Larry’s View

Larry’s view on any and everything.

Medicare part a

Medicare health insurance covers people over 65, or meet a need for the services. When Medicare was established in 1965, the original plan has 2 parts. Part A to cover hospitalizations, and part B to cover out patient services. Generally speaking, prescription drugs are not covered by either of these. Additional coverage is available under part D for required drugs. A Medicare Advantage plan will combine all 3 in a way for recipients to have one package for all their medical needs.
We will be discussing Part A of the original plan, covering the basics of the hospitalization coverage. To be covered by part A, a hospitalization needs to be at least 3 days, not counting discharge date. For coverage in a skilled nursing facility or nursing home, the issue must have been diagnosed during a hospital stay. A clear example of this application would be should a recipient need to go into the hospital due to a broken limb, or hip. Medicare would cover entering a nursing home for physical therapy under such circumstances. If patient rehabilitation services are not being covered, however another aliment requires skilled nursing, the nursing home stay would be covered. The needed care must be skill based, not a need for daily activity assistance.
Medicare will not cover a skilled nursing facility over 100 days, however for the first 20 days coverage is complete. Once the first 20 days have past, the remaining 80 will have a co-payment associated with the stay. If you are evaluating a MediGap insurance policy note that many of the companies who will sell the coverage, will include a provision for the needed skilled nursing care in their plans. Should a Medicare recipient use a portion of the 100 day allotment, and follows the stay with a 60 day ‘healthy’ period where skilled care is not needed, the 100day timer is reset, and should another reason occur, then 100 days begins again.
When a patient on Medicare enters a hospital or nursing home care, a prospective payment system is used. This system is one where healthcare providers receive a specified amount of money associated with each occurrence of care provided, regardless of what is actually used. The allotment of funds is based on diagnosis related groups. The actual amount paid is based on the diagnosis made in the hospital. Which brings up a major issue, if the patient uses less care than the hospital originally believed was needed, they are able to keep the remainder of the funds. The reverse applies here, as a patient may receive additional services, the hospital is not reimbursed beyond the orginal-diagnosed amount. To cover this issue, it is not uncommon for doctors to ‘up code’ the situation to be assured the hospital is covered in the event of overage.


February 4, 2008 - Posted by | Blogroll, Medicare

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