Insurance and Costs

Once you have made the Pomeroy Living decision, we want to help you start experiencing it as soon as possible. That means a commitment to work with you to navigate through the often confusing maze of healthcare insurance and sorting through the various payment options.

Below is some information to help get you started. We present it in a Q&A format to make it easier for you. Of course we know that your situation is unique. So once you’ve reviewed this, we will schedule a meeting to answer your questions and work through any issues that relate specifically to your situation.

Private Payment:

Our Communities all are open to direct pay, or what is referred to as private pay.  Pomeroy Living does not operate as an “entrance fee” where there is a significant amount (typically $80-100k) due up front. Rather, each community welcomes new neighbors as available for terms as flexible as month-to-month.  For more information on community specific rates, contact the community or Pomeroy Living at 248-723-2100

Health Insurance Coverage:

Our community accepts a variety of health insurances.  We also participate in the Medicare benefit program. While most expenses are covered, the final costs vary depending on your individual health care insurance program. Below is an outline of general information about the costs and insurance coverage for our rehabilitation programs.

What does my insurance cover?

Each insurance program has specific coverage benefits.  While you are most welcome to inquire about coverage with our Guest Registration department, we strongly urge you to contact your individual insurance provider for an explanation of your specific benefits.

What is Medicare?

Below is pertinent information that applies to Traditional Medicare. Please note that there are additional Medicare insurance programs available to you that have different criteria than the Traditional plan listed below.  We recommend that you contact your insurance company directly for a more detailed outline.

Traditional Medicare is a Federal Health Insurance Program for:

People age 65 or older
People under age 65 with certain disabilities
People of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant)

Traditional Medicare has FOUR Parts:

  • Part A (Hospital Insurance) Most people don’t have to pay for Part A.
  • Part B (Medical Insurance) Most people pay monthly for Part B.
  • Part C (Medicare Advantage) Private fee for service/PFFS
  • Part D (Prescription Drugs Coverage)

For more information click  (http://www.medicare.gov/)
or download the following publication: Medicare and You

What qualifies me for Medicare benefits?

Medicare does not automatically cover nursing home care.  In order to receive Traditional Medicare benefits in an extended care facility the following conditions must be met:

You must have a minimum of a three (3) day in-patient hospital stay prior to admission.
Admission to an extended care facility must take place within thirty (30) days of discharge from the hospital.  You must meet the skilled care criteria as defined by Medicare.

The maximum number of days that you may receive Medicare coverage for is 100 days.  There is no guarantee that you will receive ALL 100 days.  You must remain at a “skilled” level of care as defined by Medicare in order to receive their Medicare benefits.

What does “skilled” level of care mean?

“Skilled” care, as defined by Medicare, is care that requires the involvement of skilled nursing or rehabilitation on a DAILY basis. Skilled nursing and rehabilitation staff include: Registered and Licensed Practical Nurses, Physical and Occupational Therapists and Speech-Language Pathologists.

What does Medicare pay for?  Are there any out of pocket expenses?

During an Eligible beneficiary’s stay in a skilled nursing facility, payment is as follows:

Traditional Medicare pays 100% of the bill for the first twenty (20) days. No secondary insurance is required (i.e., Blue Cross).

From the 21st day through the 100th day, there is a daily co-insurance rate.  The co-insurance rate is adjusted yearly by Medicare. Please note that your secondary insurance may cover this co-insurance.  Again, we advise you to contact your insurance company directly for more information.

If your policy does not cover the daily co-insurance, then you are responsible for the payment.  The facility will verify any secondary insurance to be sure that the coverage is active.

In the case where there is no co-insurance coverage, the Facility will require PRIVATE payment of the daily co-insurance rate.  This amount will be due beginning on the 21st day of your Medicare benefit period.  If you qualify for Medicaid assistance AND the facility participates in the State Medicaid Program, the co-insurance amount will be payable by Medicaid, however, your monthly patient pay amount will still be due.

Other out of pocket expenses not covered by ANY insurance include personal items such as: Beauty/Barber shop services, guest meals, rental of telephone or television and wheelchair van transportation.

Will my insurance pay for a private room?

Medicare will only pay for a private room if it is medically necessary.  Otherwise, there would be an out of pocket cost for a private room

What is Medicaid?

Medicaid is a State and Federally funded program that assists residents who are economically eligible pay for their nursing home costs.

For more information click (http://www.cms.hhs.gov/Medicaidgeninfo/)

Please be advised that you may still also be asked to pay a portion of the cost for your nursing home stay known as your patient pay amount which is determined by the Michigan Department of Community Health and based on your monthly income.

Click on the following link to review the state of Michigan Medicaid options for adults in long-term care.

Long-term Care Insurance

In general, most long-term care costs are paid for by the individual.  If you have purchased a long-term care insurance policy, while we will assist you in completing forms for reimbursement, please note that our contract is with you and not your insurance company.  You are responsible for payment of facility charges.  Your eventual reimbursement is between you and your insurance carrier.

What is Respite care?

Respite care is a short stay, usually 5 – 7 days.  This program is available in our independent apartments, and nursing facilities.  Respite care is helpful if you are a primary caregiver and would enjoy a break (respite) from the daily pressure of being a primary care giver.

Respite care Costs

Respite care costs depend on the level of care the guest may require.  We encourage you to speak with the Guest Registration Department to review the individual options available.

What is Hospice Care?

Hospice care is “end of life care”. We have contracts with several providers in the local area and offer a peaceful environment and specially trained staff to assist in carrying out your Hospice plan of care.  We understand that this is a very difficult time for all involved.

Hospice Care (End of life Care) cost

There are FOUR levels of Hospice Care:

  • Level 1: Routine Hospice – there is no coverage for room and board.  This is a private pay program.  Hospice will cover the cost of medical supplies and medications for the Hospice diagnosis.
  • Level 2:  Respite Hospice – Hospice will pay in full for up to 5 days (every 30 days) in a long-term care setting.
  • Level 3:  5th Level Coverage – an insurance policy covers the cost of the room and care excluding personal items.
  • Level 4: Acute In Patient – this is a short term benefit that covers the cost for an acute episode related to your hospice diagnosis.