Hale Law Blog

Where to Turn When Life Outpaces the Body – Assisted Living vs. Skilled Nursing

The miracle medical breakthroughs of the 20th century (I limit these breakthroughs to the 20th century since any breakthrough made in the current century is still pending approval by the FDA) have made living longer, healthier lives possible. It has also made living longer unhealthier lives possible. One-hundred years ago our minds would falter and our bodies were soon to follow. Today, our bodies can go on living long after our minds have wandered away. The more frightening converse is also true – a still vibrant mind can be held interminably captive by an immobile body.

What choices do we have when we can no longer care for a loved one whose life has outpaced their health? While there are several long-term care alternatives, the two most prevalent are skilled nursing facilities and assisted living communities.

For most, the long-term care continuum meanders along a path from home health to assisted living and then finally to skilled nursing. Assisted living facilities gained popularity in the 1980s as an attractive middle ground. These communities generally offer private rooms, meals, housekeeping, help with medications, and assistance with
basic activities of daily living (“ADLs”). And because the cost of room and board averages around $1,000 less than similarly situated skilled nursing facilities, many families attempt to keep an aging loved one in assisted living for longer than medically advisable. However, because services above and beyond basic room and board are charged a la carte, residents in declining health may find themselves paying more than they would for more appropriate skilled nursing care.

The history of nursing homes in America is much more complex. The modern day skilled nursing facility arose out of the desire to phase out the traditional “almshouses” and “poor farms” of the late 19th and early 20th century. The conditions of these poorhouses were abhorrent, with the elderly living with other impoverished members of the population, including children and the disturbed. In 1935, the Social Security Act unintentionally sparked the rise of the nursing home industry by providing a fixed, steady income to the elderly. For the chronically ill, this income allowed families to consistently pay for nursing care. However, it wasn’t until the introduction of public financing
through Medicare and Medicaid in the 1960s that nursing homes became at once both profitable and affordable.

As the names imply, today’s skilled nursing facilities offer a level of care substantially higher than assisted living communities. Nursing homes are institutional care settings where all medical and personal needs are met. Residents receive physical, social, and psychological care, assistance with prescription drugs, activities of daily living, personal care and hygiene. Length of stay often ranges from temporary rehabilitative therapy to long-term care to hospice care.

Although frequently thought of as temporary destinations for the final months of life, many skilled nursing residents thrive in these facilities for a number of years. As such, it is important to understand the public payment options available to both skilled nursing and assisted living facilities.

Veterans Affairs Aid and Attendance Pension is a potential payment source for both assisted living and nursing homes. However, while a married veteran can receive up to $1,949 in supplemental income ($1,644 for a single veteran), it does not guarantee that the cost of all services will be met. VA Aid and Attendance is a program best suited for those residents with monthly income greater than $3,000.

For residents with lower income, Medicaid typically provides a much greater monthly benefit. For example, a single veteran receiving $1,000 per month in income could receive a VA Aid and Attendance benefit of $1,644 per month. This allows him only a total of $2,644 to meet a $4,000 obligation to the facility. On the other hand, under Medicaid, the same individual is responsible for a co-pay to the nursing home of no more than $940 per month, while Medicaid pays the entire remaining balance ($3,060). In this instance, the Medicaid program provides a benefit almost double that of the VA.

Next to level of care, the question of which public payment option provides the greatest benefit is the most important consideration in choosing between assisted living and skilled nursing facilities. While VA Aid and Attendance is available to both facility types, Medicaid is unavailable in assisted living communities except in rare circumstances.

The availability of Medicaid makes all the difference. If your family member would benefit from the higher level of care and therapy options of a skilled nursing facility, it is crucial to inquire about Medicaid eligibility. Once Medicaid eligibility is established, the resident can almost always receive a more complete level of care at a fraction of the cost. In many instances, Medicaid can make skilled nursing free to the resident. And in no instance will the cost of care under Medicaid ever be greater than the resident’s personal income. Moreover, Medicaid eligibility planning can redirect the resident’s accumulated assets in a way that benefits himself and his loved ones.

Jacob A. Hale is an Elder Law and Estate Planning attorney at The Hale Law Firm, P.C. in Waxahachie. To learn more about this topic, please visit www.TheHaleLawFirm.com or email the author at Jacob@TheHaleLawFirm.com

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