Page 189 - Saunders Comprehensive Review For NCLEX-RN

Case management involves consultation and collaboration with

an interprofessional health care team.
C. Case manager

1. A case manager is a professional nurse who assumes
responsibility for coordinating the client’s care at
admission and after discharge.
2. The case manager establishes a plan of care with the
client, coordinates any interprofessional consultations
and referrals, and facilitates discharge.
3. A case manager is knowledgeable in various types of
health insurance, which allows them to assist clients
in navigating health care options covered by
insurance.
D. Health Insurance
1. There are state and federal insurance plans.
2. An aim of the Affordable Care Act is to reduce the
amount of uncompensated care the average U.S.
family pays for by requiring everyone to have health
insurance or pay a tax penalty. Its goals are to expand
access to health insurance, reduce costs, and protect
clients against arbitrary actions by insurance
companies.
3. There are many insurance companies that provide
state marketplace insurance; some include Aetna,
Blue Cross Blue Shield, Cigna, Humana, Kaiser,
United, and TriCare/Humana.
4. Types of insurance plans include health maintenance
organizations (HMOs), preferred provider
organizations (PPOs), exclusive provider
organizations (EPOs), point-of-service (POS) plans,
high-deductible health plans (HDHPs), and health
savings accounts (HSAs); these offer varying options
in terms of insurance coverage and out-of-pocket
costs and premiums.
5. Medicare is a federal health insurance program for
persons aged 65 or older, certain younger people with
disabilities, and people with end-stage renal disease
(ESRD) requiring dialysis or renal transplant. Certain
premiums are attached to each part.
a. Part A: covers hospital stays, skilled
nursing facility stays, hospice care, and
some home health care
b. Part B: helps pay for some services not
covered by Part A. Medicare usually
covers 80% for approved services;

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