Options for Care When Home is No Longer an Option

While people almost always prefer to stay in their homes as they age, sometimes circumstances make this impractical.  All the same, a person who is unable or unwilling to live alone at home often will not need the level of care provided by a nursing home.  Fortunately, there is an array of “intermediate” living arrangements that may be appropriate for seniors with different needs and circumstances.

One popular option is the Continuing Care Retirement Community (“CCRC”).  A CCRC provides a “tiered” approach to addressing the aging process.  A person who can live independently would pay an “entrance fee” that can range from the low six figures to up to $1 million depending upon the facility, the type of apartment unit chosen, and the refund option, if any, selected.  People paying the lowest entrance fee would not receive any of the fee in return upon leaving the facility, and nothing would be paid to their heirs upon their death.  Those paying the higher buy-in fees would be entitled to a refund upon departure or death, typically ranging from 50% to 90%. In addition to the entrance fee, the resident would also pay a monthly fee typically ranging from $3,000 to $6,000 that usually includes one meal a day and unlimited use of the CCRC’s facilities, which may be quite luxurious.
 
One of the key benefits of a CCRC is that if a resident’s health declines, the facility offers varied levels of care that are included as part of the entrance fee and the monthly fee. A person may move from the independent living apartment to an assisted living unit, and finally to a nursing home unit, all within the same facility.  For married couples, this may be especially appealing since the “well” spouse can stay in the independent living apartment and still remain close to their spouse. 

New York also boasts a significant number of traditional Adult Homes, also known as Assisted Living Residences (“ALRs”). ALRs are licensed adult homes or enriched housing units that house five or more adult residents.  There are presently over 7,700 licensed ALR beds in New York State.

To pass muster, ALRs must provide twenty-four hour on-site monitoring, personal care services and/or home care services, daily meals and snacks, case management services, and an individualized service plan.  ALR costs are not covered by Medicaid or Medicare, although a resident’s medical care may be covered by one or both of those programs.  Long-term care insurance will usually (but not always) cover ALR costs, which can range from $1,500 to $6,500 a month.  There are currently approximately 550 ALR beds in Orange County.

Another level of care is the Enhanced Assisted Living Residence (“EALR”).  These facilities enable persons who require fairly significant assistance with daily needs such as walking or who may be incontinent to reside as independently as possible. With limited exceptions, EALRs are not suitable for persons requiring 24-hour skilled nursing care. 
 
New York also boasts a number of facilities covered under the Assisted Living Program (“ALP”).  An ALP is available to persons who are medically eligible for nursing home coverage but can be cared for in a less intensive setting.  Unlike ALRs, payment for residency at an ALP may be covered under the Medicaid program.  To be eligible, the resident is permitted to retain “non-exempt” resources of up to $14,400, and can retain monthly income of $1,404 per month.  Since an ALP is under the Community Medicaid program, there are no asset transfer penalties or “look back” periods imposed for Medicaid eligibility, unlike the nursing home Medicaid program that incorporates a 5-year look back period and imposes asset transfer penalties for non-exempt asset transfers made within the 5-year look back period.

While ALPs are attractive on many levels, the reality is that there are only 4,200 ALP beds throughout New York State, and only 95 eligible beds in Orange County, leaving many otherwise eligible folks searching for other options.

Aging is fraught with many emotional and possibly physical difficulties.  Having to to leave the comforts of one's home is a stressful reality for many seniors.  Given the range of choices available, it may be prudent to consult with an elder law attorney so that you can be sure that you are choosing the best option for your circumstances.