Beruflich Dokumente
Kultur Dokumente
1ST CASE
3 year old comes into your continuity clinic for a visit. Her BMI is less than the 5% and her weight is also below the 5%. You would like to give her increased calories and are considering a supplement. She is uninsured. What questions will you ask to assess which programs she can use? What are the potential programs that she can access? What supplement will you do?
WIC GUIDLINES
My
doctor didnt know whats covered. It helps if the doctor knows what your financial limits are.
dont know the price.
Doctors
INSURANCE ATLAS
Decision Tree
Start at top center box Clear boxes contain criteria Yes/No until reach shaded box Shaded box = Insurance/Medical Program If no arrow, then no option
DEFINITIONS
US
Citizen = birth in US Lawful Permanent Resident = Green Card Poor = below poverty level Low Income = financial need, depends Renal Failure = renal transplant OR dialysis Disabled = Eligibility criteria specified by SSI
3,820
4,780
4,390
SOURCE: Federal Register, Vol. 76, No. 13, January 20, 2011, pp. 3637-3638
No Poor & Either 1) Pregnant OR 2) Life Threatening Disease Yes No Emergency Medicaid Poor No
Yes
Medicaid No Primary Pennies No Low income 101-200% FPL Yes
Shriners Hospital
INSURANCE OVERVIEW
State & Federal Programs Local Programs
MEDICARE
VS.
MEDICAID
Federal & State $$
State administered State-determined eligibility criteria Apply at Division of Workforce Services offices
Federal $$
Federally administered National eligibility criteria Apply at Social Security Office
Medicaid, Emergency Medicaid, Baby Your Baby, CHIP, PCN, Medicare assistance programs
MEDICARE
VS.
MEDICAID
<19 or > 65 Disabled or blind Pregnant Parent/caretaker of a child <19 yo Untreated breast/cervical CA
MEDICARE
VS.
MEDICAID
Covers:
Covers:
pap, mammo, prostate CA screen, colon CA screen, flu & pneumovax NO: vaccines
VS.
EMERGENCY MEDICAID
Emergency Services for NonCitizens Emergency services only
Pregnancy (only L&D costs) Life-threatening disease
Covers:
Prenatal General medical care Medications
Criteria
Poor non-citizens & non-residents of US (including illegal aliens) NO risk to be deported Medicaid offices
CHIP
VS.
PCN
Primary Care Network
US Citizen/Resident Child Low-income Not qualify for Medicaid Health maintenance General medical care Medications Now should be open
Covers
Covers
Open-enrollment
DWS offices
DWS offices
CASE #2
An 8 year old who was born in Mexico comes to the emergency department. He has spina bifida and has the need for many services.
Where should he go for primary care? Where should he go for specialty services? Where can he fill his medications for the lowest cost?
PRIMARY PENNIES
VS.
SHRINERS HOSPITAL
Regional charity program Covers care at Shriners Criteria
Criteria
Patient Accounts-PCMC
< 18 yo Lives w/in region Chronic orthopedic condition in SLC Burns at other Shriners Hospital Citizenship is irrelevant
INSURANCE REVIEW
Local Programs
Primary Pennies Shriners Hospital Health Access Project (HAP) Intermountain Charity Services
CASE #3
A 2 year old comes into the acute care clinic with a fever and crying with urination. Her UA is positive for leukocyte esterase and nitrites. You are going to presumptively treat her with antibiotics. She has not had an UTI in the past. Her Medicaid is pending. What antibiotic do you prescribe? What do you tell the family about in terms of what will be paid for with Medicaid pending?
Cefdinir - $48 for a 125 mg/5ml bottle generic, $97 per bottle brand name Cefixime $293.00 for 100mg/5 ml bottle Amoxicillin/Clav - $36 for 600/5 75 ml bottle Trim/Sulfa- $4 program
CASE #4
A 6 year old with asthma comes into the hospital for an acute exacerbation. While in the hospital your attending tells you to order the following tests:
How much do they cost? He is insured. You are going to start a controller, what will you choose?
Albuterol
Inhalers are all the same size, so if you give a patient 1 puff of Flovent 110 mcg twice daily instead of 2 puffs of Flovent 44 mcg twice daily, you save them of their co-pays or, $35x6 = $210 per year