What is Long-Term Care?

When you think about "long-term care", you may think about care in a nursing home. Yet, long-term care includes an ever-changing array of services aimed at helping people compensate for limitations in their ability to live independently. Long-term care should meet your medical needs, as well as your social, financial and housing needs. It can range from assistance with household chores to assistance with activities of daily living to highly skilled medical care. Long-term care services may be provided in a variety of settings such as the home, community sites ( adult day care centers) or nursing homes.

The type and setting of long-term care services depend upon your particular needs. Those with physical illnesses or disabilities often need hands-on help with basic activities of daily living ("ADLs") including bathing, eating, dressing, toileting, continence and transferring. Those who are cognitively impaired usually require supervision or verbal reminders to perform routine activities or to stay out of harm's way.

Skilled care is provided on a doctor's order by medical personnel such as registered nurses or professional therapists. Although it can be provided in a nursing home, skilled care may be provided in the home by visiting nurses or therapists. Personal care (also known as "custodial care") is provided to help people perform ADLs but is less intensive than skilled care and does not require the services of a medical professional. Personal care may be provided in many settings, including a person's home or adult day care center.


How Much Could Long-Term Care Cost?

Nursing home care is the most expensive and intensive form of care. In 2007, a private pay patient's charge for a stay in a Massachusetts nursing home was approximately $275 per day 1 . Although the median 2 length of stay in a nursing home in 2004 was 471 days 3 , some stays last for many years. At $275 per day, the average annual cost of a nursing home stay exceeds $100,000, but it is not unusual for an individual to pay more  per year in some nursing homes.

Assisted living is another form of facility-based long-term care. If you lived in a single occupancy assisted living studio apartment, the cost of assisted living, including the cost of rent, food, electricity and heat, and many services such as personal care, housekeeping, meals and laundry,  would range from approximately $2,000 per month to more than $7,000 per month, or from $24,000 per year 4 . There is, however, great variation in services provided in assisted living facilities and prices could vary.

The cost of long-term care services provided outside of a nursing home varies depending on the type of service, as well as the intensity and duration of the service. In 2007, if you received 2 hours of skilled care from a nurse in your home, three times a week throughout the year, the average annual cost would have been approximately $28,080, or an average of $180 per day of care. If you received 2 hours of personal care from a home health aide in your home, three times a week throughout the year, the annual cost could have been approximately $10,920, or an average of $70 per day of care. 5

All the presented figures are subject to inflation. You should note that if long-term care costs were to increase by 5% annually, the overall cost would double in approximately 15 years.


Will You Need Long-Term Care? For How Long?

It is impossible to predict your individual chances of needing long-term care. For some, the need may follow a major illness, while for others the need may evolve more gradually. Some may require many years of long-term care, while others might need services for only a matter of months. The following chart outlines the probability of an individual being admitted to a nursing home at age 65.

Probability that a 65 year old will be in a nursing home
at some time during the rest of his/her life 6
Nursing Home Stay of:Chances for MenChances for Women
0 - 3 months11%11%
3-12 months8%10%
1- 5 years10%18%
More than 5 years4%13%
Of any duration33%52%

Please note that these figures do not include people who require home or community-based long-term care services. There are a large number of different services that are available to you in your home which can allow you to "age in place" and never have to move into a nursing home.

The above statistics also do not reflect the fact that as lifestyle and medical advancements allow people to live longer, more people will need long-term care. Therefore, your actual probability of needing at least some type of long-term care during your life is probably higher than these numbers suggest.


What Types Of Long-Term Care Services Are Available in Massachusetts and How Can You Access Them?

There are a variety of long-term care services in the Commonwealth that are regulated or monitored by a state agency. Listed below are brief descriptions of each of the services and what organizations to contact for more information. It is important to remember that each service has different financial, medical and functional eligibility requirements. Contact the agencies listed in Appendix A pdf format of Appendix_A.pdf file size 1MB to find out more about the services.


Services in the Home

Chore Services
  • Non-Medical services designed to maintain an individual's ability to live independently including shopping, planning menus, preparing meals, home delivered meals, laundry, and light house cleaning and maintenance, including vacuuming, dusting, dry mopping, dishwashing, cleaning the kitchen/bathroom and changing beds.

Contact your local Aging Services Access Points (ASAP) through the Executive Office of Elder Affairs. 7

Home Care

  • Non-medical services designed to maintain an individual's ability to live independently including shopping, planning menus, preparing meals, home delivered meals, laundry, and light house cleaning and maintenance, including vacuuming, dusting, dry mopping, dishwashing, cleaning the kitchen/bathroom and changing beds.

Contact your local ASAP through the Executive Office of Elder Affairs.

Personal Care

  • Non-medical services to help with activities of daily living, including assistance with bathing, bedpan routines, foot care, dressing, and care of dentures; shaving and grooming; assistance with eating; and assistance with moving around the home and getting in and out of bed and/or a wheelchair.

Contact your local ASAP through the Executive Office of Elder Affairs.

Home Health Care

  • Skilled medical and other services, including nursing, occupational therapy, physical therapy, speech therapy and home health aide services, are supplied by certified home health agencies and other professionals to help individuals remain at home.

Contact your local ASAP through the Executive Office of Elder Affairs or contact the Home Health Care Association of Massachusetts.

Services in a Community Setting

Social Day Care

  • Non-medical services designed to encourage physical and mental exercise and stimulate social interaction. Services are suited to the needs of participants with training, counseling and social services in a community setting, including assistance with walking, grooming eating and planned educational, recreational and social activities.

Contact your local ASAP through the Executive Office of Elder Affairs.

Adult Foster Care

  • Mostly non-medical services providing room, board, and personal care in a family-like setting to individuals who cannot live alone safely. Services include companionship, assistance with activities of daily living, host family training and monthly nurse and social worker visits to monitor placements.

Contact your local ASAP through the Executive Office of Elder Affairs.

Adult Day Health

  • Medical and other services allowing frail elders to remain in the community while coping with medical conditions, chronic debilitating illnesses or diseases that require careful monitoring and intervention. Services include therapeutic, nutritional, social and rehabilitative services, as well as support and education for participants, families and caregivers.

Contact your local ASAP through the Executive Office of Elder Affairs or contact the Division of Medical Assistance.

Dementia Day Care

  • Non-medical services in a structured, secure adult day program for individuals with dementia (Alzheimer's Disease or a related disorder) to maximize their functional capacity, reduce agitation, disruptive behavior and the need for psychoactive medication, and enhance cognitive functioning. This allows a person with dementia to stay in the community, provides the caregiver with respite from caregiving responsibilities and includes support and education for participants, families and caregivers.

Contact your local ASAP through the Executive Office of Elder Affairs.

Specialized Home or Facility Services

Respite Care

  • Medical and non-medical services to temporarily relieve caregivers of the daily stresses and demands of care for a family member. Respite could be for a few hours or a few days, depending on the needs of the caregiver and the resources available. In addition to home care, personal care and home health care, respite care services may include short-term placements in adult foster care, assisted living facilities and nursing facilities or rest homes.

Contact your local ASAP through the Executive Office of Elder Affairs.

Hospice Care

  • Medical services with an emphasis on providing comfort and pain relief for those who are terminally ill.

Contact Medicare or the Hospice Federation of Massachusetts.

Services in a Facility

Assisted Living

  • Independent housing that provides room, board and personal care, as well as a range of services, including social and educational programming and case management. Individuals can transition from completely independent housing units to extensive personal care within the same facility. Some assisted living facilities have designated units for persons with Alzheimer's Disease.

Contact the Executive Office of Elder Affairs, the Massachusetts Assisted Living Facilities Association or the Massachusetts Extended Care Federation.

Continuing Care Retirement Communities (CCRCs)

  • Housing, personal care and health care in one location. Although arrangements vary widely, individuals usually pay privately through an initial investment and then monthly service fees for a variety of services ranging from assisted living to nursing home care.

Contact the Executive Office of Elder Affairs or the Massachusetts Extended Care Federation.

Nursing Homes

  • A facility licensed by the Department of Public Health that is primarily engaged in providing nursing care and related services on an inpatient basis for short and long-term care stays at skilled, intermediate or custodial levels of care.

Contact the Department of Public Health, the Executive Office of Elder Affairs or the Massachusetts Extended Care Federation.

Who Pays the Costs of Long-Term Care?

At present, most long-term care is paid for from: (1) an individual's own resources, (2) his or her family's resources or (3) Medicaid, the federal-state government program designed to cover the health care costs of a mostly indigent population. Contrary to popular belief, traditional health insurance and Medicare usually provide little or no coverage for long-term care. Currently, most people who need long-term care services must pay for it on their own unless (a) they have long-term care insurance policies with benefits for the services they need or (b) they are or become eligible for Medicaid or other government assistance.

How Could You Plan to Pay for Long-Term Care?

Your personal circumstances should play a large role in determining how you will cover the costs of long-term care. You should consult professional advisors (such as an estate-planning lawyer or other qualified person) to consider your specific situation, including the impact of any option on your spouse or dependents, before making any decisions about how to finance your long-term care.

Savings, Pensions and Other Retirement Accounts

Many people save all their lives to have funds for retirement. These resources are intended not only to afford a comfortable standard of living in retirement, but also to prepare for certain predictable expenses, e.g., a new roof or a new car. These resources could also be considered to pay for long-term care costs.

You should consider all of your liquid assets, such as savings accounts, CDs (certificates of deposit), money market accounts, stocks, bonds, mutual funds, annuities, pension plans, profit sharing or employee stock option retirement plans and Individual Retirement Accounts (IRAs). You could use any of these sources to pay for long-term care services when they may be needed.

Residential and Real Property

In addition to your liquid assets, you may own other property that can contribute to paying for the costs of care. These assets could include your home, motor vehicle or other property. Although the value of these assets should be considered in making decisions, neither the Division of Insurance nor any other state agency recommend that any specific asset be sold.

Homeowners may also be able to tap into the value of their homes without selling them. Some financial organizations offer reverse mortgages or special loans that enable you to continue living in your own home. Some of these contracts will guarantee payments in return for a new mortgage on your home. If you wish to investigate this option, you should contact organizations such as Homeowners Options for Massachusetts Elders (HOME) at (800) 583-5337.

Private Insurance Plans: Life and Long-Term Care Insurance

Life Insurance Plans

Certain life insurance policies can be used to help finance your long-term care while you are still alive. As with other means of financing, you should check with your financial planner, either an estate lawyer or a qualified advisor, to determine the best course of action for someone in your specific circumstance. For more information about life insurance options, contact the Division of Insurance at (877) 563-4467 for a copy of Buying Life Insurance and Annuities in Massachusetts.

Cash Values

Whole life and universal life insurance policies have "cash values" that accrue throughout the life of the policy. Rather than have your beneficiaries receive the "face amount" or "policy value" of a plan upon your death, you can access the "cash value" of your policy at any time by either canceling the policy or obtaining a policy loan on the cash value. Please be aware that if you do cancel your policy and change your mind, you may not be able to reinstate the canceled life insurance policy at a later time and that there may be tax consequences.

Accelerated Death Benefits

Some life insurance policies include "living benefits" that may allow you to receive all or part of the "policy value" before death if you meet certain eligibility standards. Some of these policies will accelerate the death benefit on a tax-qualified basis to pay for long-term care services for chronically ill individuals. If you would like to investigate this option, use the worksheet in Appendix E. Also, be aware that these benefits will add to the cost of a life insurance policy and if accessed, will reduce the benefit that may be paid to your beneficiaries when you die.

Viatical Settlements

A growing number of companies called "viatical settlement firms" offer contracts allowing terminally or chronically ill individuals to obtain cash in return for making the firm the beneficiary of a life insurance policy. Anyone considering this option should be aware that these firms are not regulated under Massachusetts law and offer varying amounts of payments for viatical settlements. If you would like to investigate this option, consider contacting a number of firms before signing any such contracts.

Long-Term Care Insurance Plans

Long-term care insurance is a type of private health insurance that provides benefits to cover some of the costs of services you might need if you develop a chronic illness or cognitive impairment. A detailed discussion of long-term care insurance policies appears in Part Two of this Guide.


Government Programs

In Massachusetts, the state's Medicaid program, known as MassHealth, currently provides assistance for 70% of all nursing home residents. 8 In addition the Executive Office of Elder Affairs spends 70% of it's budget on long-term care services provided in Massachusetts, but pays almost entirely for home and community-based services. 9 To qualify for Medicaid or Elder Affairs assistance, a person may not have income or assets above a certain level.

Medicare

Many individuals incorrectly assume that Medicare will cover most of their long-term care costs. In fact, Medicare pays very little of all long-term care costs. IT IS NOT RECOMMENDED THAT YOU RELY ON MEDICARE TO PAY FOR YOUR LONG-TERM CARE NEEDS. Medicare covers only the following long-term care services:

Skilled Nursing Facility Benefit: After you have been in a hospital for at least three days, Medicare may pay for your care while you recover in a certified skilled nursing facility. It will only pay for up to 100 days, and you are responsible for a daily co-payment for every day in the nursing home between the 21st and the 100th day.

Home Health Benefit: If you are confined to your home, require skilled care for an injury or an illness and meet other specific criteria, Medicare can pay in full for services provided by a Medicare certified home health care agency. Your doctor must determine that you need home health care and set up a plan of care for you.

Medicare does not cover personal care services, such as assistance with dressing and bathing, unless you are homebound and are also getting skilled care such as nursing or therapy. Any covered personal care must also relate to the treatment of an illness or injury and you can only get a limited amount of personal care in any week.

Additionally, if you purchase a private Medicare Supplement plan (also called a Medigap plan) or enroll in a Medicare HMO plan, these plans will usually not pay for long-term care services that are not covered by Medicare. In Massachusetts, Medicare supplement policies do not cover long-term care costs, but Medicare Supplement 1 and Medicare Supplement 2 policies do pay for the co-payments for days 21 through 100 for Medicare-approved stays in nursing homes.

For a more detailed description regarding your Medicare benefits, contact the federal government at 1-800-841-2900 for the Guide to Health Insurance for People with Medicare. Also call the Massachusetts Division of Insurance at (877) 563-4467 for a copy of the Massachusetts Addendum to the federal guide.

Veterans Benefits

If you are a veteran, you may be eligible for some long-term care services in a Veterans Administration (VA) facility. To find out whether you would be eligible for assistance, contact your city/town government's Veterans Agent or the Massachusetts Department of Veterans' Services at (617) 727-3578.

The Home Care Program

This program, associated with the Executive Office of Elder Affairs, provides services to help frail elders live independently in their own home for as long as possible. Services available for income-eligible individuals include case management, home health aides, homemakers, home delivered meals, transportation, respite care and adult day care services. These services are provided through Aging Services Access Points (ASAPs) and regional Area Agencies on Aging. You can contact your ASAP through the Executive Office of Elder Affairs at 1-800-882-2003.

Medicaid

The Massachusetts Medicaid program, known as MassHealth, is administered by the state Division of Medical Assistance. MassHealth does pay for nursing home care and some home and community-based services for certain income-eligible people living in Massachusetts. To be eligible for MassHealth and receive long-term care services, you must meet state and federal eligibility rules. For more information about those who may be eligible for MassHealth and what services may be covered in this program, call the MassHealth Customer Service Center at 1-800-841-2900.



1 Source: Massachusetts Division of Health Care Finance and Policy data files for median charge, 2007.
2 A “median” is the middle number in a given sequence of numbers, and is a useful number in cases where the distribution has very large extreme values which would otherwise skew the data.  The mean (average) length of stay in a nursing home in 2004 was 827 days.
3 Source: Massachusetts Division of Health Care Finance and Policy, derived from Table 13 of the June 2008 report titled "The National Nursing Home Survey: 2004 Summary" from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.
4 Source: Massachusetts Assisted Living Facilities Association, as noted in 2008 Resources Guide.
5 Source: Home Care Alliance of Massachusetts, based on 2007 average hourly rates for home visits ($90 per hour for nurses; $35 for home health aides) x 2 hours per day x 3 days per week x 52 weeks in a year.
6 Kemper, P. and Murtaugh, C.M., Lifetime Use of Nursing Home Care, The New England Journal of Medicine, 324, (9), 595-600, February 1991.
7 Many of the services are offered by local Aging Services Access Points, or ASAPs, which used to be called Home Care Corporations. These are private non-profit providers in the community that offer services such as case management, home health, home care, home delivered meals, transportation, and respite care. The Executive Office of Elder Affairs designates and contracts with ASAPs.
8 Source: Massachusetts Division of Medical Assistance.
9 Source: Massachusetts Executive Office of Elder Affairs.