Affording Long-Term Care in a Nursing Home

Although Medicaid may make expensive nursing-home care possible, navigating admission to a relatively desirable Medicaid-enrolled nursing home is not always easy.

According to a 2021 cost of care survey by Genworth, $8,564.00 is the median monthly cost of a semi-private room in a Richmond-area nursing home. As you move closer to Washington, D.C. the average cost is $10,494.00.

Most nursing homes expect residents to pay out-of-pocket for their own care upon entry to the facility. Those individuals who cannot afford to pay privately tend to find placement in facilities with lower quality ratings. And at the steep price of over $100,000 per year—and rising—most families eventually need help paying for long-term care.

Medicaid is the primary method for covering the costs of nursing-home care in Virginia. However, Medicaid places strict financial parameters on an applicant’s income and resources, limiting the latter to a maximum of just $2,000.00. This predicament leaves families stuck between a rock and a hard place: not enough money to afford a protracted period of nursing-home care, but too much money to qualify for Medicaid. What next?

This critical juncture is where an elder law attorney’s assistance proves to be invaluable. Spend-down strategies, precise calculations and timing of expenditures, and document collection and reporting are the elder law attorney’s specialties. Working with an expert offers families peace of mind through a complicated, rigid process. Most importantly, an attorney can help families save thousands of dollars by ensuring Medicaid approves the application on the first try.

An often-successful method for obtaining a bed in a choice Medicaid-enrolled nursing home is to pay for care out-of-pocket (“private pay”) until the month when a resident’s resources are spent down to the Medicaid maximum of $2,000.00. (To search for a Medicaid-enrolled long-term facility in your area, use Medicare’s tool for comparing nursing homes, making sure to use the filter “Accepts Medicaid” under “More filters.”) A resident’s monthly nursing-home payment is part of his or her “spend down,” as is payment for other goods and services for the resident, such as clothing, supplemental health insurance premiums, and funeral/burial plans.

A Medicaid application can be filed during the month in which the resident’s resources have been sufficiently exhausted. But note, the timing must be precise, so that the resident is neither “over-resourced” for Medicaid nor unable to pay that month’s facility fees. Upon approval, the resident continues to receive the same care at the facility. A Medicaid-enrolled facility cannot discharge or discriminate against a resident for utilizing Medicaid to pay for care.

In some instances, if a resident lacks the funds to pay for his or her own care, the resident’s family may wish to pay a nursing home. However, this is a risky move, as the family is not entitled to reimbursement once/if the resident transitions to Medicaid. Additionally, Medicaid may balk at approving an application for a resident who has received financial assistance from a family member.

Finally, although Medicare does not pay for nursing-home care over a long period of time, it may help open the door to a facility for an individual who then transitions to Medicaid. Medicare provides nursing-home coverage for up to 100 days of “skilled nursing care” per illness. Along with meeting other criteria, a patient must enter the nursing home no more than 30 days after a hospital stay that lasted for at least three days (not counting the day of discharge). The care provided in the nursing home must also be for the same condition that caused the hospitalization (or a condition medically related to it). In addition, the patient must receive a “skilled” level of care in the nursing facility that cannot be provided at home or on an outpatient basis. And lastly, Medicare covers care only for people who are likely to recover from their ailments. If an individual meets all these conditions, it is possible to enter a nursing home and immediately apply for Medicaid while Medicare pays in the meantime.

The crossroads of long-term care and Medicaid coverage is complicated and having an expert by your side is invaluable. The elder law team at ThompsonMcMullan has the experience to guide you through the application and ensure an informed and streamlined process.