Paying for Nursing Home Costs: A Guide to Medicare, Medicaid and More

Navigating the myriad of ways to pay for nursing home care can be overwhelming. However, with a clear understanding of nursing home costs and the options available, it becomes manageable.

Understanding Nursing Home Costs

Nursing home costs nationwide can be daunting. In 2021, a semi-private room in a nursing home averaged $7,908 per month, with private rooms at $9,034. Even assisted living facilities, which offer a lesser level of care than nursing homes, can run upwards of $4,500 a month. Most people who enter nursing homes start by paying for their care out-of-pocket by using their savings or accessing equity from large assets like real estate. It’s clear that understanding these costs is crucial for anyone considering nursing home care.

What are the Nursing Home Care Private Pay Options?

Private pay remains a choice for those who either don’t qualify for Medicaid or prefer not to use it. This method involves tapping into personal assets or savings to pay for nursing home care. It provides more flexibility in terms of choosing the facility or level of care. However, it can quickly deplete one’s assets.

Does Medicare Pay for Nursing Home Costs?

Medicare is a federal program and primarily focuses on medical care, not long-term care. Medicare will not pay for long-term care in a nursing home facility. It will pay for a limited amount of time for skilled nursing care following a hospital stay but not for extended nursing home stays. Seniors also still need Medicare coverage for hospital care, doctor services and medical supplies while living in the nursing home. Understanding the specifics of what Medicare covers can help families plan better.

What kind of nursing home care does Medicare cover? Medicare primarily covers skilled care, which is care that can only be delivered by trained professionals. It doesn’t typically cover custodial care, which is personal care, like bathing or dressing.
How much does Medicare pay for skilled nursing home care? Medicare will cover the first 20 days of skilled nursing care at 100%. Beyond that, up to 100 days, a co-payment is required. After 100 days, Medicare will no longer pay for skilled nursing care.

Using Medicaid to Pay for Nursing Care

Medicaid is a popular option for many seniors needing nursing home care. It caters to those with limited income and assets. It is the primary payer for long-term care coverage nationwide.

Who’s eligible for Medicaid nursing home coverage? Medicaid is a joint federal and state-run program. Eligibility varies by state but generally requires meeting specific income and asset limits. Most states also have a look-back period of five years to ensure that assets weren’t sold or given away to qualify for Medicaid.
How does one apply for Medicaid, and what does Medicaid cover? Applying requires detailed financial documentation. Medicaid can cover a large portion of nursing home care costs. However, it might limit the choices of facilities. Working with an experienced elder law attorney to apply for Medicaid is not required. However, it can increase your chances of success by providing guidance, ensuring accurate documentation, and addressing any issues or appeals that may arise.
Do all nursing homes accept Medicaid? Not all nursing homes accept Medicaid. It’s essential to research and find facilities that both provide the level of care needed and accept Medicaid as a payment option.

Long-Term Care Insurance: Is It Worth It?

Long-term care insurance is designed to cover long-term care costs that Medicare and private health insurance don’t cover. This might include nursing home care, assisted living, or home care. However, the coverage depends on the policy details, and premiums can be high. In addition, the older one is, the harder it is to be considered insurable.

If long-term care insurance is an option, be sure to start planning early. Insurance companies are known to reject more applicants the older they get. Reviewing insurance plans each year to ensure that the policy still meets anticipated needs is essential. Make changes if necessary, and never stop paying the premiums so that the insurance does not lapse.

The Role of VA Nursing Homes in Elder Care

For veterans, VA nursing homes can be an option. These facilities are dedicated to providing care to veterans and may be more affordable than private facilities.

Making the Right Decision: Private Pay vs. Medicaid vs. Medicare

The decision often comes down to personal finances, care needs and eligibility. Understanding the differences between these payment methods can lead to more informed choices. As the demand for senior care services grows, it’s predicted that the cost of nursing home care will continue to rise. Planning ahead becomes even more essential.

Working with an Elder Law Attorney: The Best Way Forward

Consulting with an elder law attorney can provide invaluable insights and assistance in navigating the complexities of nursing home costs and payment options.

Planning ahead is crucial. The more you know, the better decisions you can make for yourself or your loved ones.

How Do I Make a Care Plan for Mom?

Medicare typically doesn’t pay for basic assistance, and families often don’t try to determine how to provide this care until there is a health crisis, which can lead to unnecessary stress, conflicts and escalating costs.

Nerd Wallet’s recent article, “Create a Care Plan for Older Parents (or Yourself),” says that making a care plan well in advance lets families organize, locate appropriate resources and determine ways to pay for care before a crisis hits.

A care plan is thinking through the logistics of what you’ll need as you age, so that you are prepared when the poop hits the fan with aging. A way to cope is to plan for temporary rather than permanent disability. Ask what kind of help you or your loved one might need after a hip or knee replacement. How well is the home set up for recovery? Who would help with household tasks? Contemplating a two- or three-month disability with an eventual return to health is less daunting but involves much of the same planning as a more lasting decline.

Many seniors would like to stay in their current homes as they age, something called “aging in place.” That typically means relying on family members for care, using paid workers, or both. However, if family members will be tapped, discuss the logistics, including whether and how much they will be paid. If home health aides will be hired, consider who will supervise the process.

Look at any savings that can be tapped and whether the senior may qualify for government help, such as veterans benefits, Medicaid, or state programs. Families may want to consult an elder law attorney for personalized advice.

It is important to look at the current home as “aging friendly.” An occupational therapist can suggest adaptations allowing the older person to remain in the home if they’re disabled. The sooner you get this evaluation, the more time you’ll have to prepare. Even if the home supports aging in place, the neighborhood might not. Consider how the older person will socialize, get groceries, and make it to health appointments if they can no longer drive.

An independent living or senior living facility could provide more amenities. However, these typically don’t provide long-term care. Therefore, see if the senior is okay with moving again later or whether they should begin with an assisted living or continuing care facility that can provide more help.

Once you have a plan, capture the details and share it with family members or others who may be involved. Revisit the document periodically as circumstances change. Aging planning is an ongoing process.

Reference: Nerd Wallet (Aug. 24, 2023) “Create a Care Plan for Older Parents (or Yourself)”

How to Pay for Hearing Aids

Untreated hearing loss has been linked to a higher level of depression, cognitive decline, dementia, falls, visits to the emergency room, and hospital stays. Despite this, says an article from ncoa Adviser, “Financial Assistance for Hearing Aids: A Complete Guide for Older Adults,” fewer than 15% of adults who need hearing aids use them, and the average person takes nearly nine years to go about getting a pair after being told they have hearing loss.

Part of the reason for the delay is financial. Resources for getting hearing aids vary from state to state, and even county to county, which can be confusing. Here’s how to get started.

First, check with your health insurance company to see what’s covered and ask about additional services. You’re not just buying an appliance. Hearing aids require activation and fitting, and other unexpected out-of-pocket costs may occur. Sometimes the easiest way to verify insurance is to have a hearing aid clinic check into it.

Except in five states—Arkansas, Connecticut, Illinois, New Hampshire, and Rhode Island—insurance providers are not required to cover hearing aids as part of health care for adults. Medicare Parts A and B don’t cover the cost of hearing aids or fitting exams. Still, Medicare Part B covers hearing and balance exams ordered by a doctor and an annual audiology appointment to evaluate hearing loss. Whether or not Medicare Advantage, aka Medicare Part C, provides coverage depends upon the plan.

Medicaid coverage varies by state and plan. Many people with Medicare and Medicaid can sign up with select insurance companies and get coverage at no additional cost, but the coverage varies. Also, the quality of the hearing aids may differ.

Active duty military service members and family members diagnosed with hearing loss meeting the coverage criteria may be eligible to receive hearing aids through a TRICARE-approved provider. For veterans, the VA has hearing aid benefits. They should reach out to their local office or representative. The VA website has information on how to apply for VA hearing health care and find the nearest provider.

Federal employees of the American Federation of Government Employees (AFGE) have access to discounted hearing aids, including a free hearing exam, discounted hearing aids, and aftercare support.

Those with mild to moderate hearing loss can now consider over-the-counter hearing aids. Note that the cost of the device you are buying is a third of the price. The rest of the costs are services, so be sure what services are bundled into the offerings. Instead of relying on online reviews, research trusted sources. You’ll want to clearly understand the return policy, warranty coverage for damage and loss, and customer service.

Reference: ncoa Adviser (July 2, 2023) “Financial Assistance for Hearing Aids: A Complete Guide for Older Adults”

Planning for Aging without Family Caregivers

As they age, many people have diminished capacity and cannot care for themselves. They may no longer be able to walk or drive easily and can experience difficulty with basic activities like shopping, cooking, cleaning, and arranging important doctor’s appointments. Traditionally, the adult children of the elderly have been caregivers, monitoring their parent’s health and overseeing financial decisions, reports the article “ICYMI | Getting Older Without Family” from CPA Journal. Parents without children, or those without good relationships with children, need to make alternative arrangements. An experienced estate planning attorney can help.

Living arrangements. Most people prefer to remain in their homes, in familiar surroundings. This may work if the home can be made elderly-friendly and a support system is implemented. A home alert system or automatic daily call-ins can be arranged through friends or local police departments. If remaining at home is not viable, an assisted living facility or continuing care retirement community may be the next best option if the cost can be managed.

Healthcare matters. Having a healthcare advocate is advisable for everyone. So is a Healthcare Proxy, or Healthcare Power of Attorney, which designates a person to act as the patient’s agent in making decisions. A Living Will details the kind of treatment a person does or doesn’t want if they cannot express their wishes.

Finances. As they age, people may find managing their finances too difficult. There are several options, depending on the degree of help needed. A CPA or financial advisor may be able to provide money management services. Banks may permit an account owner to add the name of another person with signatory authority—they can sign checks but are not an account owner. A representative can be named to receive Social Security funds, and they must file reports with the Social Security Administration to show how the funds have been used.

Durable Power of Attorney. This is the most critical planning tool for seniors and others. This designates an agent to act on behalf of the elderly person in financial matters. It can be created to define the scope of the agent’s authority and remains effective when the elderly person becomes incapacitated. It must be created and executed when the person has the requisite capacity.

Trusts. A trust holds legal title to an older adult’s assets, including bank accounts, brokerage accounts, or their home. The trust is managed by a trustee for the benefit of the elderly person. There are several different trusts available, depending on the situation. A Living Trust can be used while the person can still manage assets and act as their trustee, retaining the right to revoke the trust and regain title to assets. If the person becomes incapacitated, another person named the successor or co-trustee takes over, assuming the trust has not been revoked. The trustee could be a trusted professional, a relative, or a bank trust department, which may be expensive but is a good option for an aging person with significant resources but no individual to serve as the trustee.

Instead of a living trust, the elderly person may set up an Irrevocable Lifetime Trust for Medicaid and long-term care planning purposes wherein someone else is designated a trustee from the start.

Aging alone may seem like a daunting experience, but with the right planning and support network in place, it can be rewarding, enjoyable, and safe.

Reference: CPA Journal (July 2023) “ICYMI | Getting Older Without Family”

Should I Consider Working with an Elder Law Attorney?

Partnering with an elder law expert is the best way to make life transition easier as seniors age. RC Online’s recent article entitled “Why Is It Ideal for Working with An Elder Law Attorney During Life Transitions?” explains that many people have issues in the stage of life when they’re weak and not feeling well. This can result in health or mobility issues for many family members. The challenges faced by the family can cause financial strain, making lifestyle adjustments difficult, the article says.

Elder law attorneys can help family caregivers understand their loved one’s current situation and provide possible future solutions. This includes planning for situations where a debilitating illness requires long-term care.

Elder law attorneys often see various financial and medical circumstances when representing seniors in court, so their assistance can be extremely valuable when addressing issues, such as managing long-term care needs.

Specialized services for elderly care. Elder law attorneys focused on legal matters concerning older individuals. An elderly law attorney will be familiar with the elder laws of your state and will be able to identify potential conflicts or issues easily. As a result, they’ll be able to take appropriate actions to protect their client’s interests and rights.

Long-term care plan development for seniors. An elder care attorney can provide an objective perspective on the kind of care for their elders. This can help create a longevity plan that meets everyone’s needs.

The attorney will focus on families’ issues and problems as parents or spouses age. They provide legal services to individuals facing aging challenges, such as health care decisions and financial planning. An elder law attorney will consider the required level of care and whether a person can remain in their own home or require long-term nursing care.

Help for families in mediation and education. These are critical parts that play an important role during a family’s transitional phase. Mediation helps families maintain communication, and education provides knowledge for handling various issues.

It is important to have legal agreements related to retirement benefits, assets and who will be responsible for caring for an elderly loved one. An elder law attorney can help make these arrangements to prevent family fights and protect assets. They can assist seniors as well as heirs and beneficiaries to prevent losing assets due to financial problems or other circumstances.

Reference: RC Online (Feb. 14, 2023) “Why Is It Ideal for Working with An Elder Law Attorney During Life Transitions?”

Can I Protect My Elderly Parents?

Estate planning requires the ability to be realistic about current health and assets, while considering the inevitable changes to come. For adults with aging parents, having a well-thought out estate plan, regardless of the size of the estate, becomes more urgent as the time to use the documents draws closer. A recent article, “Accessing needs of aging parents,” from The News-Enterprise explains the steps adult children need to take to protect their parents.

There are four key factors to consider: medical needs, housing and care needs, finances and legal needs. All require candid, non-emotional assessments.

Start with medical, housing and care needs. Consider the next five years. Is it likely their medical condition may decline? How will their present home work, if they are unable to manage steps or need to sleep and toilet on the same level? If their home is not conducive for aging in place, will they consider moving to a better situation—or can they afford to make any changes?

Next, examine health and care needs. Do they have long-term care insurance or do they expect to apply for Medicaid? If one spouse will need memory care or one spouse dies, will the surviving spouse have the resources needed to remain in home and receive the care they need? An experienced estate planning attorney will be able to evaluate their financial situation with regard to becoming eligible for Medicaid, if this will be needed. There is a five-year look-back period for Medicaid, so advance action is necessary to protect assets.

Do they have any estate planning documents in place? Is there a will, and when was it prepared? Ask any estate planning attorney how many times seniors have told their children a will exists, only for the children to learn the will is forty years old, woefully out of date and declared invalid by the probate court. Deceased individuals may be listed as agents for Power of Attorney and Medical Power of Attorney. Funds left for heirs may no longer exist. Laws for power of attorney may not include required provisions as a result of changes to the law.

More complicated issues may exist. If appreciated real estate property has been deeded to loved ones to protect the property from nursing home costs, are the beneficiaries prepared to pay the resulting taxes? If deeded real estate property was intentionally left unrecorded, transferring property could become a legal quagmire.

The best solution is to have an experienced estate planning attorney meet with the parents, review any existing documents and prepare an updated set of documents to achieve the parent’s goals, protect them in case of medical emergencies and allow parents and children to gain the peace of mind of knowing they are ready for the future. This includes a will, power of attorney, health care power of attorney, HIPAA release, living will and, depending upon the situation, may also include trusts.

Reference: The Times-Enterprise (Nov. 5, 2022) “Accessing needs of aging parents”

Do I Need All Insurance after 65?

Seniors should be cautious about canceling their insurance policies. Consider your future insurability and your individual circumstances and life goals. There’s no one answer that fits everyone.

The primary purpose of life insurance is to replace lost income. Retirees may still want to keep their coverage because it can be an important tool in wealth transfer to the next generation.

US News’ recent article entitled “The Only Insurance Policies You Need After Retirement” advises that these guidelines can help determine which policies are essential and which could be a waste of money. Let’s look at how to decide which policies you need and which you can skip after age 65.

Must-Have Policies for Seniors. These two types of insurance are necessary for seniors.

Medical Insurance. The increasing cost of health care that comes with advanced age is a big reason to buy medical insurance. The Affordable Care Act requires everyone to maintain coverage. Most seniors 65+ are eligible for Medicare, and those still working may have benefits through their job. Note that Medicare doesn’t cover all medical costs, so look at buying a supplemental plan, such as Medigap and Part D coverage, to help pay for services not fully covered by Original Medicare. A Medicare Advantage Plan offered by private insurers is another way to fill in coverage gaps.
Homeowners or Renters Insurance. Seniors with valuable jewelry or other items may need to add a rider to their policy to fully insure these possessions. Mortgage lenders require homeowners to maintain coverage, but once the loan is paid off, it’s not required. It may be tempting to save money by canceling the policy, but that could be a costly mistake. That’s because a big loss would have to be replaced with savings.

Some Smart Options. There are other types of insurance that could be helpful to seniors.

Travel Insurance. Those who plan to travel extensively may want to buy travel insurance. Find a policy that includes features, such as emergency medical and medical evacuation services along with trip delay or cancellation insurance.
Auto Insurance. Auto insurance is required in almost every state. Any senior who is still driving and owns a vehicle should insure it properly.
Umbrella Insurance. This insurance provides additional liability coverage above and beyond what’s included in homeowner and car insurance. Your volunteer activities could put you at risk for a liability claim and warrant added insurance coverage.
An immediate annuity can help guard against outliving savings by providing a guaranteed source of income. Annuities can be purchased for a lump sum amount and provide monthly payments that are based on a person’s age and the purchase price.
Long-Term Care Insurance. Medicare won’t pay for ongoing custodial care in a nursing home or assisted living facility, and Medicaid is only available after a person has depleted almost all their assets.

One Type of Insurance to Cancel. Seniors who aren’t working don’t have a need for disability insurance.

Reference: US News (Feb. 27, 2020) “The Only Insurance Policies You Need After Retirement”

Can I Avoid the Economic Dangers of Caregiving?

AARP’s recent article entitled “5 Steps to Avoid Economic Pitfalls of Caregiving” reports that 20% of family caregivers have to take unpaid time off from work due to their caregiving responsibilities.

The average lifetime cost to caregivers in lost wages and reduced pension and Social Security benefits is $304,000 — that is $388,000 in today’s dollars. This does not count the more than $7,200 that most caregivers spend out of pocket each year, on average, on housing, health care and other needs for loved ones in their care, according to the AARP report.

Step 1: Calculate the gap. The average cost of a full-time home health aide is nearly $62,000 a year, and a semiprivate room in a nursing home runs about $95,000. Ask your parents about the size of their nest egg, how fast they are spending it, whether they have long-term care insurance and how much equity they have in their home. Compare your parents’ assets against their projected expenses to determine your gap.

Step 2: Fill the gap without going broke. Try to find free resources: Use the National Council on Aging’s BenefitsCheckUp tool to find federal, state and private benefit programs that apply to your situation. Then create a budget to determine what you can contribute, physically and in dollars, to closing the gap. In addition, ask your siblings if they can pitch in.

Step 3: If a gap remains, consider Medicaid. This program can cover long-term care. However, your parent or parents may need to spend down assets to qualify. Note that if just only one parent is in a nursing home, the other can generally keep half of the assets, up to a total of $137,400 (not including their house). However, the rules differ by state. As a result, this can get complicated. Speak with an elder-law attorney for help.

Step 4: No matter what the gap, try to get paid. If your parents have enough resources, you may discuss having them pay you for caregiving. However, you should speak with an attorney first about drawing up a contract. This should include issues like the number of hours a day you will spend on providing care and whether doing so will require you to quit your job. The caregiving agreement is written carefully, so that it does not violate Medicaid regulations about spending down assets.

Step 5: Protect your own earning ability. If you are mid-career, it is very difficult to leave a job for family responsibilities like caregiving and then go back into the workforce at the same salary. The Society for Human Resource Management says that it costs six to nine months’ salary to replace an employee, so many employers now see it is less expensive to make an accommodation.

Reference: AARP (Feb. 24, 2022) “5 Steps to Avoid Economic Pitfalls of Caregiving”

Must I Sell Parent’s Home if They Move to a Nursing Facility?

If a parent is transferring to a nursing home, you may ask if her home must be sold.

It is common in a parent’s later years to have the parent and an adult child on the deed, with a line of credit on the house. As a result, there’s very little equity.

Seniors Matter’s recent article entitled “If my mom moves to a nursing home, does her home need to be sold?” says that if your mother has assets in her name, but not enough resources to pay for an extended nursing home stay, this can add another level of complexity.

If your mother has long-term care insurance or a life insurance policy with a nursing home rider, these can help cover the costs.

However, if your mom will rely on state aid, through Medicaid, she will need to qualify for coverage based on her income and assets.

Medicaid income and asset limits are low—and vary by state. Homes are usually excluded from the asset limits for qualification purposes. That is because most states’ Medicaid programs will not count a nursing home resident’s home as an asset when calculating an applicant’s eligibility for Medicaid, provided the resident intends to return home

However, a home may come into play later on because states eventually attempt to recover their costs of providing care. If a parent stays a year-and-a-half in a nursing home—the typical stay for women— when her home is sold, the state will make a claim for a share of the home’s sales proceeds.

Many seniors use an irrevocable trust to avoid this “asset recovery.”

Trusts can be expensive to create and require the help of an experienced elder law attorney. As a result, in some cases, this may not be an option. If there’s not enough equity left after the sale, some states also pursue other assets, such as bank accounts, to satisfy their nursing home expense claims.

An adult child selling the home right before the parent goes into a nursing home would also not avoid the state trying to recover its costs. This because Medicaid has a look-back period for asset transfers occurring within five years.

There are some exceptions. For example, if an adult child lived with their parent in the house as her caregiver prior to her being placed in a nursing home. However, there are other requirements.

Talk to elder law attorney on the best way to go, based on state law and other specific factors.

Reference: Seniors Matter (Feb. 25, 2022) “If my mom moves to a nursing home, does her home need to be sold?”

What are States Doing to Help Pay Long-Term Care Costs in Future?

Starting this year, workers in Washington state must pay 58 cents of every $100 they earn into the Washington Cares Fund. That money will help pay their long-term care costs in the future. Those with qualifying long-term care insurance can be eligible for an exemption.

Next Avenue’s recent article entitled “How Medicaid and Medicare Fit Into Planning for Long-Term Care” says that starting in 2025, those Washington residents who’ve paid in for at least three out of the prior six years, or for 10 years in total, will be able to withdraw up to $36,500 to pay for their costs of care. It is an effort by the state to fill in a major gap in our long-term care system. California has also enacted a law to bring down the eligibility threshold for Medicaid to totally eliminate it by the end of 2023. New York state is considering similar legislation.

Any senior may need assistance as they age, whether due to dementia, illness, loss of eyesight, or simple frailty. The level of assistance and how long it will last can vary greatly. However, few retirees have enough saved to pay for their care for very long out-of-pocket. According to research from Boston College, more than half of today’s 65-year-olds will need a medium to high level of assistance for more than a year. Almost two thirds of that care will be provided by family members – mostly children and spouses – for no cost, but more than a third will be provided by paid caregivers.

According to the Congressional Research Service, 43% of long-term care services are paid for by the Medicaid program, 20% by Medicare, 15% out-of-pocket and 9% by private insurance. The rest comes from a combination of private and public sources that includes charitable payments and VA benefits.

Medicare Coverage. This is the federal health insurance program for people beginning at age 65. Note that Medicare only covers so-called “skilled” needs following a hospitalization. It pays for up to 100 days of care in a skilled nursing facility following a hospitalization and longer term for home health services.However, the home health coverage is not comprehensive.

Medicaid Coverage. The financial rules for Medicaid coverage are complicated and state-specific. However, generally people must spend down to about $2,000 in savings and investments. Planning to use Medicaid to pay for long-term care is also complicated by the fact that while its coverage of nursing home care is comprehensive, its payment for home care and assisted living facility fees is only partial and differs both from state to state. Even if you may be able to leverage Medicaid to help pay home and assisted living care, you must also rely on your own savings.

Out-of-Pocket Costs. The low percentage of long-term care costs paid for out-of-pocket is surprising, in light of the vast growth of both assisted living and private home care agencies over the last several decades. However, this demonstrates the fact that most older adults have limited resources to pay for anything beyond their basic living expenses. When the need for care arises, they must rely on family members or Medicaid.

Insurance. A large component of insurance coverage of long-term care consists of Medicare supplemental insurance payments for skilled nursing facility copayments. While Medicare will pay for up to 100 days of skilled care following a hospitalization, it actually pays entirely for only the first 20 days. For days 21 through 100, there is a copayment which for most is paid by their MediGap insurance. As such, long-term care insurance pays for a very small share of long-term care costs. For those who have coverage, it can be terrific. However, due to its high cost, those who have it often also have the resources to pay for their care out-of-pocket, at least for some period of time.

Veterans Benefits. More vets are taking advantage of a Veterans Administration benefit known as Aid & Assistance that will provide veterans who qualify financially with up to $2,431 a month (in 2022) to help pay for their care.

Reference: Next Avenue (Feb. 2, 2022) `“How Medicaid and Medicare Fit Into Planning for Long-Term Care”

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