KOT TASK 2 FINAL PAPER

According to medicare.gov, 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 (Medicare.gov).
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 complex process that often varies. However, below are some pointers to be addressed during the Mrs. Zwick’s discussion.
Medicare Part A, A.K.A. hospital insurance, insures hospital services days (inpatient care, general nursing care, meals, medications, semi-private/private room if medically necessary, and supplies), and up to 100 days of coverage in a Skilled Nursing Facility (SNF).
To qualify for Medicare Part A coverage, the physician orders must include the amount of midnights (count) needed to treat the illness and/or injury. Patients must stay in the hospital for over 72 hours (admitted for inpatient medical care). Hospital stay less than 72 hour, will be considered as outpatient care, and a disqualifier for coverage. At discharge, the primary care physician (PCP) must write an order for SNF services. The Medicare Part A coverage for Skilled Nursing Facilities (SNF) is contingent to certain conditions, such as, SNF is Medicare certified, patients have days left of coverage in the current benefit period, and the physician determines that daily skilled care must be received under supervision of skilled nurses, and rehabilitation personnel. These type of services will be considered “Daily Care” even if is provided for 5 to 6 days a week. 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 medicare.gov
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 medicare.gov
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 (DRA) of 2005 was signed by the President on February 8, 2006. 501 (c) section of DRA requires identifying conditions that are (a) high cost, high volume or both, (b) a results of a DRG case that has a higher payment as when present as a secondary diagnosis, and (c) a condition that could have been prevented by evidence-best practice guidelines application.
The rationale of this process was to identify, document, and promote, evidence based practices in the healthcare setting, offering safer practices to providers and a safer care environment to patients, promoting medical error prevention, and no harm to the patients.
Following DRA guidelines, Medicare will no longer pay for HAC (Hospital Acquired Conditions) not present on the patient admission day (such as, fractures/trauma caused by patient fall, decubitus ulcers stage III and IV, deep vein thrombosis post knee/hip replacement, vascular catheter associated infections, and UTI’s, among others) (CMS,2008).
As a result of the Hospital’s poor “best practice” in Mrs. Zwick’s case, related to catheter associated urinary tract infection (UTI), Mrs. Zwick will be responsible to pay for the cost of the UTI treatment, with Zero insurance reimbursement.
B1. Ethical Implication
Mrs. Zwick originally was expected to stay in the skilled nursing facility for 21 days, I which 20 days were 100% covered by Medicare Part A insurance. Adding $2,888 out-of-pocket expenses for the remaining19 days stay in the SNF. Also, she is responsible to pay, out-of-pocket, for the UTI treatment (Hospital acquired infection). All of these added costs were wrongful, inexcusable, and preventable. The Government should make healthcare institutions accountable for the inappropriate/damaging care delivered to Mrs. Zwick. Also, protection should be extended to the patients, as in Mrs. Zwick’s case, to prevent the patient from having to pay for healthcare services related to the hospital’s negligence, and malpractice.

Scenario #2

C. COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation of healthcare coverage was passed by congress as a provision Act in 1986. It allows employees as Mr. Davis, to continue the health coverage, after the termination of employment for a determined period of time. The terminated employees have the right to enroll in the COBRA program up to 30 days before the insurance provided by the employer expires. The coverage is available only to those employees laid off for reasons other than misconduct. This program allows the ex-employee to continue the health insurance coverage at a higher premium (unaffordable to many who are not receiving income) until they are enrolled in another insurance program. If the individual has lost their job due to illness leading disability, the COBRA coverage will stay in effect until they obtain disability and Medicare coverage (United State Department of Labor).

D. Challenges
Health, and health disparities, are challenges affecting governmental care for individuals with disabilities. Lack of funding, and scarce research, is preventing the creation of policies, and effective planning, for the escalating number of individuals with disabilities (such as, chronic illnesses in children and young adults). The lack of insurance coverage, for these individuals, is increasing the cost of Medicare and Medicaid for the state and local governments.
Accessing and qualifying for Medicare and Medicaid is challenging, based on their unequal regulatory policies. The most affected ethnic groups (minorities) are Native Americans, African Americans, and Hispanics. These minority groups have the highest index of chronic diseases, such as, heart disease, diabetes, high blood pressure and sickle cell disease. They have minimal, or no, access to health care.

D1. Recommendations
Local and state governments should allocate funds for preventive medicine and health education promotion. These measures will decrease modifiable health risk factors such as, obesity, smoking, adolescent pregnancies, and drug abuse. The reduction of the aforementioned modifiable risk factors will decrease the incidence of disability across all age groups.

E. Relocation
For Mr. Davis, being a citizen of a country that offers socialized medicine, such as, Japan, Great Britain, or Switzerland, will play to his advantage. Socialized medicine in Britain is covered by general taxation monies collected. Healthcare coverage for families, and/or, individuals, is not contingent to age, sex, status, or pre-existing medical condition, and with no additional billing or co-pays. Social medicine offers to their citizens’ medical needs coverage, preventive medicine, care to the disabled and special needs individuals, at no extra expenses. The disability living allowance (DLA) was created to address those with special needs and disabled individual’s needs, such as, home health care, transportation, and medication. In Japan, every citizen is enrolled in a universal insurance with an inexpensive monthly payment. Hospitals are not for profit organizations, administered by the government. Germany, offers care services based on salary earnings prior to any disability. However, pre-existing medical conditions are covered if the citizen is willing to pay half of the cost. This is a less likely system to work in Mr. Davis’s condition. Switzerland’s citizens are mandated to buy healthcare insurance, at a cost that is equal to 8% of their annual earnings (income). The coverage is not affected by age, or pre-existing medical conditions, as long as the estimated percentage is paid by the policy holder. Full Disability coverage (payment) is based on a minimum of three years contribution to the social security benefit account. This healthcare program will be beneficial to Mr. Davis as long as he has worked, and made the minimum of three contributions to his social security, as a Swiss citizen (Thomson, Osborn, Squires, Jun, 2013).

Reference
• Medicare.gov. what does Medicare part A cover. Retrieved from http://www.medicare.gov/what-medicare-covers/part-a/what-part-a-covers.html
• National Business Coalition on Health (NBCH). (2009).Healthcare purchaser toolkit. Hospital- Acquired Condition Payment Policy.2-28 Retrieved 01/03/2013 from http://www.nbch.org/nbch/files/ccLibraryFiles/Filename/000000001630/HAC%20Payment%20Policy%20Toolkit%20%28final%20version%29%20081109.pdf
• Medicare & Medicaid Research Review (2013). Medicare Non-Payment of Hospital-Acquired: Infection Rates Three Years Post Implementation. Retrieved from http://www.cms.gov/mmrr/Downloads/MMRR2013_003_03_a08.pdf.
• CMS (2012). Hospital Acquired Conditions (HAC) in Acute In-Patient Prospective Payment System (APPS) Hospitals. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/downloads/HACFactSheet.pdf.
• Medicare Part A. 2012. Retrieved from medicare.gov.
• CMS. (2008). Statute Regulations Program Instructions. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Statute_Regulations_Program_Instructions.html
• United State Department of Labor. COBRA Continuation Health Coverage. Retrieved from http://www.dol.gov/ebsa/faqs/faq_compliance_cobra.html.
• US Department of Labor Employee Benefits Security Administration. (2013) An Employer’s Guide to Group Health Coverage Under COBRA. retrieved from http://www.dol.gov/ebsa/pdf/cobraemployer.pdf.
• National Council on disability. (2009).The current state of health care for people with disabilities. Retrieved from http://www.ncd.gov/publications/2009/Sept302009#CHAPTER%208.2.1.
• Daley, C., Gubb, J. (2011). Healthcare Systems: Switzerland. Retrieved from http://www.civitas.org.uk/nhs/download/switzerland.pdf
• Busse, R., Riesberg, A. (2004). Health Care System in Transition. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0018/80703/E85472.pdf
• Thomson, S., Osborn, R., Squires, D., Jun, M. (2013).INTERNATIONAL PROFILES of Health Care Systems, 2013.Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Retrieved from http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2013/Nov/1717_Thomson_intl_profiles_hlt_care_sys_2013_v2.pdf
• Rodwin,V. (1994). Japan's Universal and Affordable Health Care: Lessons for the United States? Retrieved from http://www.nyu.edu/projects/rodwin/lessons.html