Care options: How to decide which is right for you
When I first began to focus my practice in elder law 14 years ago, the options for long-term care were limited. Generally, families chose between keeping their loved ones at home or moving them to a nursing home.
The choice was difficult with almost all home care provided by family members, some of whom quit their jobs or juggled child raising and parent care responsibilities. That still continues but there are also multiple services now to provide both non-medical and medical in-home care. The at-home care companies have become an important part of the equation.
Fourteen years ago some families in the higher asset range opted for continuing care retirement communities (CRCC) where seniors could buy in to a contractual arrangement for an apartment or cottage with an upfront payment when they did not yet need assistance.
Then they could step up to a higher level — assisted living or skilled care — on the same campus if they needed it later. That continues and there are more communities and more flexible payment arrangements than before.
Skilled care in a CCRC might be Medicaid certified or the resident might have a negotiated rate until assets are exhausted but, in any event, the idea is that he or she will continue to be cared for even if personal funds have been depleted provided he does not give his assets away.
Assisted living has exploded over the past 14 years with multiple communities and alternatives. At the same time, partly because of government incentives to contain Medicaid costs, the number of Medicaid skilled nursing beds has steadily decreased. In other words, I would be as likely today to see a family dealing with at-home or CCRC or assisted living care as I would be to meet a family considering skilled nursing in a Medicaid-certified facility.
There are major differences in levels of care, price, availability of government benefits, and regulations between assisted living and nursing home although over the past few years with the coming of “memory neighborhoods” and secure dementia units to some assisted living communities, the differences have blurred somewhat. An assisted living resident may later move to skilled care where the requirements are different.
Here are some considerations to keep in mind.
Differences in Cost. Both assisted living and skilled nursing are “pay as you go.” Skilled nursing is typically much more expensive than base assisted living. Recognizing considerable differences between communities, it is not unusual for monthly base charges in assisted living to run $5,500 to $6,000 per month while skilled nursing in Chester County and other Philadelphia suburban counties may cost $8,000 to $9,000 per month. Level of care is a major reason.
Nursing home residents are listed as nursing facility clinically eligible (NFCE). Assisted living communities are described as “personal care homes” which might be thought of as boarding homes with some personal support and assistance.
Many assisted living arrangements today permit families to add additional services such as help with bathing and dressing, companion services, and additional therapies at additional cost. At the highest level of care in assisted living, the cost could equal or possibly exceed the cost of skilled care.
Availability of government benefits. At this time the only significant government benefit available for assisted living residents is the Veterans’ Aid and Attendance program which applies to wartime veterans and their widows or widowers.
With Pennsylvania legislation passed in the past few years, Medicaid might eventually be able to cover assisted living in some limited instances but no assisted living facility in Pennsylvania has yet qualified.
As to nursing homes, although nursing home care in a Medicaid-certified facility is considerably more expensive than assisted living, when funds are depleted, if the resident applies and meets the Medicaid criteria, the government would then pick up the cost of care indefinitely. Because of this some families wait to apply for skilled care until their family member is very low in assets.
For more reasons than can be explained here, this is a bad idea. There may not be a suitable available placement in a Medicaid facility if families wait too long. Crisis can result in poor choices.
The Medicaid rules are complicated and became more so as of Feb. 8, 2006, with changes in federal legislation but much more can be done for some families if they seek help earlier.
Also, innocent payments to adult children and others depending on what they are and when they are given could result in disqualification for benefits for care unless recognized and handled. Filial responsibility where adult children might be sued for the cost of their parent’s care when funds are exhausted has become a concern. There are problems that can be corrected if recognized early and all of these issues may be addressed by planning ahead.
About the Author Janet Colliton
Esquire, Colliton Law Associates, P.C. Janet Colliton has practiced law for over 38 years, 37 of them in Chester County, Pennsylvania, a suburb of Philadelphia. Her practice, Colliton Law Associates, PC, is limited to elder law, Medicaid, including advice, applications and appeals, and other benefits planning including Veterans benefits, life care and special needs planning, guardianships, retirement, and estate planning and administration.