Medicare Policy. If you are a Medicare beneficiary, you understand that our licensed physical therapists are not enrolled as Medicare providers. Medicare has onerous technical and administrative requirements that must be met for services to be considered medically necessary covered benefits. We believe those requirements take unnecessary time away from the services we provide. Since our services are not designed to meet Medicare’s covered benefit requirements and we are not Medicare enrolled providers, our services will not be covered (paid) in full or in part, by Medicare (including Medicare Advantage Plans) even if the same services might be considered covered benefits when provided by a Medicare enrolled provider. We will not submit claims to Medicare on your behalf or provide you with a statement or billing codes that you can submit to Medicare yourself. If you want Medicare to pay for any services that might be considered covered benefits, you should seek those services from a Medicare enrolled provider. By choosing to receive our services after being fully informed of these facts, you are agreeing to pay privately for the services you receive from us even if those services might be covered by Medicare if provided by a Medicare enrolled provider. You also understand that since we are not enrolled Medicare providers and our services do not meet the technical requirements for Medicare covered benefits, our services are not subject to Medicare’s maximum allowable charge. You agree that you, your caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit our claims, invoices, receipts or statements to Medicare or your Medicare Advantage Plan for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.

Medicare Policy. Xx. Xxxxxxx is our only Medicare Provider. Other doctors in our practice are not Medicare providers. If you are currently eligible or become eligible for Medicare or any government program, you must notify me or my staff immediately, as this impacts your fees for service. If you do not notify me or my staff within 24 hours of your eligibility for coverage, the full fee for services are payable as of the date of eligibility and you will be under a Medicare Private Contract to self-pay without possibility of reimbursement, nor would you able to submit receipts yourself. Please read and sign Medicare’s form entitled, “Medicare Private Contract Agreement,” (provided separately). If you choose to see another psychologist in our office that is NOT a Medicare provider, you will be required to review and sign the Medicare Private Contract Agreement form and the Federal Notice of the No Surprises Act Notice, both provided separately. SECONDARY INSURANCE I do not offer billing services for secondary or supplemental coverage you may have. Medicare will automatically forward your claims to your supplemental/secondary insurer for processing. If I am contracted with your secondary insurer but not your primary insurer, I will provide you documentation of your services for reimbursement and payment for services will be due at the time of service.

Medicare Policy. I request that payment of authorized Medicare benefits be made on my behalf to Nashville Skin & Cancer for any services or items furnished to me by the physician(s)/practitioner(s) of Nashville Skin & Cancer. I further request authorized Medigap benefits be made on my behalf to Nashville Skin & Cancer. I authorize any holder of medical information about me to be released to the Centers for Medicare and Medicaid services and its agents and/or my Medigap carrier, any information needed to determine these benefits or benefits payable for related services. Signature: Date: Revised 3/27/12 Please see reverse side

Medicare Policy. We accept Medicare assignment on all Medicare claims. This means that we will reduce our fee to the amount allowed by Medicare. We will file one (1) secondary claim for you. You must provide us with the current and correct information at the time of your visit. If you have more than one (1) secondary insurance, you will have to file it yourself. If you ask us to perform a procedure that we believe Medicare will not approve, you will be required to sign an ABN (Advance Beneficiary Notice). Medicare requires this form be signed prior to you receiving the service. You will be required to pay the cost of the non-covered service at the time of the visit. Usual and Customary Rates: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. We are committed to your treatment being successful. I have read, understand and agree to the Financial Policy guidelines. Patient/Guarantor Signature: Date:

Medicare Policy. We accept Medicare assignment on all Medicare claims, and will file one secondary claim for you. You must provide us with the current and correct information at the time of your visit. Please notify us if your Medicare insurance is primary or secondary. Please sign below that you have read and understand our Financial Policies. Patient Name date

Medicare Policy. If you are a Medicare beneficiary, you understand your licensed physical therapists are not enrolled as Medicare providers. Medicare has onerous technical and administrative requirements which must be met for services to be considered a medically necessary covered benefit. Our services are not designed to meet Medicare’s covered benefit requirements. We are not Medicare enrolled providers and our services will not be covered (paid) in full or in part, by Medicare (including Medicare Advantage Plans). We cannot submit claims to Medicare on your behalf nor provide you with a statement or billing codes to submit to Medicare yourself. If you want Medicare to pay for any services that might be a considered covered benefit, you should seek those services from a Medicare enrolled provider. By choosing to receive our services, after being fully informed of these facts, you are agreeing to pay privately for the services you receive from us; even if those services might be covered by Medicare. You also understand, since we are not enrolled as a Medicare provider and our services do not meet the technical requirements for Medicare covered benefits; our services are not subject to Medicare’s maximum allowable charge. You agree that you, your caregivers, family members, authorized representatives or power of attorney, will not, under any circumstance, submit our claims, invoices, receipts or statements to Medicare or your Medicare Advantage Plan for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.

Related to Medicare Policy

Medicare If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines thereto. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE
Health Care Insurance While a faculty member is on an approved leave of this type, the faculty member will be advised regarding the right to continue health care benefits in accordance with COBRA during the period of unpaid absence.
Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement. Once a Medicaid application has been submitted on the Resident’s behalf, the Resident, Sponsor, and Resident Representative agree to pay, to the extent they have access to the Resident’s funds, to the Facility the Resident’s monthly income, which will be owed to the Facility under the Resident’s Medicaid budget. Medicaid recipients are required to pay their Net Available Monthly Income (“NAMI”) to the Facility on a monthly basis as a co-payment obligation as part of the Medicaid rate. A Resident’s NAMI equals his or her income (e.g., Social Security, pension, etc.), less allowed deductions. The Facility has no control over the determination of NAMI amounts, and it is the obligation of the Resident, Resident Representative and/or Sponsor to appeal any disputed NAMI calculation with the appropriate government agency. Once Medicaid eligibility is established, the Resident, Resident Representative and/or Sponsor agree to pay NAMI to the Facility or to arrange to have the income redirected by direct deposit to the Facility and to ensure timely Medicaid recertification. The Resident, Sponsor and Resident Representative agree to provide to the Facility copies of any notices (such as requests for information, budget letters, recertification, denials, etc.) they receive from the Department of Social Services related to the Resident’s Medicaid coverage. Until Medicaid is approved, the Facility may bill the Resident’s account as private pay and the Resident will be responsible for the Facility’s private pay rate. If Medicaid denies coverage, the Resident or the Resident’s authorized representative can appeal such denial; however, payment for any uncovered services will be owed to the Facility at the private pay rate pending the appeal determination. If Medicaid eligibility is established and retroactively covers any period for which private payment has been made, the Facility agrees to refund or credit any amount in excess of the NAMI owed during the covered period.
HEALTH CARE PLANS ‌ Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.
Health Care Coverage The Company shall continue to provide Executive with medical, dental, vision and mental health care coverage at or equivalent to the level of coverage that the Executive had at the time of the termination of employment (including coverage for the Executive’s dependents to the extent such dependents were covered immediately prior to such termination of employment) for the remainder of the Term of Employment, provided, however that in the event such coverage may no longer be extended to Executive following termination of Executive’s employment either by the terms of the Company’s health care plans or under then applicable law, the Company shall instead reimburse Executive for the amount equivalent to the Company’s cost of substantially equivalent health care coverage to Executive under ERISA Section 601 and thereafter and Section 4980B of the Internal Revenue Code (i.e., COBRA coverage) for a period not to exceed the lesser of (A) 18 months after the termination of Executive’s employment or (B) the remainder of the Term of Employment, and provided further that (1) any such health care coverage or reimbursement for health care coverage shall cease at such time that Executive becomes eligible for health care coverage through another employer and (2) any such reimbursement shall be made no later than the last day of the calendar year following the end of the calendar year with respect to which such coverage or reimbursement is provided. The Company shall have no further obligations to the Executive as a result of termination of employment described in this Section 8(a) except as set forth in Section 12.
Unemployment Insurance Rebate The short-term sick leave plan shall be registered with the Unemployment Insurance Commission (UIC). The employee's share of the Employer's unemployment insurance premium reduction will be retained by the Hospital towards offsetting the cost of the benefit improvements contained in this Agreement.
Health Care Benefits (a) Each regular full-time employee may elect coverage for himself and his eligible dependents* under one of the following health insurance plans:
Insurance Programs 1. The District agrees to provide a program of life, medical and dental insurance benefits for teachers. The District shall offer each employee a choice between the following two (2) programs of medical and health care:
Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.
Unemployment Insurance Unemployment Insurance coverage will be provided during the life of this Agreement for regular and auxiliary employees who would, if employed by a private employer, be eligible for such coverage under the provisions of the Unemployment Insurance Act.

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