Children with aging parents often find themselves in a challenging and all-too-familiar situation: their once strong and vibrant mother or father begins to decline rapidly, requiring more care than the family can provide. After weeks of hospital visits and medical evaluations, it becomes evident that their parent needs to transition to a long-term care facility.
According to the U.S. Department of Health & Human Services' Administration on Aging, nearly 70% of individuals aged 65 and older will need some form of long-term care during their lifetime, with 20% requiring such care for more than five years.
Navigating the Financial Side of Nursing Home Care
People often don’t think that they’ll need nursing home care, and they assume that Medicare or private health care insurance will cover it, this can be a costly mistake.
In a time of crisis, when a loved one is rapidly declining at home, finances are often the last thing anyone wants to think about. However, despite the difficulty of the situation, ensuring a secure payment source is crucial to getting them into a facility that can provide the necessary care.
We'll explore practical steps, government programs and financial options to ensure your loved ones get the care they need.
Understanding Nursing Homes and Their Costs
Nursing homes, also known as skilled nursing facilities, offer specialized long-term care with an emphasis on medical and health-related services. Unlike assisted living or independent living arrangements, nursing homes focus on providing more intensive medical care. They serve a diverse group of residents, from those needing short-term rehabilitation to individuals requiring long-term care for complex health conditions.
Because of the extensive care they provide, nursing homes are generally more costly than other senior care options. In 2023, the average monthly cost for individuals paying privately (out of pocket) was $13,688 for a shared room and $14,600 for a private room according to Genworth’s Monthly median cost analysis.
Funding Nursing Home Care: The Basics
Given the high costs associated with nursing home care, families often rely on a combination of personal funds and public assistance programs. Generally, seniors and their families use a mix of private payment methods along with government programs like Medicare and Medicaid, supplemental benefits, and insurance. These programs are designed to help older adults from various backgrounds cover the increasing costs of care.Below are some common ways to pay for nursing home care:
Private Pay
How a seniors pay for nursing home care often depends on their financial situation and family dynamics. Some seniors use personal savings, while others may receive financial help from family members. Private payment methods can include various income sources, such as:
- Roth IRA: If you have a Roth IRA, you don’t have to pay taxes on any money withdrawn after age 59 ½ because the money you deposit in this account has already been taxed. Keep in mind, though, that the money must have been in the account for at least five years, and you must meet the age requirement. You can also take out contributions you made to this account before 59 ½ without tax penalties, but you can’t take any of the investment gains.
- Traditional IRA: The rules are different for a traditional IRA, which involves pre-taxed money. When you withdraw money from such an account, both the investment and any gains are taxed at your current income tax rate. There also is a 10% penalty if you withdraw any money before age 59 ½. However, there are some exceptions to this penalty, and one is unreimbursed medical expenses.
- Other investments: Stocks, property or other items may also be used to pay for long-term care. Again, it’s best to check with an accountant or tax expert before you take any action.
- Savings: If you spend your savings on long-term care, some related expenses may be tax-deductible, particularly if you or a spouse or dependent are in the nursing home for medical reasons, such as treatment for or recovery from an illness. However, the total allowable medical expenses must be reduced by 7.5% of your adjusted gross income.
Medicare
Medicare is a federal health insurance program for people aged 65 and older, as well as those with specific disabilities. While Medicare does not cover long-term care services in a nursing home, it does provide coverage for certain aspects of care that you may receive in a nursing home setting.
It’s essential to note that Medicare nursing home coverage is meant to support individuals through rehabilitation and recovery phases, not to finance long-term care expenses in a nursing home.
While on Medicare in a skilled nursing facility, patients are generally responsible for the following costs:
- Days 1–20: Medicare Part A typically covers the full cost of care, so patients pay nothing for their stay during the first 20 days.
- Days 21–100: For days 21 through 100 in a skilled nursing facility, patients are responsible for a daily coinsurance amount, which in 2024 is $204 per day. This amount may change annually. If a patient has Medicaid or another form of supplemental coverage, it may cover the daily coinsurance cost. In Massachusetts, a more affordable but lesser-known option to cover the daily coinsurance is the Medex Sapphire supplemental plan offered by Blue Cross Blue Shield of Massachusetts. With Medex Sapphire, instead of paying $204 per day, the patient is only responsible for a monthly premium of $192.63.
- Days 101 and beyond: After 100 days, Medicare stops covering skilled nursing facility costs, and patients are responsible for all expenses out-of-pocket, unless they have additional coverage
To qualify for Medicare coverage for nursing home care, individuals:
- Must be living at home (not in a nursing home or other long-term care facility)
- A doctor has determined the need for daily skilled care.
- Must need continuous care after a minimum of three days in a hospital
- Must use a facility certified by Medicare as a skilled nursing facility
Medicaid
Medicaid can also help cover nursing home care costs, but it has specific eligibility requirements based on income and assets. Nursing homes must meet state licensing and certification standards, and Medicaid coverage must include room and board.
For those with limited income and resources, Medicaid can also assist in paying Medicare premiums and other out-of-pocket medical expenses. The program varies by state, and local resources such as Area Agencies on Aging can help families determine eligibility and benefits.
MassHealth Eligibility in Massachusetts
To qualify for Medicaid in Massachusetts, you must meet these criteria:
- Income: In 2024, the limit is $2,742 per month for single applicants.
- Assets: Countable assets must not exceed $2,000, excluding your primary residence.
- Residency: You must be a Massachusetts resident and a U.S. citizen or qualified non-citizen.
- Medical Need: Proof of medical necessity for nursing home care is required.
Applying for Medicaid: Gather documents like income proof, ID, asset statements, and residency proof. Applications are available online or at a MassHealth Enrollment Center. The review process can take up to 45 days, and you can track it online.
Medicaid Coverage for Nursing Homes: Medicaid covers accommodation, meals, nursing care, rehabilitation, and medication management. Some services, like social activities or transportation, may not be covered.
Protecting Spousal Assets: The Community Spouse Resource Allowance (CSRA) allows a spouse to retain up to $154,100 in assets.
Asset Protection and Recovery: Consider options like trusts or spend-down strategies to protect assets. Be aware that MassHealth may recover costs from a beneficiary's estate after death, though certain exemptions apply.
If Your Application Is Denied: You have 90 days to appeal a denial, with the option of legal assistance for your hearing.
VA Benefits
Veterans may be eligible for several benefits to help cover nursing home care costs. The application process can be complex, so working with a Veterans Service Organization (VSO) or local support group is recommended. Common benefits include the Aid and Attendance benefit and the Housebound allowance, which provide support for in-home care or services that enhance a veteran's quality of life. Veterans with service-connected disabilities may also qualify for additional compensation.
Long-Term Care Insurance
Long-term care insurance, also known as nursing home insurance, can help cover a wide range of senior care expenses, from nursing homes to in-home care. Eligibility typically begins when an individual can no longer perform two or more daily living activities independently, such as bathing, dressing, or eating.
The cost of long-term care insurance varies based on age, health, and the amount of coverage. For example, in 2022, the average annual premium for a 55-year-old individual purchasing a $165,000 policy ranged from $950 for a male to $2,080 for a married couple.
Conclusion
Paying for nursing home care often involves a mix of private funds, government programs, and insurance. The best option depends on the individual’s unique circumstances and needs. Once you've squared away how you plan to pay for nursing home care, initiate your research independently by utilizing resources such as View All Options (VAO), a local nursing home referral platform for nursing homes in Massachusetts .
