8 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY YOU SHOULD BE AWARE THAT NO FACILITY THAT PARTICIPATES IN THE MEDI-CAL PROGRAM MAY REQUIRE ANY RESIDENT TO REMAIN IN PRIVATE PAY STATUS FOR ANY PERIOD OF TIME BEFORE CONVERTING TO MEDI-CAL COVERAGE. NOR, AS A CONDITION OF ADMISSION OR CONTINUED STAY IN SUCH A FACILITY, MAY THE FACILITY REQUIRE ORAL OR WRITTEN ASSURANCE FROM A RESIDENT THAT HE OR SHE IS NOT ELIGIBLE FOR, OR WILL NOT APPLY FOR, MEDICARE OR MEDI-CAL BENEFITS. A. Fees for Private Paying Residents Our establishment calculates the following basic prices: for a single room for one room with two beds for one room with three beds for (Include all other accommodations here) The daily basic price for private payment and insured private residents includes payment for the services and supplies described in Schedule B-1. The principle of the day is calculated for the day of admission, but not for a day that goes beyond the date of dismissal or death. However, if you are voluntarily released from the facility less than 3 days after the date of admission, we may charge you a maximum of 3 days at the basic daily rate. We will provide you with a written message 30 days before the day`s principle increases, unless the increase is necessary because the state raises the Medi-Cal rate to a level above our normal rate. In this case, state law waives the 30-day notification. Appendix B-2 list for private payment and optional private insured residents of deliveries and services are not included in our basic daily rate, and our fees for these deliveries and services. We only charge for optional supplies and services that you specifically request, unless delivery or service is required in the event of an emergency. We will provide you with a written message of 30 days before any increase in fees for optional supplies and services.
If you are eligible for Medi-Cal after your entry, the services and deliveries included in the daily price as well as the list of optional deliveries and services may change. When Medi-Cal confirms that it will pay for your stay at this property, we will check and explain any changes in coverage. CDPH 327 (05/11) – 5 – 7 State of California Health and Human Services Agency You should look very carefully at the attached Resident Bill of Rights. To confirm that you have been informed of the Residents` Rights Bulletin, please sign here: V. Financial arrangements start with (date), we offer routine care and emergency care and other paid services. Our facility has been approved to receive payments from the following public insurance programs: Medi-Cal Medicare At the time of care, the payment for the care we provide will be made by: Resident (Private) Medi-Cal Medicare Part A Medicare Part B: Private Insurance: (Enter the name and insurance number of the insurance company) Managed Care Organization: Other Residents Part of the costs. Medi-Cal, Medicare or a private payer may require the resident to pay a co-payment, co-insurance or deductible that considers the facility to be the resident`s share of the fee. The resident`s non-payment of his share of the costs is one of the reasons for the resident`s involuntary dismissal. If you don`t know if your care can be covered by Medi-Cal or Medicare in our facility, we`ll help you get the information you need.
If our facility does not participate in Medi-Cal or Medicare and you later want these programs to cover the cost of care, you may need to leave our facility. [ONLY APPLIES IF THE DATE IS ENTERED:] On the day (date), our institution informed the California Department of Health that we were ready to withdraw from the Medi Cal program.