When you approach retirement or empty-nester mode, something in the American psyche is often triggered: You want to move somewhere with ample sunshine and less hustle and bustle.

But those considering relocation need to look beyond beaches, golf courses, and early bird specials and confront one of the least-explored parts of retirement: long-term care.

In the U.S., this fragmented system is costly and mostly provided by family. And where you move can make a huge difference in how much it costs. Granted, nobody wants to contemplate long-term care, which ranges from basic home services to memory care in a nursing home. It is unpleasant and most of us think we will never need or want it. “People do not want to talk about long-term care because they think you are talking about death,” says Dayna Steele, chief caring expert for Caring.com. “Our bodies may be lasting longer, but our brains are not.” Americans are not only in denial about the need for long-term care; they also do not know who pays for it.

Once you hit age 65, the conventional age for qualifying for Medicare and taking retirement, there is a 70% chance you will need some type of long-term care services, according to the U.S. Department of Health and Human Services. And the “longevity dividend” of people living longer means you will need this expensive care for a lengthier period of time: nearly four years for women and two years for men. “I am stunned at the number of people who think long-term care is paid for [by the government],” said Steele, who covered more than $40,000 in bills for her mother, who was in a nursing home with Alzheimer’s disease.

Moreover, there are several layers of care, ranging from adult day care to specialized institutional care for Alzheimer’s patients. Where you live in retirement is critical, because your top choice may not offer the necessary services close to where you want to live. Some states are better than others at providing care. And the cost differs considerably from region to region.

Costs Vary Widely from State to State
The costs for the most-expensive kind of care—nursing or “memory” care—average $92,000 a year nationally for a private room, according to the latest Genworth long-term care survey. At the other end of the spectrum, you can spend as little as $18,000 annually for adult day care. In the middle is $43,000 per year for assisted living, and $46,000 for home healthcare or an in-home aide. Keep in mind, however, these are just national averages. You could spend much more than these averages, depending upon the state.

A private nursing home room in New York State, for example, averages $136,000 per year. The same room in Georgia would average $74,000, and $93,000 in Arizona. More importantly, you cannot assume that the cost of care is a true reflection of the quality of the service provided. In most cases, these price tags reflect the local cost of living and labor. The Northeast is almost always more expensive than the Deep South and West in this regard.

To get a more complete picture of the cost and quality of care in any state, you have to look at a broader range of ratings that measure quality of life, selection of services, and affordability. Some communities support older adults better than others.

One of the most comprehensive surveys on senior well-being was published recently by Caring.com, a resource for long-term care. Surprisingly, the states that offered the best overall services and environment for retirees were not always the leading Sunbelt locales.

States scoring the highest were South Dakota, Iowa, Minnesota, Alaska, and Oregon. They garnered top ratings because they offered higher “quality of life in a given area for residents over 55, quality of healthcare, long-term care, support for seniors and family caregivers.” States faring the worst in the Caring.com survey were West Virginia, New York, New Jersey, Kentucky, and Indiana. Keep in mind that the research looked at everything from research from AARP surveys to the Gallup-Healthways Well Being Index, so the ratings are based on both community support for caregiving and overall cost.

What Can You Afford?
Local costs loom large not only because long-term care can become prohibitively expensive, but also because most of the costs are covered out of pocket by families.

Medicare will only cover a limited amount of skilled nursing or hospice care, not custodial care, which is what most long-term nursing homes provide. And for you to qualify for Medicaid, you need to be financially impoverished. Guidelines for that program are stringent and set by states, some of which require you be down to $2,000 in liquid assets before you can qualify. Conventional products to cover the costs of care include long-term care insurance, which becomes more costly the older you get, and you may be subjected to multiple premium increases over the life of the policy.

There are also life and annuity products that allow you to tap their cash value for long-term care, but their pricing and availability depend upon your health record and age. Bottom line: There is no perfect private or public solution for this looming cost. A six-figure bill for long-term care may be in your future. This is something you need to include in a long-range family financial planning discussion—and need to consider when weighing where to relocate.

How You Should Plan: Start the Family Conversation
Since the vast majority of caregivers are unpaid female family members who devote time and dollars to their relatives (some 80% of long-term care is provided this way), proximity to family members who are likely to help you is a key consideration before making any move.

Who is the most likely family member to provide care? Will they be close to the parent or relative? Will they have to quit a job to do it? Can siblings help? What local resources are available and how much will they cost? Would independent or assisted living be a good choice? What if more specialized care is needed? What family resources are available to cover costs of care?

Although these are difficult subjects to tackle, they should be part of a series of family discussions. How do you begin this conversation? As you consider different relocation scenarios, you need to include a “how will you live if you require long-term care” question, preferably well before you call a mover to relocate, Steele suggests. “Where do you want to live? Who is going to take care of you? How do plan to pay for it? Make a plan,” Steele says. If you need to get an idea of local long-term care costs, the Genworth survey is a good place to start. The federal government also has a useful guide to long-term care at longtermcare.gov. The latter resource will also help you locate local support services throughout the country and explain the different kinds of services available. You can also tap financial professionals for advice in relocation and long-term care planning. Most certified financial planners are well acquainted with long-term care planning. They can integrate family objectives with portfolio, tax, and estate concerns. Doctors and lawyers—particularly elder law attorneys—can also provide advice and referrals.

If you want to relocate, you need to know if it is going to work for your entire family, not for just one couple or a single person. Comprehensive planning may be nettlesome—it is not easy for any family that has not encountered these issues—but it is a good way to avoid being blindsided when you need care.