If you’ve read the excellent KFF Health News/New York Times series “Dying Broke” or attended HJ24’s session on reporting on the growing crisis in long-term care, then you may have some sense of just how broken long-term care is in USA system is.
Reporting for long-term care can be a bit complicated, due to overlapping payment sources, federal versus state regulations, and a large number of local and state programs, services, and supports. Here’s what to keep in mind as you follow stories on this topic.
Payment options
- Medicare
Many people assume that nursing home care is covered by their Medicare or Medicare Advantage plan. However, Medicare does not pay for long-term nursing home coverage. It pays for skilled care in a rehabilitation or nursing facility for a limited period of time — 100 days per benefit period — that is “necessary to improve or maintain your current condition, or to prevent or delay its worsening.” , after a qualifying hospital stay for a serious condition (think broken hip, heart surgery, head injury, etc.). Qualified senior facilities are often associated with nursing homes, thus leading to some confusion. Original Medicare will cover home health care in conjunction with skilled nursing care or therapy, but not as a stand-alone service. It also does not cover care for assistance with activities of daily living, such as bathing, dressing or toileting. - Medicaid
This is the joint federal-state health program that covers health care for those below certain income levels, including adults under the age of 65 and children. Eligibility varies by state, though most have expanded eligibility limits under the Affordable Care Act. Many older adults have both Medicare and Medicaid and are considered dual eligible. (This January 2024 tip sheet provides more specifics). Medicaid pays for 60% of nursing home care in the US - Providing long-term care
While coverage varies by policy, long-term care insurance typically pays for all or part of nursing home care, some assisted living expenses, home health care, elder day care, and other services that may an older adult is required. Premiums vary and policies can be difficult to obtain, as few companies offer this coverage. Companies also often limit coverage due to pre-existing conditions or have high premiums.
Housing and care support
- Nursing homes
These facilities offer the highest level of care, including nursing, 24-hour supervision, three meals a day and assistance with daily activities. Rehabilitation services, such as physical, occupational and speech therapy, are also available. The average annual cost of nursing home care in the US in 2023 was $104,000 for a semi-private room and $116,000 for a private room, according to Genworth Financial’s Cost of Care Survey. Expenses are paid either out of pocket or with help from Medicaid or long-term care insurance. - Assisted living
These can be a good fit for people who need help with daily care, but not as much help as a nursing home provides. Facilities range in size from 25 residents to 100 or more. Residents usually have their own rooms or apartments, with shared living and dining spaces. Different levels of care are offered, with residents paying more for additional services. The average cost of assisted living in the United States is $4,500 a month, or $54,000 a year, according to the National Council on Aging. Cost varies by state, type of community/facility and level of care needed. Genworth Financial’s Cost of Care Survey pegs this cost at $5,300 per month, or $64,000 per year based on 2023 data. - Boarding and care homes
These are also known as group homes or tenements, usually with 20 or fewer residents. Rooms can be private or shared, and residents receive help with personal care and meals. Skilled nursing or medical care is usually not provided. Costs are primarily borne by the resident or their family—Medicare does not cover these costs, although Medicaid may provide partial coverage, depending on the state and eligibility. - Continuing care retirement communities
Also known as CCRCs or life care communities, this option offers different levels of care on a campus, depending on need. Many residents start out in independent living, then may move into an assisted living facility or receive home care in their own independent unit. If necessary, they can enter the community nursing home. CCRCs can be very expensive—communities typically charge a one-time entry fee and a monthly fee after that. Most of the cost is out-of-pocket, although Medicare, Medicaid, and long-term care insurance may cover some services, depending on the level of care provided. - Home health care
Don’t confuse home health care with home care. There are two different types of services. Home health care includes a variety of clinical services provided by licensed nurses and therapists that are provided at home for an illness or injury. This may include intermittent nursing care, physical, speech, or occupational therapy, or other skilled health services. Home health care is usually only needed for a short time as an alternative to hospital care. Medicare has strict eligibility criteria for home health care services. - Care at home
This is unskilled care provided by professional caregivers, such as bathing, feeding, dressing, helping with meals, helping with walking, transportation, or other daily tasks. These services may be covered by Medicare if they are part of broader home health care coverage—for example, if a person is unable to leave home due to illness or injury and needs help with bathing or dressing . Some Medicare Advantage plans and long-term care insurance policies will pay for home care aides or attendants, but there are usually limits on the number of hours or days for this care. Many people hire home care aides privately, either through a licensed home care agency or through word of mouth, which can be less expensive but is also unregulated. Private pay home care can quickly become expensive. On average, 44 hours of home care per week can cost someone about $75,000 per year. - Some Medicare Advantage plans will cover the cost of some home care services, such as companion care and help with certain activities such as transportation or shopping. Some plans offer a limited number of hours of home care, meal delivery or other support, but for those who need more care, this option fills up quickly. Additionally, a 2024 study from the University of Washington School of Medicine found that Medicare Advantage beneficiaries actually receive fewer home health visits and have worse outcomes than those on original Medicare.
- Adult day services/day care
These services can be of help to older adults, people with disabilities and their caregivers. They are a safe, community-based environment for those who need supervision during the day or who could benefit from social interaction and engagement. According to the National Association of Senior Day Services, these day centers can address many of the health and nutritional needs of seniors along with cognitive or physical limitations in professionally staffed group settings. There are more than 7,500 adult day care centers across the United States that provide a supportive culture for those who need help. They allow caregivers to continue working during the day, and at an average cost of $2,000 per month, they are a more affordable alternative to other long-term services. NASDA’s center locator can help families find a convenient center near them. - Community services and supports
These are specific programs or services offered to seniors in the community who need assistance. It may be due to cognitive decline, frailty, inability to drive, or inability to do household tasks such as cooking or shopping due to chronic illness or other aging-related reasons. Area agencies on aging or your city, county, or state office on aging is usually the best place to learn about various community services, which may include medical care, home maintenance and repair, transportation, nutrition, and more. . Many programs have waiting lists and income eligibility may apply. It can also take time to find and sign up for many of these services. However, community programs such as PACE and CAPABLE are among those that help seniors age at home rather than in institutional settings and also reduce health care costs.
The reality is that for many older Americans, long-term care and support is a collection of family, friends, neighbors, and some cobbled together community services like Meals on Wheels or friendly visitor programs. An older person may not be sick or frail enough to need nursing home care, assisted living facilities are financially out of reach for many, and most seniors prefer to age in place whenever possible. Possible.
When reporting on long-term aged care, it is important to keep in mind the differences in and between payment, accommodation and service options. Services and programs vary by state, insurance plan, and community. For example, it is often harder to find help at home in rural areas, while those living in cities may pay more for help than those living in the suburbs.
Story ideas
- Contact your local agency on aging – are there waiting lists for certain programs, like PACE? Why? Is it a lack of participating doctors, state budget cuts, high demand or some other reason?
- Profile of a caregiver (or several) trying to balance outside employment with caring for an elderly parent. How are they managing? Do they get outside help through an aide or adult day care? How is this affecting their work? Look at both the financial and emotional costs.
- Is there such a thing as “affordable” assisted living? What is the average cost of living in such a facility in your community? What options are there for everyone else who can’t afford that level of care?
- Assisted living facilities are regulated and licensed by each state, not federally. Do they meet your community’s personnel and other requirements? How often are they inspected and by whom? What kind of offenses have they been penalized for – and are these offenses made public? If not, why not? Where can consumers go for information?
- Many communities are struggling to find home care and nursing home staff – what is the situation in your community? Are the agencies or facilities offering additional incentives or training and a real career path?
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