Long Term Care Varies, State by State

What if your parents live in Oklahoma, you live in Nebraska and your brothers and sisters live in New York and California? Having the important conversation with your aging parents about what the future might hold if one of them should need long-term care is going to be a challenge, to say the least.

It’s not just about whether they want to leave their home, reports the article “What is the best state for long term care” from The Mercury. There are many more complications. Every state has different availability, levels of care and taxes. If the family is considering a continuing care retirement community, or if the parents already live in one, what are the terms of the contract?

The differences between states vary, and even within a state, there can be dramatic differences, depending upon whether the facility being considered is in a metropolitan, suburban or rural area. There’s also the question of whether the facility will accept Medicaid patients, if the parents have long-term care insurance or any other resources.

Here’s what often happens: you open up a glossy brochure of a senior community in a warm climate, like Florida or Arizona. There are golf courses, swimming pools and a great looking main house where clubs and other activities take place. However, what happens when the active phase of your life ends, slowly or suddenly? The questions to ask concern levels of care and quality of care. Where is the nearest hospital, and is it a good one? What kind of care can you receive in your own apartment? Are you locked into to your purchase, regardless of your wishes to sell and move to be closer to or live with your adult children?

And what happens if you or a “well” spouse runs out of money? That’s the question no one wants to think about, but it does have to be considered.

For people who move to Florida, which has a very generous homestead exemption for property taxes and no state tax, the incentives are strong. However, what if you become sick and need to return north?

For seniors who live in Pennsylvania and receive long-term care and other services, the well spouse’s retirement funds are exempt for Medicaid regardless of the amount. However, if you move over the state’s border to New Jersey, and those accounts will need to be spent down to qualify for Medicaid. The difference to the well spouse could be life changing.

Delaware and New Jersey have Medicaid available for assisted living/personal care. Pennsylvania does not. The Keystone State has strict income limitations regarding “at home” services through Medicaid, whereas California is very open in how it interprets rules about Medicaid gifting.

The answer of where to live when long-term care is in play depends on many different factors. Your best bet is to meet with an estate planning elder care attorney who understands the pros and cons of your state, your family’s  situation and what will work best for you and your spouse, or you as an individual.  The attorneys at Fisher Law LLC are well versed in Massachusetts’ Medicaid (or MassHealth) regulations, as well as the VA Aid & Attendance rules, to assist you and your loved ones on long term care issues and planning.

Reference: The Mercury (March 4, 2020) “What is the best state for long term care”


Medicare Coverage for Long Term Care

Most people understand that by paying into Social Security throughout their careers, they can receive health care benefits through Medicare starting at age 65.  Individuals under age 65 who qualify to receive Social Security Disability benefits are also covered under Medicare, as well as anyone of any age who has Lou Gehrigs disease, known as Amyotrophic Lateral Sclerosis (ALS), or has been diagnosed with permanent kidney disease (end-stage renal disease) that requires dialysis or a kidney transplant.  But many people may not understand what is covered when long term care is needed.

In general, long term care is medical and non-medical care provided to a person who is unable to perform the basic actions needed on a daily basis to function independently.These basic actions are called activities of daily living and include bathing, dressing, eating, toileting, managing bowel and bladder function, and having enough physical mobility to be able to move safely to and from a bed or a chair, called transferring.  For people with chronic diseases, permanent injury such as from a stroke, or are suffering from the effects of aging, long term care is provided indefinitely without the expectation that the patient will recover.

Often patients receiving long term care services reside in a nursing home to be able to have their basic needs met.  For others who have become incapacitated due to an illness or injury, skilled nursing care may be needed with the goal of recovering to independent functional status.Medicare will pay for medically necessary acute care services and some long term care services that meet specific criteria.  Most long term care non-medical services are not covered by Medicare, such as nursing home expense or the services provided in the home for custodial-type care.

There are four specific types of long term care services, listed below, that Medicare will pay for, though certain conditions apply for most services to be covered:

  • Care in a skilled nursing facility for up to 100 days per benefit period
  • Services to treat medical conditions
  • Services to prevent further decline due to medical conditions
  • Hospice care

For a Medicare recipient to qualify for a skilled nursing home stay, the patient must have been provided acute care in a hospital for three consecutive days (often referred to as three midnights) prior to transferring to a skilled nursing facility or must be placed in a skilled nursing facility within 30 days of that qualifying acute care stay.  Being held on observation status for three consecutive days is not enough for Medicare to pay for additional care.

Once in a skilled nursing home, payment for services is based on length of stay with only a portion of the cost is covered after the first 20 days, and Medicare will not pay for the cost of the skilled nursing facility after the 100th day.These days of stay do not need to be consecutive.

When services to treat medical conditions are deemed medically necessary by a physician, Medicare will pay indefinitely on certain services as long as the physician writes an order for continued services every 60 days and these services remain medically necessary.   Services covered include intermittent or part-time skilled nursing care, therapy services provided by a Medicare-certified home health agency, medical social services, and medical supplies and durable medical equipment (of which 80% of the approved amount is covered).  For patients with conditions that may not improve, such as debility from a stroke, Parkinson’s disease, Alzheimer’s disease, Multiple sclerosis or ALS, Medicare will pay for services that could prevent further decline in their health status.   Hospice care for those with a terminal illness who have chosen to stop all active treatment and are not expected to survive longer than six months is also covered with Medicare.   This care includes medications for pain control or relief from the symptoms of the illness, as well as hospice care by a Medicare-approved hospice provider not only in the home but in a nursing home or a hospice care facility.  Lastly, some short-term hospital visits may be covered.

Understanding how to pay for long term care can be overwhelming. We help seniors and their loved ones plan for the possibility of needing long term care, including how to access and pay for it. If we can be of assistance, please don’t hesitate to reach out.





Surprising Trends in Senior Living

The traditional senior housing market is undergoing a profound change. In 2018 senior housing occupancy fell to an eight-year low, even as the senior population continues to increase, as competition for the younger baby boomer market is ramping up and forcing a change to more traditional independent and assisted living options. Active adult concepts like Margaritaville are addressing this market segment that is turned off by the idea of “senior living.” Atria Senior Living is in a joint venture with Related Companies to build $3 billion in senior luxury housing in major metro areas while overall multifamily development with an intergenerational mix of renters is also fragmenting the traditional senior housing market. Occupancy challenges in traditional independent living and assisted living communities are also finding the retention of a reliable workforce to be a continuing challenge. The truth is that the advent of smart home technology and on-demand services ordered via a smartphone, as well as home care aides,  are enabling apartment and single dwelling living for more extended periods than ever before. Younger seniors tend to want to age in place for as long as possible.

In the skilled nursing arena, Medicare fee-for-service payment reform brings forward three major provisions: the change to the case-mix classification system, the skilled nursing facility Value Based-Purchase Program, and the skilled nursing facility Quality Reporting Program. The case-mix model focuses on the patient’s condition and resulting care needs rather than the number of care services provided to determine Medicare payment. The Value Based-Purchase Program shifts the Medicare payments from volume to value driven. Finally, the skilled nursing facility Quality Reporting Program is designed, through innovation, to provide meaningful, quality measure reporting, a reduction of paperwork, and a lowering of administrative costs.

These and other changes in Medicare are helping to create an influx of capital into the senior care market incentivizing innovative partnerships and cross-continuum service development. Investors and providers will be partnering with Medicare Advantage payors, retail giants, home health, pharmacies, technology, and other provider groups to reinvent and manage the quality and cost of senior care housing, products, and services. This influx of investment capital combined with technology is destined to create fresh ways to approach senior living needs and the services that provide for them. Web-based platforms and data analytics software continue to address the battle for the retention of the health care workforce while Telehealth solutions are enabling elders in rural markets to reach providers and connect with specialists. Voice recognition software is increasingly being integrated into resident units whether they are private homes or pay for service facilities. Partnering opportunities and joint ventures will continue to create new service models that will, in particular, meet the needs of home and community-based services.

When aging in place is no longer a viable strategy a senior is faced with where to go next. Marketing senior housing to the younger baby boomers is changing, and it is data-driven. In particular, the adult Gen X children of these seniors are helping their parents to make informed decisions, and they typically get their information from online sources. Social media has become a tech tool replacing older marketing models of senior housing communities. Operators can tell their stories, address negative reviews, promote positive news items, and create conversations. Gen X adult children will be looking to social media platforms to get real and varied opinion to validate their parents’ choices.

As Medicare Advantage increases its integration in the overall health care system, data collection and its conclusions are more critical than ever. Potential residents will also be addressing concerns about health care data. More data is being gathered than ever before by Centers for Medicaid and Medicare Services (CMS) on hospital readmission rates, the prevalence of falls, and other related health information and consumers will demand to know what these statistics are before entering into a contract with a senior living community.

Seniors are being presented with more living options than ever before and the competition for their dollars will keep providers in the senior living industry highly focused and fiercely competitive. Questions facing seniors include: How and where do you want to live as you age? Are you well informed about the changing options available to you? Do you have a plan in place that is legally documented for the stages of your senior life? We can help. Give us a call and let’s start planning together.