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What happens if you are in a skilled nursing facility and January 1, comes along and you are enrolled in a new insurance but in the middle of the 100 days? For instance my father went from a Hmo 2 to a Hmo 1 during his stay in the facility ....and will probably use all 100 days. Do they end the Hmo 2 on December 31, and you pay the days past the 21 day threshold and then go into the new plan and then pay the days leading up to that cap or do you stick with the Hmo 2' s plan throughout the whole 100 days? Do they prorate the time and split the coverage time, the plans are basically the same except one is days 21 to 53 at 160 and the other is 21 to 64 at 155 but technically ends December 31,2015 and the other starts January 1, 2016....I am confused what happens

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Thank you, I called AARP and got my answer, they said on December 31, 2015 his insurance ended, any copays are owed based on that 100 day period and are owed. Now on January 1, 2016 he enrolled into a brand new HMO 2 that he gets a new 100 days for that insurance, so going forward same thing he gets first 20 days free and days 21 through 45 have a copay and 45 to 100 are free.
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Your dad is in rehab, right? Really you need to contact the new HMO as all this will be totally dependent on what the contract reads.

But in general, if the provider or the facility, is within the system (the organization) for the HMO, then coverage happens. HMOs are designed to be closed systems for care as that is central as to how costs are contained. Usually you have to be seeing a provider or getting care at a facility in the HMO system to have coverage.

It is similar to what health insurance does with it's "in network" vs "out of network" for paying on claims. But for insurance, there will be some copay for out of network while HMOs usually won't cover any outside claims.

Large HMOs - like Kaiser - are generally really great to be a member of especially if you are a still working and have kids. For the healthier elderly, they can be great too. But for those needing to move into a NH & LTC, HMOs are often not a good fit and they end up needing to qualify for Medicaid to pay for their stay. If dads rehab is looking like he will need become a permanent NH resident, you may want to find out what will need to happen (like a spend down) to make him eligible for Medicaid.
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