Does Medicare Cover Assisted Living?Read our guide to learn about assisted living and whether Medicare will cover it.
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According to the Administration for Community Living, a U.S. Department of Health and Human Services division, assisted living costs an average of $119 a day, or $3,628 a month.
For some older adults, living in their own homes as they age is not a problem. However, some can find it difficult to perform the basic personal tasks of daily living and need help to do so, without needing medical care.
An assisted living facility (ALF) may prove a useful alternative, and this article will discuss everything you need to know about Medicare and assisted living.
What Is Medicare?
The federal Medicare program is a government-sponsored health care plan for individuals aged 65 or older, disabled people, and those who suffer from End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
Medicare is made up of Part A and Part B, Part C (also known as Medicare Advantage), and Part D. There are also various Medicare Supplements Plans that range from A-N.
The Different Parts of Medicare
Medicare Part A refers to inpatient treatment and hospital care and includes hospital stays, hospital treatments, and general nursing costs.
Medicare Part B relates to outpatient or general medical coverage and includes preventive treatments, doctors’ consultations, scans, and tests.
Part C/Medicare Advantage Plans are health cover plans offered by insurance companies that have contracts with Medicare. These policies cover Part A, B, and D expenses, including costs for hospital care, prescription drug coverage, and doctors’ visits.
Standalone Part D Plans (Prescription Drug Plans) cover self-administered prescription drugs. For example, medications for high blood pressure, pain tablets, and antidepressants.
Medicare Supplement Insurance, also known as Medigap, are health insurance policies for people who have Original Medicare. These plans cover costs such as deductibles, coinsurance, and out-of-pocket costs.
What Is Assisted Living?
Assisted living is a residential setting that houses people who need assistance with daily living, such as activities and services. This is also known as custodial services.
These living spaces aim to accommodate the changing needs of their residents as they age.
The assisted living facilities don’t offer the skilled medical care provided in a nursing home, but rather assistance with general tasks and personal care that the patient can’t manage while living independently anymore.
What Are Custodial Services?
Custodial care refers to the nonmedical help a patient may need to go about their daily life.
Examples of this assistance include:
Getting out of bed
Using the bathroom
Custodial care is offered within assisted living facilities to residents who do not need the 24/7 medical care available at skilled nursing facilities (SNF).
For those who need additional care, skilled nursing facilities (SNFs) provide skilled nursing and therapy services to treat, manage, and observe medical conditions and evaluate care options.
Does Medicare Cover Assisted Living?
Medicare usually doesn’t cover your residence in an assisted living facility. It does, however, offer coverage for patients who receive care at a skilled nursing facility (SNF), after meeting specific requirements.
If an individual moves into an assisted living facility, Medicare will continue to cover what the patient had already received prior to the move. This coverage includes:
Original Medicare (Part A and Part B) does not cover custodial care when it is the only type of care the individual needs.
If you need help with the topic of life coverage or have any questions regarding Medicare or assisted living, call one of PolicyScout’s professional consultants at 1-888-912-2132 or send an email to email@example.com to find out more.
What Is a Skilled Nursing Facility and How Much Does It Cost?
Skilled nursing facilities (SNFs) provide expert nursing services to treat, manage, and oversee medical conditions, as well as evaluate care for patients who require it.
SNFs supply a higher level of medical care compared to assisted living facilities. Enrollment into an SNF can be covered by Medicare in certain cases.
In order to receive Medicare coverage for skilled nursing care, there are certain requirements:
The patient must have had a qualifying hospital stay and not used up all of their covered hospital days
The patient's doctor must deem skilled nursing care necessary
The patient's current condition is either the reason they were just hospitalized, or it developed as a result of them being in the hospital (for example, an infection picked up while hospitalized)
If all of these conditions are met, Medicare would cover 100% of the first 20 days in residential care.
If a longer stay is required or requested, then the patient would be responsible for paying a coinsurance cost of $185.50 per day between days 21-100.
Beyond 100 days, Medicare doesn’t provide any coverage for this type of care and the patient would have to pay the costs out-of-pocket.
Do Medicare Advantage Plans Cover Assisted Living?
Medicare Advantage plans (or Medicare Part C) cover as much as Original Medicare (Part A or Part B.)
However, since Medicare Advantage plans are health plans offered by private insurance companies, they supply benefits unique to each policy.
Medicare Advantage doesn’t typically cover residence in an assisted living facility or any other custodial care.
It does, however, cover medical expenses like prescriptions, surgery, doctors’ appointments, screenings, and equipment, even if you end up moving to an assisted medical facility.
It may also include additional benefits such as transportation to medical appointments, vision and hearing coverage, and even gym membership.
Costs may be covered if short-term care is needed at a skilled nursing facility following a hospitalization.
Assisted Living and Long-Term Care Insurance
Another option would be to consider a long-term care policy as a route to cover assisted living. Most long-term care insurance plans cover assisted living, but benefits vary depending on the policy.
In general, if you have long-term care insurance, your policy will usually cover the cost of residential care at an assisted living facility, if you meet certain requirements.
A long-term policy covers care up to the policy’s limits if you have a severe cognitive impairment or you can’t manage two or more out of these six daily living tasks:
Caring for incontinence
Toileting (getting on or off the toilet)
Transferring (getting in or out of a bed or a chair)
Before you shop for coverage, check out PolicyScouts Medicare hub to compare and find out which policy will suit you or your loved ones best.
When Should I Enroll for Assisted Living?
Moving to an assisted living facility is a major decision, financially and emotionally.
If you’re unsure about whether this is the correct choice, here are a few clear signs that could suggest that assisted living may be the right option:
It’s getting hard to take care of yourself
It's getting hard to manage your home
It’s difficult to get around in and outside your home
Before choosing an assisted living community, be sure to confirm that it's properly licensed and reputable.
Many state websites have online tools that allow you to look up assisted living communities in your area. You should also read inspection or investigation reports.
If you have Medicare Advantage, you can also contact your health plan provider to get details about local assisted living facilities in your area and to see what they will cover.
Minimum Age Requirements for Assisted Living
Assisted living facilities generally have a minimum age requirement. For example, some are limited to residents of 62 and older.
Be sure to contact your preferred assisted living facility to see if you are eligible to become a resident there.
What Else Can Medicare Help Cover?
If you’re interested in learning more about Medicare’s many different coverage plans for yourself or your parents, be sure to check out our Medicare hub.
Our Medicare consultants can also answer questions about coverage, costs, policy terminology, and more.