SUBDOMAIN 734.3 - ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP. Competency 734.3.4: Healthcare Utilization and Finance
A1-Which costs will be covered by Medicare Part A?
Medicare Part A is otherwise called the Hospital Insurance and covers up to 100 days of the Skilled Nursing Facility stay. To be qualified for it the patient first has to have been hospitalized for more than 3 days in a hospital (qualifying hospital stay) so the stay in it would not be considered outpatient. After the hospital stay the doctor that followed the patient in the hospital or the PCP that releases the patient from the hospital needs to write the order for the SNF services. In order for a patient to receive the services from the SNF they have to: -Have Medicare Part A insurance
-Have days left in the benefit period
-The SNF receiving the services from is Medicare certified
-Be in the SNF because of the need for daily skilled care which the SNF can provide -Receive the services rendered daily even though sometimes offered 5-6 days only -Have a condition that started during the stay in the SNF after being admitted for a hospital related medical condition (in this case stroke) While in the hospital, Medicare Part A will cover:
-Supplies used in the hospital during the stay
Everyone that has Medicare Part A can be eligible for benefits when all the below mentioned conditions are true: -Doctor’s order that states your need to stay in the hospital for treatment -The care you need can be provided only by the hospital
-Hospital accepts Medicare insurance
-Your stay in the hospital is approved by the Utilization Review Committee. The cost in traditional Medicare is $1,184(Your Medicare coverage. Hospital care inpatient. Medicare.Gov. The Official U.S Government Site for Medicare) deductible for each benefit period for hospital stay from 1-60 days, $296 coinsurance per day of each benefit period from day 61-90 and $592 coinsurance per each "lifetime reserve day" after day 90 for each benefit period up to 60 days over your lifetime. After the 60th day of the lifetime reserve day the beneficiary pays all the costs. If the patient breaks on a SNF, which means for whatever reason does not receive the daily skilled care (in this case patient was weak for one week due to SNF acquired UTI)their SNF coverage may affected depending on the days missed. In the scenario given the patient only missed 7 days so in this case the coverage would continue the same as it would if there was no missed day. This is applicable because Medicare pays everything the first 20 days and every day after that (21st day and up) the patient pays $148/day up to the 100th day(Your Medicare coverage.Skilled Nursing Facility (SNF) care.The official U.S Governemnt Site for Medicare) as long as the break in is not more than 30 days. If it is more than 30 days that the patient needs a new qualifying hospital stay for any medical condition. If the break in is at least 60 days in a raw than the current benefit period will end and a new SNF period will be renewed with maximum coverage up to 100 days. With this being said, the patient’s daughter in the scenario will pay for 14 days the shared coverage of $144.50/day x 14days.This is after the break in days have been deducted from the total 40 days stay in the SNF and liquidated with skilled care needed days.
A2- Which costs will be covered by Medicare Part B?
Medicare Part B covers medically necessary services and preventive services. In the scenario given the Durable Medical Equipment(DME) –Walker-will be covered by Medicare Part B 100% as long as it is prescribed by an MD and is medically needed to assist the patient when is released home and to prevent any fall.
A3- Which costs will be covered by Medicare Part D?
Medicare Part D is the Medicare prescription drug coverage/plan. It adds coverage for the prescription medications to the original Medicare...