Beware of Hidden Fees in Assisted Living Facilities

“Families can be blindsided with extra costs,” says Colleen Duewel, an aging life care professional and founder of LionHeart Eldercare & Consulting. “Even when families take time to carefully consider their options, they often don’t know what to look for or which questions to ask to fully understand what’s not included.”

Hidden costs often include added fees for higher levels of care:

• Assistance with daily activities (dressing, bathing, eating)
• Dementia or memory care

Hidden costs of these goods and services vary by facility:

• Hygiene products such as deodorants and shampoos
• Household supplies such as paper towels, toilet paper, cleaning supplies, plastic cutlery, paper plates  
• Incontinence supplies (often not included in the base price, or provided with an additional fee)
• Medication management and delivery
• Meal brought to a room (vs. a meal eaten in a dining area)
• Personal laundry
• Salon services 
• Cable TV
• Therapy copayments (speech, occupational, physical)
• Transportation to appointments
• Meals or refreshments for visitors 

“We were surprised to find that one facility covered the cost of incontinence supplies, but billed separately for personal laundry, which is usually included,” says Stapleton. He notes that medication management fees can also vary. Some facilities charge a flat rate for residents taking up to a half dozen medications, but costs often increase if the number of prescriptions increases. “For my mom’s care,” says Stapleton, “medication management included prescription drugs, multivitamins and supplements, so it’s easy to get up to five or six pills a day.”

Planning for the unexpected

For many families, these costs can erode retirement savings or lead to difficult decisions down the line, such as relocating a loved one, as Stapleton had to do with his mom. Worse, some discover that once a family member requires a higher level of care, they’re pressured to move to a more expensive facility or risk eviction.

“People need to understand what they’re agreeing to before moving in,” says Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care in Washington, D.C. “Ask what’s included in the base rate, what triggers extra charges, and who decides when more care is needed. Surprises in care shouldn’t come with surprise bills.”

Don’t sign anything until you know what it will cost, warns Dee Pekruhn, director of life plan communities, services and policy at LeadingAge, a trade association representing senior housing and long-term care facilities. “Most assisted living communities have a base rate, but the real cost depends on how much help your loved one needs day-to-day, and that can change quickly.”

Eldercare experts recommend paying close attention to these eight areas to avoid surprises and unexpected bills.

1. Understand the contract.

Families must ask what is included in the base rate, what services cost extra, who determines if more care is needed, and whether outside support is allowed. Some experts suggest having an elder-law attorney or aging life care professional, also known as a geriatric care manager, review the contract.

2.  Request a full cost breakdown.

When choosing an assisted living facility, ask for a full written cost breakdown beyond the base rate, including fees for services like medication management, transportation and therapies. Clarify how often rates can change, who decides if more care is needed, and whether outside help is allowed. Because cost disclosures vary by state and there’s no federal standard, check with your state’s regulatory agency to understand what’s legally required.

3. Pricing is tiered by level of care.

Most facilities begin with a base monthly fee that covers room and board. Additional charges are then applied depending on the resident’s level of needed assistance, which is determined through an upfront nursing assessment of their ability to perform specific tasks, known as activities of daily living, or ADLs. Care levels usually range from Level 1, requiring minimal support, to Level 4, which may include help with tasks like transferring from bed to chair. Families may not realize that even modest increases in support, like dressing or bathing assistance, can significantly increase monthly fees. Cognitive impairment can also play a role in determining the appropriate level of care.

4. Appeals take time and persistence.

Unlike health insurance plans, there is no formal process for appealing care decisions at assisted living. The facility director of nursing in consultation with the executive director could determine that a resident needs more support, such as 24/7 care which is an additional fee per hour., . Ask for a care plan that reflects both the facility’s assessment and what everyone agrees is appropriate.

5. Medicaid and Medicare coverage is limited.

Assisted living is primarily private-pay. Very few facilities accept Medicaid, and Medicare does not cover assisted living — only short-term rehab or skilled nursing care under specific conditions. Don’t rely on these programs to fund long-term assisted living. Some exceptions exist, like Medicare Part B covering outpatient therapies or hospice care, but these should be confirmed with the facility.

6. Private caregivers may reduce costs in some cases.

Some families try to reduce facility charges by hiring private caregivers, but this strategy is only cost-effective when a resident needs limited support, for just an hour or two, like help getting out of bed or dressing in the morning. For those with cognitive decline who require round-the-clock care, private care ends up costing significantly more than what the facility provides. Assisted living charges a base rate plus care levels, but even the highest level may not provide the care that a resident needs like transferring them from bed to a wheelchair. In contrast, the base level price for a nursing home provides 24/7 care that many residents often need so families can avoid hiring private aides and paying additional out-of-pocket expenses. Always check if the facility allows private health aides to provide care for your loved one, if the facility's care level does not meet all the resident's needs. Some facilities may require families to use preferred agencies to hire an aide because they can assure training and quality requirements are met.  

7. Explore cost-management strategies.

For families on a tight budget, taking over certain care-related tasks can make a noticeable financial difference. For example, handling laundry at home rather than paying the facility’s weekly service fee — often $50 to $100 — can save hundreds over the course of a year. Similarly, buying incontinence supplies like briefs, pads or wipes in bulk from retailers such as Amazon, Walmart or Costco and setting up a recurring monthly delivery can significantly reduce costs compared to facility markups. Another money-saving strategy is providing personal toiletries such as shampoo, toothpaste and body wash, which facilities often charge extra for or bundle into premium care packages. Every small adjustment adds up over time and can help stretch limited financial resources while still ensuring a loved one’s basic needs are met.

8. Emotions can cloud judgment.

The emotional toll of caregiving often mirrors the financial burden. Families want only the best for their loved ones, but discussions about the cost of care, like hiring night nurses, can feel both painful and inappropriate in the moment. Overwhelmed by emotion, caregivers are often willing to do whatever it takes to ensure their family members’ comfort and dignity. In such circumstances, practical concerns around finances can easily take a back seat.