Health Insurance Plan Selection for Family with Multiple Conditions

The case study discusses various health insurance plans that can be suggested to a family with several conditions, including maternity expenses, mental health issues, high cholesterol, and medication for psychosis, depression, and cholesterol. The family's income is $80,500, which does not qualify for premium tax credit, but they may still benefit from Cost-Sharing Reductions (CSR) by enrolling in a Silver Plan. The case study also highlights the importance of good nutrition during pregnancy, increased coverage for mental health services, and the availability of various insurance plans to support different medical conditions.

CASE STUDY 1
Assignment
CASE STUDY
Student Name:
Student ID:
Course Name:
Course ID:
Faculty Name:
University Name:

CASE STUDY 2
CASE STUDY
There are a number of health insurance plans which can be suggested to the family. There are
many conditions with the family members which need to be taken care of before selecting an
insurance plan. The family can opt for more than one insurance plan to support their
condition .
In this, we will first take a look at the plans mentioned in the table. Then discuss them one by
one and find out which plan is most suitable for the family member. The plan is for a young
person. Also, there is a pregnant female in the family. Along with this, there is medication for
psychosis , depression and cholesterol.
Plan Main Benefits
1) Maternity
Insurance plan
Covers all complications of maternity expenses
along with new born baby care.
2) Medicaid
Alternative
Benefit Plans
Covers mental health. Also covers the factors
causing mental illness.
3) Medicaid Provides coverage with family of low income
4) Community
Health Centres
Some hospital and health care centres do provide
cover regardless the ability to pay
5) Medicare
Assistance
Provide free medicines.
6) Foundation for
Health
Includes state by state information on different

CASE STUDY 3
coverage coverage option
Maternity benefits are one of 10 essential benefits which are covered by most of the
insurance plans. It was not a granted benefit before 2014. Only about 12% plans in the market
had the maternity benefit. But now there are many special riders which insurers can opt for
along with the maternity plan. Earlier it was only viable to the women who are not pregnant
and was not available to the one who had already conceived. But now the maternity benefits
can be taken by the women who are pregnant. There are various services covered for the
mother and the baby. The outpatient services which will include the antenatal and postnatal
care. The lab checkups for various diseases like gestation diabetes , screening and
medications are also included. There are services like Inpatient hospitalisation during
delivery and the fees of the treating physician are also included in the insurance plan. There
are a lot of expenses of newborn baby in the hospital itself. The newborn baby care has also
been included in the insurance. As the new mothers required much counselling regarding
baby care. Hence in this, the counselling with the physician on lactation is also included.
Insurance also provides coverage for rental breast pumps. Maternity Insurance is a mandatory
benefit.
The maternal care includes a broad spectrum. It includes regular medical visits to the
physician , prenatal testing, nutrition, exercise and test for diagnosis of infections. All these
should be there during the pregnancy phase. It is very important to have good nutrition as this
supplies directly the child directly food and nutrition through mother. This also helps in
having a healthy lactating phase.

CASE STUDY 4
There are lot of inequalities in healthcare when it comes to mentally ill patients. The main
factor contributing to their ill health is lack of proper treatment and care. There are two laws
which are passed in 2008 that created equality for mental health services in Medicare and
private insurance. These laws especially meant that coverage for mental health services will
have the same benefits as per the other general insurance. It includes the cost sharing
arrangements such as deductibles and co-payments and limits on coverage. The people
suffering from mental illness have increased protection since 2008. The plans now offer a
series of health insurance exchange in parity with the general insurance cover. There is a
broad improvement in health insurance coverage. Now the people need not depend on public
mental health system or charity care. Through insurance, they can take care of their mental
health. There is also focus on particular clinic care in early detection and intervention and
diagnosis of mental illness. There is increased coverage on pharmaceuticals. There is also the
elimination of exclusion. There are still many challenges. Now with the reforms, we require
evidence-based practise. There is also a requirement of better coverage. But currently the
system is far better than what is was earlier. The plans now cover the disease without
exclusion. There might not be any rider or tax benefit provided.
People with high cholesterol get health plans easily as it is not termed as a disease. There is
some extra premium charged on the base amount. In this diseases like stroke is covered.
Almost all the health insurance plans cover high cholesterol. There are many riders also
available. It can be added without any further cost. Also, there is tax befits offered by
Medicare under this category. Along with this, there are many community health care centres
which provide various exercise plan and diet modification plan under the insurance cover.
This saves the further worsening of the future condition. Also, there is counselling and
regular session and also health checkups under the insurance plan. The main complication of
high cholesterol is a stroke. In the case of Medicaid, depending on family income there is

CASE STUDY 5
coverages post stroke. Insurance plans are available in market to inspire of various diseases
and complications.
Federal Poverty Level Guidelines & Tax Implications
Household
Size
100% 133% 150% 200% 300% 400%
1 $11,880 15800 17820 23760 35640 47250
2 $16020 21307 24030 32040 48060 64080
The family income is $80500 which is 505% of the Federal Poverty Level (FPL) which
does not qualify for premium tax credit. The criterion for availing tax subsidy is met only
if the annual income is within 400% of FPL. However, extra savings known as Cost-Sharing
Reductions (CSR) can accrue by paying less out of pocket expenses “which is only available
if enrolled in a Silver Plan”. The Silver Plan pays 70% of the covered medical costs and are
the only ones offering CSR. The remaining 30% premium to be paid by the policy holder
excludes the monthly premium and can vary with different insurance companies. An
illustrative Silver Plan showing average out of pocket expenses is as given below.
Cost sharing Category(family) Average for a Silver Plan($)
Deductible 6480
Doctor Visit 29
Specialist Visit 56

CASE STUDY 6
Generic Drugs 13
Preferred brand drugs 47
Non preferred brand drugs 89
Speciality drugs 31%
Annual Expense 12270
It is to be noted that the monthly premium depends on the insurer, the number of people, age,
whether you smoke and the region you live. The average monthly premium for a person aged
30 comes to about $312.
References
Knox, C. A., Delaney, J. A., & Winterstein, A. G. (2014). Anti-diabetic drug utilization of
pregnant diabetic women in us managed care. BMC pregnancy and childbirth, 14(1), 1.
Anderson, M., Dobkin, C., & Gross, T. (2012). The effect of health insurance coverage on the
use of medical services. American Economic Journal: Economic Policy, 4(1), 1-27.
Bartlett, J., & Manderscheid, R. (2016). What Does Mental Health Parity Really Mean for the
Care of People with Serious Mental Illness?. Psychiatric Clinics of North America, 39(2),
331-342.
Levine, D. A., Morgenstern, L. B., Langa, K. M., Piette, J. D., Rogers, M. A., & Karve, S. J.
(2013). Recent trends in cost‐related medication nonadherence among stroke survivors in the
United States. Annals of neurology, 73(2), 180-188.