Medicare Advantage plans, QHPs, and Medicaid MCOs: The Pro’s and Con’s

Student 1

Sumetria Saunders posted Aug 29, 2018 5:49 PM


The three plans that I will discuss are Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations. Medicare Advantage is for those that have Medicare. Medicare Advantage plans provides a combination of benefits from Medicare Parts A, Medicare B and Medicare Part D prescription drug benefits. The Medicare is “a federal program” (Lipschutz 2015) Qualified Health Plans are available on the Marketplace and cover ten essential health benefits. These plans are funded by federal and state partnerships.  Medicaid Managed Care Organizations is a plan that a Managed Care Organization administers health benefits by using Medicaid benefits for people that have Medicaid.  The Medicaid plans are funded jointly by state and federal. The three plans have different types of medical coverages that I will discuss below.

Prescription drug coverage for Medicare Advantage must cover drugs in six protected classes. The Qualified Health Plans must cover the largest number of drugs in a class. The Medicaid MCO must cover all FDA drugs that have rebate agreements.

There is an out of pocket limit on Medicare Advantage and Qualified Health Plans. The Medicaid MCO Plans limit is 5% of monthly /annual income.  The people with Medicaid MCO’s pays the least out of pocket. This is helpful for the Medicaid MCO population.

The is no balance billing for Medicaid MCO Plans and Medicare Advantage. The Qualified Health Plans don’t have a restriction for balance billing.  The balance billing policy is helpful for the Medicare Advantage and Medicaid MCO policy holders. They can’t be billed by medical providers for balances left after the insurance pays their portion.  The people with Qualified Health Plans can be billed after the insurance pays the medical provider.

Switching the plan mid-year is an option for Medicare Advantage and Medicaid MCO Plans. This is helpful if providers terminate their contract with the plan. This is not an option for Qualified Health Plans.


Lipschutz, D. & Callow, A. (2015). Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations. Retrieved from

Student 2

alisha Adams posted

Analysis of Medicare Advantage Plans, QHPs and Medicaid MCOs

American healthcare insurance system is basically comprised of publicly funded plans as well as privately administered covers. Lack of universal health care in America encourages the adoption and prevalence of private health insurance covers to people under publicly funded Medicare and Medicaid. Medicare Advantage Plans, Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations (MCOs) constitute the most popular privately administered plans available in the marketplace (Lipschutz et al., 2015). The plans have distinctive offers to clients, implementation strategies and different targets therefore exhibiting their specific advantages and disadvantages.

Medicare Advantage Plans

Medicare Advantage plans provide for coverage benefits stipulated by the traditional Medicare in the sense that clients cannot substitute benefits other those provided by general Medicare plans. The programs fundamentally cater to senior citizens without healthcare coverage as well as a defined set of people with disabilities (Lipschutz et al., 2015).

Pros: Covers for virtually all prescription drugs in protected classes defined by 6 categories, additional two drugs for all protected drug classes, pharmacy and therapeutics.

-Plans are subject to asset test which determines the cost-sharing subsidies available for specified categories of client’s income ratio to Federal Poverty Level.

Cons: Confined to time and distances stipulated by the regulations and, terms and conditions.

Qualified Health Plans (QHPs)

QHPs are subject to consumer protection standards enforced at state levels irrespective of the establishing minimums and standards set by the federal government. QHPs mostly provide coverage for non-elderly citizens without other coverage options and all plans must meet the Affordable Care Act minimum requirements (Lipschutz et al., 2015).

Pros: Covers benefits in 10 essential health insurance categories and allows for substitution of benefits within categories, unlike Medicare Advantage.

Cons: The plan does not allow policyholders to change plans mid-years in case the plan terminates providers from the network.

The absence of drugs’ protected classes other than requirements on covering a greater number of drugs as covered by the benchmark plan.

Medicaid Managed Care Organizations (Medicaid MCOs)

Medicaid MCOs caters for low-income individuals and provide coverage to disabled people. The program is funded by both federal and state governments and administered jointly or by either of the governments (Lipschutz et al., 2015).

Pros: Covers all Medicaid benefits stated by the federal government and additional benefits set by the regulations of the state.

Covers all FDA approved drugs and prescription drugs according to state regulations.

Cons: Does not provide for federal or state requirement on minimum revenues to be spent on healthcare expenses.

Exemption of certain populations and services due to limited cost sharing at the state level.


Lipschutz, D., Callow, A., Pollitz, K., Musumeci, M., & Jacobson, G. (2015). Comparison of        Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified     Health Plans and Medicaid Managed Care Organizations. Retrieved from            health-insurance-markets/

Student 3

Vonetta Ellison posted Sep 5, 2018 6:28 AM

The Medicare Advantage (MA), Qualified Health Plan (QHP), and Medicaid MCOs are big health insurances today in the market, which are different to each other in terms of their general approach, prescription of drugs, cost-sharing, out-of-pocket limit, and in other aspects. Medicare Advantage (MA) is a health insurance that covers the same benefits with Medicare, however, recipients are restricted to certain list of benefits that the health insurance provides. MA provides convenience to its consumers since they offer a plan finder tool in their website which allows users to search for plans that is suitable for them. The information that they can access online gives them the knowledge about their plan features. Another advantage of MA is its 24/7 assistance which makes them easy to contact whenever inquiries or problems arises. A disadvantage of having MA aside from its lack of flexibility in the benefits that it covers, MA does not acknowledge out-of-network providers in billing. In addition, they do not readily disclose the contracted providers which is important.

Qualified Health Plans requires users to cover 10 essential health benefit from their benefit categories. Unlike MA, QHP is more flexible in terms of their approach since they allow users to select and manage the health benefits as long they have to cover the 10 essential health benefit. QHP also doesn’t require a number of drugs to be covered unlike MA where there are drug specifications that users must comply with. QHP includes the billing of services provided by out-of-network providers and even the emergency services outside the network. One of the disadvantage of this health plan is its unavailability to provide online plan tools implemented in the federal Marketplace. It also lacks the disclosure of the lists of health benefits that must be covered, which is important to allow users to arrive in decision-making for their health plan.

On the other hand, Medicaid MCO is governed by the federal law which mandates participating states to cover certain benefits. It is upon the discretion of the states whether to add other benefits in the list covered or to sustain the health plan for long-term services. Drug coverage decisions depends on the clinical effectiveness guidelines set by the consensus of the state. Unlike QHP which doesn’t have restriction as to the billing of out-of-network providers, the Medicaid MCO same as with MA limits balance billing to the providers within the network.


Lipschutz, D. & Callow, A. (2015). Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations. Retrieved from

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