Medicaid Policy Payment Terms
Professional Medicaid Policy Payment Terms template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Medicaid Policy Payment Terms
TEMPLATE • Inspection-Ready AFH Standard
1. Private-Pay to Medicaid Spend-Down Disclosure
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. State Medicaid Rate Terms & Copay Obligations
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. Room Retention & Spend-Down Timeline
Provider Signature / Date
Resident / POA Signature / Date
Purchase to Unlock Full Document
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Document Section Breakdown (4 Sections)
Private-Pay to Medicaid Spend-Down Disclosure
Required private-pay duration policy prior to accepting Medicaid contract rates.
State Medicaid Rate Terms & Copay Obligations
State daily rate breakdown, resident participation copay obligations, and billing dates.
Room Retention & Spend-Down Timeline
Notice requirements for Medicaid transition, room retention rights, and bed hold terms.
Provider & Guarantor Acknowledgment Signatures
Legal sign-off agreeing to Medicaid conversion criteria and financial disclosures.
Or get this form included in the Operations & Records Bundle ($69)