MAUNALANI NURSING AND REHABILITATION CENTER
RESIDENT'S ADMISSION AND FINANCIAL AGREEMENT

When the terms "you", "your" and "I" are used, they refer to the resident or someone with legal authority to act on his/her behalf. When the terms "our", "we" and "Maunalani" are used, they refer to Maunalani Nursing and Rehabilitation Center, a Hawaii nonprofit corporation.

Maunalani Nursing and Rehabilitation Center (MNRC) . This document is a legal contract and sets forth the terms and conditions of your admission to Maunalani including your financial responsibility. You should carefully review and complete this document before signing. If you need assistance in completing or understanding this Agreement, please ask the staff for assistance or you may wish to consult an attorney or a family member before you sign this Agreement. If it is difficult for you to read the print on this document, you may request a large print version or request that this Agreement be read to you.

1. Traditional Medicare and/or Medicare Advantage Plan Beneficiaries.

If you are a Traditional Medicare and/or Medicare Advantage Plan beneficiary, you agree to pay Maunalani the co-insurance amounts and any other amount, which Maunalani may charge you to cover services for which your insurer does not provide reimbursement. Maunalani will only charge you for services that are not reimbursed by your payor and only to the extent that Maunalani is permitted to charge you for those unreimbursed services under the CMS program. (See Resident Manual for items covered/not covered by Medicare)

2. Private-Pay Residents.

Upon admission to Maunalani, or upon your payment status change to private pay, you will be asked to pay the room and board charges for the number of days left in the month and an advance deposit of $8,000.00 (eight thousand dollars). The amount of deposit will be credited toward the actual charges of your care and services during the last month of your stay. If any amount of the deposit is not used, it will be refunded to you within 30 days of your discharge from Maunalani without interest. If the amount of deposit is insufficient to cover your charges, you will be billed for the difference. An advance payment or deposit is not required if it is clear that your stay will be covered by Medicare or Medicaid or other insurance plans with which Maunalani has contractual agreements. Once your care is no longer covered by Medicare or Medicaid, an advance payment and a deposit will be required. You agree to pay all charges for the items and services that are provided by Maunalani for which you are responsible. The Resident's Manual given to you as part of the admission packet describes more fully the basic services which are included in the room and board charges and any supplemental services or products that you may request. You will be given at least thirty (30) days notice of any changes in Maunalani's charges or billing practices.

3. Medicaid Recipients.

If you apply for Medicaid, you will be responsible for promptly notifying our Social Services Department or our Business Office of your application. You will be considered a private-pay resident while your Medicaid approval is pending; that is, you will continue to receive a bill from Maunalani until you present to Maunalani an official letter of coverage from Medicaid. When your coverage by Medicaid is verified, we will refund to you any amount that you have paid which will be covered by Medicaid (except for an applicable deductible, co-payment and coinsurance amounts, if any). You will be responsible for supplemental services that are not reimbursed under the Medicaid program. If you request an item or service for which a charge is assessed, Maunalani will inform you that there will be a charge and what the amount of the charge will be. Maunalani will not charge any resident who is a recipient of Medicaid for any item or service for which payment is made by Medicaid.

4. Basic Services

Maunalani shall provide you with basic services required to meet your needs, such as personal care, room, board, laundry and general-duty nursing care consistent with state and federal licensure and certification standards and requirements. Maunalani staff will also work with other health care professionals to establish a care plan that is appropriate for you. A description of the basic services provided by Maunalani is contained in the Brochure in your admission packet.

5. Supplemental Services

In addition to the Basic Services that are available to all residents, you may request other services (such as a private room or private-duty nursing care) for which you will be charged separately on your bill. Supplemental services are not reimbursed through Medicaid or Medicare and may not be reimbursed through other third-party payors, such as long-term care insurance. A description of the supplemental services that are available is contained in our Brochure.

6. Billing and Collections.

You will receive an itemized statement for all charges for which you are responsible on a monthly basis and upon your discharge from Maunalani. It is your responsibility to make payment regardless of whether the source of payment is from an account payable to a representative acting on your behalf or whether the funds are in a joint account with another person. In the event that you fail to pay your charges when due, you will be responsible to reimburse Maunalani for its costs of collecting any unpaid charges, including attorney's fees. Maunalani is authorized to assess a finance charge of one percent (1%) per month on all amounts past due. A $15 late fee will be assessed every month in which the bill remains outstanding. If you have any questions about your bill, please, see our Billing Specialist in the Business Office and we will explain it to you.

7. Damage to Property.

You will be financially responsible for any damage you may cause to Maunalani property, excluding ordinary wear and tear. You will also be liable for any damage which you are responsible that occurs to the property of other Maunalani residents.

8. Guardian/Fiduciary

If you have a legal guardian or any other person who has legal access to your income or resources, such guardian or person will be required to enter into this Agreement and will agree to provide Maunalani with payment for your care from your income or resources. Your guardian or legal representative will not incur any personal financial liability for your care. Your guardian or legal representative will have the right to participate in planning for your care.

9. Assignment of Representative Payee

Maunalani is authorized to act as representative payee for your Supplemental Security Income (SSI), General Assistance (GA) or other public or private benefits that you may receive. Maunalani will not use your personal funds to pay for services or products that are paid for by Medicare, Medicaid or any other reimbursement program (except for applicable deductible, co-payment and coinsurance amounts).

By signing below you authorize Maunalani to act as your representative payee.