Choosing and Paying for a Long-Term Care Facility

By Attorney Joseph L. Matthews, Nolo

Understand the different types of long-term care facilities — and how planning ahead can help you choose the best option.

Despite significant recent growth in home care and alternative seniors' residences, nearly one of every two women and one of four men over age 65 will enter a long-term care facility (a.k.a. "nursing home") at some time in their lives. Many nursing facility stays are short ones, to allow a senior to recuperate from an illness, injury, or surgery. But many other stays are extended: More than a third of all nursing facility stays last more than a year, and many last three years or more.

Many people would prefer to remain outside a care facility. However, some seniors, because of their condition, circumstances, or the unavailability of in-home services or affordable assisted living residences, can receive adequate care only in a residential care facility.

Most residents in long-term care facilities cannot function without 24-hour monitoring, extensive personal assistance, and nursing care because of illness or physical or mental limitations. Other residents are in relatively good physical and mental health, but too frail to live alone at home. If they had more family or resources, many of these people might be able to make do with home care or living in an assisted living facility. For lack of an alternative, they become long-term care facility residents.

Choosing the Appropriate Level of Care

There is a great range in the levels of care available in long-term residential facilities. Care ranges from intensive 24-hour care for the seriously ill (which is called skilled nursing care) to long-term personal assistance and health monitoring with very little active nursing (often called custodial care). Some facilities provide only one level of care, while others provide several levels at the same location.

Skilled nursing facilities provide short-term, intensive medical care and monitoring for people recovering from acute illness or injury. Other facilities — called nursing homes, board and care homes, sheltered care homes, or something similar — provide custodial care, long-term room and board, and 24-hour assistance with personal care and other health care monitoring, but not intensive medical treatment or daily nursing.

Your task is to find a good and affordable nursing facility that provides not just care, but the right type of care. For someone with severe physical or mental limitations, it is crucial to find a facility that provides the kind of attention and care that meets the individual's specific needs. For people who need little or no actual nursing care, the task is to find a facility that provides physical, mental, and social stimulation rather than merely bed and board.

Hospital-Based Skilled Nursing Facilities

Hospital-based skilled nursing facilities, also known as extended care facilities, are departments within hospitals. They provide the highest levels of medical and nursing care, including 24-hour monitoring and intensive rehabilitative therapies. They are intended to follow acute hospital care due to serious illness, injury, or surgery.

Unlike other nursing facilities, hospital-based facilities are not for permanent residence, but for a short-term stay until a patient can be sent home or maintained elsewhere. Hospital-based facilities are very expensive ($300 to $500 per day), but the average stay is generally short (usually a matter of days or weeks) and, for those who qualify, is usually covered by Medicare or private insurance.

Skilled Nursing Facilities

Nonhospital-based skilled nursing facilities (SNFs) provide a relatively high level of nursing and other medical care, as well as personal care and assistance, for people whose illnesses or impairments require close monitoring.

Around-the-clock nursing is available from licensed vocational or practical nurses, with at least one supervising registered nurse on duty at all times. In addition to nursing, most other prescribed medical services can be provided, including various rehabilitative therapies. An SNF is almost always for short-term recovery from a serious illness, injury, or surgery that required hospitalization. A few people may spend months in an SNF, but most stays last only days or weeks.

The cost of SNF care ranges from $200 to $500 per day. Medicare, Medicaid, and private insurance will pay for SNF care, but only up to specific coverage limits.

Intermediate Care Facilities

Intermediate care facilities (ICFs) provide less nursing and other medical care than SNFs. ICFs are for long-term residents with chronic illnesses or impairments, whose conditions are not as acute as those of SNF residents. Residents in an ICF are usually ambulatory, for example.

Staff is geared as much toward personal care and assistance as to medical care, although there is always a licensed vocational or practical nurse on duty. ICFs generally care for people who need a long recovery period from serious illness, injury, or surgery, but who no longer need the level of nursing care and high-tech monitoring that an SNF provides.

Costs range from $150 to $400 per day. Medicare does not cover ICFs and private insurance coverage is rare, usually requiring prior approval. Medicaid, however, may cover much of the cost of ICF care.

Very few facilities are set up to be ICFs alone; most are part of an SNF or a custodial care facility.

Custodial Care Facilities

Custodial care facilities provide services that are often lumped together under the heading of custodial care: personal assistance and low-level nursing care, but not intensive medical care. Sometimes referred to as rest homes or nursing homes, these custodial care facilities (CCFs) are considerably less expensive than SNFs or ICFs and, in addition to monitoring residents' physical conditions, they provide social, educational, and recreational activities as well as organized exercise. Because CCFs do not provide extensive medical care, they are appropriate for people whose physical and mental conditions do not require constant attention or intervention.

Because of the limited medical and nursing care they offer, CCFs cost about $100 to $250 per day, considerably less than SNFs or ICFs. However, most residents stay in a CCF for a lengthy period of time, at a cost of $30,000 to $150,000 per year. CCFs come in all shapes and sizes, from five-bed facilities in converted private homes to 100-bed facilities with large common areas and extensive social, physical, and educational activities.

Paying for Long-Term Care

Your toughest challenge may be footing the bill. Long-term care facilities of all levels are very expensive, but depending on the type of care you need and the type of insurance you have, you may get some help covering the cost. Skilled nursing facilities run between $300 and $500 per day, although stays there are relatively short and Medicare or private health insurance will usually pick up much of the tab.

Long-term custodial care — the kind that may last for years — costs between $3,000 and $10,000 per month. Neither Medicare nor medigap private insurance supplements pay any of the cost of custodial care. Medicaid will pay the full cost of custodial nursing facility care for people with very low income and few assets. Some veterans may also find coverage for custodial care through the Veterans Administration. Long-term care insurance, for those who have it, may also cover some of the cost of custodial care.

If a facility is certified by the federal government, it may be more affordable. The Healthcare Financing Administration has certified about 85% of all nursing facilities; HCFA certification means that the facility is eligible to receive Medicare and Medicaid payments. Some facilities do not meet HCFA standards. Other facilities charge high prices and simply do not want to accept residents who depend on Medicaid payments.

Unless you have an unlimited supply of money to pay for long-term care, make sure that any facility you consider is certified. Certification means that the facility meets some certain minimum health, safety, and care standards. And certification also means that if someday you should need and qualify for Medicaid coverage for your stay, you will be able to receive it without having to move to a different facility.

Finding a Good Long-Term Care Facility

Unfortunately, as we've all heard on the news, some facilities provide substandard living conditions and even a dangerous lack of care. Still others give basic care that meets technical health standards but offers little else, and have an atmosphere that is debilitating or demoralizing to the residents.

However, there are also excellent long-term care facilities that provide high-quality care while assisting residents to maintain active lives with a full measure of dignity. Because there are many levels and types of nursing and personal care, your task is to find a good, affordable facility that is right for you.

Your best bet is to ask around for referrals. Here are some good sources of information and referrals:

Hospital discharge planner. The discharge planner will often be available for advice if you are going straight from a hospital to a long-term care facility.

Your doctor. Ask your doctor about personal experience he or she may have had with facilities in your area.

Organizations focusing on specific illness. Check with organizations that focus on your particular illness or disability, such as the American Heart Association, the American Cancer Society, the American Diabetes Association, or the Alzheimer's Disease Foundation.

National long-term care organizations. A number of private organizations such as American Association of Homes for the Aging specialize in long-term care and give referrals to local facilities.

Government agencies. You can often get targeted referrals from the federal Area Agencies on Aging, or from state and local agencies found through Senior Referral and Information numbers in the white pages of the phone book or your local county social services or family services agency.

Church, ethnic, or fraternal organizations. Ask about long-term care facilities that members have used successfully or that are operated by or affiliated with the church or organization.

Relatives, friends, and neighbors. They may have had experience with a long-term care facility or know someone who has, and are often your best sources of information.

Planning Ahead

If at all possible, your search for a nursing facility should not be a hurried, emergency procedure. As soon as you begin to see that your current living arrangements may become insufficient and neither home care nor assisted living will provide the care or monitoring you need, begin planning.

Finding out which long-term care facility might be the best in a particular area can take time. Many good ones operate at full capacity, so they may not be able to accept a new resident at short notice.

You must also consider how you will pay the facility. You'll have to calculate family assets and income, along with reverse mortgages and the amounts that might be contributed byMedicare, veterans' benefits, and any long-term care insurance. Medicaid coverage may be available for people with low income and few assets other than a home. It helps to understand Medicaid rules ahead of time, both perhaps to save some assets by advance planning and to make sure that Medicaid will cover care in a particular facility if and when the resident qualifies.