MEDICAL INSURANCE

I. PURPOSE:

To outline the responsibility of the Veteran Home Resident to obtain and maintain primary/supplemental health insurance, prior to and after becoming a permanent resident of a NJ Veterans Memorial Home Facility.



II. DEFINITIONS:

A. Admission means the procedure for entering one of the New Jersey Veterans' Memorial Facilities.

B. Aid and Attendance is a financial benefit determined by the Department of Veterans Affairs for a veteran who is in need of the regular aid and attendance of another person or who is permanently housebound.

C. Allowable deductions means those approved items which will be subtracted from the gross income, including the personal needs allowance,
when calculating care and maintenance fees.

D. Care and Maintenance Fee means the actual cost of services for an individual in one of the New Jersey Veterans Memorial Facilities.

E. Gross Income means all income and/or revenue received by the resident for a given period. Includes, but not limited to, funds received for labor or services, social security, pensions, aid and attendance, net rental income of property, proceeds of business or enterprises, and investments not to include losses. Disability compensation funds shall not be counted as gross income.

F. Medicare means a system of governmental insurance for providing medical and hospital care for the aged from federal social security funds.

G. Needy veteran, for medical insurance purposes, means an individual who has no source of income or accountable assets.

H. Supplemental insurance means a health insurance policy in addition to the primary insurance carrier.

 

III. PROCEDURE:

A. On the day of admission the applicant must provide documentation of primary and supplemental health insurance coverage.

MEDICAL INSURANCE
 
 

1. The applicant must sign Part XVII-Certification of the Admission Application, which states that as a condition of admission and continued stay at a NJ Veterans Memorial Home, the applicant must maintain primary and supplemental health insurance policies.

Medical expenses not paid by an insurance carrier will be the responsibility of the applicant/responsible payor.

2. If the applicant does not provide proof of health insurance, admission will be delayed until the applicant has applied for the required health insurance.

a. Requests for exemptions must be submitted to the Division Director for review and approval.

3. If a secondary insurance policy is not purchased, the resident/responsible payor is to be notified that no medical deduction will be granted for the resident/spouse/eligible others and that resident/responsible payor will be responsible for all related costs.

4. Applicants who maintain HMO health insurance policies must comply with one or more of the following:
 

a. change insurance for the applicant to a non-HMO plan,
b. handle all required referrals for care and treatments prior to services being rendered,
c. permit the facilities primary physicians to assume responsibility over all medical management. The resident/responsible payor will assume responsibility for all medical related expenses, or
d. arrange for the primary HMO physician to continue medical management and ensure that all state, federal, and facility requirements are maintained.


B. Residents who reside in the facility are required to maintain both primary and supplemental health insurance.

 
 

1. Health insurance premiums are an allowable deduction and will be deducted from the income in the same manner as the Personal Needs Allowance (PNA) for residents who maintain insurance.


C. If a resident does not carry primary and/or supplemental health insurance:
 
 

1. The facility is authorized to purchase a basic health insurance policy for residents with no source of income.

2. If it is determined that the cost to the facility for health insurance is not cost effective, then the Business Office is to write to the Division Director requesting an exemption from purchasing a health insurance policy.
 

a. If a policy is not purchased, the resident/ responsible payor is to be notified that no medical deductions will be granted and the resident/ responsible payor will assume responsibility for all medical expenses.
 

3. The Social Service Department shall refer to the Entitlement Counselor potential eligible residents for Aid and Attendance in order that an application may be processed.
 

a. Once Aid and Attendance is received, if health insurance is being provided by the facility, payment for the health insurance will be deducted from the income source.


D. Residents/representative payors who drop primary and/or supplemental health insurance will:

 
 

1. become responsible for all medical expenses;

2. not be allowed deductions for medical expenses for the resident/spouse as long as health insurance's are not maintained;

3. have referrals made for collection if payment for services is not received;

4. have discharge from the facility recommended if debt remains uncollected, and;

5. be advised by the Social Service Department that the facility will purchase supplemental health insurance policies at the resident's expense.


E. Process for collection will occur in accordance with procedure #44-03-009 - Delinquent Accounts.

Original: July 1998

BUSINESS OFFICE  - 44-03-002

 

« Business Office Table of Contents