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What Families in the U.S. Should Prepare For
For families living in the continental United States, Puerto Rico can become an attractive option when an aging parent needs more daily assistance.
Perhaps the parent was born in Puerto Rico and wants to return. Maybe relatives already live on the island. Or the family has discovered that residential elder care in Puerto Rico may offer options worth considering.
But before comparing homes, families need to understand something important:
Paying for an elderly home and paying for an older person’s medical care are usually two different things.
Medicare, Medicaid, Social Security, veterans benefits and private insurance may all play a role—but families should not assume that any one of them will automatically pay the monthly cost of an elderly home in Puerto Rico.
Start With the Actual Monthly Cost of the Home
There is no single price for elder care in Puerto Rico.
Homes vary considerably in size, location, staffing, room arrangements and the level of assistance residents require. A relatively independent older adult may have very different costs from someone who is bedridden, has dementia, requires extensive help with daily activities or needs close supervision.
Instead of asking only:
“How much is the monthly fee?”
ask:
“What would the total monthly cost be for my parent’s current level of care?”
That second question is much more useful.
Depending on the home, the monthly payment may include some combination of:
- Room and meals
- Laundry and housekeeping
- Assistance with bathing, dressing and toileting
- Medication supervision or administration
- Recreational activities
- General supervision
- Help with mobility and transfers
- Coordination with family members
Other services or supplies may cost extra.
Families should specifically ask whether additional charges apply for things such as diapers and personal-care supplies, transportation to medical appointments, increased assistance, special diets, one-to-one supervision, medical equipment, outside nursing services or changes in the resident’s condition.
A price that initially looks inexpensive can become much higher once additional services are added.
Do Not Assume Puerto Rico Uses the Same Care Categories as Your State
Families in the U.S. are accustomed to terms such as “assisted living,” “memory care,” “board and care,” “skilled nursing facility” and “nursing home.”
Puerto Rico has its own licensing system and terminology for residential establishments serving older adults.
For that reason, it is better to compare what the home actually provides rather than trying to match its name to a familiar mainland category.
Ask what assistance is available today—and what happens if your parent’s condition becomes more difficult six months or two years from now.
That can have a significant effect on the long-term cost.
Medicare Generally Does Not Pay the Monthly Residential Fee
This is one of the biggest financial misunderstandings families encounter.
Medicare is primarily health insurance. It generally does not pay for long-term custodial care when someone mainly needs help with activities such as bathing, dressing, eating and using the bathroom. Medicare also does not normally pay the ongoing room-and-board cost simply because an older adult lives in a residential care setting.
Medicare may still pay for covered medical services the person receives while living there, depending on the circumstances.
For example, Medicare coverage may apply to qualifying physician services, hospital treatment, certain therapies, medical equipment or short-term skilled nursing care when Medicare requirements are met.
But that is very different from Medicare paying the home’s monthly bill.
Families considering Puerto Rico should build their budget assuming that the residential portion of care may need another source of payment.
Medicaid in Puerto Rico Is Not Simply “Medicaid in Another State”
This is another area where mainland assumptions can cause problems.
Puerto Rico has its own Medicaid program, administered through the Puerto Rico Department of Health and the government health plan known as Plan Vital. The federal Centers for Medicare & Medicaid Services specifically notes that Puerto Rico’s Medicaid program operates differently from programs in the 50 states and Washington, D.C.
Plan Vital provides health coverage to eligible Puerto Rico residents through managed-care organizations.
Families should not, however, assume that because Medicaid in their home state may help finance nursing-home care, Puerto Rico Medicaid will automatically pay the monthly bill at the elderly home they select.
Puerto Rico has been developing and expanding its long-term services and supports system, and recent Puerto Rico Medicaid planning documents continue to describe broader LTSS development as an area of ongoing work.
The safest approach is simple:
Never choose a home based on the assumption that Medicaid will eventually pay for it.
If Medicaid assistance is important to the family’s financial plan, confirm the individual’s Puerto Rico Medicaid eligibility and ask the program specifically whether the particular type of facility and service being considered is covered.
Puerto Rico’s Medicaid program provides an online application process and local Medicaid offices for eligibility assistance.
Social Security Retirement Benefits and SSI Are Not the Same Thing
This distinction is extremely important for someone moving from the mainland United States.
Regular Social Security retirement benefits are based primarily on a person’s work history and Social Security contributions. Puerto Rico has hundreds of thousands of residents currently receiving Social Security retirement, disability and survivor benefits.
Those monthly benefits are often an important source of income that families can apply toward residential care.
Supplemental Security Income (SSI), however, is different.
SSI is a needs-based federal program for qualifying older adults and people who are blind or disabled and have very limited income and resources.
Under current Social Security Administration rules, a person generally must reside in one of the 50 states, the District of Columbia or the Northern Mariana Islands to receive SSI. Puerto Rico residents are generally not eligible.
That means a family whose parent currently receives SSI in a state should not assume that the SSI payment will continue unchanged after a permanent move to Puerto Rico.
Contact Social Security before relocating.
This can materially change the family’s care budget.
Veterans and Surviving Spouses Should Check VA Benefits
If the older adult is a veteran—or in some circumstances the surviving spouse of a veteran—another important program to investigate is the Department of Veterans Affairs Aid and Attendance benefit.
Aid and Attendance can provide additional monthly payments to qualifying people who already receive a VA pension and meet additional requirements.
Eligibility may include situations in which someone needs another person’s help with everyday activities such as bathing, feeding or dressing, is largely confined to bed, has qualifying severe vision limitations, or resides in a nursing home because of physical or mental disability.
It is not available to every veteran, and income, assets, pension eligibility and care needs matter.
But families with military service in their history should investigate it rather than assuming they do not qualify.
For some families, an additional monthly VA benefit can become an important part of the elder-care budget.
Long-Term Care Insurance May Help—But Check the Policy Before Moving
If your parent has long-term care insurance, find the actual policy before choosing a home in Puerto Rico.
Do not rely on a decades-old memory that “Mom has nursing-home insurance.”
Ask the insurer:
- Does the policy cover care in Puerto Rico?
- What type of licensed facility qualifies?
- Does the home have to meet specific staffing or licensing requirements?
- Is there an elimination or waiting period?
- What level of assistance triggers benefits?
- Is there a maximum daily or monthly benefit?
- Is there a lifetime maximum?
- What documentation will the facility need to provide?
Ideally, obtain the insurer’s answer before signing a residential agreement.
Puerto Rico Government Programs May Provide Additional Help
Puerto Rico’s Department of the Family operates programs serving older adults and economically vulnerable residents.
The Administration for Families and Children (ADFAN) includes social services for older adults, while other Department of the Family programs provide assistance such as nutritional support for eligible individuals.
These programs should not be interpreted as a promise that the government will pay for a privately selected elderly home.
Rather, they are resources families can investigate when an older adult has limited income, lacks family support or needs assistance identifying available services.
The correct program will depend on the person’s financial situation, level of care and circumstances.
Build Two Budgets, Not One
For a family coordinating care from the States, one of the simplest ways to avoid confusion is to create two separate monthly budgets.
Budget 1: Residential Care
Include:
- Monthly elderly-home fee
- Additional level-of-care charges
- Personal supplies
- Clothing
- Transportation
- Special supervision
- Personal spending
- Services not included in the contract
Budget 2: Health Care
Include:
- Medicare premiums
- Medicare Advantage or prescription-plan costs
- Copayments and deductibles
- Prescription drugs
- Medical equipment
- Dental, vision and hearing expenses
- Services not covered by insurance
Then list the parent’s available income separately:
- Social Security retirement
- Pension income
- Savings
- Investment income
- Long-term care insurance
- VA benefits, if eligible
- Family contributions
- Other verified assistance
This gives the family a much more realistic picture than simply comparing the home’s advertised monthly price.
Questions to Ask Every Elderly Home Before Signing
When comparing homes in Puerto Rico, ask for the financial terms in writing.
At minimum, ask:
- What is the base monthly charge?
- What exactly is included?
- Which services cost extra?
- Does the price change when the resident needs more assistance?
- Is medication management included?
- Are personal supplies included?
- Is transportation included?
- Is there an admission fee or security deposit?
- How much notice is required before a rate increase?
- What happens financially if the resident is hospitalized for several days or weeks?
- What circumstances could require the resident to move to a higher level of care?
- What payment methods or public-benefit programs does the home actually accept?
If the answer to an important cost question is vague, ask again before signing.
The Most Important Financial Rule
If you are arranging elder care in Puerto Rico while living in Florida, New York, Texas or somewhere else in the States, try not to build the plan around money that might become available later.
Build it around income and benefits that have already been confirmed.
A good financial plan should answer three questions before the move:
How much will the home actually cost?
Which medical expenses will insurance cover?
Where will the remaining monthly money come from?
Once those three numbers make sense together, the family can evaluate the home itself instead of discovering financial surprises after the parent has already moved.
HogarDeAncianos.com can help families identify elderly homes throughout Puerto Rico and begin comparing options. Before making a final decision, families should speak directly with the home and independently verify any government, insurance or veterans benefit they plan to use.
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