Long-Term Care

You may be able to receive long-term care in your home. It can include both skilled services (such as nursing services and physical, occupational or speech therapy) and non-skilled services (such as personal care, homemaker services and hospice care).

If you are in a nursing home and are planning on going home, you should talk about your needs with your nursing home social worker. In addition, you can call the designated home health agency in your area. Designated home health agencies are licensed by the State of Vermont to provide both skilled and non-skilled long-term care services. You can see a list of the agencies, here.

Medicaid or Medicare may pay for long-term care services provided in your home by licensed home health agencies. Other ways to pay include long-term care insurance and private pay (paying out-of-pocket).

There are also private companies that can provide non-skilled services (personal care), but not skilled care, in your home. These companies are not licensed by the state. They cannot receive payment from Medicaid or Medicare.

A nursing facility provides the highest level of long-term care. Nursing facilities provide room, board, nursing services and assistance with daily activities of living. These are things like dressing, eating, bathing and toileting. Nursing facilities must provide long-term care that allows residents to attain or maintain the highest practicable level of functioning.

There are several ways to pay for nursing facility expenses. They include “private pay” (paying out-of-pocket), long-term care insurance, Medicaid and Medicare. Most nursing homes accept Medicaid and Medicare coverage.

Residential care homes provide care to people who are unable to live independently, but do not need the level of care and services provided in a nursing home. In Vermont, a residential care home means: a place that provides room, board and personal care to three or more residents who are not related to the licensee.

Residential care homes must be licensed by the State of Vermont as either Level IV or Level III.

Both levels of residential care homes must provide:

• room and board
• assistance with personal care
• general supervision, and/or
• medication management

Level III homes also must provide the additional service of “nursing overview,” where a nurse oversees an individualized treatment plan to maintain a resident’s well-being.

Licensed residential care homes may accept Medicaid coverage, long-term care insurance and private pay (paying out-of-pocket).

An assisted living residence is a program or facility that combines housing, health and supportive services to support resident independence and aging in place. Assisted living residences must be licensed by the State of Vermont.

At a minimum, assisted living residences must offer these things within a home-like setting:

• private bedroom
• private bath
• living space
• kitchen capacity, and
• a lockable door

An assisted living residence must also provide:

• a daily program of activities and socialization opportunities – including access to community resources, and
• social services – including information, referral and coordination with other community programs and resources such as hospice, home health, transportation and other services to support a resident who is aging in place

An assisted living residence may not admit a person who has the following equipment, treatment or care needs:

• ventilator
• respirator
• stage III or IV decubitus ulcer
• nasopharangeal suctioning
• oral or tracheal suctioning, or
• two-person assistance to transfer from bed or chair, or to move about

A person who is already living in an assisted living residence and later develops a need for the equipment, treatment or care listed above or develops a terminal illness may be able to remain in the residence. This is true as long as the assisted living residence can safely meet the resident’s care needs, or the resident’s needs are met by an appropriate licensed provider.

Assisted living residences may accept Medicaid coverage, long-term care insurance and private pay (paying out-of-pocket).

Adult family care homes are available only if you are in Vermont’s Choices for Care Medicaid program. Adult Family Care (AFC) is a 24-hour, home-based, shared-living option. Authorized agencies contract with private, unlicensed family homes that serve one to two people who are not related to the family home provider. The home provider receives a stipend to provide services to the people in the adult family care home.

The Department of Disabilities, Aging and Independent Living supports two home share programs in Vermont:

• HomeShare Vermont serves Addison, Chittenden and Grand Isle Counties
• HomeShare Now serves Washington and Orange Counties

“Homesharing” arranges live-in matches between Vermonters who have a living space to share and others who need a place to live and can offer support (such as personal care, housekeeping and socialization).

HomeShare Vermont also helps seniors and people with disabilities find paid caregivers to help them remain in their homes.

Medicaid is a joint federal/state program that pays for long-term care expenses for eligible Vermonters. Whether Medicaid will pay for your long-term care is determined by federal and Vermont law. In Vermont the long-term care Medicaid program is called Choices for Care Long-Term Care Medicaid.

You must be found both financially and clinically eligible for Choices for Care in order for Medicaid to pay for your long-term care expenses. In general, you must have limited financial means and require total or extensive assistance with activities of daily living. These are things like dressing, bathing, toileting and eating.

Learn more about what Choices for Care Long-Term Medicaid covers and how to apply in the Choices for Care section of our website.

In a nursing facility: Medicare will pay for long-term care expenses in limited circumstances. Medicare will pay for nursing facility care when a person requires daily skilled care after a three-day hospital stay. Medicare will pay for a maximum of 100 days of nursing facility care per benefit period. A benefit period ends when you do not require skilled care for at least 60 days.

Medicare does not pay in full (100%) for the maximum 100 days.

Medicare pays 100% for days 1-20. For days 21-100 there is a copayment that you must pay. For 2020 the copayment was $176.00 per day. For 2021 it is $185.50 per day. If you have other insurance, such as a Medicare Supplement policy, it may cover your copayment.

If you require daily skilled care after 100 days, Medicare no longer pays any of your nursing facility expenses. You will need to pay with another kind of insurance or out of your own pocket.

In your home: Medicare can also be used to pay for skilled and non-skilled services provided by a licensed home health agency, when you are “confined to home” and in need of intermittent skilled services. Medicare coverage of these home health services is for a 60-day period. There is no limit to the number of 60-day periods you can have each year.

Long-term care insurance is an insurance policy you can buy to cover long-term care expenses for a period of time. You have to apply for long-term care insurance and you are not guaranteed acceptance. If you already need long-term care, you will not be able to purchase long-term care insurance.

If you are able to purchase it, you will be required to pay premiums until it is determined by the insurance company (as set forth by the terms of your policy) that they will pay for long-term care services.

The premium amounts you will pay depend on factors such as your age, medical history, family history and type of long-term insurance you purchase. Policies will vary in terms of coverage, such as when coverage begins, what long-term services and supports are included, and the length of coverage.

The decision on whether or not to purchase long-term care insurance is complex. You need to consider both the advantages and disadvantages of buying such a policy.

More Information on Long-Term Care Insurance

• NAIC (National Association of Insurance Commissioners) “Shopper’s Guide” (2013)
• Forbes article on the long-term care insurance market in the United States (2017)
• Forbes column about long-term care insurance (2016)