✨ Residence and Care Agreements

I am looking into the option of buying into a CCRC. I would appreciate some answers from the NaCCRA members at different CCRCs to the following questions:

1. How common is it for CCRCs to offer their ALF and SNF facilities to non-residents who did not pay an entry fee? While most of the contracts I looked at mentioned nothing about the CCRCs accepting “outsiders”, the contracts stipulated that if if one needs a room in the healthcare Facility and there is none, the resident will be moved off campus to another place selected by the CCRC. In this case, the resident has the option to move back (at their own expense) if and when a room becomes available. Does it happen often that residents are told to move to another place off campus?

2. Some of the Type A contracts I looked at also stated that in case there are no rooms available in ALF, the CCRC resident has the option to hire assistance in their Independent living residence at their own expense, while paying the very high monthly fees for the type A contract. Is this common in Type A contracts?

3. Is it common to see in Type A contracts an open ended list of healthcare exclusions (provided only as examples)? Then they specify that if the type of service is not available at their facility, the resident is on their own.

Thanks in advance.

P.S. This being the first time I use this forum, please let me know if I get notified via email if someone posts an answer. Also do members have to actively look at the forum to know if there is a question?

Susan,

I am sure you understand that with the exception if an equity type CCRC, you are not buying anything but are signing a contract. In return the provider agrees to provide certain services and you agree to abide by certain rules and regulations, which include paying a monthly fee, and perhaps a substantial entry fee. If some or part of this fee is refundable, take special note of how these refundable funds are accounted for on the financial statements.

It I not uncommon for CCRCs to offer their ALF and SNF facilities to non-residents who did not pay an entry fee. These are commonly known as direct admits or non-contract holders. The contract should cover the terms if a bed is not available.

As for #3, from my experience, yes, but I have not reviewed many contracts.

You should be notified of a reply if you checked that option.

Jim Haynes

Susan, regarding #3,if a Provider is not licensed for or able to treat a particular medical condition, a Type A Contract usually has a clause that addresses that stipulation/exception to providing residents such medical care in Assisted Living and Skilled Nursing/Memory Care. For example, some Alzheimer's conditions cannot always be managed by a CCRC facility. Other serious medical conditions may also be beyond the "scope" of care by the CCRC.

It is a good idea to have a legal advisor and/or a financial advisor go over the Contract with you prior to signing such a document to determine the obligations you will be entitled to if you should have to move to different levels of care.

Good luck in your quest.

Thanks for the replies.

Being knew to the forum I could not figure out where to check the option for being notified about an answer. I looked at my profile and it is not there unless I missed it. I'd appreciate a pointer to where this option might be.

Sorry, I used the wrong term, I know I am not "buying" anything....

Susan, contracts are written in favor of the CCRC owner / management. it is common for CCRCs to say if there is no room available in advanced care that they can move you anywhere, without stipulating where. One might consider that they would act to protect their reputation and would act as best they can to have you get good care. And this may never have happened. But there is no guarantee.

An attorney looked at my contact, one of the largest CCRCs, when I had residence (older building) problems after moving in. She pointed out nothing is guaranteed, forget whatever marketing and sales told you, only the contract matters. She said even life care is not guaranteed. States do not have regulation to protect those in independent living, at most some states have something about having financial documents submitted, so you can see those. I think many residents are very happy. Some are not, but they sold their home so no where to return to, can't move in with the kids (may have none), gave the money (a large chunk of their life savings) to the CCRC mostly as a non-refundable fee. Most residents are in their 80s and up, many are frail, and are there for the life care. They probably are focused on health care and not concerned much on problems with their residence, food, etc. Younger retirees, as CCRCs court them more now, may care about the overall community, so it is important that prospective residents talk with residents inside to know about any issues. It is hard to meet some, sales matches those considering a move in with happy residents for dinner (some who get a fee for helping with a sale as I learned in one community). Here, again a very large CCRC, management often just does not reply to resident's complaints, some health related. They manage by silence if they don't want to deal with something, because they can, so some residents are frustrated. You can get some attention at the resident council, but that has limitations and not for personal issues, with one vote really - management's. Those in assisted living in my state have a state level bill of rights. Not those in independent living. If you leave, on a non-refundable entrance fee, guess what.

Susan,

There doesn’t seem to be any way you can be notified by email of responses to messages posted by you specifically. But the “Forums” section of the Profile includes the option of having all messages of specific forums, or of all forums, emailed to you.  

If you want the messages of all forums emailed, select “Forum General Preferences”, and then under “Message Delivery” check “Send Email”.  

If you want the messages of only specific forums emailed, do the same thing, but also do the following: Select “Forum Memberships”.  For each forum of interest, click on the pencil icon on the right hand side.

Then under “Message Delivery” check “Send Email”.

Concerning your question #1:  

Although it is common for CCRCs to admit nonresidents to their special care facilities, this would not be mentioned in the contract because the contract is intended only for residents. This practice helps the CCRC to keep costs down for the residents, by charging market rates for beds or apartments in the special care facilities not occupied by residents.

From my own experience in checking out various CCRCs, I think it isn’t very often that it’s necessary for a CCRC resident in need of special care to get that care away from their own CCRC. In the case of a Type A contract at least, the cost should be covered by your own CCRC. Also, you can ask the CCRC how often it happens, and what are the facilities used.

Question #2:

I don’t know how common it is for CCRCs to allow a resident to hire assistance to enable them to live in their IL apartment if no space is available in the ALF. Yes, the monthly fee of a Type A CCRC is relatively high, but this is an option, not a requirement. The alternative is to transfer to a different facility. I have heard of instances where residents would prefer to hire assistance to stay in IL, rather than transfer to their own CCRC’s ALF, but this may not be permitted. The CCRC may not allow it because it’s judged that there would be a safety risk, even with one-on-one assistance.

Question #3:

I don’t quite understand what you are saying is in a contract. I would think a contract would have to be specific and definite (not an “open-ended list” just as examples) about what health conditions are not covered.

Thanks, wanttoknow and Linda.

What I found unreasonable in the contract mentioned in Question #2 is that when the CCRC runs out of space by bringing in non residents to ALF (not even because the space is full with residents), it makes residents double pay for ALF: through the monthly fee for the type A contract and then by forcing the resident to hire outside help and pay for it, with zero discount in the monthly fee. At least this specific contract spells this out. Yes, moving to a different facility might be an "option", but isn't one of the major benefits advertised for a CCRC the availability of continuum care on the same campus?

As far as Question# 3 goes, this is what the contract states for this Type A agreement:

"Health Care Exclusions: Waverly Heights, at its discretion, may provide any of the services not covered by the Monthly Fee or the required insurances at an additional charge, or refer you to another provider capable of providing such services. Health Care exclusions are not covered by the Monthly Fee. They include, but are not limited to: specialized or sub-acute treatment as defined by Waverly Heights, physical, occupational, and speech therapy, IV therapy, medical or diagnostic tests, physician services, ....." - and the list goes on.

I am not a lawyer, but this tells me that this specific CCRC can provide or exclude whatever healthcare services they want, at any time they decide so. I am wondering what is then the high monthly fee for, for this Type A contract when under healthcare (the most important reason to be in a CCRC for most of us) anything can be excluded. Is it common to see this type of open ended list of exclusions in a Type A contract?

I will go back and check again my profile's settings, as I was still not notified about your posts.

Susan,

Re question #2:

Yes, the availability of a continuum of care on the same campus is a major benefit of the CCRC model. But this doesn’t work perfectly, and one needs to be aware of this before making any commitment—in part by making the effort to understand the contract, as you are doing.

One Type A CCRC with which I’m familiar doesn’t take in non-residents to their special care facilities, but still has had a problem with finding room in AL for all the residents who need that.

There’s a trade-off involved in maintaining adequate space and staff to handle all resident special care needs vs. keeping the entrance and monthly fees affordable for present and prospective residents. I have wondered how those CCRCs which take in non-residents to their special care facilities attempt to calibrate how many they can take in without depriving residents of needed care on-site.

It might help to find out what the experience of a CCRC has been with regard to running out of space in the special care facilities. Beyond asking the marketing person, there may be opportunities to get information directly from residents. Many CCRCs provide prospective residents with various ways to interact with residents as part of the marketing and application process.  

I haven’t before heard of any Type A CCRC that requires residents to hire their own help in IL, if there’s no room for them in AL, no matter what the reason. That would indeed be a violation of the Type A concept. Can you quote the language of the contract?

Re question #3:

I don’t believe that the Type A CCRC monthly fee is intended to provide all health care—just what is referred to as “custodial care”. Assisted living provides assistance with “activities of daily living”—bathing, dressing, etc. Skilled nursing provides skilled nursing, which goes beyond assisted living with more intensive care usually provided by certified nursing assistants supervised by a registered nurse.  

Most of the non-custodial health care needed should be covered by Medicare.

Look at what the Type A contract you have says is covered. A Type A contract I have refers to an appendix, which is actually a Skilled Nursing admission agreement, which explains what supplies and services are covered by the monthly fee in Skilled Nursing. The contract also includes a section on “Excluded Health Services”, which starts out by excluding everything not expressly stated as covered elsewhere in the contract, and goes on to list many specific exclusions.

A specific exclusion that just caught my attention is “any items or services for which no reimbursement is available from Medicare, or a similar govermental insurance program for which you qualify;”. This would include the “routine skilled nursing care at the Health Center” which the contract earlier says is covered by the monthly fee!

Hi wantoknow:

Despite following instructions for setting my profile to be notified about posting to all forums, I was not notified about your reply.....

Question #2

You asked about the language in the type A contract about assisted living services when there is no room in ALF. Here is what it states, knowing that in Pennsylvania, (where this specific CCRC is) there are 2 differed types of assisted living services, one of them being "personal care":

"Personal Care will be provided in a Waverly Heights Personal Care unit on a temporary or permanent basis in a manner consistent with the requirements of licensing authorities. The Monthly Fee will cover only Personal Care. If a personal care unit is not available, you may have the option of remaining in your residential unit with private companions at your expense or Waverly Heights might provide the services it determines are necessary to care for you in its skilled nursing facility."

The contract doesn't specify anywhere who are the licensing authorities (something that one can find out) or what "manner consistent with the requirements of licensing authorities" might mean...

Question #3

Both AARP and other resources (books, A Place for Mom state that: "an extensive contract (type A) is the most expensive agreement, and it gives residents unlimited access to health care with little or no increase in the monthly fee”....

This contract I am looking at leaves the door open for expanding the list of exclusions as the CCRC decides.

Medicare doesn't pay to the best of my knowledge for routine healthcare in a nursing home; it only pays for temporary "skilled nursing" after a surgery or accident, etc. Even that it is limited. I might be wrong...

The more I learn about these CCRCs, the more worried I am. They sound like a trap with no reasonable option out, with a resident having an uncontrollable major risk hanging over their head. One has to be lucky for things to turn out the way one would hope. The problem is that there are no enticing and easy options for dealing with what's coming when one starts to have health issues.

Also I could not find any resource where I could easily search for CCRCs by parameters that might be of interest to me (e.g. all CCRCs in Connecticut which have type A contracts, are in the suburb of a large city, close to hospitals and a university, etc...).

Susan,

I just discovered that, although in “Forum General Preferences” I had checked the boxes for “Send Forum Messages To Me Via Emaii” and  “to apply these message delivery options to all my forums”, in “Forum Memberships” it says “This forum does not send emails.” for eleven of the forums including this one.  So I didn’t know until now that you had responded to my last message.

Re #2:

I am not an expert, but I would not consider this a true Type A contract because it says if a personal care unit is not available, “Waverly Heights might provide the services it determines are necessary . . in its skilled nursing facility.”

If the contract itself says it is Type A, it would be interesting to know if the use of this term in the contract is sanctioned by the Pennsylvania Insurance Dept., (the regulator of CCRCs), and, if so, how the Pennsylvania Insurance Dept. defines it.  

https://www.insurance.pa.gov/Coverage/ContinuingCare/Pages/default.aspx

It might be informative to read the Insurance Dept.’s instructions to CCRCs about their required Disclosure Statements, or the CCRC regulations.

A contract I have for a facility in another state (not labeled “Type A”), says “If such care is appropriate in the Assisted Living Section but space is unavailable, (name of facility) shall arrange for your care at an alternate site on or off the premises of the Community until space becomes available.”

The contract isn’t going to say anything about the “requirements of licensing authorities” because these may change over time. In Pennsylvania Personal Care Homes are licensed by the Dept. of Human Services.

Re #3:

You are right in what you said about what Medicare covers in a nursing home.  

Have you looked at the contracts of any other CCRCs? 

Do you feel that CCRCs are a “a trap with no reasonable option out, with a resident having an uncontrollable major risk hanging over their head” because of having to commit a large sum of money up front?

I have found this website helpful in researching CCRCs.

https://mylifesite.net

Thanks for the pointers. If I decide to pursue this CCRC any further, I will definitely check what the Pennsylvania Ins. Dept has to say.

I will try to see if Jim Hynes can change something to enable email notifications to be sent for selected or all forums. One cannot keep checking to see if something was posted or not...

Yes, I am looking at other contracts and learning a lot from them. They are very "tricky", to put it nicely.

I am worried about the CCRCs as I can see that the huge amount of $s one has to pay upfront is unsecured and because residents in most places have little or no say in what management does. If a CCRC is doing poorly, it can go bankrupt and best case even if residents do not end up on the street, it can be restructured, taken over, etc. with contracts meaning little and residents having to put up with diminished services, etc. Residents have little or no protection as there is not federal regulation and states are very taxed about what they do. At least this is my conclusion based on what I learned until now.

I am quite familiar with mylifesite. They recently changed their business model and now CCRCs pay if they want their information published. It will take time for the new database to be populated and have at least some of the info the prior version had. I hope it builds back and that it will be sustainable, as there is no other useful resource for CCRCs which is not just marketing info for those that are listed.

One of the best resources for people like me looking at options would be this website, if it was used to capture anonymous information from all members (residents) to provide "insider" info about topics important to prospects.

Susan,

When I first started exploring CCRCs I subscribed to the semi-annual or quarterly print-magazine Sourcebooks put out by this organization, and found them an excellent source of information for getting started on the search. Now, of course, they have a website. They cover the Mid-Atlantic area from New Jersey to Virginia

https://www.retirementlivingsourcebook.com/about-us

Thanks!

It is a very rough road and a lot of homework is required. We live in Portland, OR but do not know yet if we want to stay here. If I were to move, I'd rather be on the East Coast .... This is a 2-3 year project for me, for now I am learning.

The Subscribe button is on the right side of the screen between Switch to Threaded View and Return to Forum buttons, as part of the thread itself. When you reply, it should be there.

I do not get what you describe. I'll try an experiment in the General forum, to see if starting a thread gives me the ability to subscribe to it.

I am sorry... I am sure that you are logged in (it is displayed only then) and that the screens are the same for all of us. I sent you my email, I cannot explain it better.

Regardless, it was nice exchanging info with you. Stay well!

Susan,

I realize this is a delayed reply to your post of last July about considering the East Coast v. Portland OR.

I was raised in the midwest and lived/worked in TX, ID, CA. Our first CCRC (that didn't work out) was TX.

I looked at a map of the lower 48 for "What's next? Where can I avoid bitterly cold weather? What areas have I heard good things about? What state regulates the industry better than TX does?" Because I don't have offspring, staying close to family and grandkids was not part of the decision. State chosen: North Carolina. We knew no one already living in the area.

So here are some observations:

I lived and worked in three different time zones prior to coming to Eastern (Central, Mountain, and Pacific). Eastern was the toughest for me to get used to. I'm a sports fan, so some televised events went well into late hours. Our DVR helps with recording the evening news that comes on during dinner hour, versus 5:30 p.m. elsewhere in the county.

We discovered we could easily Amtrak to interesting places, since our CCRC is 6 minutes from a train station. We've "amtraked" to Wash DC, NYC, etc. where one really doesn't need their own car. We haven't tried going south yet, but will probably do so once Covid is in everyone's rear view mirror.

The east coast has nice diversity of terrain -- mountains to sea shore. In our area, definitely the 4 seasons, but not extremes of any. During my search, a Marketing person said, "North Carolina is ready for the half-backs." (Say what?) I learned the term refers to those from the midwest and northeast who retire to Florida life. They get tired of the sameness of the weather, the crowding of the medical system during snowbird season, evacuations/preparations for hurricanes. They sort of miss the 4 seasons. All told, they choose to move "halfway back."

If you're interested in one-on-one communication with me, you can try sending me a "private reply" (an option I see above as I type this). I don't know how that works.

Hi Jennifer:

Thanks for your helpful posts. The benefit of this forum is sharing info and learning from each other.

For us, finding the "right" option for the next phase of our lives is a major project that we are not taking lightly. So we have not yet made any decisions as these are very difficult decisions, most with no return option.The list of priorities is long and life is complicated. But I'd rather spend more time than make rushed choices. Thanks for your comments.

Hi wantoknow:

In one of your prior replies you mentioned that you wondered about how CCRCs balance the need for space for residents vs. how many non-residents they take in.

As I am learning about this website, I came across an interesting presentation from 2019 that maybe has some implied answer. The Document Library has an entry for Actuarial Info which has a document "What Residents Need to Know About Actuarial Studies". This is a presentation at the March 5, 2019 webinar for NaCCRA. It has (old) but interesting statistics from AV Powell (from their database of 167 CCRCs), that are most likely used by CCRCs to determine how many non-residents they can accepts. Hopefully webinars will resume and we will be able to see updated info.

I also figured out the very painful way to be notified: one has to SUBSCRIBE for each thread. I could not find a way to subscribe by Forum. But at least now I am notified if you reply, wantoknow. Obviously if someone starts a new thread in a Forum, I would not be notified.

I can find no way to subscribe to a thread. Perhaps only those who start a thread can do that.

The only forums you can subscribe to are: General, Entrance Fees, NaCCRA Governance, and Resident Engagement.

I looked around in the Pennsylvania Insur. Dept. website. The Disclosure Statements I saw were at least five years old, so probably all are. Pennsylvania is known as a state with very little regulation. And there are a huge number of CCRCs in Pennsylvania compared to other states. Those two facts are related.

To address the worries expressed in your paragraph beginning “I am worried about . . . .”, I think the best strategy would include the following, in addition to going over the contract with a fine tooth comb:

1. Select states with stronger regulation.

2. Select providers with stronge experience, a sense of social mission, and high ethics.

3. Scrutinize the various kinds of reports, if necessary with the help of a professional.

audited financial statements 

actuarial studies

resident satisfaction surveys

4. Get involved with the residents of CCRCs in which you are interested, through whatever 

opportunities are provided through marketing (or otherwise).

Some examples from my own experience.

1. California - stronger laws, but not strong enforcement.

2. The Kendal Corp., a Quaker-related organization which operates, or provides operating support, to CCRCs in various states.

3. After I got on the waiting list of one CCRC, I was able to attend certain events there, and used those opportunities to read a report on the results of a professionally conducted resident satisfaction survey, which had been placed in the library.  

4. After I got on the waiting list of another CCRC, I was able to stay there over 2-3 days and participate in various resident activities. This included a general residents’ meeting with management at which an Assisted Living resident very dramatically complained about how residents with dementia were disrupting meal times in Assisted Living. 

The extent to which residents can have a voice in how the CCRC is managed depends not just on the provider and regulator, but on the extent to which the residents are motivated to assert themselves. The populations of different CCRCs differ in this regard, and you can gauge this by getting involved with them.

I appreciate all your good advice. One can never be careful enough.

My personal email is steu@comcast.net

If you send me an email, I can send you a screen capture of where the subscribe option is for a thread, if you care for it. One cannot attach a file to this thread.

Thanks "Wanttoknow" for your thoughtful and helpful entries in this forum. My wife and I have made a deposit on a CCRC under construction in Healdsburg CA which is a "joint venture?" between the San Francisco Zen Center and Kendal Corporation.. Big move! and your entries are really appreciated .

I have been reading about the Enso Village since it was first announced. Keep us posted once you move in. Kendal Corp has a great reputation on the East Coast,

Ann MacKay

Based on what I read about it, Enso Village will not have nursing care on site. Their website states: "Skilled nursing services for residents who come to need them are planned to be coordinated with local, high-quality providers." This is a "new way" of providing what they still call a "lifecare community".

Yes, these are not uncommon practices. Set you preferences using the My Forum Preferences button in each forum you follow.

Jim Haynes