Does Medicare Pay for Assisted Living?

Key takeaway:

• Medicare is not a long-term-care insurance program. It does not include assisted living coverage.
• If you wish to have insurance coverage for time in an assisted living facility, you must seek out private insurance alternatives.
• There are numerous private insurance programs that will cover long-term care, including assisted living facility costs.
• You may be eligible for tax deductions from long-term care insurance premiums.

Does Medicare Pay for Assisted Living?

Medicare is a federal health insurance program in the United States that provides medical coverage for seniors aged 65 and older, as well as those who are under 65 and permanently disabled.

While Original Medicare will cover healthcare needs that are medically necessary, it is not a long-term care insurance program. Because assisted living is not a medical need, assisted living costs are not within the Medicare insurance program. Medicare will not pay for assisted living.

What Is an Assisted Living Facility?

An assisted living facility provides a combination of housing, personal care services, and healthcare support to individuals who need help with daily activities, but do not require the level of medical care provided in a nursing home.

Medicare primarily covers medical services and does not pay for the cost of room and board, personal care services, or other non-medical expenses associated with assisted living.

Do Medicare Advantage Plans Cover Assisted Living Costs?

Medicare Advantage Plans do not, at this time, provide direct insurance coverage or pay for assisted living facility. Although they do not pay for assisted living, some Medicare Advantage Plans offer coverage that is related to long-term care. This can include support for in-home health services, home modifications to improve mobility and safety as well as adult daycare services.

Medicare Advantage Plan benefits change annually. So if this interests you, check the benefits for the coming year during the annual election period from October 15 through December 07.

It is worth mentioning that Medicare does cover short-term stays at a skilled nursing facility. This type of facility provides medical care to patients who need help with activities such as eating, walking, and bathing.

What Is Skilled Nursing Care??

When answering the question “Does Medicare cover assisted living?” We find many clients confuse the Skilled Nursing care provided by Medicare with Nursing Home care. They are not the same. Medicare does cover skilled nursing care, but not time in assisted living facilities.

Medicare covers skilled nursing care during periods of recovery from an event that resulted in hospitalizations. This is the same level of on-site care received with inpatient hospital care that may also include physical therapy, intravenous injections and so on.

How Much Skilled Nursing Medical Insurance Does Medicare Provide?

Medicare covers skilled nursing facility (SNF) care under its Part A (Hospital Insurance) benefits. However, there are specific conditions and requirements that must be met for Medicare to provide coverage, and they are as follows:

• Qualifying hospital stay; To be eligible for Medicare coverage of SNF care, the patient must have had a qualifying inpatient hospital stay of at least three consecutive midnights before being admitted to a skilled nursing facility. The transfer to the SNF must generally happen within 30-days of the hospital discharge.

• Doctor’s certification; A doctor must certify that the patient requires daily skilled nursing care or skilled rehabilitation services. The care must be related to the condition that led to the hospital stay, or a condition that arose during the hospital stay.
• Medicare-approved facility; The SNF must be Medicare-certified for the patient to receive Medicare coverage for their care.
• Benefit period; Medicare covers SNF care in benefit periods. A benefit period starts when the patient is admitted to a hospital or SNF and ends when the patient has not received inpatient care in a hospital or SNF for 60 consecutive days. There is no limit to the number of benefit periods a patient can have.
• Coverage limits; Within a benefit period, Medicare covers up to 100 days of SNF care. For the first 20 days, Medicare typically covers the full cost. From days 21 to 100, the patient is responsible for a daily co-insurance amount, while Medicare covers the remaining costs. With a Medicare supplement plan, SNF costs for up to 100 consecutive days would be fully paid for.

What Services Are Covered Under Medicare in an SNF?

Medicare Part A covers various services in a skilled nursing facility (SNF) when specific conditions are met, such as a qualifying hospital stay. The covered services include:

• Semi-private rooms: Medicare covers the cost of a shared room in the facility but not a private room unless it is deemed medically necessary.
• Meals: Coverage includes the cost of meals provided by the SNF.
• Skilled nursing care: Medicare covers the cost of nursing care provided by licensed practical nurses, registered nurses, or licensed vocational nurses, including the administration of medications and wound care.
• Physical therapy: Services such as mobility exercises, gait training, and strength training may be covered when deemed necessary by a physician.
• Occupational therapy: Services aimed at improving daily living skills, such as dressing, grooming, and eating, are covered when deemed necessary by a physician.
• Speech-language pathology services: These services help patients with speech, language, or swallowing disorders and are covered when deemed necessary by a physician.
• Medical social services: Counseling services and assistance with social issues related to the patient’s care are covered.
• Medications: Medicare covers the cost of medications that are administered while the patient is in the SNF.
• Medical supplies and equipment: Medicare covers the cost of medically necessary supplies and equipment used during the patient’s stay in the SNF.
• Ambulance transportation: Medicare covers the cost of ambulance transportation to the nearest provider for medically necessary services that cannot be provided at the SNF.
• Dietary counseling: Nutrition counseling services are covered when provided by a registered nutrition professional.

What Are the Alternative Options for Financing Assisted Living?

When it comes to financing assisted living, it’s crucial to explore alternative options since Medicare typically doesn’t cover these expenses.

Some of the most common financial options for paying for assisted living include:

Medicaid

As a state and federal program designed to assist low-income individuals with medical expenses, Medicaid can be a valuable resource for those seeking financial help for assisted living. Unlike Medicare, Medicaid often covers long-term care services, including assisted living, in certain states.

Long-Term Care Insurance

Unlike other types of insurance, long-term care policies cover the costs of participating in an assisted living community, such nursing homes, and home health care services.

These policies can help offset the financial burden of assisted living, but it’s crucial to understand the specific terms of coverage, such as waiting periods, daily benefit limits, and policy maximums.

Some life insurance policies come with benefits that can help with long-term care or assisted living care. Reach out to us for details.

Veterans’ Benefits

Veterans and their surviving spouses may qualify for financial assistance through the Department of Veterans Affairs (VA) to help cover assisted living costs.

Personal Savings and Assets

For many seniors, personal savings and assets can be a primary source of funding for assisted living expenses. This option may include using retirement accounts, cash from a life insurance policy, investment portfolios, or the sale of personal property, such as a home.

Spending personal savings is the worst case scenario in paying for assisted living cost. Assisted living insurance, offered by private insurance companies, can save you from running out of money to cover assisted living costs.

Reverse Mortgages

A reverse mortgage is an option for seniors who own their homes and wish to convert their home equity into cash to cover assisted living costs.

This type of loan allows homeowners aged 62 and older to access the equity in their homes without needing to sell the property or make monthly payments.

The loan becomes due when the homeowner sells the home, moves out, or passes away.

State-Specific Programs

Several states offer programs that provide financial assistance for seniors who require long-term care services, including assisted living. These programs may have specific eligibility criteria and may vary in the type and amount of assistance provided.

Examples include state-funded home and community-based service programs, state supplement programs, and property tax relief programs. Researching and applying for these programs can help alleviate the financial burden of assisted living expenses.

What Is the Average Cost of Assisted Living?

The average cost of assisted living varies based on factors such as location, facility amenities, and level of care required. In the United States, as of 2021, the national average cost was approximately $4,500 per month or around $54,000 per year. Prices can range from as low as $3,000 per month to over $5,000 per month in certain areas or for specialized care.

Several factors contribute to these costs, including housing, meals, housekeeping, utilities, transportation, and social activities. Additionally, personal care services like medication management, bathing, and dressing assistance can increase the cost. As residents require more specialized care or suffer from conditions like dementia, the cost of assisted living tends to rise.

It Depends on Where You Live

Geographical location does play a significant role in determining costs. Assisted living facilities in metropolitan areas, for example, typically have higher fees compared to rural locations. State-to-state variations also exist, with some states having more affordable assisted living facilities compared to others.

Closing Thoughts

Medicare primarily covers medical services and short-term skilled nursing care rather than long-term care in assisted living facilities. It simply does not cover assisted living.

It is crucial for individuals and their families to explore alternative funding options, such as long-term care insurance, Medicaid, or personal savings, to cover the costs associated with assisted living. Assisted living coverage must be purchased long before it is needed.

By being well-informed about the services Medicare covers and planning for long-term care needs, seniors and their families can make educated decisions about their future and ensure they receive the necessary support to maintain a comfortable and fulfilling life.

You can read more on Medicare, including a comprehensive guide to Medicare coverage linked here.