Family Matters

Assisted Living or Nursing Home care: how to pay?

We're looking at the future for my mom (she was recently diagnosed with Dementia but it's not 100% confirmed until she does the final round of testing with a specialist next month) and are discovering that assisted living centers and nursing homes are very expensive.  $4k a month seems average.  We've checked with her insurance and with Medicare, but neither of them cover them.  If she gets really bad and becomes homebound, she can get 1-8 hours a day of home health, but that's it until she needs SNF (which really is only after an incident like a stroke or heart attck, and then it only covers 100 days and then she has to leave) or hospice if she's in the final stage of dying. 

For those who have parents who have Dementia, who is looking out for them?  How are they able to continue living independently and safely (which is what my mom wants to do)?  What are you doing if nobody in the family seems able to take in the parent?  If they are in nursing homes or assisted living, how are they being paid for?  Any options or ideas?  Can you buy a long-term care policy at this point: does it exist?

I'm gathering all the information I can at this point so we can make some good decisions regarding the future - which is what her neurologist recommended.  Thanks.

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Re: Assisted Living or Nursing Home care: how to pay?

  • I may be crazy, but I swear my great grandmother lived in a nursing home that was paid for by Medicare because no one in my family could swing the monthly bill for private nursing home. My other great grandparents were better off and paid for private nursing home themselves, which as you said was extremely expensive. 

    Are you sure she isn't covered for public nursing home?  

  • What commonly happens is that all the patient's funds are spent on assisted living/nursing home costs, then they go on Medicaid, and that covers care.  But not all places take Medicaid patients, so you'll need to look around

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    What commonly happens is that all the patient's funds are spent on assisted living/nursing home costs, then they go on Medicaid, and that covers care.  But not all places take Medicaid patients, so you'll need to look around

    Exaclty.  But, we need to hang on to what little money she has for as long as possible.  She's only 70 and she doesn't have the best health as it is, and she needs to save the money for future medical problems. 

     

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  • I'm a hospital social worker so hopefully I can answer some of your questions.

    You are right in that Medicare only pays for an acute rehab or SNF stay after a medical event like a stroke/hip fracture.

    You've got some options:

    1.  Keep her in her current living situation  (house/apartment) and pay for caregivers to come in and help.  This is called private duty care and can be quite expensive but it is one way to keep her at home for as long as possible.  You can even pay for 24/7 private duty care but that is more expensive than moving her into a nursing home.  However some people choose to do it if they have the funds and want to avoid a nursing home.

    2.  Move her into an assisted living facility that specializes in memory care.  Most folks sell the family member's home in order to have the funds for this as insurance and Medicaid do not pay for it.  Many of these facilities are on the same grounds as a long term care facility so that the individual can transfer over there smoothly once they can no longer live by themselves in the apartment.

    3.  Move her into long term care and apply for Medicaid.  All of her savings will have to be used up first, then Medicaid will take any social security and pension checks that come in each month and then pay the difference on the nursing home bill.  You are not required to liquidate property assets to get on Medicaid, if I remember correctly.  Not every nursing home accepts Medicaid, so the options are more limited than if you paid out of pocket for long term nursing care.

    I honestly don't know about applying for LTC plans once she has a diagnosis, you'll have to look into that. I know LTC plans help pay for both assisted living and long term care.  

    As far as paying for medical expenses that come up, Medicare will pay for much of it, but there will always be co-pays and prescription drug costs.  However if she is in a long term care facility her medications should be included in her bill.  If she doesn't already, I'd sign her up for a secondary insurance to help cover what Medicare won't.  AARP is a popular one that many of my patients have, also Blue Cross.

    whatever you do I would avoid switching her to a cheaper 'medicare replacement plan' such as Humana Gold, UHC, Advantra, etc.  They may appear cheaper on the surface but they do not cover acute rehab/SNF very well at all if she were to need a rehab stay at some point in the future, which most individuals do at some point.   Many individuals have these plans and think they have Medicare but they do not.  So then they break a hip and end up paying out of pocket for weeks at a SNF.  If they'd had traditional Medicare, that would have been covered.  /end soap box :)  

    of course one final option would be to move her in with you or another family member but this is really doesn't work if you are working and can't be home with her 24/7.  With dementia she will need 24/7 care at some point, you are wise to be looking into your options now!  

    let me know if you have any other questions I might be able to help with, sorry to write a novel, I hope it was helpful! 

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  • You cant save her money for future medical expenses.  Once she goes into a nursing home paid by medicaid, they just pay everything, and she doesnt need any money.  You (or other family) will have to cover incidentals like haircuts, new clothes, etc.  
  • image pugznploons:

    I'm a hospital social worker so hopefully I can answer some of your questions.

    You are right in that Medicare only pays for an acute rehab or SNF stay after a medical event like a stroke/hip fracture.

    You've got some options:

    1.  Keep her in her current living situation  (house/apartment) and pay for caregivers to come in and help.  This is called private duty care and can be quite expensive but it is one way to keep her at home for as long as possible.  You can even pay for 24/7 private duty care but that is more expensive than moving her into a nursing home.  However some people choose to do it if they have the funds and want to avoid a nursing home.

    2.  Move her into an assisted living facility that specializes in memory care.  Most folks sell the family member's home in order to have the funds for this as insurance and Medicaid do not pay for it.  Many of these facilities are on the same grounds as a long term care facility so that the individual can transfer over there smoothly once they can no longer live by themselves in the apartment.

    3.  Move her into long term care and apply for Medicaid.  All of her savings will have to be used up first, then Medicaid will take any social security and pension checks that come in each month and then pay the difference on the nursing home bill.  You are not required to liquidate property assets to get on Medicaid, if I remember correctly.  Not every nursing home accepts Medicaid, so the options are more limited than if you paid out of pocket for long term nursing care.

    I honestly don't know about applying for LTC plans once she has a diagnosis, you'll have to look into that. I know LTC plans help pay for both assisted living and long term care.  

    As far as paying for medical expenses that come up, Medicare will pay for much of it, but there will always be co-pays and prescription drug costs.  However if she is in a long term care facility her medications should be included in her bill.  If she doesn't already, I'd sign her up for a secondary insurance to help cover what Medicare won't.  AARP is a popular one that many of my patients have, also Blue Cross.

    whatever you do I would avoid switching her to a cheaper 'medicare replacement plan' such as Humana Gold, UHC, Advantra, etc.  They may appear cheaper on the surface but they do not cover acute rehab/SNF very well at all if she were to need a rehab stay at some point in the future, which most individuals do at some point.   Many individuals have these plans and think they have Medicare but they do not.  So then they break a hip and end up paying out of pocket for weeks at a SNF.  If they'd had traditional Medicare, that would have been covered.  /end soap box :)  

    of course one final option would be to move her in with you or another family member but this is really doesn't work if you are working and can't be home with her 24/7.  With dementia she will need 24/7 care at some point, you are wise to be looking into your options now!  

    let me know if you have any other questions I might be able to help with, sorry to write a novel, I hope it was helpful! 

    This was very informative. I didn't know a lot of it. Thank you so much for typing all of that out! We are going through a lot of this with my grandfather currently. 

  • I am not a social worker or anything, but pugznploons said what I was going to say, but much better.  My grandfather passed away in February, and my grandmother has Alzheimer's so she recently went into a home.  Grandpa had picked out the nursing home and gotten the paperwork filled out (he knew he was fighting a losing battle to cancer) so that even the financial part was figured out.  We are selling her house, which is very hard to do, but if it means grandma is in a better place, it's what needs to be done.  My grandma is not so far gone yet that she doesn't worry about how the bills will get paid, and so selling the house and being able to tell her she doesn't have to worry about bills ever again is a great feeling to have.
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  • Not sure where you live, but in my area (St. Louis) there is a company that has many different nursing home types, assisted living up to full on nursing and dementia units. My step-aunt's condo was being put into foreclosure and my stepdad had to make arrangements for her. He called around a lot and found that this place (which is really nice and has many facilities!) has a foundation that provides people unable to pay assistance. She moved in and loves it. Call around and ask about that. Also, a local university in town that has a law school has an elder care  area, where law students work supervised to do legal work for the elderly, like living wills, power of attorney, etc. They helped him along the way. You might want to look into this and call local law schools to see if they can help you with the legal side of things and to see if they have recs for you.
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  • image MarynJoe:
    image dirtyred:

    What commonly happens is that all the patient's funds are spent on assisted living/nursing home costs, then they go on Medicaid, and that covers care.  But not all places take Medicaid patients, so you'll need to look around

    Exaclty.  But, we need to hang on to what little money she has for as long as possible.  She's only 70 and she doesn't have the best health as it is, and she needs to save the money for future medical problems. 

    She won't qualify for Medicaid until all of her funds are used-up, so she can't have a nest egg and qaulify for Medicaid-paid care. They also do a 5-year "look back", so you can't transfer her funds or assets into anyone else's name to zero-out her balance. You will have to provide finacial records prooving her net worth and expenses from the 5 years previous to a Medicaid application (banks can provide copies at a fee). The only expense you are allowed to "pre-pay" with current funds are funeral expenses. Contact a local funeral home (they you think will be in business when gma passes) and set-up a pre-pay account. They will know what you're talking about.

    Keep copies of everything. Keep copies of copies. This is a very tough road that will require a great deal of organization and advocacy. Good luck.   

     

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  • Any chance your father is an honorably discharged veteran?  When we were going through this 3 1/2 yrs ago with my dad we found out that VA will help pay for nursing home/assisted living care in certain cases - that extended to the spouse also.

    My dad's assets had to be under 80,000.00 and then the help is a sliding scale - the less assets the more help you might get.  I'm in the military and I had never heard of this.  My father had more than 80,000.00 in assets so we had him in a private pay facility.

    Hope that may help 

     

     

  • You are getting excellent information here.

    I am a nurse at both a SNF and with Hospice. I agree with keeping her home as long as she is safe. I encourage you to look into alz/dementia support groups in your area now. There may be people there with additonal informational resources.

    If you have an specific questions please feel free to PM me.

    Best of luck to you.

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  • Thanks everyone.  My mom is in an apartment and doesn't have any 'extras'.  She's always lived paycheck to paycheck.  She has a little in the bank in a fund for an emergency, but that's it.  So, there's nothing to sell.

    My dad was in the military for 4 years, honorably discharged, but they divorced over 20 years ago.  Would that still count?

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  • image MarynJoe:

    Thanks everyone.  My mom is in an apartment and doesn't have any 'extras'.  She's always lived paycheck to paycheck.  She has a little in the bank in a fund for an emergency, but that's it.  So, there's nothing to sell.

    My dad was in the military for 4 years, honorably discharged, but they divorced over 20 years ago.  Would that still count?

    I'm not sure but I would start with social workers at the places you may consider for your mother as well as the VA.  I shudder to tell you to go there because you can call 3 different times and get 3 different answers.  Whatever they tell you, make sure you ask them where you can find that info on their website.

    Did your father remarry?  How about your mom? 

     

  • I would also recommend starting discussions regarding power of attorney. We just went through this with my grandmother (she passed away 2 weeks ago). Her dementia progressed extremely quickly, and they almost weren't able to get POA transferred to my mother, who was handling all of her finances/medical care/etc. 

    For her bills, we were able to rent out her house, and that combined with the SS payments were enough to pay for the memory care unit. Once she went into Hospice, I believe much more was covered.  

    Sorry to hear about your mom, it's a difficult situation.  

  • image kmmssg:
    image MarynJoe:

    Thanks everyone.  My mom is in an apartment and doesn't have any 'extras'.  She's always lived paycheck to paycheck.  She has a little in the bank in a fund for an emergency, but that's it.  So, there's nothing to sell.

    My dad was in the military for 4 years, honorably discharged, but they divorced over 20 years ago.  Would that still count?

    I'm not sure but I would start with social workers at the places you may consider for your mother as well as the VA.  I shudder to tell you to go there because you can call 3 different times and get 3 different answers.  Whatever they tell you, make sure you ask them where you can find that info on their website.

    Did your father remarry?  How about your mom? 

     

    He remarried.  Mom did not.

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  • I agree with "suzymarie". In order to have medicaid pay all expenses your mother can liquidate her assets by signing them over to a familiy member that she trusts. Then she will still have funds but medicaid wil be none the wiser. If you know what longterm care facility you are interested in, call them and set up an appointment to learn more. Different nursing facilities have different methods. Also, definantly look up a support group for dementia disorders. It will benifit everyone involved, greatly! One thing I know to be true - If you are not ready for this to be her perminant place of living then don't go this route. You can look into having a nursing aide stay with her in her home. You'd be surprised at how little income aides work for. You may be able to pay eight bucks an hour out of pocket. When families bring there loved ones into a nursing facility to live short term, it almost always ( 9 out of 10 times ) ends up being longterm. Ive seen patients come in for rehabilitation short term and after being there they will get depressed or there health will start to go downhill. Ive worked 5 years of long term care and I would not recommend it to anyone. Let it be your absolute last choice. You can search the net and check out the different places ratings before choosing. Also, if you do put her in a home make sure to make "surprise" visits. You just never know and would'nt believe some of the neglet an abuse that can and does go on!
  • I'm a health and life insurance broker, and underwriting would not approve now that diagnosis is made.  Those policies go through underwriting.   I do have a client that has adult day care that takes care of patients with dementia and the like.  They have great activities.  Their family members drop them off when they go to work and pick them up in the afternoon at the end of the traditional business day.  Then the family members take care of them in the evening until bedtime and on weekends.

    It's reasonably priced and seems to work well for them.    They provide meals and the like and have an LVN on staff and doctor on call.  Of course it doesn't hurt that the day care center is a couple blocks from a major hospital if needed.

     Blessings and best of luck.

  • totally forgot about adult day programs, definitely look into them!  They are great for those in the early-middle stages of dementia.  

    one place you could go for local resources is your local Area Agency on Aging.  

    I doubt she would be able to get anything from the VA since he re-married.  Also the veteran has to be 70% service connected or higher to really qualify for VA long term care benefits.  Most of the time the only benefits a spouse of a veteran gets are survivor payments after the veteran has passed.  Again with their divorce I don't think she'd be eligible for anything but you could call the outpatient social worker at your local VA hospital/community clinic and ask.  

    and I think there are plenty of good long term care facilities out there and while each does have faults, they are not all hell holes as they are sometimes portrayed.  The Medicaid facilities may not be as nice as the pricier private pay facilities, but there are good options out there.  

    it sounds like with her limited assets medicaid will be the way to go once you need long term care for her.   

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  • image MarynJoe:

    Thanks everyone.  My mom is in an apartment and doesn't have any 'extras'.  She's always lived paycheck to paycheck.  She has a little in the bank in a fund for an emergency, but that's it.  So, there's nothing to sell.

    My dad was in the military for 4 years, honorably discharged, but they divorced over 20 years ago.  Would that still count?

    No since they divorced she would not qualify for VA benefits where do you live, their are some states that allow Medicaid to pay for Assisted Living Facilities fees.

  • image BBnME2:
    I agree with "suzymarie". In order to have medicaid pay all expenses your mother can liquidate her assets by signing them over to a familiy member that she trusts. Then she will still have funds but medicaid wil be none the wiser. 

    Oh, yes, they will be!  Read livinitup's post about the five-year lookback period. OP, I'm sorry that you're dealing with all this.

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  • Her diagnosis of Dementia is not 100% confirmed.  Her first tests indicated some issues.  She tested again 6 months later, but she wasn't feeling well and the tests showed more problems and gave the Dementia diagnosis, but it wasn't an accurate reflection of her abilities due to her fatigue.  (Actually, I'm surprised they went through with the testing.  They shouldn't have.  When my mom is sick, stressed, or upset, she kind of shuts down and really lets it get to her.  She's always been like that.)  So, her neurologist wants us to go to a specialist on a day she's feeling well so we can get a more accurate diagnosis.  We're holding off on that apopintment until we see if we can get a long-term care policy in place first.

    I'm wondering if a LTC policy will hold that 2nd test against her even though the neurologist realizes that it was not an accurate test result and wants new testing?

    I've noteded that long-term care policies vary in price depending on how much $ coverage you have per day.  How do you know what you need in coverage per day?  There's no point in buying a policy if you find out that it doesn't cover what you need and you don't have the money to make up the difference.

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  • image MarynJoe:

    Her diagnosis of Dementia is not 100% confirmed.  Her first tests indicated some issues.  She tested again 6 months later, but she wasn't feeling well and the tests showed more problems and gave the Dementia diagnosis, but it wasn't an accurate reflection of her abilities due to her fatigue.  (Actually, I'm surprised they went through with the testing.  They shouldn't have.  When my mom is sick, stressed, or upset, she kind of shuts down and really lets it get to her.  She's always been like that.)  So, her neurologist wants us to go to a specialist on a day she's feeling well so we can get a more accurate diagnosis.  We're holding off on that apopintment until we see if we can get a long-term care policy in place first.

    I'm wondering if a LTC policy will hold that 2nd test against her even though the neurologist realizes that it was not an accurate test result and wants new testing?

    I've noteded that long-term care policies vary in price depending on how much $ coverage you have per day.  How do you know what you need in coverage per day?  There's no point in buying a policy if you find out that it doesn't cover what you need and you don't have the money to make up the difference.

    start looking at facilities and get prices so you can figure out how much you'll need.

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  • Like another person mentioned, Once she eventually qualifies for Hospice (approx 6 months or less to live) they are covered basically 100% by any insurance including medicare.  You can set it up either in a nursing home, at home (with drop in nurse visits and family covering the rest) or in a hospice inpatient unit.  

     

  • image suzymarie:

    Like another person mentioned, Once she eventually qualifies for Hospice (approx 6 months or less to live) they are covered basically 100% by any insurance including medicare.  You can set it up either in a nursing home, at home (with drop in nurse visits and family covering the rest) or in a hospice inpatient unit.  

    my understanding was that the family still has to pay room and board at the nursing home facility. 

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  • My mom is covered for hospice.  It's the time between now and hospice that we can't figure out.  It could be a few years, it could be 15 years.  That's what's tough.
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  • image scarlettoctober:

    image BBnME2:
    I agree with "suzymarie". In order to have medicaid pay all expenses your mother can liquidate her assets by signing them over to a familiy member that she trusts. Then she will still have funds but medicaid wil be none the wiser. 

    Oh, yes, they will be!  Read livinitup's post about the five-year lookback period. OP, I'm sorry that you're dealing with all this.

    I know people who have done this in extreme cases. Im not recommending you do it yourself per say. Ive known single mothers apply for medicaid during unemployment and they pulled out there savings from the bank. If your mother signs over he cash (legally) then she shouldnt have a problem. Ive seen patients families become power of attorny and take legal reciept. This way could get you in trouble but if she did actually give it up to someone then there really isnt much anyone could do legally. The money is not hers anymore technically but the familiy member can spend "there money" on anything she would need. Its a tricky situation and you would have to cross your t"s and dot your I's but i've seen it done.
  • You may want to check with your or your hubbies insurance.  My old company offered a health benefit for my parents elder care that I signed up for.  It was reasonably inexpensive for me, and gave me some piece of mind...
  • image MarynJoe:
    image dirtyred:

    What commonly happens is that all the patient's funds are spent on assisted living/nursing home costs, then they go on Medicaid, and that covers care.  But not all places take Medicaid patients, so you'll need to look around

    Exaclty.  But, we need to hang on to what little money she has for as long as possible.  She's only 70 and she doesn't have the best health as it is, and she needs to save the money for future medical problems. 

     

    What we did with my MIL is we sold her home and liquidated her assests and placed some of the funds in an account that would pay for a year or so of her care at the SNF. The rest we wrote up as a loan repayment to us and placed the funds in an account for "rainy days" ie hosptital bills ect. We did this with the help of a finacial planner. If you mother owns her home she can quick claim deed the property over to you now so when she gets to the point of needing medicaid help it's not listed as her asset and you can sell it to help pay for unexpected expenses.

    The quick claim deed part assumes your mother will not need care for thenext 5 years.

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