Pre-admission Payment Requirements

Foss Home requires a prepayment at the time of admission. Our current rates. There are a few exceptions to this policy listed below. All Residents admitting to Foss Home are required to provide proof of payment source they plan to use. If documentation is not received to verify insurance benefits, Resident will be billed and expected to pay on a private pay basis. Documentation required to show proof of payment source:
1. Copy of Social Security Card
2. Copy of Medicare card
3. Copy of any other insurance card, which indicates claims address and phone number If card is not available, please bring a copy of a previous “explanation of benefits” they have paid on your behalf.
4. Copy of DSHS identification card and/or award letter
5. Copy of Long Term Care insurance policy
6. Information concerning Resident’s inpatient care in the past 60 days.

Medicare A and pre-authorized Managed Care recipients are allowed admission to the Transitional care unit without pre-payment. Medicaid or Medicaid pending recipients may prepay an amount equal to an estimation of the monthly Medicaid participation, calculated by the business office, or $6,000.00 which ever is lower. To qualify to make the lower payment, proof of acceptance by or application to DSHS is required.

The prepayment is always applied to the services received.

If a Medicare resident anticipates using more than 20 days and they do not have a Medicare supplemental insurance and they feel they will not be able to pay the current per day co-pay amount, they should let the social worker or business office know immediately.

When a Resident no longer qualifies for skilled care under the Federal Medicare system guidelines, or their managed care organization disqualifies them for benefits they must pay the pre-admission payment as outlined above.

Resident’s or their financial representative should telephone or visit the resident’s account bookkeeper in the business office no later than 72 hours after admission. This meeting is essential to proper communication to eliminate any financial questions.

Residents or their financial representative need to contact the business office at least three (3) months prior to the point they feel they will need State assistance.

Payment Sources

Private Pay Resident assumes full financial responsibility for all charges with no insurance payment sources.

Managed Care Resident belongs to an insurance group that manages their healthcare. Resident is responsible for any co-payments or deductibles dictated by the insurance plan. Residents must be pre-authorized for care at Foss Home, by their plan, before admission. If there is no pre-authorization, the Resident is responsible as Private Pay.

Medicare A Resident must be covered under the Federal Medicare system. Questionnaire must be completed. (Copy attached)

A. Resident qualifies for benefits because of medical condition. This is determined by Foss Home’s Nursing staff, basic factors are:

1. qualifying hospital stay of three (3) days and

2. seven (7) days per week nursing intervention or five (5) days per week of rehabilitative services prescribed by attending physician.

B. The amount of benefits available in general is 100 days. 20 days paid in full and 80 days requiring a co-payment per day. Please refer to the program room rates sheet for current co-pay amount.

1. To determine what benefits each resident has available to them, Foss Home needs to know the past 60 day history of medical treatment on an inpatient basis.

Medicare recipients may also have a supplemental insurance which pays the Medicare deductible and co-pays. In this case, Foss Home will bill the insurance company for the appropriate amounts if the Resident requests us to do so. Please furnish information concerning that insurance policy including the claims department telephone number and billing address.

Medicare recipients may have DSHS as their supplemental insurance to pay co-pay amounts. Please see the Medicaid pay source for information on eligibility and application.

Medicaid (DSHS) (State Assistance) Resident must apply for and receive a determination on their eligibility.

A. General rules for eligibility are outlined in a handbook available on request. If the Resident is coming into the facility at a skilled level, does not feel they can pay their insurance companies required co-pays or deductibles, they should ask for a handbook and inform the social worker that they may need State assistance.

B. Any resident not coming into the Facility at a skilled level, who qualifies for state assistance immediately, must notify the admission coordinator that they need state assistance from the date of admission. If this is not done, they will be responsible to pay the private pay rate until Foss Home is notified and can request the State to complete the necessary evaluation.

C. Any Resident who needs State assistance sometime after admission will be responsible to pay a private rate until the later of two events:

1. They notify Foss Home’s Business office or social worker of their need for State assistance.

2. The State financial worker determines that they are financially eligible.

D. Medicaid works on an ability to pay basis. If a Resident has any income there will be a participation payment required. Foss Home will bill you for the amount determined by the state.

E. Resident’s who are in the application process must make their estimated participation payments as calculated by Foss Home Business office personnel.

Other Private Insurance Resident has other insurance, which pays for inpatient care in a skilled, or long-term care facility. These policies vary considerably. The only way to determine benefits is to call the insurance representative and discuss the current situation with them. In general these residents are billed on a private pay basis. Foss Home will submit records for claims or the Resident may do so on their own. Some insurance companies require documentation from Foss Home directly; we will work with the insurance company to facilitate payments.

Foss Home Ancillary Service Charges

The services and supplies listed below are not covered by the daily rate. We will bill, on your behalf, Medicare and/or other insurance according to information you provide. Resident’s who receive Medicaid benefits will have no financial obligation for medical services or supplies. They do however have responsibility for **other services listed.

Medical Services

Dental services provided in Foss Home’s Clinic

Laboratory

Occupational Therapy

Physical Therapy

Speech Therapy

Medical Supplies

Braces/slings

Catheters and supplies

Complex medical equipment

Drainage Bags

Oxygen and supplies

Prescription medications

Tube feeding supplies

Wound care supplies

**Other Services

Beauty Shop

The charge for these items does not appear here because the services are tailored to your specific needs. Foss charges on a cost plus markup basis. Foss Home does accept Medicare assignment, meaning we will accept, as payment in full, the Medicare allowed amount for all services and supplies.

Medicaid Participation

The amount of Medicaid participation to be paid is specified on the Medicaid Institutional Award letter. You are expected to pay the specified amount to the facility every month from the resident’s income or resources or both. Failure to pay the participation may result in the following consequences:

If the Department of Social and Health Services (DSHS) determines that a Medicaid client’s income and assets are being mismanaged by a third party, they may petition the court to appoint a guardian to ensure that the funds are used for the care of the client or to inquire as to the existing guardian’s use of the funds.

If the subject monthly amount of participation is not paid as required, residents are subject to the following action by the facility:

a. Notice of non-payment; if account remains delinquent, then;
b. Discharge notice for non-payment, with notice or resident appeal rights;
c. If there is no resolution on appeal and account remains delinquent discharge for non-payment.

Delinquent accounts may be referred to an attorney for collection and the defaulting person responsible may be personally responsible for the amount due, costs, fees and penalties.

Resident’s Personal Funds
Recent legislation requires facilities to promptly remit the balance of a deceased resident's personal funds with a final accounting to the Department of Social and Health Services (DSHS), Office of Financial Recovery (ORF) within forty-five days after the resident's death. Residents affected are individuals who are recipients of Aging and Adult Service Administration long-term care services.

If the funds are needed to pay burial expenses, the facility can request a release of funds for burial costs from the Office of Financial Recovery.