Managed Care Insurance
Business Office Coordinator
The GRAND of Dublin
When it comes to insurance, there are many different types and this can cause confusion among both residents and family members. Managed Care Insurance is a common type of insurance that is sometimes hard to understand how it works. For example, there is many types of Medicare that are managed by other insurance companies such as Aetna and Humana. Both Managed Medicare’s and Traditional Medicare have similarities, such as both require a 3 day inpatient hospitalization prior to admission to a Skilled Nursing Facility, have a 100 day benefit period and require a sixty day break in between benefit periods to be covered.
Unlike Traditional Medicare, where the facility is able to determine if the person is still at a skilled level of care or not, Managed Medicare is managed by the insurance company such as Aetna and Humana and require updates from the Skilled Nursing Facility to determine continued eligibility. Often times, these Managed Care plans only offer the beneficiary only about fourteen to twenty-one days even though their policy states they have up to a hundred days available. When an update is requested, the Skilled Nursing Facility is required to send updated skilled notes, therapy notes, physician notes and orders and other items they may ask for. Based upon these items, the insurance company then either decides to continue paying for the resident’s stay or they issue a NOMNC, which is a Notice of Medicare Non Coverage. Once the NOMNC is issued, the resident or family is able to call a third party entity, known as Livanta to file an appeal if they do not agree with the decision. During this appeal process, the resident will continue to receive all skilled care including therapy services. If it is found that the NOMNC is upheld, the resident has 48 hours’ notice to discharge. If the resident wins the appeal, they will be assigned another review date by the insurance company, usually a week later.