Understanding Your Primary & Secondary Insurance Coverage and Your Co-Pay Responsibilities

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Even when you don’t make or request changes to your Health Insurance Plan, in today’s world, you can be sure of one thing. It doesn’t matter whether your coverage is through Medicare, Managed Care, Medicaid, through your previous employer, or all of the above, your plan’s co-pays  do change every year!

Whether this will be the first time that you use your insurance coverage to pay for a skilled nursing facility, or not, please be aware that your primary insurance NEVER pays your co-pays, and less than 15% of individuals have a secondary policy that does. Billing specialists in our Hamlin Place Business Office are ready to review your insurance coverage and co-pays with you or your family member or POA, to ensure you know how much your co-pays will be, and when they are due for payment.

Here are some coverage options to consider:

Medicare Part A:

Following a minimum mandatory 3 day acute care hospital in-patient qualifying stay, Medicare Part A eligible recipients have up to a 100 day skilled nursing facility benefit period, per spell of illness. The actual number of days that Medicare will cover you depends on a physician’s certification that specifies the medical necessity for you to continue to receive skilled services on a daily basis. Coverage guidelines come from the federal government, and are strictly enforced.

Coverage includes a semi-private room, nursing care, therapy, nutritional meals and snacks, prescribed medications, laboratory and radiology services, activities and social services including discharge planning.

2014

Day 1 through Day 20: Co-pay = $0

Day 21 through Day 100: Co-pay = $152.00 per day

If you have a Medicare supplement insurance policy, such as Blue Cross or AARP, etc., you are required to notify our Business Office and provide us with a copy of your ID cards. Our Billing Specialist will contact their representative to determine if your policy covers the skilled care daily co-pay, and what are the deductibles and limits. If you do not have a supplemental or secondary insurance policy that includes coverage for the daily co-pay, you are responsible for this cost. If you already were an in-patient in another nursing facility within the last sixty days, your days at that previous facility are counted from Day 1.

When you have been notified by the facility that a determination has been made that your Medicare coverage will end, you may choose to extend your stay at Hamlin Place at your own cost, (see below Private Pay).

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HUMANA (HMO & PPO) Managed Care Medicare Replacement Insurance:

2014

Day 1 through Day 10: Co-Pay = $0

Day 11 through Day 100: Co-Pay = $25 per day

We accept Humana Plans, when their physicians pre-authorize coverage for your short term rehabilitation. Your length of stay will depend upon a continuing coverage determination made by a visiting Humana physician. Our Case Manager will be available to assist you in planning your discharge. Under Humana, services provided and coverage limitations are based on Medicare’s guidelines for skilled nursing facility care. If you already were an in-patient in another nursing facility within the last sixty days, your days at that previous facility are counted from Day 1.

PRIVATE PAY

Hamlin Place accepts long term care private pay admissions, or to extend a short term stay, or for Respite Care. Those wishing to apply for admission must verify their ability to meet the financial responsibilities to pay monthly invoices in advance upon admission. Please contact the Admissions Department with any questions.

If you have a long-term care insurance policy, our Business Office can assist you with filing your claims, but your insurance claims department will reimburse you directly. Remember that Hamlin Place requires full payment for each month in advance, not later than the 10th of the month.  Any long term care insurance coverage, limitations, deductibles, and waiting periods, must be verified prior to acceptance.

MEDICAID MANAGED CARE

As the payor of last resort, Hamlin Place accepts payment through the Institutional Care Program (ICP). Our Business Office staff can assist you filing your application with the Florida Department of Children & Family Services. Final approval is not guaranteed, as individuals are required by law to prove eligibility, citizenship, financial qualification, and a medical level of care that can only be clinically certified by a physician.

Upon admission, you will be responsible to pay a monthly patient liability, which in most cases is equal to your monthly income from Social Security plus any other pensions that you currently receive. A $35 monthly personal spending allowance is deducted.