The Complexity of Medicaid Managed Care and the History of TRICARE for Life (Essay Sample)

The Complexity of Medicaid Managed Care and the History of TRICARE for Life Student's Name Department, Institutional Affiliation Course Name & Number Instructor Due Date The Complexity of Medicaid Managed Care and the History of TRICARE for Life Medicaid managed care is a networked healthcare plan where insurance agencies collaborate with an eternal managed care organization (MCO) to pay health providers for services rendered to its members. Its primary goal is to promote preventive care and wellness while reducing healthcare costs by collaborating with primary care physicians who, in turn, work with healthcare facilities. Despite these improvements from the fee-for-service program, Medicaid managed care is more complex than developing private sector managed care programs primarily due to its nature and benefits (Zott & Ryan, 2021). First, Medicaid eligibility is complex, comprising rigid rules that determine who can join or cannot join the plans. For instance, children under foster or custody care or those with delicate medical conditions are excluded, while adults who do not qualify for the plan throughout are also excluded (Maniates, 2024). Furthermore, the plans may exclude some services even for those who are eligible for the coverage. The federal government also imposes complex regulations on states regarding Medicaid, including mandatory quality strategy, which must be reviewed yearly. Additionally, states and areas must have annual reporting indicating quality and claim data. Medicaid managed care involves penalties, fines, and restrictions on health providers, states, and members who do not comply with the Medicaid contracts. Some agencies use other methods such as withholding capitation until the requirements are met, making public individual performances, and giving incentives. While these strategies help ensure quality care, they make the process longer, time-consuming, and complex than privately managed care (Zott & Ryan, 2021). These, coupled with the disorganized eligibility criteria, which may exclude critical services such as mental health in some states, make the program less convenient compared to private managed care. TRICARE for Life is a medical coverage program otherwise known as the Medicare-wraparound program, which provides services to individuals who are eligible for TRICARE and Medicare parts A. Simply, it is a supplement to Medicare for individuals who are covered under TRICARE, health coverage for individuals on active duty and their families. Previously, an individual lost their TRICARE eligibility once they attained the age of 65 because they could now be covered under the Medicare Part A program. However, the National Defense Authorization Act of 2001 extended TRICARE eligibility to cover individuals after attaining 65 years, retirees, their families, and spouses. Consequently, getting a TRICARE for Life became automatic as long as the individual was eligible for TRICARE and Medicare parts A and B. In this case, TRICARE for Life became a right for eligible beneficiaries regardless of age or place of residence. After becoming automatic and consequently a right for eligible beneficiaries, TRICARE for Life revolutionized the military health system in different ways. Some of its strengths, which affect the survival of the system, include its broader choice of providers where beneficiaries can seek services in a Medicare provider or military clinics depending on available capacity. Secondly, it has reduced out-of-pocket costs for benefits as long as the services offered are covered under Medicare and TRICARE (Military Officers Association of America, 2020). A combination of the two programs ensures extended coverage; therefore, individuals are likely to spend less than when covered under TRICARE or Medicare separately. Third, the program's extension to retirees and their families is beneficial to the military health system because it supplements the limitations of Medicare coverage while ensuring continuity of healthcare services from active duty to retirement. Finally, the close collaboration between the Centre for Medicare Services (CMS) and the Department of Defense has made it easier and faster to claim benefits. In most cases, individuals may not be required to file claims. Despite the strengths that enhance the military health system, the TRICARE for Life program has various issues that threaten the stability and suitability of the system. For one, individuals will still be required to pay for services not provided in both TRICARE and Medicare coverage, limiting the benefits of TRICARE and Medicare. As such, it is not all free for eligible beneficiaries because it will depend on the services offered. Secondly, the program is characterized by low-quality healthcare compared to private health coverage, primarily due to lower pay for physicians and healthcare providers (Kostas-Polston et al., 2023).The negotiated rates have seen some providers drop out of the program, leaving beneficiaries with few options, affecting the quality of care. With the rising number of active duty individuals, families, and retirees, the system cannot provide adequate healthcare services to the military population unless they work with all service providers regardless of location. Finally, the lack of proper coordination between physicians, Medicare providers, and the Department of Defense has led to inconveniences, especially in emergencies, threatening the sustainability o...