One issue that brings family and friends to an elder law attorney’s office is concern about how to pay for the cost of care if a loved one has to move into a memory care facility. A memory care facility is housing that specializes in providing care for people who have Alzheimer’s Disease or some other form of dementia. These facilities have specially trained staff who provide frequent monitoring and a safe environment. Many times as a dementia patient’s health declines, she or he needs assistance with all of their activities of daily living such as eating, bathing, dressing, and toileting. There may even be a need for assistance with organizing his or her day or taking medication. It is also important for family and friends to discuss housing options soon after a diagnosis of dementia is made so that they can support a change in abode in the future should it be necessary. All of this discussion and planning is critical for the safety and health of both the person diagnosed with dementia and his or her caregiver(s).
A most distressing situation can arise when couples are living alone together in their home with one or both diagnosed with dementia. If one or both have declining health to the point where either or both cannot be left alone, have become very aggressive, or wander away from home, there needs to be a plan in place to avoid crisis management of care. According to the Alzheimer’s Association, 6 out of 10 people who have dementia will wander away from home. In these situations memory care facilities can be a good alternative to living at home. These facilities have responded to the tendency to wander by equipping doors with alarms, installing elevators that require a code for safe entry , and enclosing outdoor spaces. Some facilities even offer tracking bracelets that give their residents more freedom of movement within the facility.
Keeping a spouse or loved one with dementia at home can sometimes unknowingly lead to abuse in an attempt to keep the spouse confined to certain areas of the home, trying to get the spouse to eat, drink, bathe, get dressed, or stay inside of the home. In one instance, a daughter was so frustrated with her mother not eating her food that she slapped her mother so hard that she drew blood. The resulting trip to the emergency room for treatment led to the police being called and the daughter being arrested for assault. In another instance, church members reported a family to Adult Protective Services (APS) because the adult children paid for caretakers to come into the home between the hours of 10am until 9pm at which point the parents were put to bed and left alone all night. Most families try to manage keeping their loved ones at home with family members providing the caregiving or by hiring a caregiver to come into the home for as long as possible. But sometimes the family must look for a memory care facility for their loved one’s safety and quality of life.
There are some signs to alert the family that a memory care facility may be needed:
Source: Alzheimer's Association
Many families are overwhelmed when they realize that they cannot continue to care for their loved one(s) at home and then investigate a memory care facility.
They must then identify a facility that they feel comfortable moving their loved one(s) into. It is advisable to visit facilities unannounced and on weekends to observe the difference in the staffing levels. Ask if the staff has dementia-specific training and how do they handle aggressive dementia residents? If it appears that the facility is using anti-psychotic drugs on the residents to control behavior, that should be a red flag.
There are many different types of memory care facilities:
Group Homes: Small group homes with less than 20 people are normally located in residential communities. These facilities normally have at least one staff person on the property at all times and can monitor whether a resident’s medicine is being taken and can make and provide meals and activities. Group homes typically do not have any nursing or medical assistance on site.
Assisted Living: Most assisted living facilities have a memory care unit which is secured by a locked entry door that residents cannot open, or a secure elevator entrance to ensure that the dementia residents do not wander away. The residents are normally able to move about the memory care unit as they wish unless they exhibit disruptive behavior. These facilities typically do not have nursing or medical assistance on site but will monitor that medicine is taken, food is eaten, and daily personal hygiene is performed. Normally, the resident will have a one-person room. As the name suggests, it is important to remember that in order to be able to move into an assisted living facility, the resident must be able to care for basic living needs.
Nursing Homes: Most people associate long-term care with stand-alone nursing home facilities which achieved some notoriety due to the high incidence of COVID-19 during the early months of the pandemic. For whatever reasons, many of these facilities have lost residents and many may no longer be financially viable. These facilities provide twenty-four-hour skilled nurses on duty, nutritionists, social workers, and there is normally a doctor who makes rounds within the facility at least once a month.
Continuing Care Retirement Community (CCRC): A CCRC is a community that has housing for independent living, assisted living, and skilled nursing care all on the same campus. This allows a person or couple to move in when they are still able to live independently and then move to more appropriate housing if their health declines. These communities require a hefty entrance fee and monthly payments.
According to the National Investment Center for Seniors Housing and Care (NIC) memory care facilities are the fastest growing segment of the senior housing industry. They are also the costliest, according to the 2021 NIC data, the average memory care monthly rental is $6,935.00, and can easily run over $10,000 a month depending on the services and amenities offered. Costs vary from state to state. When doing an initial investigation of a memory care facility, always ask if the facility accepts Medicaid in the event that your loved one(s) may run out of money. This is because Medicare, Medicare Advantage, and regular health insurance do not pay for long-term care. If there is a long-term care insurance policy, it may help to off-set the cost of care. Additionally, if the dementia resident is a veteran or the spouse of a veteran and over the age of 65, they may be able to apply for benefits to help pay for their cost of care under the Aid and Attendance program. Most families must pay out of their own pocket for long-term care. Payment for long-term care can be a source of grave concern, if not outright panic, for some families.
Instead of panicking over long term care costs, families must begin planning. First, each state has its own regulations. There are some regulations that apply nationally in which a person’s personal residence and a car are exempt and will not disqualify them for financial assistance under the Medicaid Long-term Care (MA-LTC) program. Some people consider transferring assets, divorce, purchasing an annuity, and other ways to spend down their assets so that they can qualify for MA-LTC. These strategies all have their risks, especially if one is not working with an elder law attorney because regulations and laws differ from state to state. An example of a common regulation applicable to (MA-LTC) programs is a five-year look-back regarding asset transfers, which can affect eligibility. Before making any financial changes, a family should meet with an elder law attorney to determine what laws might be applicable in your state. A good place to identify a possible attorney with whom to consult is the National Academy of Elder Law Attorneys (NAELA) website which has a state specific attorney locater.
There are a lot of “urban myths” circulating that need to be dispelled. First, MA-LTC has certain provisions which only apply to married couples. Those provisions, known as the “spousal impoverishment rules,” protect the community spouse (the one who is not ill and will remain in the community). Basically, MA-LTC permits the community spouse to retain the house, a car (sometimes limited in value), term life insurance, pre-paid burial plans, and personal effects (so long as they are not of investment-grade quality, i.e., a Rembrandt painting). These assets are referred to as exempt resources. The remaining assets are known as non-exempt resources.
In addition, MA-LTC permits the community spouse to keep a certain portion of liquid assets (stock or cash) known as the Community Spouse Resource Allowance (called the “CSRA”).
Once an application is filed, the MA-LTC agency will determine the amount of funds that the community spouse is permitted to retain. According to the CSRA rules, a spouse is permitted to retain 50% of the total non-exempt resources that the husband and wife own at the time the ill spouse entered the facility. The maximum CSRA is adjusted annually and can be increased with a court order.
The community spouse is permitted to keep all of his/her income. However, if his/her income is below a certain level, then MA-LTC rules permit the community spouse to keep a certain portion of the ill spouse’s income (called the Spousal Monthly Maintenance Needs Allowance).
Another caveat to MA-LTC planning is that some states have “Filial Responsibility” laws that make adult children responsible for their parent’s medical bills if the parent cannot pay. Twenty-seven (27) states plus Puerto Rico hold adult children financially accountable in some way as of 2021. The regulations for a single person mirror those for married couples.
Although memory care facilities are expensive, they cannot be dismissed as an alternative to in home care for a loved one diagnosed with dementia. The cost of care is not a challenge that a family has the luxury of avoiding. Planning to enter a memory care facility is the type of planning that a family should not have to be engaged in when their loved one is in a hospital facing imminent discharge.
