I think we're veering of course when we start assessing the benefits of Medicare Advantage Plans vs. traditional Medicare plus supplemental plans. Here is how one CCRC, The Forest at Duke in the Research Triangle Area of NC treats medical insurance coverage. I hasten to point out that this CCRC might be atypical because of its strong affilation with Duke Medical Center, which appears to be the provider of medical services on campus at this CCRC. And Duke Medical is likely to be in-network for a lot of Medicare Advantage plans. Here's the language in their CCRC agreement with residents:
2. Health Insurance:
You shall maintain eligible Medicare coverage (and supplemental health insurance coverage) or health insurance coverage that adequately covers hospital, medical,prescriptions and skilled nursing deductibles and co-payments required under your primary insurance policy. Your primary and secondary insurance coverage must recognize The Forest as a healthcare provider, or you shall be responsible for services rendered that otherwise could be covered by insurance. You agree to furnish The Forest
with evidence of such coverage prior to the Date of Occupancy as stated in Exhibit A and also upon request. If your health insurance coverage lapses, The Forest may require you to reapply for suitable insurance coverage. If you are unable to obtain suitable insurance coverage, you shall be responsible for any healthcare services rendered that otherwise could be covered by insurance. Upon request by The Forest, you shall provide evidence of health
insurance coverage.
3.
Medicare-Certified Skilled Nursing Facility Beds:
The Forest maintains a limited number of Medicare-certified beds in the skilled nursing facility, which are available for use by residents whose skilled nursing care would qualify for Medicare payment on an “if and as available” basis. In the event that you need admission and the admission would qualify for Medicare payment, then your financial responsibility to The Forest will depend upon the type of Medicare coverage you have and whether The Forest is a contractual provider for your coverage.
a) Medicare-certified bed is not available.
In the event that there is not a Medicare-certified bed at The Forest at the time you require admission, you may either choose to obtain skilled nursing care services at another healthcare facility at your cost until such time as a Medicare-certified bed becomes available at The Forest (presuming you would use a facility that could provide a Medicare-certified bed) or be admitted to a bed in the skilled nursing facility at your cost which is not certified to accept Medicare payment until such time as a Medicare certified bed becomes available at The Forest.
b)
Medicare-certified bed is available and you have traditional Medicare.
If you are admitted to a Medicare-certified bed in the skilled nursing facility and you have traditional Medicare coverage, The Forest will accept the Medicare reimbursement amount of such care while you shall be responsible for any applicable deductible, co-payment and/or co-insurance amounts that are not paid by Medicare and any supplemental Medicare insurance that you maintain.Residence and Care Agreement The Forest at Duke
c)
Medicare-certified bed is available and you have Medicare Advantage coverage for which The Forest is an in-network provider.
In the event that The Forest is an in-network provider for your Medicare Advantage coverage, then The Forest will accept the reimbursement amount from your Medicare Advantage insurance carrier while you shall be responsible for any deductible, copayment and/or co-insurance amounts that are not paid by the Medicare Advantage insurance that you maintain.
d) Medicare-certified bed is available and you have Medicare Advantage coverage for which The Forest is not an in-network provider.
The Forest will charge you the full private-payment amount for your admission into a Medicare-certified bed and credit against your financial obligation to The Forest the amount that is paid by your Medicare Advantage insurance if the insurance provides an out-of-pocket network benefit. In the event that your Medicare Advantage insurance will not pay any amount to an out-of-network provider, then you will not be admitted to a Medicare-certified bed at The Forest. A full private-pay resident in a Medicare certified bed may be required by The Forest to relocate to a bed that is not Medicare certified when such a bed becomes available.
Bottom line: read the fine print. Here's the website for this CCRC, which does not go into this detail.
https://forestduke.org/
