In the following post, we break down the cost of assisted living communities in the D.C. area and provide resources that will help qualified applicants pay for their stay at an assisted living community.

​In the D.C. area, including surrounding counties, we’ve seen the monthly rate for assisted living be as low as $1,650 per month, which includes the costs of room, board, and care. We’ve also seen the total cost per month for assisted living exceed $20,000. How is that possible? Well, if someone lives in an assisted living community and hires her own caregiver—between the community’s monthly fee and the cost of the caregiver, the total cost of stay can exceed $20,000 per month. If no outside caregiver is hired, then $13,700 is the highest per month cost we’ve seen for an assisted living community in the D.C. metropolitan area. For your reference, generally people do not need to hire outside caregivers to assist them while staying at an assisted living community; however, there are rare cases when it makes sense for the family to do so.

In sum, the per month cost of assisted living can range from $1,650 to $13,700. Here are the four variables that drive the monthly cost for assisted living:

  1. Location – the more expensive the area of the community, the higher the monthly rate
  2. Amenities – the nicer the amenities, the higher the monthly rate
  3. Level of care – the higher level of care, the higher the monthly rate
  4. Length of stay – the shorter the length of stay, the higher the monthly rate

In this next section we break down the ways that you can pay for a stay at an assisted living community.

  1. Out-of-pocket
  2. Long-term care insurance– this is something that you pay for out of pocket in advance of needing care that will help pay for care if the criteria written within the long-term care insurance policy are met.
  3. The Veterans Administration– through grants and at select communities, the VA will pay for room, board, and care (1). At other communities the VA may only pay for the cost of care, leaving the cost of room and board up to the resident. Applicants must qualify and meet certain financial and health requirements. To apply we recommend visiting your local VA medical center or call 877-222-8381 (2).
  4. Government subsidies– Some state and county governments offer subsidies to their residents to help pay for the costs of long-term care. Here are two programs for Virginia and Maryland residents:
    1. Virginia’s Auxiliary Grant – Virginia has an Auxiliary Grant that helps low income individuals afford assisted living. To determine eligibility the family may visit hereand then call their local department of social services.
    2. County grants through Maryland – Some counties offer subsidies to participants with limited income. To locate a county that participates in the Senior Assisted Living Group Home Subsidy program, have the family contact their local Senior Information and Assistance Program Montgomery County participates in the program. Hereis a link to Montgomery County’s program. At the time of the writing of this article, Prince George’s County was not participating in the program.
  5. Medicaid Waiver – Those who qualify for long-term care may be eligible for the Medcaid Waiver Program. Through the program, Medicaid will pay for the resident’s stay at a qualifying assisted living community. Usually these communities are group homes that have opted to participate in the state program. To find out more, it would be best to consult an elder law attorney or your local department on aging.

The process to find an appropriate, suitable assisted living community can be daunting. We’re here to help. Give us a call or contact us here if you have any questions about senior living.




Medicaid “spend down” is when someone spends his or her assets or income to qualify for Medicaid. If a person’s income or assets exceed the law’s limit, Medicaid won’t help that person pay for things such as long-term care in a nursing home. However, Medicaid does permit a person who has income or assets above the limits to make purchases AND be eligible to qualify for Medicaid Long-Term Care as long as: (1) those purchases are enough to put them under the law’s income and asset limits; and (2) are permissible purchases under the law’s guidelines. In the following post, we discuss the items that you can spend money on without Medicaid penalizing you.

If you would like to refresh yourself with the differences between Medicaid, Medicaid Long-Term Care, and the Medicaid Waiver Program, please do so by reading the following article, which will also discuss the qualifications for each of these programs.

It may also be helpful to review the difference between countable and non-countable assets here.

State Medicaid programs have their own asset limits; however, most asset limits are approximately $2,000 in countable assets. A person with more than $2,000 in countable assets will not receive help from Medicaid Long-Term Care 1. As a result, many applicants will enter “spend down” mode. During “spend down” mode, applicants are only allowed to make certain purchases and transfers. During the application process, a Medicaid case worker will review the applicant’s buying and selling activity for the previous five years. If the case worker finds unauthorized transfers or purchases, the applicant will likely be penalized. That penalty is usually in the form of a delay of aid to the applicant in proportion to the amount of the unauthorized transaction vis-á-vis the average cost of a nursing home in the state. As a result, it’s important for an applicant to spend money on permissible purchases before applying to Medicaid Long-Term Care.

Below is a list of permissible purchases to reduce one’s countable assets 2; however, please consult an elder law attorney before entering “spend down” mode—the law constantly changes, the limit varies by state, the strategy differs based on marital status, and there are nuances to the list below:

  • Home improvements – yes, you may be able to invest in your home; however, some states set an equity limit to one’s home value. Homeowners whose equity exceeds the state’s limit may not qualify for Medicaid under the state’s asset restriction.
  • Vehicle repairs or purchases – only one vehicle is exempt; it’s also likely a vehicle’s value can’t exceed a certain amount so check with an elder law attorney in your state for what you’re permitted to own.
  • Uncovered medical devices – can only deduct medical expenses that you are responsible for paying. Each state has a list of medical expenses that it approves. The following list includes items that are common among states, however, it is best to check with an elder law attorney in your state to identify which purchases it authorizes:
    • Nursing home services
    • Prescriptions and medically necessary over-the-counter drugs
    • Eyeglasses
    • Dental services
    • Personal care
    • Transportation to and from medical expenses
  • Paying off debt
  • Hire a family member to provide care – in some states you may hire a family member as the caregiver. The rate that the family member charges must be reasonable.
  • Funeral arrangements via an irrevocable funeral trust – commonly, states permit people to spend up to $15,000 per spouse on funeral arrangements.
  • Annuities
  • Life insurance policies with a cash value of less than $1,500

The above list highlights some general items that one may spend his or her countable assets on to qualify for Medicaid Long-Term Care. When applying for Medicaid Long-Term Care, a case worker will review the applicant’s income, medical needs, and expenses. While an applicant may earn income above the law’s limit, he or she may be able to qualify for Medicaid Long-Term Care by deducting permissible purchases from his or her income and qualify for Medicaid Long-Term Care. For instance, let’s say an applicant has no assets and is paying for nursing home services and other medical needs with her social security. If a case worker determines that the applicant’s permitted expenses exceed her income and she has a medical need for nursing home care, then she will likely qualify for Medicaid Long-Term Care.

If all of this sounds confusing, then contact us and we will put you in touch with a local elder law attorney who will review your case.

This article is not intended to give any legal advice; we hope that you can use it to gain a general understanding of how the system works. Please, consult an attorney if you are looking for counsel.  



For simple tasks, automation works; however, when a process’s inputs differ, automation is less effective than manual effort. Coordinating senior care is difficult to automate because the inputs, a person’s circumstances, differ from client to client and the solutions differ based on the family’s needs, bandwidth, and preferences. Many companies have tried to automate the senior living search process. However, to us, it’s obvious that technology is not as effective at exploring a family’s circumstances as a human. Here’s why:

Trust. Building trust is imperative to care coordination because the advisor must explore personal family matters before making a recommendation. Once trust is established, the advisor can ask questions such as, “Does your loved one have a 401k,” or “Does your loved one receive social security, and if so, how much is his or her monthly check.” Whereas, many automated processes fail to obtain financial information because seniors and families are skeptical of disclosing financial information to these systems. By building trust and getting access to families’ financial information, an advisor who provides a high level of customer interaction may be able to make more suitable placements than a company whose process is heavily automated.

Unique circumstances. While you would think a person’s health profile should not deviate too far from the norm, that is not the case! People are special. Each client has his or her own set of needs. An advisor must accommodate those needs via the search. A search may include finding an assisted living facility near a dialysis center or finding one near a geriatric psychiatrist. At this point, no automated senior living search advisor can handle the unique circumstances of each client effectively—there are simply too many permutations of cases for any system to be user-friendly while providing an exceptional search. Clients with special circumstances need to either do the search on their own or have a person do the search for them to get the results that meet their needs.

Feedback. When an advisor searches for a place for a client, one of the most important aspects of the search is for him or her to listen for feedback. There are always things that an advisor needs to follow up on. Whether it’s aggregating the questions from the assisted living communities about the resident’s medical history or asking the client about his or her experience visiting a community. Follow-up is imperative to fine-tune a search and ensure the client visits suitable communities. The best way to get specific feedback, is to ask specific questions. In order to ask specific questions, one has to have a deep understanding of the situation, which at this point is something a human can excel at versus a machine. Because feedback is vital to the senior living search process, we believe that a manual, person-driven process will excel over an automated one.

While the term “manual” has a slow context to it, we wanted to use this post to highlight another context of the term—and that’s “accurate.” By using a “manual” advisor we believe that you will reach your destination sooner because that person’s ability to gain trust, handle unique circumstances, and gather feedback is far superior to what an automated process can handle. Let us know if you would like a person to help you with your search by calling Tim at 540.330.4103.


Most of the time people don’t choose to go into a nursing home or skilled nursing facility, so it’s no wonder why they are often caught off guard figuring out how the system works and knowing what their responsibilities are. In light of this common predicament, we wanted to release a post to guide families through the complexities that arise during and after their loved one’s stay at a skilled nursing facility.

Know If and How Long A Stay Is Covered
Usually a hospital stay precedes a stay at a skilled nursing facility. When this is the case, your hospital social worker will notify you if your loved one’s insurance will cover his or her stay at the skilled nursing facility. While at the skilled nursing facility, it’s important you make the effort to meet with the social worker. He or she will schedule regular care plan meetings with you. During these meetings you will learn about your loved one’s progress and if the center’s team expects the insurer to continue coverage.

Sometimes an insurer will cease covering a patient’s stay at a skilled nursing facility. That’s because either the patient has run out of covered days or has recovered to a point that he or she no longer needs the center’s services. Patients may appeal the insurer’s decision, but from our experience it is very rare for patients to win their cases. The downside of not winning is the patient is liable for the bill accrued during the trial, which can sometimes take weeks.

Have the skilled nursing facility review your loved one’s prescriptions and write new prescriptions when necessary. The center can call in the prescriptions to your local pharmacy, but it’s likely you will have to hand deliver any prescriptions for narcotics. Discuss with the social worker and the nurse what you need to do at your last care plan meeting.

Whether the patient is being discharged home or someplace else, request a list of the current prescriptions and their corresponding instructions.

Medical Devices
Make sure the center has ordered the proper medical devices for your loved one. Some common examples of medical devices that we see centers ordering for patients are walkers, wheelchairs, hoyer lifts, and hospital beds. Granted, each of these medical devices must be warranted in order for the center to order them. It’s important that you ask your social worker if he or she would recommend any medical devices. Trust their answers, the social workers are just as interested in keeping your loved one safe as you are. As a result, they will give you their honest opinion about what your loved one should and shouldn’t require.

The unfortunate reality is that insurance does not cover transportation from a skilled nursing facility back to the community. You will be responsible for organizing transportation from the center upon discharge. The most popular transportation options are you, a taxi, or a hired caregiver.

Primary Care Physician Appointment
While many centers have their own primary care physicians, it’s not guaranteed that he or she will assess your loved one during his or her stay. Ensuring that your loved one sees his or her primary care physician at the end of his or her stay or directly after is very helpful. During this visit, the physician should review, yes again, the patient’s prescriptions and write any the center wasn’t willing to write or missed. Additionally, the physician may sign off on home health services if the center did approve the patient for home health. We’ve seen it many times–a patient was written an order for home health, such as physical therapy, but he or she couldn’t get it because he or she hadn’t seen a primary care physician in over a month.

Prior to discharge, either ask the social worker for an in-house primary care physician to visit your loved one or make an appointment yourself. Scheduling an appointment does not require that much effort from you, but it will potentially save you a lot of hassle down the road.

Find a Safe Environment
Often patients who leave a skilled nursing facility aren’t 100%, which means they still require care after their stay. It’s important you have a plan to care for your loved one. You, a family member, a hired caregiver, or an assisted living community are caregiving options. Whatever option you choose, consider the needs of the patient and your resources, including time and money.

While there is a lot to do prior to a discharge from a skilled nursing facility, there are many resources available to help you make this transition as smooth as possible. If you have any questions, please feel free to contact us and we will help you choose the best path forward.


On Friday, March 13, 2020, the Centers for Medicare & Medicaid Services (“CMS”) issued a statement that waives the three-night hospital stay requirement for Medicare to pay for a patient’s stay at a skilled nursing facility (“SNF”). That means patients at a hospital no longer need to stay at a hospital for three nights in order for Medicare to pay for their stay at an SNF.

This waiver will likely cause SNF occupancy rates to rise as hospitals admit more COVID-19 cases and therefore must free up beds to handle their caseloads. Some experts, including those that conducted this Harvard study, fear that hospitals and SNFs may not have enough beds to handle all of the incoming cases. Additionally, not all admitted patients need a skilled level of care, and therefore, do not meet the requirements to be admitted into an SNF. Group homes could serve a vital role in helping patients with non-skilled needs get the care they need and free up beds at hospitals and skilled nursing facilities.


Telehealth was once restricted by the Health Insurance Portability and Accountability Act (“HIPAA”) because the law limited the use of telehealth meetings through popular channels such as Skype and Zoom. As people quarantined to limit the spread of COVID-19, the government relaxed regulations, which now allow professionals to share health care-related information via Skype and Zoom. A range of health care providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, are using telehealth to give advice to their patients. While these former restrictions had merit and did help to protect patient privacy, the new rules allow for a vastly different health care system. Here’s what we see:

​Check-in visits, medication refills, and mental health support are among the most popular reasons that people use telehealth services. Many insurance providers, including Medicare, now reimburse payers for telehealth services. This has been in response to keep people in their homes and away from others; however, the problem with that is they don’t interact with their doctors as often. Many people must visit their doctor routinely for prescription refills and general health check-ups. Doctor’s office visits have dropped significantly. In fact, health care jobs have declined, which seems counterintuitive given we are in the middle of a medical crisis. Regardless, telehealth services have a real opportunity to fill a void in this type of environment, that is to provide a medium by which practitioners can give health care advice to their patients.

The other thing we see is that video conferencing has helped social workers and patients with care coordination. Lessened HIPAA restrictions and “no visitors” policies at nursing homes have limited assisted living communities from accessing patients in person. Some nursing homes we work with are setting up video conferencing lines so that the homes can interview patients remotely. This has been a tremendous opportunity for the industry and patients, particularly for low-income patients. Previously, few homes wanted to interview a low-income client because it was a lot of work for not a lot of money. With the ability to interview patients over video, the communities protect their time and money—no more sending a nurse to a skilled nursing facility to maybe get a client. As a result, more communities are willing to interview more clients, which means hospitals and skilled nursing facilities have a better chance of discharging patients who no longer require their respective level of care.

As of now, the new terms of telehealth and video chat are temporary, but we hope that the channels, such as Skype and Zoom, alter their platforms to be HIPAA compliant so that when the rules tighten back up, those channels can still cater to a need.


I have met and developed great relationships with several social workers through this business. From the start I was amazed by how much they do and what they are responsible for. I wanted to write a piece about them, particularly the ones who work in a hospital or skilled nursing facility. I know there are other types of social workers, but these are the ones that I have come to know. Through this piece, I hope at least one additional person develops a newfound respect for the profession and for the people who dedicate their lives to helping others.

A social worker is someone who helps people adapt to society, which could be orchestrating medications, medical devices, or services for a proper and safe discharge from an establishment. A social worker’s job is intense. They are often managing cases where a patient’s lifestyle has changed such that the appropriate plan is not appealing to the patient or is hard to achieve because the patient lacks resources or family support. The latter of these two issues is far too common, which means social workers are constantly having to create solutions with very little resources—multiply that by 60 and that is why this profession is one of the most intense I can imagine. Social workers routinely look out for people who don’t have a support system to look out for themselves. This is also why I call them “The Guardians of Society.”

Patient, compassionate people tend to excel at the profession. In my opinion, that’s because they have to win their patients’ trust in order to suggest a plan. As a result, social workers are tasked with remaining patient and compassionate in the midst of chaos and deadlines. Here’s an example of a typical problem they may face: an insurance company ceases payments to a facility because the patient no longer meets a certain level of care to justify his or her stay. As the patient remains at the facility, his or her costs may exceed tens of thousands of dollars a month. The facility will have to pay for the costs itself. The facility administration will look to the social worker to create a plan to get the patient out of the facility as quickly as possible without compromising the safety of the patient, because if that patient is readmitted into a hospital, then the “system,” particularly CMS, will penalize that facility in the form of reduced future payments. The social worker must balance the safety of the patient and the economic impacts on the facility—this can create a very stressful situation.

You may share the opinion that social workers are the hidden centerpiece of today’s health care system. So much relies on them. And to do their jobs well, they must have a breadth of skill sets including business acumen, knowledge of medical terminology, legal knowledge, communication skills, and relentless work ethics. A social worker must combine the intel from the doctors, in-house counsel, family, patient, and administration to make a plan for the patient. What a task!

It’s amazing with the caseload that social workers have that they are so successful at what they do. In the US, approximately 15% of all patients admitted to the hospital were readmitted within 30 days during 2019 1. Considering the typical case load at any given hospital or skilled nursing facility, that number is outstanding. And it’s as low as it is because we have a system in which social workers help coordinate all the different stakeholders at play. As that 15% number decreases, tax dollars can be allocated elsewhere, insurance premiums may go down, and individual patient outcomes will improve. For the reasons that social workers help patients and, bigger picture, help our society function, I think it’s appropriate to deem them America’s Guardians.

March was Social Work Appreciation Month, but there is no time like the present to thank social workers for all that they do, particularly now as their case loads begin to build and as they stand on the front lines of this battle against the invisible enemy.