As part of this assignment, it is required to consider two cases, each of which is associated with patient support programs in the United States. Both cases propose to calculate the financial feasibility of the Medicare and Medicaid programs in terms of economic opportunities and therapeutic needs. Both cases demonstrate that programs to alleviate the financial burden of health care can be effective, but include many bureaucratic complications. Moreover, as a rule, they are only conditionally free and require the coverage of part of the costs.
Case 1
The situation with 72-year-old Charles, who came under the attention of doctors due to acute pain in the family, requires a clear distribution of what services and to what extent Medicare will pay. Care of the patient within the framework of therapy in the hospital for 7 days occurs after the direct appointment of a doctor. If the hospital accepts the Medicare program, that is, it works privately on public funding, Charles can be referred to the Medicare Part A insurance plan.
Even though staying in the hospital is covered by insurance, the patient will still have to pay coinsurance costs. Charles’ meetings and consultations with the anesthesiologist, neurosurgeon, and chief physician, if all these physicians are assigned to the same hospital, are included in the cost of the hospital stay. This is because, as a standard, the first part of the Medicare program covers surgical operations and diagnostics before them, respectively. Medicare Parts A and B traditionally do not include those aspects of health considered optional and non-essential, such as cosmetic and dental medical issues. Such aspects of Charles’s health as monitoring and control of pain, and diagnosis before surgery, can be categorized as essential. This is due to the fact that in addition to acute pain, Charles suffers from a complete loss of movement skills.
Skilled Nursing Facility (SNF), as one of the options for Charles’s stay after refusing to perform an operation on him due to possible complications, is a way of professional assistance in physical rehabilitation. This type of care is special and the money for it is allocated by Medicare only if it is necessary for the patient to recover and is in the short term, not exceeding one hundred days. This type of therapy requires the intervention of registered nannies and/or physical therapists only. If the SNF is given to a person, it also includes custodial care, covering many of the person’s regular activities that they can usually do on their own (Thomas, 2019). Examples of custodial care include assistance in bathing, eating, walking the stairs, cooking, or cleaning. Only for three weeks, the insurance fully covers all costs, but already from the 21st day, Charles will be forced to pay coinsurance. After another 80 days, Medicare will fully expire, and the patient will have to pay the full price for the services provided.
However, one should take into account that if Charles chooses to forego in-hospital care and prefer home care, obtaining free treatment may be more difficult. The fact is that Medicare traditionally refuses to cover the cost of personal care in the event that custodial-type services are the only necessary ones (Barry, 2020). By refusing professional help from graduates, Charles will not receive free care, so it is highly recommended to seek the help of licensed professionals with professional skills in the recovery process after an injury.
Case 2
The case involving the Falcon family and their provision of medical support under the Medicaid program highlights how difficult it can be to get free medical care for middle-income citizens. Although Mr. Falcon’s condition should progressively worsen in the future and is already at the moment requiring placement in a nursing home, the Falcons’ financial condition does not allow them to receive Medicaid assistance. This program is intended exclusively for those segments of the population who are ready to prove at the legal level that their condition is below the poverty line.
Only if Ms. Falcon finds a way to invest in incalculable funds, reducing the amount in the account to 2-3 thousand dollars, can her husband be guaranteed to receive state-sponsored medical care. The value of the Falcons’ $200,000 home is not relevant for Medicaid assistance. This state is included in the so-called non-calculable assets that are not added to the resource limit, beyond which the provision of services is denied (Dupont, 2022). The highest indicator of Medicaid financial wealth based on West Virginia data is $24,353 per year, an amount that the couple’s insured income does not exceed. Falcon’ security income must not exceed $3,000 a year, and in the absence of a pension, their income makes them, combined with advanced age, able to receive community-based medical support through this program.
If Medicaid approves assistance for the Falcons, Mr. Falcon will be provided with care. This type of long-term care will also include physical therapy, healthcare services, and a room for an elderly person to live. The only thing Mrs. Falcon will have to pay for is coinsurance, which is renewed every month.
References
Barry, P. (2020). Medicare for dummies. Wiley & Sons.
Dupont, L. (2022). Medicare, Medicaid, and long-term care.A Place for Mom. Web.
Thomas, M. D. (2019). Social security & Medicare facts. The National Underwater Company.