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Kot Task 2 Essay

2035 words - 9 pages


According to, Medicare insurance coverage is governed by federal and state laws, and the decision of whether a service is covered, or not, is made by Medicare. Moreover, insurance coverage/decisions are handled by local companies that process Medicare claims. These companies will make the decisions of whether procedures, and/or interventions recommended, are medically necessary, and whether that particular service is covered in their area (
Scenario# 1
A1. Medicare Part A
Explaining insurance coverage to Mrs. Zwick, and her daughter, must be done in a simple and informative manner, keeping in mind that insurance coverage is a ...view middle of the document...

Furthermore, patients will qualify for SNF services if their illness is a hospital-linked medical condition, and/or, it is a condition that began during SNF care that is associated to a hospital related condition (hospital acquired infections, decubitus ulcers, fractures post falls among others).

Summarizing, Mrs. Zwick was admitted as an inpatient for five days post stroke. The afore mentioned condition met the criteria for Medicare Part A Hospital coverage. This insurance contains an annual deductible, and/or, co-insurance for the benefit period in which the patient is financially responsible. Assuming that this medical condition may have happen in a foreign country during an overseas vacation, none of the above medical expenses would have been covered by Medicare Part A. Also, Mrs. Zwick had met the criteria for Skilled Nursing Care; the first twenty days of service are fully covered by the insurance. Starting on the twenty-first day, and up to the fortieth days stay, a co-payment charge of one hundred and fifty two (152.00) dollars co-insurance per day will be assessed.
Hospital stays original Medicare cost according to
I. $1,216 deductible per benefit period coverage.
II. Days 1–60: $0 coinsurance for each benefit period.
III. Days 61–90: $304 coinsurance per day of each benefit period.
IV. Days 91 and beyond: $608 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over the individual’s lifetime).
V. Beyond lifetime reserve days: all costs.

Skilled Nursing Facility cost in original Medicare cost according to
I. Days 1–20: $0 for each benefit period.
II. Days 21–100: $152 coinsurance per day of each benefit period.
III. Days 101 and beyond: all costs.

Patients who acquired nosocomial infections (hospital-acquired infection) such as Urinary Tract Infections, which required treatment, such treatments are not covered by Medicare Part A (National Business Coalition on Health (NBCH), 2009). However, it does cover 80% of the payment for the approved medical equipment used, but, the remaining 20% is the patient responsibility (Medicare Part A (Hospital Insurance), 2014).
A2.Medicare Part B.
Preventive, and medically necessary equipment, are covered by Medicare Part B; including assistive devices prescribed by the practitioner, such as, a walker (an assistive ambulatory devise which is covered 100% under this plan). Proper indication, and medical necessity, must be documented at patient discharge for reimbursement.

A3. Medicare Part D
Prescription drugs are covered by Medicare Plan D. This plan adds coverage to the original Medicare plan. Patients must know that medications are arranged by TIERS classification, and copayments are driven by the rank of the medication TIERS (high medication TIERS = high medication copay and vice versa). Patients are responsible for out of pocket medication copayments.
B. Reimbursement
The Deficit Reduction Act...

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