paying for assisted living

When Will Health Insurers Pay for Someone’s Stay at an Assisted Living Community?

Assisted living communities have served an important role in the US’s health care continuum—often they have been the next stop for older people who have been discharged from a hospital or a skilled nursing facility. Assisted living communities assist their residents with medication management and activities of daily living. With such an important role serving seniors, why don’t insurers pay these providers to keep their constituents safe?

Apart from long-term care insurance, it is not common for health insurers to pay assisted living communities because many insurers and providers operate on a fee-for-service basis. That means providers charge the insurers for each procedure/line item. Under this payment structure, preventative care, like what is provided in assisted living communities is over looked by the insurers–much like your insurer now probably doesn’t pay for your vitamins or exercise classes.

The Center for Medicare and Medicaid Services(“CMS”) in tandem with private insurers, are experimenting with a fee-for-value payment model. Through this model, a cohort of providers are paid a flat fee to manage the health of the insurance company’s constituents. In this model, the group of providers can earn more money by reducing the health care costs of the insured population.

As this new fee-for-value system rolls out, assisted living communities will have an opportunity to take payments from insurance companies as a way to reduce the cost of managing the health care costs of their constituents, most notably through lowering readmission rates into hospitals.

If assisted living communities become part of the formal health care continuum, many will have to change the way they do business. Now, a lot of assisted living communities operate as hospitality companies with a sliver of supplemental care. That’s because these communities must woo consumers in to their communities and we believe they do that through enhancing their hospitality features over care capabilities. The way we understand consumers is they generally require a minimum level of care and then focus on choosing a community with the nicest hospitality features that they can afford.

Under a system by which an insurance company pays an assisted living community, a community must show it knows how to manage a population of people effectively. To do this, assisted living communities may have to improve their health care capabilities. A few notable aspects that Dr. Kevin O’Neil pointed out in his interview with Senior Housing News is senior living communities must work on systems to help prevent falls and manage the medications of its residents better1. That means communities may need to have software systems in place to track metrics about their residents, to train their staff to spot people who are a fall risk, and to hire more staff to manage the communities’ residents better.

Two things need to happen for assisted living communities to take payments from insurers: (1) assisted living communities need to focus more on providing health care; and (2) insurers and providers need to organize under a fee-for-value system. When those two aspects occur in a given market, then you will see assisted living communities take payments from insurers as a result of caring for the insurers’ constituents.





Power of Attorney
-This person can pay your bills, make investment decisions, market and sell your house
-Depending on how you want it written, it can become active immediately or based on certain criteria

Private Personal Information Profile
-Power of attorney will thank you if you have one of these

Physician Orders for Life-Sustaining Treatment – Good if you have a life-limiting condition, such as dementia and heart disease. Typically has four sections:
-CPR this is the same as the Do Not Resuscitate (“DNR”) form.
-Medical Interventions – life-sustaining treatments
-Artificial nutrition – feeding tubes

Advanced Healthcare Directive – Referenced when a patient cannot make his/her own decisions and is on life-sustaining treatment. Typically composed of two parts:
1. Living will – important for describing what you want your end of life treatment to be. You want to consider what level of mental awareness and physical functioning is acceptable for doctors to continue to provide prolonging treatments. Give a copy to friends, family, your physician, hospital, and lawyer. Carry something in your wallet that says you have an advanced directive and who to call to access it.
2. Medical power of attorney – you appoint a person to fill in the gaps that your living will doesn’t address. A doctor may reference both your living will and your medical power of attorney to create the POLST form, if you haven’t done so already.

HIPAA release – For someone that you trust to get access to your medical records.
-“The HIPAA Privacy Rule allows HIPAA-covered entities (healthcare providers, health plans, healthcare clearinghouses and business associates of covered entities) to use and disclose individually identifiable protected health information without an individual’s consent for treatment, payment and healthcare operations. In all cases, when individually identifiable protected health information needs to be disclosed, it must be limited to the ‘minimum necessary information’ to achieve the purpose for which the information is disclosed.”
-May come in handy so that your medical power of attorney or agent can have access to information that gives him or her the information to make decisions about you if you’re incapacitated, to dispute a bill, or to discuss medical conditions with your doctor if you’re still lucid.
-People also may give their lawyers permission, since their lawyer may have a copy of their living will.

Will or Living Trust
-Will – Gives directions on how to distribute assets after one dies, their estate will enter the probate process, by which a judge will give legal permission for assets to be distributed to heirs.
-Living Trust – may reduce legal fees in the long run, may have certain estate tax advantages, and mitigates the estate from going through probate.

End of Life Wishes –
-Talk with a funeral director to learn about your options and let you know the costs of each.
-Write down instructions and share them with family members and include them in your will or trust.
-Make sure you either pre-pay or have funds allocated to pay for your arrangements in your will or trust.


In this post, we describe the general differences between assisted living communities and nursing homes. We gathered the information below from Washington D.C. and Maryland sources. While the laws vary from state to state, generally, assisted living communities and nursing homes of each state operate similarly. Prior to your loved one moving into a nursing home or assisted living community, a nurse will assess him or her to make sure that he or she qualifies for the level of care that you are applying to. To save on costs, we recommend applying for the lowest level of care first. With that said, here is a guide to help you determine the appropriate setting of care for your loved one.

Assisted Living Communities

Assisted living communities may prepare meals, do house chores, organize activities, manage medications, and provide custodial care for their residents. Custodial care means helping with the six activities of daily living, which include: transferring, walking, toileting, bathing, dressing, and eating. Before becoming a resident, a nurse may assign a level of care to an applicant1.

Level 1 – Needs oversight of one or more of the ADLs
Level 2 – Needs occasional hands-on assistance with one or more ADLs
Level 3 – Needs frequent hands-on assistance with one or more ADLs

The community will charge the applicant based on the level of care the resident requires. If a person requires too much care, then the assisted living community may reject the application. A person cannot live in an assisted living community if he or she2:

  • Is dangerous to him/herself or to others
  • Needs more than intermittent skilled nursing care(generally needs more than 35 hours of home health or skilled care per week)
  • Need treatment of stage 3 or 4 ulcers
  • Needs ventilator services
  • Needs treatment for an active, infectious, and reportable disease or a disease or condition that requires more than contact isolation.

Nursing Homes

Nursing homes must provide three meals a day, housekeeping, laundry, and maintenance to the building. Just like assisted living communities, nursing homes also provide custodial care and medication management. They differ from assisted living communities because they can provide routine skilled care.

Most nursing homes employ nurses, physical therapists, occupational therapists, and doctors. With these professionals onboard, nursing homes can provide a higher level of care than assisted living communities. While some of the following services may be provided at an assisted living community, those who need the following on a routine basis should consider moving into a nursing home.

  • Immunizations
  • Feeding tubes
  • Catheters
  • Treatments requiring direct nurse supervision and observation

Those who require the following, even on an intermittent basis, should consider moving to a nursing home:

  • Ventilator services
  • Wound management, particularly stage 3 or 4 ulcers

Again, these are general rules, so if you are confused if your loved one requires too many skilled services or not, check with a nurse. If you don’t know one, then have one come assess your loved one from the assisted living community that you are considering. From our experience, nurses from assisted living communities are happy to qualify potential residents. If you’re not comfortable with that option, then some states have programs set up at local health departments to provide assessments. In Maryland, the program that does assessments is called Adult Evaluation and Review Services (AERS).

We also wanted to shed some light on the costs of assisted living communities and nursing homes. Here are the average monthly costs that we’ve researched in the DC, Maryland, and Virginia areas:

​Here are several payers for each type of care. Some payers require the applicant to qualify before the payer will sponsor the care. Not all counties have the same sources of payers as the ones we’ve listed below, but it’s worth checking with your county to see if the county has the program and if you qualify.

Once you’ve selected a care setting, if you still need help choosing the right community, we do an assessment using the following criteria: health, wealth, lifestyle, and preferred location. You can contact us here. You may choose to use our services for free or for a fee. We’re happy to help in the capacity that you choose.




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.