Once again, thank you for your interest.

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1 Thank you for your interest in long-term care at Hebrew SeniorLife, a private, non-profit organization. For 100 years, the Center has been providing compassionate care to the elderly. Since 1903, the Center has grown from a small home in Dorchester serving a handful of elderly, to an internationally recognized leader in the field of senior care. At the main campus in Roslindale, we provide unparalleled quality of care to our long-term residents. At the Gloria Adelson Field Health Center in Dedham, we have taken our knowledge of delivering quality care one-step further. With this new campus we have tuned resident s care into a revolutionary movement allowing for more choices in a home environment. Our long-term residents live in neighborhoods and are cared for by a team of nurses, certified nursing assistants, a social worker, physician, and recreational therapist. Physical therapy, occupational therapy, creative arts therapy, speech/language pathology, and respiratory therapy are available as needed to residents of the Centers. Our in-house staff of primary care physicians specializing in geriatric medicine provides comprehensive care to the Centers residents. Complementing the team of physicians, nurses and therapists are specialists in dentistry, podiatry, audiology, dermatology, neurology, cardiology, and more, all of whom are available on-site at the Centers. I hope you will find the enclosed information helpful. In this packet you will find answers to frequently asked questions, as well as information on dining at the Center, activities and programs, and the cost of long-term care. If you are interested in admission to one of the Centers, I encourage you to complete the enclosed Application for Admission and related documents and return them to us at your first opportunity. Making a decision regarding long-term placement is often difficult; we are committed to helping you and your family as much as possible through this process. If you have never visited the Hebrew Rehabilitation Center or the Gloria Adelson Field Health Center, I invite you to contact the Admissions Department to schedule a tour. Please call us with any questions about the Centers, the application process or the status of your application. We appreciate your interest in Hebrew SeniorLife and look forward to assisting you. Once again, thank you for your interest.

2 HOW TO APPLY FOR LONG-TERM RESIDENCE We understand that the process of applying to a long-term residence facility can be a challenging time for families. We are committed to helping in the process as much as we can. If you have any questions regarding the admissions process, please call us at (617) Step 1- Application To apply for admission to long-term care at the Centers, please complete and submit the enclosed Application for Admission. We ask that you provide all of the information requested, including the financial information, and print clearly. Once your Application for Admission has been received, the assessment can begin. To help us expedite the admission process, please include with your Application for Admission: Four Authorization forms (enclosed) signed by the Applicant or Durable Power of Attorney (we will gather the applicant s medical records). Completed Financial Guaranty form (enclosed) Copies of health insurance cards (both sides) Copy of Durable Power of Attorney (if applicable) Copy of Health Care Proxy or Living Will (if applicable) Copy of Guardianship Decree (if applicable) Verification for all assets listed in financial page of application (i.e. bank statements, Trust documents, etc.) Please send your Application for Admission and the materials listed above to: Hebrew Seniorlife Central Admissions Office 1200 Centre Street Boston, MA

3 Step 2- Assessment Once we have received your completed Application for Admission, we will contact you and arrange for a meeting with the applicant- as well as his or her family- and a social worker. During this meeting, the social worker will complete an assessment of the applicant s current and projected care needs. If applicant lives outside of the Boston area, alternate arrangement for the assessment will be discussed. Step 3- Admission Once the assessment is completed and you have been approved for admission by our Financial Services office, you will be ready for admission to the Center. Please keep in mind that there is a high demand for the quality of care provided at the Center and that we operate at close to maximum occupancy throughout the year. As such, there may be a period of time before admission is possible. This period of time can vary greatly depending on bed availability and the level of care required, however we will do everything we can to advance the process. When a space does become available, the admissions office will contact you. It is expected that the applicant will be admitted within 1-2 weekdays of the offer for admission. If this is not possible, the applicant or family may choose to pay the current daily rate to hold the bed until the applicant is ready for admission.

4 Frequently Asked Questions Regarding Admission for Long-Term Residence at Hebrew SeniorLife s Centers How long is the waiting list? There is no single waiting list for admission to the Centers. The length of time an applicant might wait is based on multiple factors and could range from a few days to a number of months. The applicant s care needs and bed availability each factor greatly in determining the length of the wait. If you have any questions about the admissions process or want to discuss your particular situation, feel free to call the Coordinator of Long Term Admissions in the Central Admissions Office. I don t need a nursing home yet; can I still put my name on the waiting list? Inquiring about long-term residence and what the Centers offer is a great start to learning about your options. Our active waiting list is intended for applicants who are actively pursuing admission and would be prepared to move into our facility immediately. You may also choose to be an Inactive Applicant. In that case, an application will be kept on file in the event you require our services in the future. This saves you and/or family from the stress of completing paperwork in the midst of a crisis. Are private rooms available? Yes. At our facility in Dedham, each household is equipped with fourteen private rooms. In Roslindale, however, there are a limited number of private rooms available. If requesting a private room in Roslindale, there is an additional fee of $15.00-$50.00 per day. Individuals can request a private room either during the application process or once they have become residents. For those receiving Medicaid benefits, this additional room charge is not covered and would therefore need to be billed to a third party. How do I apply? Enclosed with this packet you will find an Application for Admission, as well as some additional forms. Please refer to the document How to Apply for Long- Term Care Admission for a more detailed description of the admission process. You can call us at at any time during the process if you have questions.

5 How is long-term care paid for? Long-term care is paid for privately, or, for those who qualify, by state assistance (Medicaid or MassHealth ). If you have a long-term care insurance policy, you will need to speak with your insurance agent to be sure that your particular policy will cover your care at the Center. The enclosed Long-Term Care Per Diem Room Rates sheet details the cost of care at our facilities, as well as what is included and excluded from the daily rate. Please note: Medicare does not cover room and board in long-term care. Medicare pays medical services like lab work, therapies and doctor s visits. Do you have an Alzheimer s Unit? Yes. Both of our facilities are equipped with Alzheimer s units. At our Roslindale Campus, we have 2 Special Care Units for residents with dementia who require or would benefit from those services. To be admitted, there must be a diagnosis of dementia. We then assess the prospective resident on a case-bycase basis. We are able to care for residents with dementia on many of our other units. We admit residents to our other units based on their level of functioning and care needs, not their diagnosis. This type of unit is also available at our Dedham campus. How will my medical care be provided? One of the many distinguishing features of Hebrew SeniorLife is our model of care. Medical care is provided to the residents by on-site staff of primary care physicians and nurse practitioners, all of who specialize in geriatric medicine. The primary care staff is complemented by an on-site dentist, as well as on-site specialists in audiology, dermatology, gynecology, neurology, ophthalmology, optometry, orthopedics, podiatry, psychiatry, radiology and surgery. Hebrew SeniorLife is part of a network consisting of Beth Israel Deaconess Medical Center affiliated specialty physicians, diagnostic centers and clinics. When necessary, acute hospital care is provided at Beth Israel Deaconess Medical Center. What can you tell me about the staff? At Hebrew SeniorLife, we truly value our employees and have done so for more than 100 years. Perhaps that s why we enjoy one of the lowest employee turnover rates for senior care in the country (National Average-52%, HRCA- 5.4%). In fact, more than one-third of our employees have been with us for more than 10 years!

6 HEBREW SENIORLIFE 1200 CENTRE STREET BOSTON, MASSACHUSETTS PHONE FAX APPLICATION FOR ADMISSION APPLICANT INFORMATION FOR LONG-TERM RESIDENCE Applicant Name (First, Middle, Last) Street Address and Apt. # Hebrew Rehabilitation Center NewBridge on the Charles Gender M F City State Zip Residence Type: House Apartment With Family Senior Housing Assisted Living Nursing Home Other If at a temporary location (e.g. hospital or rehab setting) please provide name and location: Social Security Number Phone Number Date of Birth Age Birthplace US Citizen Ethnicity African American Asian Caucasian Hispanic Native American Other Yes No Religion Primary Language Marital Status Spouse s Name (if applicable) Single Married Widowed Divorced Separated Name of person completing this application Relationship to applicant How did you learn about HSL? Office Use Only Date rec d: SW: Applicant #: Copy to Fiscal: MCD packet MCD Transition Forms G&R Form Date:

7 MEDICAL INFORMATION Please provide name, address & phone numbers of applicant s medical care providers: PHYSICIAN NAME SPECIALTY ADDRESS/ZIP PHONE NUMBER Primary Care Does the applicant have a pacemaker? Yes No If yes, please indicate physician managing pacemaker: PHYSICIAN NAME ADDRESS/ZIP PHONE NUMBER Please list any hospital admissions in the past 5 years, including psychiatric and nursing home admissions: HOSPITAL DATES ADDRESS/PHONE (IF NOT IN BOSTON) REASON FOR HOSPITALIZATION

8 Health Insurance Information You must submit copies of all health insurance cards including Medicare, Medigap (Medex, AARP, etc.), MassHealth, HMOs, other insurance, and notices of eligibility for state or federally funded programs. Medicare Number MEDICARE INFORMATION Are you enrolled in a Medicare HMO (e.g. Secure Horizons, First Seniority)? Yes No Do you have Medicare Part A? Yes No Do you have Medicare Part D? Yes No Insurance I.D.# Part B? Yes No BIN #: PCN #: Group No.#: Effective Date: If you are not eligible for Medicare, please explain: SUPPLEMENTAL INSURANCE Plan Name (e.g. Medex Bronze): Policy # Company Name, Address and Phone Number (e.g. Blue Cross of Massachusetts): Who is the insured? Patient Spouse Name on Policy (if other than applicant) Policy Type Individual Group Group Name (if applicable) Group # (if applicable) MASSHEALTH / MEDICAID MassHealth Number RID Number Suffix Code Date Medicaid Application Filed Location Filed Revere Taunton Springfield Tewksbury Other I am not already enrolled on Medicaid, but I believe I may be eligible for Medical Assistance/Medicaid Yes No

9 FINANCIAL INFORMATION (CONFIDENTIAL) INCOME MONTHLY AMOUNT Social Security $ SSI $ Pension $ Trust $ Other Monthly Income $ ASSETS DESCRIPTION AS OF (DATE) VALUE Real Estate Owned $ Savings Account $ Checking Account $ Retirement Account $ Stocks and Bonds $ Other Assets $ Total Assets: Submit verification/s (recent statements) for above $ Transferred Assets: Have you transferred any assets in the past 60 months? Yes, Date: / / No If Yes : Submit Verifications with this application. Long Term Care Insurance Yes No (if yes, please provide copy of policy) Pre-Need Burial Contract or Trust established Yes No Person responsible for the applicant s financial matters: Name Address Phone Relationship to Applicant IMPORTANT, PLEASE READ CAREFULLY: MEDICARE Part A and Part B does not pay for long-term care, such as custodial care in a nursing home. Room and board long-term care is paid with private assets and income, long-term care insurance benefits, and/or MassHealth/Medicaid. We must know in the source of payment in advance of admission. As an applicant, if you think you may be eligible for Medicaid on admission or within six months after admission, it is Hebrew Rehabilitation Center policy that you complete a Masshealth Senior Medicaid Request application prior to admission. If you need a LTC Masshealth/Medicaid application, please let us know and we will provide one for you. For assistance regarding MassHealth eligiblility, please call the Admissions Coordinator in Financial Services at (617) for additional assistance.

10 CONTACT INFORMATION Please list the names and addresses of family members and friends who should be contacted with information and/or in case of an emergency. We will be using this information both pre-admission and once the applicant has been admitted. CONTACT #1 Contact Name Mr. Mrs. Ms. Street Address and Apt. # City State Zip Relationship to Applicant Role(s) Check all that apply Accountant Attorney Durable Power Of Attorney Elder Advocate Health Care Proxy Trustee Legal Conservator Legal Guardian Power of Attorney Paralegal Temporary Guardian Home Work Ext. Cell Pager Fax SEASONAL ADDRESS (IF APPLICABLE) Address City State Zip Dates From / To / Phone Contact Name Mr. Mrs. Ms. Street Address and Apt. # CONTACT #2 City State Zip Relationship to Applicant Role(s) Check all that apply Accountant Attorney Durable Power Of Attorney Elder Advocate Health Care Proxy Trustee Legal Conservator Legal Guardian Power of Attorney Paralegal Temporary Guardian Home Work Ext. Cell Pager Fax SEASONAL ADDRESS (IF APPLICABLE) Address City State Zip Dates From / To / Phone

11 CONTACT INFORMATION CONTINUED Contact Name Mr. Mrs. Ms. Street Address and Apt. # CONTACT #3 City State Zip Relationship to Applicant Role(s) Check all that apply Accountant Attorney Durable Power Of Attorney Elder Advocate Health Care Proxy Trustee Legal Conservator Legal Guardian Power of Attorney Paralegal Temporary Guardian Home Work Ext. Cell Pager Fax SEASONAL ADDRESS (IF APPLICABLE) Address City State Zip Dates From / To / Phone Contact Name Mr. Mrs. Ms. Street Address and Apt. # CONTACT #4 City State Zip Relationship to Applicant Role(s) Check all that apply Accountant Attorney Durable Power Of Attorney Elder Advocate Health Care Proxy Trustee Legal Conservator Legal Guardian Power of Attorney Paralegal Temporary Guardian Home Work Ext. Cell Pager Fax SEASONAL ADDRESS (IF APPLICABLE) Address City State Zip Dates From / To / Phone

12 The next four (4) forms are Authorization forms. These forms authorize Hebrew SeniorLife to request medical records from doctors and/or hospitals on your behalf. Please ONLY fill out the applicant s name, Date of Birth and Social Security number. IF POSSIBLE, PLEASE HAVE THE APPLICANT SIGN THESE FORMS. If you are signing as Health Care Agent, please include a copy the Health Care Proxy. Some medical facilities will not accept documents signed by Health Care Agents unless there is also a written statement from an MD stating the Proxy has been invoked. If you have a copy of the Durable Power of Attorney, that should be sent as well. If you have any questions, feel free to contact us at (617) Thank you for your cooperation. Sincerely, Hebrew SeniorLife Central Admissions Department

13 AUTHORIZATION FORM For the Release of Protected Health Information to HSL Patient/Resident Name (Please Print) Date of Birth Social Security Number By signing this Authorization Form, I understand that I am giving my authorization to HSL s designated medical record or database custodians to request my protected health information (PHI) from the following person(s) or organization(s) named below: Name of Health Care Provider Street address City, State, and zip code Telephone number Fax number I specifically authorize the use and disclosure of the following PHI: (Please provide a description of the particular data, such as doctor s notes, nurse s notes, etc., and period of time you are requesting) The information to be used or disclosed pursuant to this authorization form may include information relating to behavioral and mental health observations, which are part of the medical record. I may revoke this authorization at any time by notifying HSL in writing to the Medical Records Department/1200 Centre Street/Boston, MA of my intent to revoke this authorization. A revocation form can also be obtained by contacting the Medical Records Department. However, I also understand that such a revocation will not have any effect on any information already disclosed to HSL before HSL received my written notice of revocation. Unless earlier revoked, this authorization will expire on the 180th day of the signing or as otherwise specified below: If neither federal nor state privacy laws apply to the recipient of the information, I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by privacy laws. I may inspect and receive a copy of the information to be used and disclosed pursuant to this Authorization form. Please make such intentions clear to the Medical Records Custodian when submitting this Authorization form. This Authorization is voluntary and I may refuse to sign this form. I understand that I am not required to sign this Authorization form in exchange for receiving treatment from HSL. X Signature of patient/resident or Durable Power of Attorney Date Printed name of patient or resident Printed name of Durable Power of Attorney (if applicable) Relationship giving representative authority to act for patient/resident (if applicable) 1200 Centre Street Boston MA phone fax

14 AUTHORIZATION FORM For the Release of Protected Health Information to HSL Patient/Resident Name (Please Print) Date of Birth Social Security Number By signing this Authorization Form, I understand that I am giving my authorization to HSL s designated medical record or database custodians to request my protected health information (PHI) from the following person(s) or organization(s) named below: Name of Health Care Provider Street address City, State, and zip code Telephone number Fax number I specifically authorize the use and disclosure of the following PHI: (Please provide a description of the particular data, such as doctor s notes, nurse s notes, etc., and period of time you are requesting) The information to be used or disclosed pursuant to this authorization form may include information relating to behavioral and mental health observations, which are part of the medical record. I may revoke this authorization at any time by notifying HSL in writing to the Medical Records Department/1200 Centre Street/Boston, MA of my intent to revoke this authorization. A revocation form can also be obtained by contacting the Medical Records Department. However, I also understand that such a revocation will not have any effect on any information already disclosed to HSL before HSL received my written notice of revocation. Unless earlier revoked, this authorization will expire on the 180th day of the signing or as otherwise specified below: If neither federal nor state privacy laws apply to the recipient of the information, I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by privacy laws. I may inspect and receive a copy of the information to be used and disclosed pursuant to this Authorization form. Please make such intentions clear to the Medical Records Custodian when submitting this Authorization form. This Authorization is voluntary and I may refuse to sign this form. I understand that I am not required to sign this Authorization form in exchange for receiving treatment from HSL. X Signature of patient/resident or Durable Power of Attorney Date Printed name of patient or resident Printed name of Durable Power of Attorney (if applicable) Relationship giving representative authority to act for patient/resident (if applicable) 1200 Centre Street Boston MA phone fax

15 AUTHORIZATION FORM For the Release of Protected Health Information to HSL Patient/Resident Name (Please Print) Date of Birth Social Security Number By signing this Authorization Form, I understand that I am giving my authorization to HSL s designated medical record or database custodians to request my protected health information (PHI) from the following person(s) or organization(s) named below: Name of Health Care Provider Street address City, State, and zip code Telephone number Fax number I specifically authorize the use and disclosure of the following PHI: (Please provide a description of the particular data, such as doctor s notes, nurse s notes, etc., and period of time you are requesting) The information to be used or disclosed pursuant to this authorization form may include information relating to behavioral and mental health observations, which are part of the medical record. I may revoke this authorization at any time by notifying HSL in writing to the Medical Records Department/1200 Centre Street/Boston, MA of my intent to revoke this authorization. A revocation form can also be obtained by contacting the Medical Records Department. However, I also understand that such a revocation will not have any effect on any information already disclosed to HSL before HSL received my written notice of revocation. Unless earlier revoked, this authorization will expire on the 180th day of the signing or as otherwise specified below: If neither federal nor state privacy laws apply to the recipient of the information, I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by privacy laws. I may inspect and receive a copy of the information to be used and disclosed pursuant to this Authorization form. Please make such intentions clear to the Medical Records Custodian when submitting this Authorization form. This Authorization is voluntary and I may refuse to sign this form. I understand that I am not required to sign this Authorization form in exchange for receiving treatment from HSL. X Signature of patient/resident or Durable Power of Attorney Date Printed name of patient or resident Printed name of Durable Power of Attorney (if applicable) Relationship giving representative authority to act for patient/resident (if applicable) 1200 Centre Street Boston MA phone fax

16 AUTHORIZATION FORM For the Release of Protected Health Information to HSL Patient/Resident Name (Please Print) Date of Birth Social Security Number By signing this Authorization Form, I understand that I am giving my authorization to HSL s designated medical record or database custodians to request my protected health information (PHI) from the following person(s) or organization(s) named below: Name of Health Care Provider Street address City, State, and zip code Telephone number Fax number I specifically authorize the use and disclosure of the following PHI: (Please provide a description of the particular data, such as doctor s notes, nurse s notes, etc., and period of time you are requesting) The information to be used or disclosed pursuant to this authorization form may include information relating to behavioral and mental health observations, which are part of the medical record. I may revoke this authorization at any time by notifying HSL in writing to the Medical Records Department/1200 Centre Street/Boston, MA of my intent to revoke this authorization. A revocation form can also be obtained by contacting the Medical Records Department. However, I also understand that such a revocation will not have any effect on any information already disclosed to HSL before HSL received my written notice of revocation. Unless earlier revoked, this authorization will expire on the 180th day of the signing or as otherwise specified below: If neither federal nor state privacy laws apply to the recipient of the information, I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by privacy laws. I may inspect and receive a copy of the information to be used and disclosed pursuant to this Authorization form. Please make such intentions clear to the Medical Records Custodian when submitting this Authorization form. This Authorization is voluntary and I may refuse to sign this form. I understand that I am not required to sign this Authorization form in exchange for receiving treatment from HSL. X Signature of patient/resident or Durable Power of Attorney Date Printed name of patient or resident Printed name of Durable Power of Attorney (if applicable) Relationship giving representative authority to act for patient/resident (if applicable) 1200 Centre Street Boston MA phone fax

17 Hebrew Senior Life - Long-Term Care FINANCIAL GUARANTY In consideration of the admittance of, hereinafter called "RESIDENT", to Hebrew Rehabilitation Center (HRC), I hereby guarantee full payment, exclusively and solely from RESIDENT S available funds, for any medical, physician, or ancillary services not reimbursable by RESIDENT S insurance coverage(s) or benefits, until medical assistance MassHealth/Medicaid coverage is necessary. I further acknowledge that I may not misuse or transfer any Resident s funds or countable assets that could otherwise be available for Resident s medical care, and that in the absence of said misuse or transfer will not be responsible for any medical payments on behalf of RESIDENT from my personal funds or resources. Further, I as the Responsible Party or Authorized Agent agree to act in good faith with HRC on financial matters, and to cooperate with HRC and the Division of Medical Assistance in the completion and filing of an application for Long-Term Care Medicaid when necessary, and agree to cooperate with any additional Medicaid redetermination compliance or ongoing MassHealth actions. HRC s private pay bills are payable in advance, starting on the day of admission and due the first of each month thereafter. Please see included room rate sheet. HRC reserves the right to change its rates as it deems necessary, in which case we shall provide you with at least sixty (60) days advance notice in writing, sent to the undersigned at the address printed below, or to such other address as the undersigned may submit in writing to HRC. The Responsible Party also guarantees full payment of any non-medical services (such as personal needs items and beauty parlor/barber charges) provided at the request of RESIDENT or guarantor. Resident: X Date: / / (Signature) Resident's Agent: X (Signature: Responsible Party or Authorized Agent) Date: / / Resident/Agent: X (Please Print Name) Address: Witness: X Date: / / (Signature) (Please Print Name) FIN-GUAR-LTC HSL (Rev ) ETB.doc

18 Hebrew SeniorLife ACKNOWLEDGEMENT OF BED HOLD POLICY The following HSL Bed Hold Policy pertaining to Medical Leave and Non-Medical Leave is effective beginning October 1, Medical Leave of Absence The Center will hold your bed for up to 10 days per episode of Medical Leave without payment. It is important that you or your financially responsible representative keep in touch with the unit social worker during the initial 10-day period of hospitalization. The Center will be working very closely with the hospital to ensure a timely discharge back to HRC. After the 10 days, a bed hold fee of $250 per day will be charged in order to hold your original bed. If you are subsequently admitted to HRC s Medical Acute Care Unit post your acute hospitalization this stay is considered part of your medical episode and is also counted as part of the original 10-day bed hold. If you are subsequently admitted to skilled nursing unit we are allowing an additional 10 days to the original bed hold. This allows for a combined total of 20 days. After the 20 days, a bed hold fee of $250 per day will be charged in order to hold your original bed. Non-Medical Leave of Absence For Non Medical Leave of Absence, the Center will hold your bed for 5 days per calendar year without payment. It is very important that you tell us when you are going to be away from the Center overnight and that you communicate with your social worker regarding your plans. A Bed Hold fee of $250 per day will be charged if you would like your bed held beyond the 5 (five) days per year. Please note: Unused days cannot be carried over into the following calendar year. If you decline to hold the bed, the HSL reserves the right to pack up and store your belongings, and may admit another resident to your former room. HSL will do everything in its power to readmit you to the next available and appropriate bed in a semi private room. By signing this form you acknowledge that you are aware of HSL s Bed Hold Policy. Resident s Name:(please print) Resident s Signature: Responsible Person s Name: (please print) Responsible Person s Signature: Legal Authority/Relationship: S:\FISCAL-ARcommon\ADMISSIONS\Bed Hold Policy Acknowledgement (Rev ) doc.doc Date: / /

19 Long-Term Care Daily Rate Information Rates: See Menu of Long-Term Care Room Types and Rates Note: Rates are subject to change with 60 days notice 1) The daily room rate* includes the routine services and amenities that are not covered by Medicare Part B**, such as Room and board Routine nursing services and routine personal care assistance Linen and laundry service Medications*** On-site vision, hearing, and dental services (subject to HRC program guidelines) On-site recreational and wellness activities, religious services, cultural programs, and social events 2) Additional charges apply for physician, nurse practitioner, rehab (physical, occupational, speech therapy), radiology, lab, and other medical services. These services are typically covered by the resident s Medicare Part B and Medigap policies.** 3) The following optional services are available for additional fees: Telephone service Cable television service On site beauty parlor and barber shop Dry cleaning; newspaper delivery; guest meals, off site events * The routine long-term care services listed in 1) above are NOT covered by Medicare Part A Hospital, Medicare Part B Medical, or Medigap health insurance; they must be paid by personal funds, long-term care insurance, and/or for those who have met the eligibility requirements, by Long-Term Care MassHealth (Medicaid). **Per 2) above, Medicare Part B and Medigap insurance cover Part B - billable services such as Physician/Nurse Practitioner, Therapies (Physical, Occupational, and Speech), Radiology, and Lab. Residents need to be enrolled in Medicare Part B or in an equivalent plan that covers Part B-covered services. HRC recommends that residents also carry a Medigap policy (such as Medex Bronze or AARP) to cover deductible and coinsurance. Unless the resident is on MassHealth (Medicaid), HRC will bill any portion of these 2) services not paid by Medicare B or Medigap to the resident. If a resident is enrolled in a Medicare HMO-type plan, HRC will assist with conversion back to regular Medicare A and B as soon as possible. The care management and referrals/authorizations provided by such an HMO plan no longer apply once the resident is admitted to HRC, since care is managed by HRC s network of physicians and providers, making the HMO plan no longer appropriate. *** Medications. We recommended that private pay residents maintain enrollment in a Medicare Part D prescription drug plan for maximum flexibility if care needs change in the future. Medications are currently included in HRC s daily rate, so HRC will bill the Med D plan on behalf of the resident and refund the amount collected to the resident/guarantor. Once a resident qualifies for MassHealth, they are switched to a zero-premium MedD plan and the refund no longer applies.

20 Menu of Long-Term Care Room Types and Rates Hebrew Rehabilitation Center now offers long-term care services in two locations: our original location in Roslindale and on the campus of NewBridge on the Charles in Dedham. At either location, residents and families can expect the same quality of care that Hebrew Rehabilitation Center has been offering since Residents can choose from a menu of room types and rates at both locations. Rates are on a per-day basis by room type, and offer options for MassHealth members and those paying privately for their care. For more information, contact the Admissions Office at Roslindale Campus NewBridge on the Charles Campus TRADITIONAL LTC Semi Private (shared bath) Daily Rate Private Room Supplement Daily Rate Private Room Supplement Private (shared bath) Small Private (private bath) Preferred Private (private bath) MEMORY SUPPORT Semi Private (shared bath) Daily Rate Private Room Supplement Daily Rate Private Room Supplement Private (shared bath) Small Private (private bath) Preferred Private (private bath) Prices are effective 10/1/2014 and are subject to change MassHealth covers Semi-Private accommodation; however, a MassHealth member who wishes private accommodation may have a third party pay the daily Private Room Supplement. If a private pay, private room resident converts to MassHealth and would like to remain in a private room, third party payment of the Private Room Supplement is expected. If the resident declines to pay the Private Room Supplement, the resident will be placed on a waiting list for the next available Private Room with a shared bath or Semi-Private Room.

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