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Published by: NURSETOPNOTCHER on Sep 02, 2009
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Siena College TaytayCHAPTER VIII:
College of Nursing
Health Care in the United States
 The federal Medicare program is a health insurance program for the elderly anddisabled. Medicare is administered by the Centers for Medicare and MedicaidServices ("CMS"), which was formerly the Health Care Financing Administration(HCFA).
Medicare provides benefits for:
 Those who have reached age 65 and are entitled to receive Social Security orRailroad Retirement benefits
Disabled individuals of any age who have received Social Security or Railroaddisability benefits for at least two years
Other Medicare participants may include:
Persons eligible for Social Security benefits who have end-stage renal diseaseand require kidney dialysis treatment
Persons over age 65 who are not eligible for either Social Security or RailroadRetirement benefits who purchase monthly Medicare coverage
Medicare Part A Hospital Insurance Program
 This program provides beneficiaries with coverage for mostly hospital-relatedclaims, including:
Inpatient hospital care
Limited post-hospital skilled nursing facility
Home health care
Hospice care
Medicare Part B Supplementary Insurance Program
 This program focuses on medical costs other than hospitalization, such as:
Physician and surgical services
Diagnostic tests
Home health care
Physical, speech and occupational therapy
Medical supplies
Durable medical equipment
Ambulance services
Some preventive care servicesEnrollment in Part B coverage is optional.Each program requires different deductible and co-payment amounts.
Medicare Exclusions
Medicare Part A and Part B coverage doesn't include:
Custodial nursing home care
Most outpatient prescription drugs
Routine physical examinations
Routine eye examinations and eyeglassesEdge R. and Groves J. R. (1999) Ethics of Health Care: A guide for Clinical Practice. C& E Publishing Inc.San Juan Metro Manila. 2nd Edition. pp. 117-134.
Siena College TaytayCHAPTER VIII:
College of Nursing
Hearing examinations and hearing aids
Routine dental services
Routine foot care and orthopedic shoes
Most immunizations
Personal convenience items
Cosmetic surgery
Medicare Part C
Any individual who is entitled to Medicare benefits under Part A and enrolled underPart B may choose from several types of health insurance plans under Medicare PartC (Medicare Choice program) including:
Coordinated Care Plans such as health maintenance organizations ("HMOs"),preferred provider organizations ("PPOs"), and provider-sponsoredorganizations ("PSOs")
Private Fee-for-Service Plans
Medical Savings Accounts ("MSAs")
Medicare Part D
Medicare Part D is an optional prescription drug benefit. People who are entitled tobenefits under Part A or enrolled in Part B are eligible for Part D. They can enroll in astand-alone drug plan or private health plan that offers drug coverage. Participantspay a deductible, coinsurance and a monthly premium.
Medicaid is a jointly-financed federal-state health care program that providesmedical assistance to:
Low-income elderly
 The blind or disabled
Families with dependent children*Medicaid is the primary public financing program for long-term nursing home andhome care services.Eligibility requirements vary greatly from state to state. All states, however, mustprovide Medicaid coverage to the categorically eligible. Categorical eligibility isrelated to economic need and income. States may also provide Medicaid coverageto the medically needy, frequently persons in need of expensive nursing home orhospital care.
Generally, Medicaid pays for:
Inpatient and outpatient hospital services
Prescription drugs
Physician services
Laboratory and X-ray services
Custodial nursing home care
Benefits vary from state to state, and may also cover:
Edge R. and Groves J. R. (1999) Ethics of Health Care: A guide for Clinical Practice. C& E Publishing Inc.San Juan Metro Manila. 2nd Edition. pp. 117-134.
Siena College TaytayCHAPTER VIII:
College of Nursing
Dental care
Medical equipment
Foot care
Optometry services
Clinic services
Rehabilitative services
 Transportation to obtain medical care
Formal Justice
- Any criteria could be used such as age sex, marital statusa\landownership provided that the criteria was applied equally in all similar cases.
Material Justice
- Principles that specify relevant characteristics of determinemorally relevant criteria in regard to treatment.
Theories of Justies
Egalitarian Theories
- emphasize equal access to goods and services.Egalitarians believe that an affluent society as ours must find a new way toprovide universal heath care to all its citizens.
Utilitarian Theories
- emphasize a mixture of criteria so that public utility ismaximized. Public utility is the greatest good for the greatest number.Utilitarian accept that
 political planning and intervention as methods of redistributing goods and wealth to bring about public utility.
Health must be rationed and provided only to those who will benefit most anddenied to those who will benefit less such as elderly—Callahan & Lamm.
Libertarian Theories
- emphasize personal rights to social and economicliberty.
Managed CareThe following are guidelines regarding physician-patient practice:
Efforts at cost containment should not place patient welfare at riskPlan coverage should not affect the practitioner’s duty to provide informedconsent The practitioner has duty to serve as the patient advocatePatients must assume responsibility for selecting their own health care plan
Two-Tier System and the Decent MinimumTwo-Tier System
- everyone would be guaranteed coverage for basic care andcatastrophic health needs. This coverage of a descent minimum of care would be distributed on the basis of need, with everyone being assured equal access to basic and catastrophic services.
The Oregon Rationing System
In 1983, the state of Oregon began work on a controversial plan for theallocation of health care resources. The goal, noble enough, was to provide Medicaidbenefits for
people than had previously been covered. One option wouldobviously be to raise more money for health services, though the corresponding taxincreases would have been unpopular. Oregon chose another approach: to makeEdge R. and Groves J. R. (1999) Ethics of Health Care: A guide for Clinical Practice. C& E Publishing Inc.San Juan Metro Manila. 2nd Edition. pp. 117-134.

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