KOT 1 Task 2
734.3- Organizational Systems & Quality Leadership
734.3.4: Healthcare Utilization and Finance
A1. MEDICARE PART A
The discussion with Mrs. Zwicks’s daughter about coverage requirements needs to be informative and easy to understand so she can help explain it to her mother. Medicare part A is hospital coverage for inpatient stays. This particular part of Medicare covers critical access hospitals, inpatient rehabilitation facilities, and long term care hospitals. It will also cover inpatient care in a skilled nursing facility, hospice, and some aspects of home health. Mrs. Zwick was admitted to the short term acute hospital due to a stroke and it was necessary for her to be discharged to a skilled nursing facility for further care. To determine the coverage Mrs. Zwick will have for her skilled care the requirements of the coverage need to be looked at. Due to the stroke and her inpatient admission, she required
critical access to care. She was admitted for five days so both factors met the criteria for coverage for Medicare part A. These included meals, nursing care, semi private room, any hospital services, supplies, and any possible mental health needs. Medicare part A has an annual deductible or co-insurance for the benefit period. Unfortunately, if the patient was traveling out of the country, no medical expenses would be covered under this part of Medicare. Mrs. Zwick met the eligibility for coverage for admission to the skilled facility. There must be at least a three day stay at the hospital,. She was there five days, so she began receiving Medicare covered skilled care. Because she met the criteria, Medicare part A covered the skilled stay for the first 20 days. Medicare part A does not cover the co-insurance amount for each day after the twentieth day. Mrs. Zwick’s stay was 40 days so the patient and her daughter need to be aware the patient will owe $144.50 per day for the remainder of her stay. Having a hospital acquired infection does not come into play when coverage is considered. Medicare part A does not pay for care of a patient that is non-medical in nature. It does however pay for medical equipment that has been approved but the patient is responsible for 20% of the cost. (Medicare Part A (Hospital Insurance), 2012).
A2. MEDICARE PART B
Medicare Part B is medical insurance that covers treatments or services needed to treat or prevent medical conditions that meet the standards of medical practice. Medicare part B covers equipment that is prescribed for home use, necessary services including outpatient care, home health, lab, and some preventative services. Particular things like braces, medical supplies, surgical dressings, splints, and casts are also covered. Particular prostheses are covered. The medical equipment covered will need to be rented or purchased. Equipment vendors can help the patient know what is covered for rental or purchase.
If Mrs. Zwick needed blood, she would be responsible for the co-payment for blood processing and handling services for every unit she received. The deductible does apply to blood. If the blood is received from a blood bank at no charge then she would not have to pay for the units. If the provider pays for the blood, she must pay for the first three units of blood she receives in a calendar year. The patient may also have to pay 20% of Medicare approved premiums for doctor services, outpatient therapy, and durable medical equipment. If the patient receives outpatient mental health care, they will be responsible for 40% of the approved amount. (Medicare part B (Medical Insurance) 2012).
A3. MEDICARE PART D
Medicare is the prescription coverage plan. Each plan has its own formulary or list of drugs that are covered. Many Medicare drug plans place drugs into different tiers on their formularies. These tiers have different costs. In most...