ContentsWhat is a nursing home? What are the eligibility requirements? Are nursing home facilities regulated by Federal policies? Services in a nursing home facility The costs for nursing home care Who pays for nursing home care? Medicaid and Medicare How to select the right nursing home Nursing Homes - Frequently Asked Questions
According to the Centers for Disease Control and Prevention (CDC), there are 15,600 nursing homes in the U.S. serving over 1.4 million residents with 1.7 million beds. Although declining in numbers in the early 2000's, nursing homes are on the rise again in American, and for good reason.
Nursing homes account for the primary care of 10 percent of all Americans over the age of 85. Moreover, it is predicted that 40 percent of those currently over the age of 65 will enter a nursing home at some point in their lives.
Given the importance nursing homes in our and our loved one's future, understanding what exactly a nursing home is, how it operates, and what the regulations mean for you and your family is absolutely critical.
What is a nursing home?
A nursing home is a residence for seniors who don't necessarily need ongoing medical care like in a hospital or skilled nursing facility, but can't live independently because they need custodial help with daily non-medical activities, also known as the “activities of daily living”.
Nursing homes can provide this non-medical custodial care, as there are employees on-site 24 hours a day. Some nursing homes have medical care, such as units that help those with Alzheimer's disease or on-site nurses for non-emergency medical treatment.
The key point about nursing homes is that they are for anyone who may need 24-hour care that is not necessarily medical in nature. Nursing home care is provided by licensed facilities. Residents receive help with many daily non-medical living activities, such as:
- Transferring to or from bed or chair
- Using the toilet
- Caring for incontinence
- Preparing and cleaning up after meals
- Managing money
- Taking medication
- Shopping for groceries or clothes
- Using the telephone or other communication devices
- Caring for pets
- Responding to emergency alerts such as fire alarms
And the list goes on. There is a major difference between a nursing home and skilled nursing facility, in which the latter performs typically shorter-term specialized and licensed medical care following a hospital visit, whereas a nursing home is more focused on long-term custodial care where resident need daily non-medical assistance.
According to the AARP, 80 percent of nursing home residents required help with 4-5 activities of daily living, including bed mobility, transferring, dressing, eating, and toileting.
What are the eligibility requirements?
To be admitted to a nursing home, there is required information you must provide to the facility. It's important to be as prepared as possible to the process is completed as seamlessly as possible.
The facility you apply for will complete a physical assessment on you and ask you if you have any medical condition that restricts your daily activities. If you do, you will likely be eligible for nursing care.
However, depending on the facility, they may not have certain capabilities to meet certain levels of care. For example, not all nursing facilities are set up to take patients that need constant health care such residents that are on a ventilator or other life extending devices. If they have dementia or Alzheimer's, that particular nursing home may not have a memory care or Alzheimer's unit.
In fact, almost half of nursing home residents across the United States have dementia according to studies, so most nursing home can accommodate this disease.
The next thing is depending on how you or the resident are planning to pay, the nursing home will need to have availability. For example, if you are on Medicaid, there may only be a certain number of Medicaid Certified beds.
Nursing homes will also require all of your medical information, history, and medication, your Medicare or Medicaid benefits, and family member contact details.
If your loved one does not qualify for skilled nursing care, they may be a better candidate for another form of senior living, such as an assisted living facility, care homes in the area or a private duty home care provider. Medicaid services are typically limited for assisted living facilities compared to nursing home care.
Are nursing home facilities regulated by Federal policies?
In 1987, Congress passed a major reform of nursing home regulation contained in the Omnibus Budget Reconciliation Act (OBRA). This piece of legislation mandated surveys of all nursing home residents across the United States. Deficiencies found would be corrected by the facility, or they would face penalties.
These state survey agencies license nursing homes for the state, and certify that they meet participatory conditions for Medicare and Medicaid.
Further federal regulations for long-term care facilities are covered under The Older Americans Act from 1965, updated in 2016. This legislation requires each state to have an Ombudsman office which is responsible for:
- Carrying out certain functions on behalf of residents transitioning from a long-term care facility to a home care setting
- Identify, investigate, and resolve complaints of any residents of a long-term care facility, including residents with limited or no decision-making capacity and who have no known legal representative, taking specified actions with respect to residents unable to communicate consent
The state survey agency is also mandated to promote the submission of data on elder abuse, neglect, and exploitation. The inspection findings from the national surveys are reported on the medicare.gov website under the “Nursing Home Compare” tool, and a star rating is applied to each facility.
Services in a nursing home facility
Nursing home facilities provide you and your loved ones custodial care in the form of daily living from Certified Nursing Assistants. This includes medication scheduling, meals, bathing, mobility, and much more.
According to research, nursing home residents receive on average 3.7 hours of direct care per
day. This also includes an average of 1.4 hours from a registered nurse (RN).
Nursing home staff encourages residents to take meals in the general dining room if medically able. It is good for your mental health to get out of your room and meet other residents so you do not feel isolated. Remaining social is an important consideration for an aging population. The movement also helps strengthen your physical abilities.
Most nursing home will have daily activities, both for you in your room or in a group setting, typically directed by an Activity Director, other staff, and volunteers.
For residents that are physically able to get out and about, most nursing homes have planned activity tripswithin the area which gets residents out for some fresh air and fun. Facilities will usually have a van to transport residents with staff to help on excursions.
Nursing homes also usually have church serviceon Sunday's that residents may attend. Further, some nursing homes will bring in outside church groups to come in for services.
Community groups often play a role in local nursing homes activities. These include church groups, school groups, youth groups like the Boy or Girl Scouts, who come to entertain and interact with residents.
If medically required, residents may be eligible for physical or occupational therapyprovided by a licensed Physical Therapist and trained therapy assistants.
For medication, a Certified Medication Assistant or a nurse assistant will dispense daily meds according to a physician or nurse's orders each day.
Special meal plans can be provided if a resident has certain dietary restrictions such as liquid, soft or pureed foods.
Some facilities have pets in-house to interact with the residents that enjoy animals. Depending on the facility and the capabilities of the resident, they may allow the resident to have their own pet if it meets the home's requirements. You can check on this when interviewing different facilities.
Nursing homes usually contract with a physicianand or a licensed Physician's Assistant / Nurse Practitioner to come in weekly to check on residents that are ill or need further evaluation.
With your physician's approval, they can even bring in specialiststo examine a resident, like a podiatrist, or a mental health consultant. For example, you can have certain x-rays, electrocardiograms, swallow tests, or hospice services if necessary. Keep in mind, these are not part of the resident's nursing home care payment. These are the type of things which Medicaid, Medicare or other insurance may help pay.
A nursing home will have procedures in place to help a resident arrange transportationto a doctor's visit, or if the need arises for them to go to the hospital for tests, or even if they need hospitalization. The facility may even pay for these rides. Ambulance transport will need to be paid by your health insurance and you.
The costs for nursing home care
The costs for a long-term care facility differs from state to state and for each facility. It will also depend on whether you want a semi-private room or a private room.
According to the U.S. Department of Health and Human Services, these are the average costs of nursing home care as of 2016:
- $6,844/month for a semi-private room
- $7,698/month for a private room
Although, according to new findings by Genworth, these costs have risen:
Yes, it can be expensive, but keep in mind the average cost is based on cost of living in your area. Genworth has a great calculator you can use to see what it will cost in your city and state.
Despite the high cost of nursing homes, according to the AARP the majority of residents do not pay out of pocket. Approximately 65 percent of nursing home residents are supported by Medicaid, which pays for an average of 45 percent of the total nursing home bill. The same research notes that only 22 percent of current nursing home residents pay out-of-pocket or through private long-term care insurance.
The above costs do not include the resident's medications, or any other therapy or tests they may receive. The resident or family members will need to pay for clothing and personal items they may need or want at the nursing home.
If they need a wheelchair or walker, you should bring your own or the home can help you order one. Medicare may help pay for these items. Some facilities will allow you to bring in a special chair or other items from home to make your room feel more like home. Be sure to discuss this with the facilities you visit.
Who pays for nursing home care?
Some people believe Medicare will cover nursing home care. It does not. Nursing homes are custodial, which means you get help with day-to-day non-medical activities, which Medicare doesn't cover. A skilled nursing facility (SNF), on the other hand, may be covered by Medicare, as it is considered medically necessary care beyond a hospital stay. Skilled nursing facilities are short-term rehabilitation providers that provide rehab services such as physical therapy and occupational therapy. Many nursing homes have converted some long term Medicaid licensed beds into short-term Medicare rehab, so many nursing centers provide both services.
That said, Medicare and or other insurance coverages you have can help you pay for some services, such as medications while in the nursing home. You mustcheck your Medicare, Medigap, Medicare Supplemental plan, or any other health insurance you or your spouse may have to be sure what's covered.
For many patients leaving the hospital following a post acute stay, they will first enter one of the local Medicare rehab facilities, and then move on to a long-term stay in a nursing home. The coordination of Medicaid and Medicare is essential to make sure you don’t get stuck with a bill that may cost as much as $300 a day.
There are four ways to payfor long-term care in a facility depending on your circumstances:
- Out of pocket payments
- Long-term care insurance
- Veterans Affairs benefits
Let's look at each of these in detail
Out of pocket payments
You are required to use the private pay option if you have enough income and assets available to you to use for nursing home care. There are a few options for obtaining funds instead of or combined with using your savings in this category:
- Pension income
- Family aid
- Retirement accounts
You may choose to enter in an annuity contract with an insurance company to help pay for a single payment or a series of payments. Here, the insurance company will send you an annuity, which is a series of regular payments over a specified and defined period. There are two types of annuities:
- Immediate annuity
- Deferred long-term annuity
Deferred long-term annuities are available to people up to age 85. Similar to other annuities, in exchange for a single premium payment, they receive a stream of monthly income for a specified period of time.
The annuity creates two funds: one for long-term care expenses and another separate fund that you can use how you desire.
Key things to consider before purchasing a deferred long-term care annuity:
- If you do not use the long-term care fund, you can pass it on to your heirs.
- The annuity may not be enough to pay the long-term care expenses.
- The long-term care portion of the annuity may satisfy the requirements for a tax-qualified long-term care policy.
- The effect that annuities can have on your taxes is complicated. Consult a tax professionalbefore purchasing one.
- An annuity can affect your eligibility for Medicaid.
Trusts are a legal entity that allows a (the trustor) to transfer assets to another person (the trustee). Once the trustor establishes the trust, the trustee manages and controls the assets for the trustor or another beneficiary.
The two type of trusts that can help pay for long-term care services are:
- Charitable Remainder Trusts
- Medicaid Disability Trusts
A Charitable Remainder Trust allows you to use your own assets to pay for long-term care services while contributing to a charity of your choice and reducing your tax burden at the same time. You can set up the trust so you will receive payments from the trust to save for long-term care services while you are alive.
Keep in mind that the amount available for you to use for long-term care services is based on the amount of your donations.
A Medicaid Disability Trust is limited to persons with disabilities who are younger than age 65 and qualify for public benefits. This is the only kind of trust that is exempt from rules regarding trust and Medicaid eligibility.
Here are some key things to remember before setting up this trust:
- The state can recover any remaining amount in the Medicaid Disability Trust when you or your spouse dies.
- The tax implication for this type of trust is complicated. Consult a tax professional before establishing a Medicaid Disability Trust.
Accelerated death benefits
A feature included in some life insurance policies allows you to receive a tax-free advance on your life insurance death policy while you are still alive. Sometimes this is an extra cost to your policy, or it may be included. Again, check with your life insurance agent for details.
You can sell your life insurance policy for its present value to raise cash for any reason. However, this is only available to men 70 or older or women age 74 and older. You could then use the funds for long-term care.
Keep in mind there may be no death benefits that remain. Also, there may be tax assessed on the proceeds of the sale.
There are plans which allow you to sell your life insurance policy to a third party and use the money you receive to pay for long-term care. The plan does have requirements and drawbacks. First, you must be terminally ill with a life expectancy of fewer than two years. The less life expectancy you have, the larger percentage of the money you receive.
During the settlement process, a viatical company pays you a percentage of the death benefit on your life insurance policy, which is based on your life expectancy.
The viatical company then owns the policy and is its beneficiary. The viatical company also takes over payment of premiums on the policy. As a result, you get money to pay for care, and the viatical company receives the full death benefit after you die. The money is also tax-free.
There are many different strategies for protecting assets and accessing the Medicaid benefits. Read our comprehensive guide to Medicaid Planning.
Long-term care insurance
Long-term life insurance is designed to cover long-term support, including personal and custodial care in a variety of settings such as your home, a community organization, or in a nursing home.
This insurance product reimburses policyholders a daily amount (up to a preselected daily amount) for long-term care services. Recipients can select a range of care options and benefits which allow them to get the services they need, like nursing home care.
There are many variables to what you can purchase in a long-term care policy such as how old you are when you purchase it, what your health is when you purchase, and whether or not you are already in long-term care.
These insurance policies do require medical underwriting as an individual policy, rather than a group policy which often does not require underwriting. There are also maximum amounts these will pay per day, or years they will pay. Be sure ask these questionsabout any policy you may want to purchase.
Since many consumers are reluctant to buy long-term care insurance because they fear their investment will be wasted if they don't use it, some insurance companies have begun combining life insurance with long-term insurance.
These products are relatively new, and the features are changing as the product evolves. Check with your life insurance provider if you are interested in this type of product.
Veterans Affair benefits
The Department of Veteran Affairs (VA) pays for nursing home care services for service-related disabilities and for certain other eligible veterans.
Minimum duty requirements
Veterans who enlisted after September 7, 1980, or who entered active duty after October 16, 1981, must have served 24 continuous months or the full period for which they were called to active duty in order to be eligible. This minimum duty requirement may not apply to veterans discharged for hardship or a disability incurred or aggravated in the line of duty.
The VA will also pay for veterans who do not have service-related disabilities, however, only if they are unable to pay for the cost of necessary care, depending on the veteran's income level.
Further, a person who served in the active military service and who was discharged or released under conditions other than dishonorable may qualify for VA health care benefits including qualifying Reserve and National Guard members.
Long-term Services:VA provides nursing home level of care to Veterans through three national programs: VA-owned and operated Community Living Centers (CLC), State Veterans' Homes owned and operated by states, and the community nursing home program. Each of these programs has admission and eligibility criteria.
VA is obligated to pay the full cost of nursing home services for enrolled Veterans who need nursing home care for a service-related disability. No matter your situation, please consult your local VA county office for more details.
You may also call the VA at 1-877-222-8387 Monday – Friday 8:00 AM to 8 PM Monday – Friday EST for more information or to apply.
VA provided nursing home care for all other Veterans is based on available resources. For more information on Extended Care Services and Geriatrics, visit their website.
You may also apply online at Vets.gov or download an application form and mail it to: Health Eligibility Center Enrollment Eligibility Division 2957, Clairmont Rd., Ste: 200, Atlanta, GA 30329-1647
Medicaid and Medicare
Medicaid covers nursing home facility care for those who are eligible. It's important to know that Medicaid programs and eligibility for service vary from state to state. You have to meet certain eligibility requirements regarding your health, income, and assets to qualify.
Approximately 65 percent of nursing home residents are supported primarily by Medicaid. Further, Medicaid pays for about 45 percent of the total nursing home bill.
Medicare does not cover long-term care in nursing homes. However, it does provide nursing and rehabilitation for up to 100 days in a skilled nursing facility, many of which are also nursing homes.
An important point to consider is that if your spouse is working, or on Social Security, their income will not be considered in the Medicaid decision.
Please see our recent post on how to access Medicaidfor nursing home and long-term care on for in-depth information on Medicaid funding for nursing home care.
How to select the right nursing home
To choose the right facility for yourself or a loved one, first you need to decide on the location. Compile a list of the facilities and addresses, telephone numbers, and look them up on the internet to gather initial information about the nursing homes you may be interested in.
Next, you mustbrowse Medicare.gov, where you can view the results of long-term care facility surveys, and compare the ones that may be of interest to you.
You can now choose the nursing homes you want to consider, and go to the facilities and visit them! You can also call ahead of time to ask questions about special care needs or other questions you may have. It's always good practice to call and schedule an appointmentbefore showing up in person.
Tour the nursing home
If you have time, you might consider going ahead of time to look around by yourself before your tour to get a feel for the place. If appropriate, you can even chat with a couple of residents if possible to get their perspective on the nursing home.
If you have a short-list, or one nursing home you favor, consider going there in the morning, afternoon, and evening to get a better feeling of how the facility operates and its diligence of care.
When you visit the nursing home, you should print the checklist at the Caregiver's Library to take with you. It has the pertinent questions you need to ask, and it will help you make your decision.
If special care is needed as for an Alzheimer or Dementia resident, you will want to make sure you choose a facility that has Alzheimer or Memory Care unit and discuss the procedures for those units. This is why calling ahead of time is the best option, to clear up any critical questions like this.
Be sure to ask if they have Medicaid bedsif that is how you plan to pay. Some facilities will allow you to be admitted to the facility before Medicaid is approved, upon submitting proof of your application to the facility. This is known as “Medicaid Pending” which can be a stressful situation as the nursing home will be providing skilled nursing care, but will not be getting paid. Being as prepared as possible for the Medicaid process is very important.
If you are hospitalized while a family member is searching for a nursing home, an admissions representative from the nursing home may be able to visit with the patient and family members in the hospital.
The nursing home representative may also do an assessment, and speak to you about the facility. They can answer any questionsyou or your family members may have so you can decide if you will be a good match for the nursing home. Be aware that if the resident is currently in the hospital, and you need to find a nursing home, you may need to find one that is also a skilled nursing facility.
Sometimes a patient will leave the hospitaland enter skilled care in a nursing home, expecting to go home after a short time of physical therapy. If for some reason the therapy is not successful, or their condition worsens, they may be informed they must go to a nursing home if other full time 24-hour care is not available.
In this case, the nursing home may have to move them from skilled nursing to their nursing home unit. This is okay; the patient can transfer when they find a more suitable nursing home.
Choosing the right nursing home for yourself or a loved one is never easy, but if you follow the above criteria, it will help ease the burden of the process.
Nursing Homes - Frequently Asked Questions
How big are the rooms normally?
The size will vary from one nursing home to another. If it is a shared room, the area for one resident may be quite small, as in a shared hospital room. Some rooms have their own bathrooms and some bathrooms are shared with another room.
However, some of the newer facilities may surprise you with the size of the rooms and the amenities they have available. Some are large and lovely.
Can couples live together?
In some facilities, they do allow couples to live together. You will need to check with each facility you interview. This could be a way of saving money, instead of paying for two separate rooms.
Are there policies on services for the LGBT adult community for nursing homes?
Please refer to the basics of Long-term Care Considerations for LGBT Adults.
Are pets allowed?
You will need to check with the facilities you research; some do, others allow small dogs or cats. Some facilities even have pets on-site for the residents already.
Is there beauty salon access?
Yes, most nursing homes have a beauty salon where a beautician comes in regularly for appointments. There is a charge, but it is usually affordable. Most also do men's hair and beard services.
Are these guidelines the same if someone already lives in a Senior Retirement Village where they have access to Independent Living, Assisted Living and Nursing Home Care?
You should consult with the administrative staff of your community to find out what their policies are. There may be costs associated with moving to a more suitable nursing home care from independent or assisted living.
Is it true that someone admitted to a nursing home normally never leaves?
That is not necessarily true. If a resident is going to a short-term rehabilitation center, then they will definitely be either moving back home or to a senior living facility. For residents that require long-term care, some residents do get well enough to go home or go to an assisted living community. Many residents however do enter a facility with severe medical issues, and are not able to leave.
Are residents allowed to go out of the facility on home or family visits?
Yes, residents can go out on day visits, if they are medically able or have the support of a family member. Family members can easily make arrangements with the nursing home to pick up their loved ones. You must check with the nursing home on the particulars of this.
Normally the staff will have them ready to go, making sure they have any needed medications or other items they may need to take with them. For security reasons, almost all nursing homes have you sign them in and out.
If they need other transportation such as a wheelchair, the facility may be able to do drop-offs and pickups, depending on the situation. Most facilities will have you pay for this type of ride.
Are most long-term care facilities safe?
Yes, most are well regulated,have excellent oversight, and compassionate staff. Unfortunately, there are some that are not well managed or staff. This is why you want to visit, ask questions, look at their survey results, and talk with residents before committing to a nursing home.