no supporting evidence to prove the quality of their program (Medicare
Advocacy, 2018).   

Yet, Medicare Advantage programs are more attractive
and beneficial to a physician and hospital. Because Medicare Advantage programs
tend to provide a higher number of coverage and tend to be more than the
traditional Medicare program, it’s seen as a better match for the physician and
medical facilities (Afendulis, 2012). By accruing more revenue from the
individual’s social security, this increases the overall revenue for the
hospital as well as the physicians (J Oncol, 2009). That’s why the Medicare
Advantage plan would be an ideal choice for the hospital and the physician.


As a way of physician reimbursement, capitation has
been around longer than fee-for-service (Healthcare Incentives, 2015). Capitation
is the opposite of fee-for-service. Capitation payments are payment arrangement
between the state and health plan upon a capitation contract by a health
insurance and medical provider (Investopedia, 2018). They are fixed monthly
payments by a provider, clinic, or hospital per patient enrolled in a health
plan (Alguire, 2018).The fixed monthly payments are calculated one year in
advance and it remains fixed for that year despite how often the patient seeks
medical services (Investopedia, 2018).  Basically,
physicians get a guaranteed income flow based on the range of services that are
provided, the number of possible patients they may see, and the time frame
during which the services are provided (Alguire, 2018).  The purpose of capitation is to put health
practices at risk for a set per member, per month fee allowing it to have a
strong incentive on managing the care of patients so that a profit can be made
(Healthcare Incentives, 2015). The information is available to the public as a
measure of healthcare quality as well as be linked to financial rewards
(Alguire, 2018).

When a primary care physician signs a capitation
agreement, some of the services included in the payment plan are preventive,
diagnostic, and treatment services, injections and immunizations, outpatient
laboratory tests, routine hearing and dental services, and counseling services
(Alguire, 2018).Under a capitation system,
healthcare service providers could be paid per month or per patient regardless
of how many times patients are scheduled to be seen or despite what services
are being rendered (Goodson et. al, 2001). Capitation gives health care
providers a secure, expected cash flow (Healthcare Incentives, 2015). Whether
an individual seek care for each period of time, healthcare providers are paid
a set amount for each registered individual assigned to that physician (Investopedia,
2018). For instance, a primary care physician may be paid $30 for each one of
the 120 patients under his/her cares, for every month, yet the doctor may only
end up seeing 35–40 of them (35-40 visits) on average. In simple terms, the
physician collects an average of about $90 per each patient’s visit during an
average month.

The amount of compensation is based on the average projected
healthcare utilization of that patient (Goodson et. al, 2001). In other words,
more compensation is remunerated for patients with general or complicated
medical histories. Additional factors that need to be considered are physical
location, sex, race, employment type, and age. In my cases, a risk pool is recognized
as a percentage of the capitation payment (Alguire, 2018). That means that the
money in the risk pool is not accessible to the physician until the end of a
fiscal year. Therefore, if the health plan does financially well, the money is
paid to the physician; however, if the health plan does not do financially
well, the money goes toward shortage expenses (Alguire, 2018).

With the aspect of care delivery, the capitation
system provides financial confidence to doctors, hospitals, and insurance (Goodson
et. al, 2001). Healthcare providers assume the risk of more patients, who have
became sick and needs care, than anticipated. In reference to the primary care
physician example, if an illness spreads amongst the doctor’s patients, he/she may
end up seeing 55-60 patients three or more times in that month for
approximately over 200 visits. Thus, the physician will receive around the same
payment, averaging about $18 per visit.

Capitation has been used as a base system in health
programs for over a decade ago. Large insurance companies steered away from
systems because the rising costs of lab tests, diagnostic procedures, and
medication were severely restricting earnings (Goodson et. al, 2001). A good
tactic to reduce operational costs would be to combine capitation for basic
services and payments for less-required health care needs (Goodson et. al, 2001).
Capitation encourages preventive health care while limiting the treatments
allowed for cost examination and alterations between doctors, service
providers, and health programs (Goodson et. al, 2001). As a payment model, capitation
has become the preferred form of providing health care payments for medical and
health plans because it allows physicians to improve the management of
resources at a local level (Goodson, et. al, 2001)..