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Are you prepared for the future? Discover essential insights into long-term care options and planning, including home health care, assisted living, and financial assistance.

According to KFF, 57% of us will need assisted living, not uncommonly followed by nursing home care. 39% of us will need nursing home care. Absent a stroke, major heart attack or fall, most of us will begin with home health care.

Navigating Estate Planning and Medicaid Eligibility

While estate planning with a view toward the possible future need to establish Medicaid eligibility privileges planning with real property, making that property less liquid can create significant cash flow problems if we need home health care or assisted living.

A care manager can make arrangements, assess needs and advise us or family members or friends serving as our agents or an individual or a corporate trustee serving as our co-trustee or successor trustee. A revocable living trust can require or suggest that a care manager be hired, specify areas of inquiry, and how funds should be spent. This can be especially important for the rising tide of “orphan elders.” In every family, in every group of friends, there is bound to be someone who is the “last man standing.”

Understanding Home Health Care and Assisted Living

Medicare regulations allow a doctor to prescribe physical therapy and speech and language therapy and nurse visits at home. If one of these is prescribed, occupational therapy and visits by a certified nurse’s assistant can also be received. But while the regulations permit up to 28 hours per week, or 35 in special circumstances, the payment structure is such that we almost never see people receive more than six. The nurse may visit once per week, a therapist twice, and a certified nurse’s assistant three times, usually to help someone bathe. In addition, the frequency of required reassessments has increased to once a month, with those assessments cutting into actual care. Because of this, part of the hollowing out of Medicare, most home health care is provided by family members or is paid, usually at $30-35 per hour in four, eight or twelve hour shifts. Unless arrangements are made for live-in caregiving or a day rate, none of this is during the evening or on the weekends.

Relying on home health usually means relying, at least in part, on care by family members who may never be compensated or may be compensated by being named in a Transfer on Death or Lady Bird Deed.

Exploring Financial Assistance Programs

There is a Texas Medicaid waiver or demonstration program subsidizing 30-50 hours of homemaker and home health care per week to keep people who otherwise would need nursing home care at home but one cannot plan based on an assumption that the state legislature will adequately fund it or that a client will come to the top of the waitlist at a propitious moment.

Community attendant services of 12-20 hours per week and temporary respite and other temporary care available through the Administration on Community Living and administered by the local Area Agency on Aging target people with minimal assets and income.

VA Aid & Attendance, a cash benefit, 12-20 hours of home health care per week and, for military retirees, geriatric care may be available.

Most of us must cobble together one source and another. However large our nest egg, home health can rarely last forever: we must move into assisted living. “Memory care” is simply a wing in assisted living. Other than the VA, there is no public financial assistance for assisted living: it is all private pay. VA Aid & Attendance does pay for assisted living for veterans who qualify but the post-Vietnam service requirements are more onerous, meaning that fewer veterans will qualify in the years to come.

Medical necessity for assisted living is requiring “substantial assistance,” not just stand-by assistance, with at least two of the activities of daily living:

  • bathing and grooming,
  • dressing,
  • using the toilet,
  • maintaining bowel and bladder continence,
  • moving from one place to another or from one position to another, and
  • getting sufficient nutrition and hydration,

regardless of who prepares the meals. Medication management, making and getting to doctor’s appointments and communicating at them and similar tasks are not considered, however critical. Assisted living facilities typically charge extra for these or, in the case of doctor’s visits, leave arrangements to the family or a hired care manager.

Medical necessity for nursing home care is one of three things:

  1. experiencing cognitive decline to the extent that it is unsafe to remain at home or in the community;
  2. needing physical or speech and language therapy five days per week; or
  3. needing care provided by, at the direction of, or under the supervision of a nurse seven days per week.

Particularly if we live past the average age of 73 for men or 79 for women, we are likely to live for a decade with two or more chronic conditions, six to eight years of physical decline and a cognitive terminal drop in the three years before death. It is easy to see how we exhaust our resources paying for home health and assisted living and then find ourselves in a nursing home on Medicaid.

The best long-term care planning may well be living so as to delay needing long-term care.


Elder law attorney, Terry Garrett, CELA, is a member of the National Academy of Elder Law Attorneys and is an Approved Guardianship Attorney. She assists people in elder law, estate and special needs planning, guardianship and settling estates. She graduated with honors from Cornell University. She was on the Dean’s List at Wharton Business School. She earned her J.D. at Columbia Law School, receiving the Parker Award and a Mellon Fellowship.

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