Third Party Private Insurance and Managed Care. If the Resident is covered by a private insurance plan or under a managed care benefit plan that has a contract with the Facility, payment will be according to the rates for coverage of skilled nursing facility benefits agreed upon by such plan and the Facility. Residents who are members of a managed care benefit plan that has a contract with the Facility to provide specified services to plan members will have such services covered as long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for payment for those services not covered under his or her plan and for applicable copayments, coinsurance and/or deductibles. If the Resident is covered by a private insurance plan or managed care benefit plan that does not have a contract with the Facility, and where the private insurance or managed care plan reimbursement is insufficient to cover the cost of care, the Resident will be responsible for any difference in accordance with federal and State laws and regulations.. The Facility will bill the Resident for any such difference on a monthly basis as described in the “Private Payment” section above The coverage requirements for nursing home care vary depending on the terms of the insurance or managed care plan. Questions regarding private insurance and managed care coverage should be directed to the social work staff and/or the Resident’s insurance or managed care plan, carrier or agent. The Resident, Sponsor and/or Resident Representative shall notify the Facility immediately of any change in Resident's insurance status or coverage including, but not limited to, ineligibility, termination, discontinuation of coverage, and/or any decrease or increase in benefits. If the Resident is covered by a private insurance plan or under a managed care benefit plan for either all or a portion of the Facility’s charges pursuant to the terms of the Resident’s plan, by execution of this Agreement the Resident hereby authorizes the Facility to utilize participating physicians and providers of ancillary services or supplies, if required by the plan for full benefit coverage, unless the Resident specifically requests a nonparticipating provider with the understanding that there may be additional charges to the Resident for using such nonparticipating providers.
Third Party Private Insurance and Managed Care. (1) The admission and continued care of Residents at the Facility under coverage provided through a private insurance plan or managed care health plan are subject to the approval and conditions of the private insurance or managed care company operating the plan. The Resident is responsible for timely advising the Facility of what benefits, if any, may be available from his or her private insurance and/or managed care plan. Payment by the private insurance or managed care company to the Facility is based on the applicable provider agreement and covers only services specified within the provider agreement. Services not covered by a provider agreement must be either pre-approved for payment by the managed care company or paid by the Resident and/or Designated Representative.
(2) If the Resident is covered by a private insurance plan or under a managed care benefit plan that does not have a contract with the Facility, and where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The Facility will bill the Resident for any such difference on a monthly basis according to its terms for private payment. The coverage requirements for nursing home care vary depending on the terms of the insurance or managed care plan. Questions regarding private insurance and managed care coverage should be directed to the Business Office.
