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What Exactly is Long Term Care?
The term, “long-term care”, sometimes abbreviated as LTC, can be quite vague, and many people are uncertain as to exactly what this means. To begin, there are specific activities that one must do on a daily basis to take care of oneself. These activities are bathing, dressing, grooming, using the toilet, mobility (the ability to move about), transferring (i.e., moving from a bed to a wheelchair), and eating. These activities are commonly called Activities of Daily Living (ADLs). If one cannot complete these activities without assistance, they are unable to live independently. In very simple terms, long-term care is assistance for persons who can no longer perform these basic day-to-day activities on their own. Relevant to the elderly, the need for care can be due to the natural process of aging, a sickness, or the progression of Alzheimer’s, Parkinson’s disease, or another type of dementia.
Medicaid, a federal and state health care program for financially needy persons, offers a further definition of LTC. Medicaid defines it as assistance for persons who have chronic, ongoing illnesses or disabilities, and because of these conditions, care equivalent to that which is provided in a nursing home is required. “Nursing Facility Level of Care” is not federally defined, and each state is left to define what it means for its state and long-term care Medicaid programs. Therefore, the criteria for this level of care is not consistent across states. Furthermore, many states now offer personal care assistance via their Regular State Plan Medicaid program, which via most pathways, allows for a more lenient care requirement.
In addition to non-medical care, long-term care also assists persons with health related issues. However, for the most part, long-term care is non-medical in nature. The variety of services and care assistance that make up long-term care, and the settings in which it can be provided, is quite large.
Most elderly persons prefer to age in their homes, which makes in-home care (in one’s home or the home of a relative), a popular form of long-term care. Via this type of care, a variety of in-home care services and supports are provided to help seniors live as independently as possible, while also helping to keep them safe. Most common is personal care assistance, also called custodial care or attendant care, provided by home care aides or personal care attendants. Assistance includes helping seniors with bathing, putting on / taking off clothes, combing their hair, brushing their teeth, going to the bathroom, eating meals, moving about the house, and transitioning from a seated to standing position, etc.
Attendant care may also include assistance with activities that are not vital to everyday living, but are required to live independently. These activities, called Instrumental Activities of Daily Living (IADLs), include preparation of meals, laundry, light housecleaning, shopping for essentials, medication management, and non-medical transportation. This type of care might also be called homemaker services or companion care services.
Home health care, for persons who need minimal assistance with health related tasks, is also a type of in-home long-term care. It is provided by medical professionals and may include assistance with insulin injections, checking vital signs, and changing bandages. Home health aides also provide personal care assistance.
While one may not think of personal emergency response systems (medical alerts) as a type of long-term care, it is a long-term care service that assists the elderly in continuing to live independently. In the event of an accident, such as a fall, an elderly individual can call for help. Some systems are automated and can detect a fall, automatically calling for assistance. In addition, some are able to monitor the location of the senior, which is particularly beneficial for persons with Alzheimer’s or another related dementia who have a tendency to wander.
Adult Day Care
Adult day care, sometimes called adult day health care, provides daytime supervision, personal care assistance, meals and snacks, and recreational and therapeutic activities, in a community setting. Limited medical care and therapies, such as physical, occupational, and speech, may also be provided, and some facilities may specialize in Alzheimer’s or dementia care. This type of long-term care is particularly relevant for family caregivers who need a break from their caregiving duties (this is called respite care) or who have to work during the day. Some adult day care centers provide transportation to and from the facility.
Adult Foster Care
Adult foster care homes provide a home-like setting for elderly individuals who require non-medical care and cannot live independently. Also called board and care homes, adult family care, and adult family living, the senior lives in the same home as their caregiver. Room and board, supervision, companionship, housekeeping, and assistance with daily living activities, such as bathing, dressing, eating, mobility, transitioning, and toiletry may be provided. An adult foster care home may house and care for only one senior or there may be multiple seniors in the same home. Generally speaking, the maximum number is 4, but this number may vary slightly based on the state. Some states allow a relative, including an adult child, to serve as the “foster home” provider.
Assisted living is a type of residential care for seniors who can no longer live independently in their homes, but do not yet require nursing home care. Stated differently, persons do not require 24 / 7 care. Along with room and board, around the clock supervision, personal care assistance, housekeeping and laundry, medication management, social and recreational activities, service coordination, and transportation assistance may be provided. In addition to frail, elderly persons, individuals with early to mid-stage dementia may be appropriate candidates for assisted living. It is common for assisted living residences to offer various levels of care and for the cost to be higher for persons who require a greater level of care.
Whether or not assisted living is considered long-term care is a subject of debate. The answer lies in the amount of care the assisted living resident requires and who is paying for it. More on Medicaid’s coverage of assisted living.
Memory (Alzheimer’s Residential) Care
Memory care, also called Alzheimer’s care or memory care units, is specifically intended for persons with Alzheimer’s disease or another form of dementia. This type of care may be provided in units within an assisted living residence or nursing home facility or in a standalone memory care residence. Since the focus is on dementia care, the units / residences are designed with this disease in mind. As an example, dementia patients commonly wander and a memory care unit may be designed to allow wandering without the stress of coming to a dead end. In addition, the staff are trained specifically in working with persons with dementia and cognitive issues. With Alzheimer’s care, there is also a higher level of care and security than with traditional assisted living, and activities are geared towards persons with dementia. Care and supervision are available 24-hours / day. It is well-agreed upon that memory care is considered long-term care.
Nursing Home Care
Nursing home residences, also called skilled nursing facilities, offer a higher level of care than do assisted living residences. In fact, the only place in which one can receive more extensive care is in a hospital. In addition to a room (shared or private) and meals, 24-hour medical care and supervision is provided. Other services may include skilled nursing care, personal care assistance, medication management, rehabilitation therapies (occupational, physical, speech), and social and recreational activities.
Short-term nursing home care, for example, for the purposes of rehabilitation after a stroke or an accident, is not considered long-term care.
What Long-Term Care is Not?
Long Term Care Insurance
There is quite a bit of confusion surrounding long-term care insurance. Many people mistakenly confuse Medicaid with long-term care insurance, and therefore, incorrectly think that they can rely on Medicaid to cover their long-term care needs. Remember, Medicaid is a program for persons that have a financial need. Many persons also, incorrectly, believe that Medicare will cover their long-term care needs. Further adding to the confusion, long-term care insurance is sometimes simply called “long-term care”.
A long-term care insurance policy provides financial assistance specifically for long-term care for persons who have a persistent, ongoing health condition, a disability, or an illness that worsens over time, like Parkinson’s disease, Lewy Body dementia, and Alzheimer’s. Long-term care insurance may cover personal care assistance, hospice care, durable medical equipment, and home modifications. To be very clear, long-term care insurance is not a need based program. It is an insurance policy that one purchases, and almost always purchases, before the need for care has arisen. This type of insurance policy, though often quite costly, can be extremely beneficial, as regular health insurance plans do not cover long-term care; they won’t pay for needs that aren’t medical related. Long-term care insurance services can be provided in a number of settings, which includes one’s home, adult day care, adult foster care, assisted living, and nursing homes. Without long-term care insurance, persons either have to pay privately for care or qualify for a need based program that provides long-term care, such as Medicaid.
Short Term Care / Rehabilitation
Short-term care is generally defined as care that is required for a couple of days to a few months. This includes rehabilitation and care following an injury or accident, recovery from surgery, and care while sick. Like long-term care, short-term care can be provided in a variety of settings. This includes a hospital, an assisted living facility, a nursing home residence, and one’s home. What sets short-term care apart from long-term care is that the condition is not chronic. Rather, the individual will get better and be able to function independently again, while persons who require long-term care will likely require care for the rest of their lives.
Who Pays for Long-Term Care?
In addition to long-term care insurance, there are other funding sources that will assist with covering the cost of long-term care. To be clear, regular private health insurance plans will not cover long-term care costs.
As mentioned previously, Medicaid is a state and federal healthcare program, and via this program, long-term care and supports are funded. This is a need-based program, which means seniors must have limited income and assets. There must also be a functional need for such care. Eligibility requirements for Medicaid long-term care vary based on the state, and even within the same state, the eligibility requirements may vary based on the program for which one is applying. See eligibility requirements by state here.
Medicaid long-term care was originally provided only in nursing homes. All states are required to cover the cost of nursing home care for persons who meet the eligibility requirements. This is because it is an entitlement program. This type of care is often called Institutionalization Medicaid. With Medicaid nursing home care, the recipient must reside in a facility that accepts Medicaid as a form of payment, as not all facilities do.
HCBS Medicaid Waivers
Overtime, states implemented Home and Community Based Services (HCBS) Medicaid Waivers, also called 1915(c) Waivers, to provide long-term care services and supports in the community instead of only in nursing homes. Not only did this prove to be more cost efficient for states than nursing home coverage, but most seniors prefer to grow old in their own homes. Unlike the state Medicaid program through which nursing home care is provided, HCBS Waivers are not entitlement programs. Waivers have a specific number of participant enrollment slots, and once they have been filled, a waitlist forms. They are also limited to specific groups of people, such as persons over 65 years old, persons with Alzheimer’s disease and related dementias, and persons with disabilities between the ages of 19 and 64. Worth noting, the program may only be available in specific geographic locations within a state. Examples of services and supports that may be provided via HCBS Medicaid Waivers are adult day care, adult foster care, durable medical equipment, home health aides, personal care attendants, home and vehicle modifications, respite care, chore and homemaker services, and personal emergency response systems.
HCBS Waivers will not pay for room and board in adult foster care, assisted living, or memory care. Via some Waivers, personal care assistance and other supportive services may be available in this setting. Learn more here.
Regular State Plan
To provide access to home and community based services to more people and to prevent the need for costlier services, some states also began offering long term-care through their Regular State Plan Medicaid program. Via the State Plan, Medicaid will not deny eligible applicants services, given they have met all the eligibility requirements. As with Institutionalization Medicaid, there is never a waitlist for benefits. Most, but not all states, currently offer in-home personal care assistance (help with bathing, grooming, dressing and undressing, and toiletry) under their State Plan Medicaid program.
Community First Choice (CFC), also called the 1915(k) State Plan Option, is another option through a state’s Regular Medicaid program that allows states to extend attendant care services to eligible applicants. This may include personal care assistance, light housecleaning, laundry, grocery shopping, meal preparation, and medication monitoring. For CFC, an applicant must require the level of care provided in a nursing home.
The 1915(i) Home and Community Based Services (HCBS) State Plan Option is yet another option. This allows states to offer a much wider array of long-term care benefits than the other two options. 1915(i) HCBS allows states the flexibility of offering much the same services as HCBS Medicaid Waivers, but applicants do not have to demonstrate as high a functional need. With this option, only specific groups, such as frail elderly individuals, may be eligible. Available benefits may include assistance with daily living activities, case management, assistive technology, non-medical transportation, adult day health care, and respite care.
Medicare (Does Not)
Medicare, also called Original Medicare, will not cover the cost of long-term care. Medicare is a federal program that provides health coverage for persons who are 65 years old and older or disabled. Unlike Medicaid, Medicare does not have income and asset limits.
Medicare (Part A) will pay for short-term skilled nursing home care in a Medicare approved facility, but this is very limited. The program will only pay up to 100 days, per illness, for persons who were hospitalized a minimum of 3 days. They must be admitted to a nursing home within 30 days of hospitalization. Nursing home care must be for the same illness as for hospitalization and prescribed by a physician. It must be thought that the individual will recover and ongoing care will not be required. If improvement stops and it is clear the individual is not going to improve further, Medicare will no longer pay for care during the 100 day limit.
In addition to short-term skilled nursing care, Medicare will also pay for home health care (rehabilitation and skilled nursing) on a short-term basis (irregular care over a period of not more than 21 days). This type of care does not cover assistance with daily living activities, such as bathing, eating, and dressing. However, one beneficial long-term care support is partial payment of durable medical equipment, such as wheelchairs and walkers.
The Exceptions: Medicare PACE and Medicare Advantage
Medicare PACE (Program of All-Inclusive Care for the Elderly), or based on the state, sometimes called LIFE (Living Independence for the Elderly), provides long-term care services for persons who would require nursing home care without assistance. This may include persons with Alzheimer’s disease. Long-term care may include in-home personal care assistance, adult day health care, skilled nursing, chore services, preparation of meals, respite care, and durable medical equipment, such as wheelchairs, hospital beds, and oxygen. PACE / LIFE participants may be enrolled in either Medicare or Medicaid, or both, which is called dual eligible. There is also an option to privately pay for services for persons who are not enrolled in either program. Unfortunately, PACE / LIFE is not available nationwide, nor is it available in all areas of a state that offer the program. See if there is PACE / LIFE in the area in which you reside here.
Medicare Advantage (MA) plans are offered through private insurance companies and provide a way for persons to receive their Medicare benefits. Extra benefits that are not available via Original Medicare are generally provided. These might include dental, hearing, vision, and gym memberships. In 2019, some Medicare Advantage plans started offering long-term care services and supports, and in 2020, the list of possible LTC benefits expanded. These options may include adult day care, in-home assistance with daily living activities, home modifications, respite care, meal delivery, and non-emergency transportation. Not all MA plans offer long-term care benefits.
Department of Veterans Affairs (VA)
Long-term care is also available via the VA for veterans who have VA health insurance and meet the eligibility requirements for such care. Long-term care benefits may include adult day health care, in-home personal care assistance, homemaker and home health aides, and respite care. The VA may also cover the cost of nursing home care, such as in State Veterans Homes or Community Nursing Homes. More on VA nursing home care. While the VA will not pay for room and board in assisted living, they may pay for some care services.
Worth mentioning, there is an Aid & Attendance Pension for veterans that require assistance with daily living activities. This pension provides additional monthly cash benefits above and beyond the basic VA pension. These funds can then be used for in-home care, adult day care, adult foster care, assisted living, home modifications, or nursing home care. There is also a Housebound Pension for veterans who, for the most part, are confined to their homes. This extra monetary benefit can also be used to pay for long-term care services and supports.
Many states also offer non-Medicaid programs. These programs assist low income elderly persons in maintaining their independence at home or provides additional supportive services to assist unpaid family caregivers. Some states also have prescription assistance programs, which don’t pay for long term care, but can help offset one’s expenses so that more funds are available to pay for care. In addition, there is the Older Americans Act, which makes supportive services, such as home delivered meals, transportation, in-home personal care assistance, and homemaker assistance, available to seniors to promote independent living. These services are made available through one’s local Area Agency on Aging office.
Common Misperceptions about Long Term Care
There are several common misperceptions about long-term care. Persons often mistakenly assume they already have long-term care coverage, whether it be through their regular health care plan, Medicaid, or Medicare. Persons also sometimes wrongly believe they won’t require long-term care or their family will provide any needed care. With the high cost of long-term care, it is important to plan for care needs in advance. If a need for Medicaid long-term care is a likely possibility, it is extremely helpful to discuss this with an experienced Medicaid Planner. These professionals can help persons to plan for future needs and can assist in restructuring finances so that one will be eligible for Medicaid assistance in the future. Find a professional Planner here.