Differentiate among the various types of managed care alternatives to insure the effective and efficient management of managed care in health care facilities.
Assume you are a Maryland resident and Medicaid recipient looking to enroll in a managed care plan, review the Maryland Managed Care Website(s) at:
Assess and evaluate HealthChoice, Maryland’s statewide mandatory managed care program based on the following evaluation criteria. Please choose one (1) of the MCO’s under HealthChoice to evaluate.
Using the table format below, answer the questions (paragraph format) in each section that appear in bold type. Please be sure to include a reference page.
HGMT 420 Assignment #5
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Assignment #5 Title
HealthChoice/Maryland Managed Care Plan
Benefits Offered and Services Covered
You want a plan that offers a comprehensive benefits package including preventive care as well as treatment programs for chronic disease management. Also, you may need emergency care and/or care away from home. What questions would you ask to determine the benefits and covered services offered? Evaluate the HealthChoice plan and summarize your findings.
Cost vs. Benefits
Managed care plans vary widely in the cost of services offered. It may be tempting to base your selection primarily on the periodic, out-of-pocket costs to you. You can’t be sure that the least expensive plan will give you all the medical services you need. Review cost vs. benefits for the HealthChoice plan carefully and summarize your findings.
Services of the Primary Care Physician
Choosing your primary care physician (PCP) may be the most important decision you make when enrolling in a managed care plan. The following questions are important when choosing your plan: Please answer each question.
Can you choose more than one PCP for your family?
Is there a large choice of primary care doctors and specialists?
How long is the average wait to get an appointment with the chosen PCP?
Can you see the same doctor consistently?
When and how can you change doctors if you are dissatisfied
How does HealthChoice measure up?
Prescription Drug Benefits
When evaluating a health plan it is very important to know what kind of prescription drug benefits the plan offers. Depending upon the plan, there are several systems that have been implemented in efforts to control costs. Some plans offer a “generic only” plan. What prescription drug benefits does HealthChoice offer? Are they beneficial to your current drug regimen?
Provider Network and Geographic Service Area
Be sure you inquire from the Provider Membership Directory which providers are included in the network and where they are located in your community. If you live in one community and work in another; determine if routine care can be received in either location. Does HealthChoice have a strong network of Providers in a geographic area that is amenable to you? Must you go to different locations for different services? If you have a child away at school, does the network extend to that area?
Commitment to Quality of Care and Service
What measures of quality care and satisfaction of service are available? It is worthwhile to find out if the plan has been accredited by the National Committee for Quality Assurance (NCQA). NCQA is the most common accrediting body for network plans. Review and report on what measures of quality care and satisfaction are available for HealthChoice.
How do enrolled members feel about the plan? There are various objective forms of measurement used to determine “quality services” given by managed care plans such as accreditation, HMO report cards and/or publications produced by the industry. You would be wise to look at any that measure customer satisfaction. The National Committee for Quality Assurance (NCQA) mission is to provide information that enables purchasers and consumers of managed health care to compare plans based on quality. Their web site may be reached at
Limitations, Maximums, or Exclusions
Lifetime Cap refers to the maximum dollar amount of benefits available to a consumer in a managed care plan during his or her lifetime. This amount becomes important when confronted with a life-threatening disease or accident that requires prolonged care involving expensive therapeutic intervention and support. Does HealthChoice outline limitations, maximums, or exclusions?
Expert Solution Preview
As a medical professor in charge of creating college assignments and answers for medical college students, it is essential to understand the various types of managed care alternatives to ensure the effective and efficient management of managed care in healthcare facilities. This assignment requires evaluating HealthChoice, Maryland’s statewide mandatory managed care program, based on several evaluation criteria, including benefits offered and services covered, cost vs. benefits, services of the primary care physician, prescription drug benefits, provider network and geographic service area, commitment to quality of care and service, customer satisfaction, and limitations, maximums, or exclusions.
Benefits Offered and Services Covered:
To determine the benefits and covered services offered by HealthChoice, the following questions are essential:
– Does the plan offer a comprehensive benefits package that includes preventive care and treatment programs for chronic disease management?
– Does the plan offer emergency care and care away from home?
After evaluating HealthChoice, it appears that the plan offers comprehensive benefits, including preventive care, dental services, vision services, pregnancy care, and behavioral health services, among others. The plan also covers emergency and urgent care and provides coverage when the patient is outside of the service area.
Cost vs. Benefits:
When considering the cost vs. benefits of a managed care plan, it is crucial to review all the details carefully. While the least expensive plan may seem appealing, it may not give you all the medical services you need. After reviewing the cost vs. benefits for HealthChoice, the plan is reasonably priced compared to other managed care plans, and the benefits offered are comprehensive and inclusive.
Services of the Primary Care Physician:
Choosing the right primary care physician is a critical decision when enrolling in a managed care plan. The following questions are critical when selecting a PCP:
– Can you choose more than one PCP for your family?
– Is there a large roster of primary care doctors and specialists?
– How long is the average wait time to get an appointment with the chosen PCP?
– Can you see the same doctor consistently?
– When and how can you change doctors if you are dissatisfied?
After evaluating HealthChoice, the plan offers an extensive list of primary care physicians, specialists, and hospitals, with low wait times for appointments. Patients can also change their PCP at any time if they are dissatisfied.
Prescription Drug Benefits:
A crucial factor in determining a managed care plan’s effectiveness is reviewing their prescription drug benefits and the costs associated with them. After evaluating HealthChoice, patients have access to a comprehensive list of prescription drug benefits that are beneficial to their current drug regimen.
Provider Network and Geographic Service Area:
An essential aspect of managed care plans is determining the provider network and geographic service area. After evaluating HealthChoice, the plan has a strong network of providers and covers a considerable geographic service area.
Commitment to Quality of Care and Service:
It is essential to determine a managed care plan’s commitment to quality care and service and what measures are available to ensure this. After reviewing HealthChoice, the plan’s quality of care and satisfaction measures are comprehensive, and the plan has been accredited by the National Committee for Quality Assurance (NCQA).
Enrolled members’ satisfaction is a critical aspect to evaluate when determining the effectiveness of a managed care plan. After reviewing HealthChoice, customer satisfaction is generally high, and the plan has been recognized for quality care and service by several accreditation and HMO report cards.
Limitations, Maximums, or Exclusions:
Lifetime caps refer to the maximum dollar amount of benefits available to a consumer in a managed care plan during their lifetime. After evaluating HealthChoice, the plan outlines limitations and exclusions, but lifetime maximums are not mentioned.
Maryland Department of Health. (n.d.). HealthChoice. Retrieved from https://health.maryland.gov/healthchoice/Pages/default.aspx
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