What is assisted living?
Assisted living facilities cater to individuals requiring non-medical custodial care and aid with daily activities like bathing, dressing, and medication management.
Does Medicare pay for assisted living costs?
Medicare does not pay for assisted living. But Medicare may still pay for your medical needs while being a resident of assisted living on Medicare.
Medicare does not provide coverage for the expenses related to residing (“rent”) in an assisted living facility, also known as custodial care.
Care centered around helping with the activities of daily living is not considered medically necessary when it does not result from a medical condition . Thus, it falls outside the scope of the federal health insurance program.
Medicare’s coverage for long-term care is limited to cases where skilled nursing or rehabilitative services are required, and even then, it will cover skilled nursing care for a specific duration.
What is the major distinction between skilled nursing facility and assisted living?
Unlike nursing homes, assisted living facilities do not offer skilled medical care or medically skilled services, but focus on providing general assistance and personal care that might be lacking when living independently.
In general, nursing home or skilled nursing facilities are appropriate for individuals with complex medical needs requiring constant medical supervision and skilled nursing care and are expected to recover to full functionality in a relatively short tie period.
Assisted living facilities are long-term non-medical care better suited for seniors who can still manage some aspects of daily living, but need help with certain activities and benefit from a supportive living environment.
What Will Medicare Parts A & B of Medicare Pay For?
Medicare Part A (hospital insurance), which focuses on inpatient hospital care, offers restricted coverage for a brief period in a skilled nursing facility after an inpatient hospital stay. To be eligible for this limited coverage, specific conditions must be met, including a qualifying hospital stay and a need for skilled nursing or rehabilitation services, like occupational or physical therapy. Then, Medicare covers skilled nursing care.
Medicare Part B (medical insurance), which handles outpatient services, may cover medically necessary medical supplies and services for individuals residing in assisted living facilities.
For instance, an assisted living community might collaborate with an independent home health care agency to offer physical therapy services, or they may arrange for visits from a doctor on-site. In certain situations, they might administer injections for residents with diabetes or handle bandage changes. These medical services would typically be covered by Medicare.
Medicare benefits in assisted living communities may include the following:
Medical supplies like wheelchairs, oxygen, and walkers
Physical, occupational, or speech therapy
Part-time or intermittent skilled nursing
Medical social services to cope with issues from an illness
Non-skilled assistance with daily activities, which is a significant aspect of assisted living care, is not covered by Medicare. This is why the general answer to, “Does Medicare pay for assisted living?” is no.
However, if you transition to an assisted living community, Medicare will continue to cover your prescription medications and any other medical services that were previously covered under your plan while you were living at home.
Who qualifies for assisted living?
Common qualifications for assisted living include:
Activities of Daily Living (ADLs)
Individuals who have difficulty or need help with activities such as bathing,
dressing, grooming, toileting, eating, and mobility are often good candidates for assisted living.
Instrumental Activities of Daily Living (IADLs)
These are more complex activities, such as managing medications, handling finances, cooking, housekeeping, and transportation. If a person requires support with these tasks, assisted living can be suitable.
Safety Concerns
Seniors who face safety risks living independently due to issues like falls, memory problems, or physical impairments may benefit from the supervised and secure environment of an assisted living facility.
Social Isolation
Assisted living can be beneficial for individuals who feel isolated or lonely living alone and would benefit from the social interaction and community engagement provided by the facility.
Willingness and Desire
The individual should be willing to move into an assisted living community and feel comfortable with the idea of receiving assistance and care in a communal setting.
What are the pros and cons of assisted living?
Overall, assisted living facilities offer a supportive and social environment, providing help with daily activities and ensuring safety and security. The trained staff offers care and assistance, and residents can enjoy recreational activities and transportation services.
However, the cost can be a drawback, and it may involve adjusting to communal living and a potential loss of independence. Medical care is limited, and the quality of facilities varies. You should make a decision based on your needs, preferences, and available options.
What’s the highest level of assisted living?
The highest level of assisted living is often referred to as “memory care” or “special care units.” Memory care is a specialized form of assisted living designed to meet the unique needs of individuals with Alzheimer’s disease, dementia, or other memory-related conditions.
Memory care units typically provide a higher level of supervision, security, and specialized care to ensure the safety and well-being of residents with memory impairments. The staff in memory care facilities undergo additional training to understand the challenges faced by individuals with memory loss and how to provide appropriate care and support.
In memory care personal care units, the physical environment is often adapted to help residents navigate their surroundings more easily. They may have secured access to prevent wandering, memory prompts, and specific design elements to reduce confusion and anxiety. Activities and programs are tailored to engage and stimulate residents’ cognitive abilities, promote social interaction, and maintain a sense of familiarity and routine.
Medicare does not pay for room and board or personal care services , but it will usually cover some of the medical costs residents may encounter. Typically, Medicare coverage is for outpatient care under Medicare Part B.
Due to the specialized nature of memory care and the increased level of care provided, memory care units may have higher costs compared to standard assisted living facilities. Families seeking memory care for their loved ones should carefully evaluate the facilities, staff qualifications, and available services to ensure they meet the specific needs of their family member with memory impairment.
Do Medicare Advantage Plans Cover Assisted Living Costs?
A Medicare Advantage plan or Medicare Part C doe not cover the costs associated with assisted living.
Some plans provide additional benefits that can help with caregiving needs such as adult day care, caregiving support, limited meals at home, and transportation to medical appointments. The specific services covered, benefits, and limitations vary a lot from plan to plan. Not all Medicare plans are the same.
You might want to check out our posts on the reality of Medicare Advantage plans and what it means for many seniors.
Does Medicare Supplement Cover Assisted Living Costs?
Medicare Supplement plans, also known as Medigap plans, are offered by private insurance companies and intended to fill the gaps in Original Medicare coverage.
These plans by private insurance providers must adhere to standardized benefits across the country, as mandated by the Centers for Medicare & Medicaid Services (CMS).
Medigap plans only pay the copays, deductible and coinsurance of Medicare Part A and Medicare Part B. Assisted living coverage is not included in Medicare or a supplement. However, having original Medicare plus a Medigap plan remains your best bet for comprehensive and reliable health insurance.
Medigap and Medicare Advantage plans might also cover the aforementioned medically necessary medical supplies and services for individuals residing in assisted living facilities.
Does Medicare Cover Assisted Living for Dementia?
Assisted living communities are not covered even for individuals who need Dementia care. However, there is an option called the Program for All-inclusive Care (PACE) designed for the elderly who are eligible for both Medicare and Medicaid.
How Much Does Assisted Living Cost?
The average cost of assisted living is $119 per day, equivalent to $3,628 per month, as reported by the government’s Administration on Community Living. However, some assisted living facilities may charge as much as $5,000 per month, with this being considered on the lower end of the price range.
How Can I Pay for Assisted Living?
The majority of individuals pay for a stay at an assisted living facility through private funds, relying on personal savings or income. Other common methods of financing include Medicaid, which provides health care assistance to those with limited income and resources, and private long-term care insurance. Additionally, some people use financial instruments like reverse mortgages, life insurance options, retirement accounts, and annuities to cover the costs associated with assisted living.
What Other Care Options Are Covered by Medicare?
Medicare Part A offers coverage for skilled nursing care, but only under specific circumstances and for a limited duration. The care must be provided less than seven days a week or less than eight hours a day, lasting for no more than 21 days, with some exceptions.
Other care options that might be covered by Medicare include:
Home-based care, such as part-time or intermittent home health aide services
However, Medicare does not cover daily 24-hour care at home, meals delivered to your home, or homemaker or custodial services if those are the only services needed.
Medicare covers both hospice and respite care
Hospice provides care and support for terminally ill individuals, while respite care offers short inpatient stays for hospice patients, allowing their caregivers to rest.
Programs of All-Inclusive Care for the Elderly (PACE)
It’s a Medicare/Medicaid program that supports people in meeting their healthcare needs within their own community, reducing the need for care facility placements. It covers services like prescription drugs, doctor visits, transportation assistance, home care, and necessary nursing home stays.
A number of states also offer help with assisted living costs for qualifying older adults with limited financial resources.
Does Medicaid cover assisted living? Yes, Medicaid can help cover costs of assisted living. Your Medicaid coverage will depend on where you live and which specific Medicaid assistance you receive.
Depending on your medical condition or income, you might qualify for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). Social Security also offers “compassionate allowances” for people with certain serious conditions to help them get disability benefits more quickly.
Long-term care insurance plans are offered through private insurance providers and may cover several types of long-term care.
Eligible veterans may be able to receive assisted living benefits through the Veterans Administration (VA).
Matthew Claassen
Matthew Claassen, CMT and CEO of Medigap Seminars Insurance Agency. Medigap Seminars is an award winning premier national Medicare Insurance Brokerage, ranked among the top in the U.S.A. Matthew is considered a leading national expert on Medicare and Social Security. Mr. Claassen is a distinguished member of the Forbes Business council, an invitation only organization of business leaders and entrepreneurs. He and his team have received awards from many of the countries largest insurance companies including Mutual of Omaha, Aetna, Humana, Cigna, United American, United Healthcare and others. His videos have become the most popular Medicare educational videos on YouTube with millions of views. As a financial analyst Matthew lead a team of researchers to win the 2009 Best Equity Research & Strategy Award from The Technical analysis magazine.
