Health Care Delivery Systems Example

It was like any other sunny day at the park. The sun was bright, the air was fresh, and I had just settled down to read a book. As I surveyed my surrounding, I saw a mother with her small child at the swings. The child appeared to be slumped in the swing as the mother looked grimly on. As I resumed reading my book, I heard a blood curdling scream. The mother at the swings was cradling her child in her arms and sobbing. A bystander took the child from its mother and began to perform CPR. I nudged my way through the crowd to observe the scene. The child appeared ashen and unresponsive.Health Care Delivery Systems Example

The bystander’s efforts seemed fruitless. The ambulance finally arrived and pronounced the child deceased. The mother was hysterical and screaming that her child died because she could not provide sufficient health care because of the high cost. In 1956, U. S. Congress passed the Dependents Medical Care Act, allowing the Department of Defense to provide civilian health care to dependents of military service members. Like any newly passed law, this law had many trials and errors, and was finally amended in 1967 and named CHAMPUS (Civilian Health and Medical Program of the Uniformed Services).

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CHAMPUS was a federally-funded health benefits program which provided supplemental care to military, Public Health Service facilities for retired U. S. military personnel, as well as dependents of active-duty, retired and deceased military. It provided authorized in-patient and out-patient care from civilian sources, when medically necessary, on a cost-sharing basis, and was administered by private parties under government contracts (TRICARE Plans). In 1995, CHAMPUS was revised and renamed TRICARE.Health Care Delivery Systems Example

TRICARE covers 100% insurance for its active duty members but for those who are no longer on active duty they have the options to choose from three main coverage choices of health care. They can either choose from TRICARE Prime, TRICARE Standard, or TRICARE Extra. Military dependents and retirees must choose the TRICARE option that best suits their needs and budget. Since I am a military member, I receive TRICARE Prime. TRICARE Prime is a health maintenance organization (HMO) style plan. Under TRICARE Prime, beneficiaries must choose a primary care physician and obtain referrals and authorizations for specialty care.

In return for these restrictions, beneficiaries are responsible only for small copayments for each visit. Co-payment is for those who are no longer on active duty but still want to maintain TRICARE Prime. For example, for each visit of a physician a member may be required to pay $5, regardless of the expense of the services rendered. Or, for each prescription for drugs and medicines, the member may have to pay a flat $2 regardless of the actual cost. There is no enrollment or co-payment fee for active duty military and their family members (Understanding TRICARE).

Like any other insurance company, TRICARE Prime has its limitations and exclusions. There are no major limitations with TRICARE Prime even if you are active duty and have a preexisting condition that was not diagnosis prior to enlisting in the military; TRICARE Prime will pay for the treatment. In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder) or injury or for the diagnosis and treatment of pregnancy or well-baby care.Health Care Delivery Systems Example

All services and supplies (including inpatient institutional costs) related to a non-covered condition or treatment, or provided by an unauthorized provider, are excluded (TRICARE Prime Handbook, 2006). If a nonmilitary person was to lose their health coverage they would either qualify for Medicaid or Medicare, depending on their age and eligibility. Medicaid is available only to certain low-income individuals and families and is a state administered program in which each state sets its own guidelines regarding services eligibility.

Medicaid makes payments directly to the health care provider. Sometimes a co-payment is necessary. Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. COBRA (Consolidated Omnibus Budget Reconciliation Act) is another option which provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates (U. S. Department of Labor, 2007). This coverage is only provided when extenuating circumstances call for it. This is a great option for those who can afford the high premiums but not such a good idea for those who do not have employers paying part of their premium and are between jobs. The Health Insurance Portability and Accountability Act (HIPPA) not only protects someone’s right to privacy but it helps protects people’s rights when health coverage is involved.Health Care Delivery Systems Example

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If you are eligible for coverage under a family member’s employment-based plan, HIPAA includes protections for coverage under group health plans that prohibit discrimination against employees and dependents based on their health status, limit exclusions for preexisting conditions, and guarantee access to individual policies for people who qualify (U. S. Department of Labor, 2007). The cost of health insurance is not getting any cheaper and the lack of the insured is growing at a considerable rate. It is a very sad day for us as Americans when we cannot afford to take care of our own.Health Care Delivery Systems Example