Understanding Your Benefits

Kim Butler
Business Office Manager
Arlington Court Skilled Nursing & Rehab

My name is Kim Butler and I am the Business Office Manager at Arlington Court. I am responsible for the billing in the facility.  I work with the insurance companies including Medicaid and Medicare to ensure our residents receive the benefits they are entitled to.  I am also responsible for assisting residents and their family members as they navigate the difficult world of insurance.   I want to briefly go through the different types of insurance plans and provide a brief overview of each in hopes of helping our families better understand their benefits.

There are four main types of insurance that are prevalent in Skilled Nursing. The main types of insurance are Medicare, Managed Medicare, commercial plans and Medicaid plans. Every plan is different when it comes to skilled nursing facilities.

Medicare:  Medicare will cover your stay at 100% days 1-20 and will cover your skilled stay days 21-100 with a copay of $176.00 per day after a qualifying hospital stay. If you have a secondary insurance, most should cover all or a huge portion of the copay.

Managed Medicare and Commercial Plans: Most plans require a preauthorization before a skilled stay. There is usually a copay starting on day 21 unless you have a secondary. Most secondary insurances should cover all or a huge portion of the copay. Some managed Medicare plans will cover everything at 100% depending on the plan. If you have met your max out of pocket, you will be covered at 100% during your stay.

Medicaid: Depending on what type of Medicaid you have, a preauthorization before a skilled stay may be required. Most Medicaid plans do not have a copay and are covered at 100%. However, you could have a patient liability if you are here longer than 90 days under traditional Medicaid.

Being Discharged

When a resident starts doing either too well or plateauing, their insurance plan will cut them from a skilled stay. With Medicare and Managed Medicare plans, the plan has to give the resident 48 hours notice to give them time to either file an appeal or to finalize discharge planning. If the resident decides to appeal, a third party will review their case and make the final decision on if more days can be approved or if the discharge needs be finalized.

Unfortunately, commercial plans do not require any notice be given when they decide to cut. In most cases, they require the resident to discharge the very next day. There is not a lot of time to get a peer to peer (our doctor and the insurance’s doctor to discuss the case) to be done if the resident wants to appeal the decision. This can put a lot of stress on the resident and their families because it does not give a lot of time to prepare for the discharge.

Planning Ahead

It is always helpful for the resident and/or family member to be knowledgeable with the plan holder’s insurance benefits. Understanding the benefits will help to save stress and confusion when going to a skilled nursing facility.

At Arlington Court, we will start discharge planning on day 1 of your admission so you can be prepared for your discharge in case your insurance decides to cut. We have several great team members at Arlington Court that are familiar with the different types of insurance plans and will answer any questions that you and/or your family member may have during your stay or before your stay begins with us. Please reach out to our team at Arlington Court by calling 614-451-5677.