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Health Care Coverage Research Paper

Julie Johnson

Florida State University College of Social Work

SOW 5603-0003

Professor Brenda Legaspi

September 25, 2022

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Medication Assistance Programs

John, like 26 million other U.S. residents, does not have health insurance to cover his medical

needs (Murez, 2022). There is proposed legislation to provide approximately $60 billion worth

of assistance to help uninsured people obtain health care coverage (Murez, 2022). Meanwhile, to

fill in the gaps, there are programs to assist people in obtaining low-cost or free health care. One

of those programs is medication assistance to cover the skyrocketing cost of prescriptions.

John, who lives in Winston-Salem, North Carolina, is fortunate to live near resources that can

help him obtain the prescription he needs. One of the programs John could utilize is The Shalom

Project which offers free medication prescribed by their physician to indigent and homeless

people. This fits in with their mission to reduce poverty and its negative impact (Medical, n.d.).

The Shalom Project offers care every Wednesday from 5:00 p.m. to 7:00 p.m. for walk-ins only

except the weeks of July 4th and Christmas (Medical, n.d.). They provide on-site and off-site

prescription refills and discount pharmacy cards (Medical, n.d.).

Another option for John is the Crisis Control Ministry which provides medication services

through the first free pharmacy in North Carolina, food assistance, and financial assistance

(Client, n.d.). They are staffed full-time, and services are on a first come-first serve basis (Client,

n.d.). Their services are short-term until permanent solutions can be found (Client, n.d.).

Health Care Coverage Options

On Healthcare.gov (2022), there were 84 plans that John qualified for based on his age and

income. Silver plans were recommended because he would get an additional discount. There is

also a filter to put in prescriptions that need covered such as John’s Cymbalta.

Based on plans that cover John’s medication, there were two plans that were considered to be

appropriate. Blue Local Silver $0 Deductible III with Wake Forest Baptist Health was the first
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plan that was considered for John. This plan offers a $0 monthly payment for the premium, $0

deductible, no charge for provider visits, and the option to go outside the network at extra costs

since it is a POS plan (Healthcare, 2022). Cymbalta is not covered, but there is an equivalent

medication available (Healthcare, 2022). Prescriptions are on a tiered price scale, so they all have

some kind of copayment (Healthcare, 2022). The out-of-pocket limit per year is $625 per person

(Healthcare, 2022).

The other plan that in the comparison for John was Ambetter Balanced Care 30 which has a

premium of $25.86 per month based on John’s income and a $625 deductible (Healthcare, 2022).

Patients are required to see providers in the network and no costs outside the network are

covered since it is an HMO (Healthcare, 2022). Cymbalta is not covered, but there is an

alternative medicine that is (Healthcare, 2022). Medication does not cost anything once the plan

deductible has been met (Healthcare, 2022). There is no charge for physician appointments after

the deductible is met which also applies to lab costs (Healthcare, 2022).

Eligibility and Feasibility for John

Based on John’s income of $15,000, he qualifies for a premium tax credit of $709 per month

which is used to determine monthly premiums (Healthcare, 2022). Based on this information,

John qualifies for additional discounts if he selects a Silver plan as opposed to a Bronze or Gold

plan (Healthcare, 2022). These discounts are applied to deductibles and coinsurances to lower

the overall cost of care (Healthcare, 2022). This website is designed for people who need

affordable health care but may not be eligible through work or because of limited income. Since

these plans were developed for individuals who have financial struggles like John, it is feasible

for him to apply with reasonable certainty that he will be able to obtain coverage.
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Documentation for Application

To successfully complete the application, the applicant must provide basic demographic

information, address, and social security number, so documentation of those items would be

helpful (Healthcare, 2022). They also required income information from all available sources,

employer information, and if the employer offers health insurance plans, so a tax return from the

previous year would be beneficial since it would have all sources of income listed in one place

(Healthcare, 2022). Each person who applies for healthcare on the site is required to fill out an

Employer Tool to determine if their employer offers insurance and if so, what kind they offer, so

John would need this from his employer (Healthcare.gov).

Application Timeframes

The Healthcare Marketplace has open enrollment beginning on November 1 each year and

ends January 15 (Healthcare, 2022). Applications can be done online through their website, on

the phone, with a paper application, or through providers/agents (Healthcare, 2022). A patient

may apply outside of open enrollment if they experience a qualifying life event such as marriage,

divorce, or change in employment status (Healthcare, 2022). Eligibility is determined at the time

of application on Marketplace, so John would be able to enroll in his plan at that time unless

there is notification that documentation needs to be submitted then there could be a delay of up

to one month (Healthcare, 2022). If nothing further is required, coverage begin the next month

once the premium has been paid to the insurance provider as needed (Healthcare, 2022).

Alternatives for Uninsured

John could participate in the Community Care Clinic in Winston which is a free healthcare

clinic that treats patients who are 200% below poverty and do not qualify for insurance

(Community Care, n.d.). This clinic provides free healthcare and medication to patients like John
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who do not have insurance but have needs (Community Cares, n.d.). They are available four

days per week with an appointment once the patient has completed the enrollment form

(Community Cares, n.d.).

Another option for John is the Mobile Health Unit from Atrium Health which travels around

the community 4 days per week to provide uninsured patients medical and food insecurity

services at no cost (Community, n.d.). Some of the things John could receive help with are

primary care, prescriptions, labs, nutrition counseling and boxes of locally grown food given on

a weekly basis (Community, n.d.). The clinic is staffed by volunteers from the hospital who

enroll patients and keep up with their health records (Community, n.d.).

Final Recommendations

My recommendation for John is that he needs a permanent solution to his health needs, but he

also needs an alternative to provide him services in case he does not qualify for insurance. I

would start with applying for the Ambetter Balanced Care plan because once the deductible is

met, John would not pay for any medical care in his network. Although the Blue plan does not

have a monthly premium like Ambetter, John would have to pay 50% of services once his out-

of-pocket expenses were met. This could create a hardship on John since care is expensive.

If he was not accepted by a permanent insurance company like Ambetter, I would recommend

John take part in the Mobile Health Unit from Atrium health since they are linked to a major

hospital in the local area, they have plenty of availability, and they provide local, healthy food

and nutrition services which could benefit John. They offer medication management and

physician services as well as coverage for some specialties. Between these options, John’s needs

would be covered, but I would also recommend he utilize The Shalom Project as needed for the

other services they provide such as food donations since he is on a limited income.
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References

Client Services. (n.d.). Crisis Control Ministry.

https://www.crisiscontrol.org/what-we-do/services/overview.html

Community Care Center (n.d.). carectr.org

Community Health Alliance (n.d.). Atrium Health Wake Forest Baptist.

https://www.wakehealth.edu/about-us/serving-our-communities/community-health-

alliance

HealthCare.Gov (2022). https://www.healthcare.gov/see-plans/#/aptcw2q2

Medical Clinic and Pharmacy (n.d.). The Shalom Project.

https://theshalomprojectnc.org/medical-clinic

Murez, C. (2022). Just 8% of Americans Lack Health Insurance, a Record Low. U.S. News.

August 3, 2022. https://www.usnews.com/news/health-news/articles/2022-08-03/just-8-

of-americans-lack-health-insurance-a-record-low#:~:text=3%2C

%202022%20(HealthDay%20News),in%20America%20without%20health

%20insurance.