Business Office Coordinator
The GRAND of Dublin
As the Business Office Coordinator, working with all types of insurances is a daily occurrence within the facility. Medicaid Pending is different from typical insurance as BOC’s work with the family to gather information to submit to Job and Family Services (JFS) so the resident is able to get Medicaid. Some common things that JFS require when applying for Medicaid first is to fill out the application, which includes income information such as all bank account balances, life insurance policies (cash value amount is required) , social security, retirement accounts, pensions, annuities, etc. Also, if there is any properties such as cars or houses in the residents name, or if there is a spouse in the community. Other documents that are required is proof of citizenship which includes social security cards, birth certificates and drivers licenses.
If a resident owns a house, they are able to keep possession as long as they plan on returning to their house at some point and they submit that in writing to JFS. If there is a spouse in the community, JFS allows the spouse to keep the house and cars, and does not include their income in the residents break down of financials and assets. Medicaid has recently changed to this in the past few years, as many are still nervous that they will lose their homes and all the income just to receive Medicaid.
All assets combined need to be under $2000 to qualify for Medicaid. If they have more than the required limit, they are able to spend down the funds, which would include paying the residents bill privately at the facility and purchasing any items that the resident would need. One applying for Medicaid often has a misconception that they are able to gift property or funds that they have to a family member so they do not lose the items, but this can disqualify them from receiving Medicaid and delay the process for up to five years due to a penalization.
As the Business Office Coordinator, I am there to help any residents and family members with any questions/concerns that they may have with Medicaid or any other insurances. It can be an intimidating process and lengthy, so it is my job to make it easier for them as they are already dealing with transitioning into long-term care, or working on getting themselves stronger to go home.
Commercial and Managed Medicare Coverage
Business Office Coordinator
The GRAND of Dublin
What does your Commercial or Managed Medicare insurance mean for your rehabilitation stay? It important that you understand how your coverage effects a variety of areas of your stay in a short term rehab facility, from admission, to type of room, to amount of therapy you receive to per day/week, how much it will cost you out of pocket, up to your prospective discharge date. If you are looking for Skilled Rehab for yourself or a loved one it is important that you educate yourself on what coverage you have. A lot of times the Business Office at your prospective Facility has access to this information and can help you understand your coverage.
Most Insurance providers require precertification for you to even come to a Skilled Nursing Facility. This is done by the facility, with the paperwork provided to them from the hospital. Some insurance companies will only authorize a Semi-Private room (you’re bunking up with a stranger for your rehabilitation stay). A request is submitted to the insurance company and they generally take 24-48 hours to respond (they don’t always say yes). You cannot transfer to the facility until the service is authorized. Once the hospital and facility are notified of authorization, the hospital will then arrange transportation to the rehab center.
Many Insurance companies cover 100% for the first twenty days, following a more Medicare-like guideline. The will have a set amount or percentage due per days for days twenty one on. Other insurance plans have a deductible due up front and a daily coinsurance starting on day one of admission. Almost all Insurances have an amount that you have to reach paying privately before they pay your services at 100% with no Out of Pocket cost. This is known as your annual Out of Pocket Max.
Some Insurance companies have a “Level” that they assess your rehab need at. This level dictates the amount of nursing care and therapy the facility will provide to you on a daily/weekly basis. (Example: Anthem Level 2 covers 90 minutes of Therapy no less than 3 days per week, where Anthem Level 3 states 90 minutes of Therapy no less than 5 days per week). So you might come into your Rehab stay thinking that you will have therapy 5-7 days per week, and might only be seen 3 times a week because that is all your insurance has authorized the facility to treat.
On a regular basis your Insurance Company will ask for updates from the facility. These updates include nursing and therapy notes documenting your progress (or sometimes lack of progress). At any point that insurance company can decide that you are ready to go home, or no longer meet skilled criteria and are in need of Long Term Care which is not covered by the insurance. Managed Medicare Insurance plans will issue a “Notice of Medicare Non-Coverage” giving you AT LEAST a two day notice. They are not required to give you any more notice than 2 days that you will no longer be covered your skilled stay. If you have a commercial insurance plan, they do not have to follow Medicare guidelines and do not need to give you any notice. A commercial plan might review your update, and say we are going to stop paying effect the previous day. It is on you to discharge or pay privately at the facility if you stay.
With all of the different types of Insurances and Plans out there it is important to do your research before selecting one for yourself. If you do find yourself in a situation where you don’t know your coverage or have questions, call your insurance company, talk to your hospital social worker, or the Business Office at the Rehab facility. We all have a plan in mind of how everything will work out perfectly. Unfortunately your insurance company (and life) doesn’t always follow that perfect plan. Make sure you are doing your homework, so things don’t come up and leave you so shaken that is sets you back in your progression to home.