Does Medicare Cover Assisted Living?

Michael T. Braden, March 13, 2021 GENERAL MEDICARE

DOES MEDICARE PAY FOR ASSISTED LIVING?

DOES MEDICARE PROVIDE FOR ASSISTED LIVING FACILITIES?

No, Assisted living facilities are often referred to as Long Term Care Facilities. These facilities serve individuals requiring non-medical custodial care and assist with daily activities they cannot perform on their own. These ADLs (Activities of Daily Living) include Dressing, Bathing, Medication Management, getting in and out of a Chair or a Bed, Walking Independently, going to the Restroom, and eating.

Many individuals have a separate Long-Term Care Policy they plan to use to cover the projected costs of Assisted Living in the future. That is because Medicare does not cover assisted living, and it was never designed to. It was envisioned as Health Insurance, not Custodial Care.

Medicare usually pays for any of your Medical needs while you are a resident of any Assisted Living Facility/Long Term Care Facility. However, Medicare will not provide any assistance with the cost of rent or fees for an Assisted Living or Long-Term care Facility.

For those who need assistance with the cost of staying in a long-term care/Assisted Living Facility, you can contact your state's Medicare Department.

Care focused on 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.

ISN'T EVERYTHING THE SAME WHEN IT COMES TO ASSISTED LIVING?

In general, Nursing Homes or Skilled Nursing facilities are appropriate for individuals with complex medical needs that require constant monitoring and medical supervision. These patients are expected to recover in the near term, at which time they will be discharged to return home and skilled nursing care. They are expected to regain full functionality in relatively short order.

Assisted Living is defined as a setting where residents are unable to perform all seven Activities of Daily Living. In ALFs (Assisted Living Facilities), residents receive only non-medical assistance and personal care. Typically, the only thing preventing most ALF residents is their inability to perform all seven Activities of Daily Living independently. These are the tasks that prevent the beneficiary from living safely and independently.

WHAT YOU CAN EXPECT MEDICARE TO PAY FOR?

MEDICARE PART A

We all know that Medicare Part A is the portion of Medicare that covers Hospital inpatient care. Medicare Part A extends coverage to include restricted coverage for minor/brief recovery periods in both SNFs (Skilled Nursing Facilities). You must meet the minimum standards set forth by Medicare. You needed to have been in the Hospital for at least 3 days and have your Doctors and/or Hospital Administration attest that you require Skilled Nursing Care or Rehabilitative services as part of your recovery. If additional Occupational, Speech, or Physical/Occupational therapy is needed, Medicare will cover it.

MEDICARE PART B

Typically, we refer to Medicare Part B as the Outpatient side of the Medical coin. Medicare Part B covers Durable Medical Equipment, Preventive Care, Intravenous Drug Therapies in a Clinic, Hospital, or doctor's Office, Lab Work, Imaging, Outpatient Services, and preventive services. Generally, all of these Part B benefits will follow the Medicare beneficiary if they reside in an Assisted Living facility.

Here is a brief image of how this might work:

Examples include an Assisted Living Community collaborating with an Independent Home Health Care Company/Organization/Agency that offers physical therapy services, or scheduling on-site visits with a doctor. In certain situations, they may administer injections to residents with diabetes or perform bandage changes. Medicare would typically cover these medical services.

MEDICARE BENEFITS IN ASSISTED LIVING COMMUNITIES MAY INCLUDE ANY OF THESE ITEMS BELOW:

•  Durable Medical Equipment, such as wheelchairs, oxygen, and walkers. There is an option for a battery-powered/electric wheelchair; however, the Medicare Beneficiary must meet with the Doctor in person at the doctor's office to discuss.

•  Physical Therapy, Speech Therapy, and Occupational Therapy.

•  Intermittent or Part-Time Skilled Nursing Visits.

•  Social Services outreach to help beneficiaries adjust to and cope with issues arising from illness or accident.

• 
  

Caregivers who can offer assistance with non-skilled assistance in executing the Activities of Daily Living, which is arguably the most significant reason people are in a Non-Skilled Care Facility/Assisted Living environment. In some cases, having someone from an agency such as Visiting Angels or Home With Help can be the difference between staying at home and residing in a facility. Vital, non-skilled assistance with daily activities, which we all realize is usually the most significant part 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.

WHAT IS THE LITMUS TEST TO QUALIFY FOR ASSISTED LIVING?

ADL'S (ACTIVITIES OF DAILY LIVING)

Individuals who have difficulty with, or need assistance with, activities such as bathing, dressing, grooming, toileting, eating, and mobility are often good candidates for assisted living.

Activities of Daily Living Chart

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (ADLs)

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 ISSUES

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.

BECOMING ISOLATED FROM SOCIETY

Assisted living can be beneficial for individuals who feel isolated or lonely living alone and would benefit from the facility's social interaction and community engagement.

LACK OF DESIRE OR WILLINGNESS

The individual should be willing to move into an assisted living community and be comfortable receiving assistance and care in a communal setting.

PROS AND CONS OF LIVING IN AN ASSISTED LIVING COMMUNITY

Overall, assisted living facilities offer a supportive, social environment that helps with daily activities and ensures safety and security. The trained staff provides care and assistance, and residents can enjoy recreational activities and transportation services.

However, the cost is a drawback, and it may require adjusting to communal living and a potential loss of independence. Medical care is limited, and facility quality varies. You should make a decision based on your needs, preferences, and available options.

ARE THERE DIFFERENT LEVELS OF AN ASSISTED LIVING COMMUNITY?

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. Staff in memory care facilities receive additional training to understand the challenges individuals with memory loss face and 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, implemented memory prompts, and incorporated 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 higher level of care it provides, memory care units may have higher costs than standard assisted living facilities. Families seeking memory care for their loved ones should carefully evaluate facilities, staff qualifications, and available services to ensure they meet their family member's specific needs.

HOW DOES ASSISTED LIVING WORK/INTERACT WITH MEDICARE PART C?

Some Medicare Advantage plans offer additional benefits to support caregiving, including adult day care, caregiver support, limited home meals, 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. The only way to know for sure is to review the benefits in your plan's Summary of Benefits (SOB).

If you do not already have a local Medicare Broker, I suggest looking for one nearby. You can ask for their help researching the specific benefits of your plan, and they may have better options for you in the future. It is in EVERY Medicare beneficiary's best interest to work with an Independent, Licensed Medicare Broker.

NEITHER MEDICARE SUPPLEMENT PLANS NOR MEDIGAP COVER ASSISTED LIVING

Medigap plans only pay the co-pays, deductible, and coinsurance of Medicare Part A and Medicare Part B. Assisted living coverage is not included in Medicare or a supplement.

Even though Medicare Supplement Plans and Medigap Plans do not cover Assisted living, we at Braden Medicare believe that the best option for complete, comprehensive healthcare is Original Medicare with Medicare Supplement Plan G or Medigap Plan F, period, and it is not even close.

DO ASSISTED LIVING FACILITIES ADMIT DEMENTIA PATIENTS?

Assisted living communities are not covered, even for individuals who need Dementia care. However, there is an option called the Program of All-Inclusive Care for the Elderly (PACE) designed for older adults eligible for both Medicare and Medicaid.

WHAT DOES IT COST TO STAY AT AN ASSISTED LIVING FACILITY FOR A YEAR?

The average cost of assisted living is close to $130 per day and $3,900 per month. However, some assisted living facilities charge as much as $5,000-$10,000 per month, which is considered on the lower end of the price range.

WHAT ARE PAYMENT OPTIONS FOR ASSISTED LIVING FACILITIES?

Most individuals pay for stays in assisted living facilities out of pocket, relying on personal savings or income. Other standard financing options include Medicaid, which provides health care coverage to those with limited income and resources, and private long-term care insurance. Additionally, some people use financial instruments such as reverse mortgages, life insurance, retirement accounts, and annuities to cover the costs of assisted living.

ARE THERE ANY OTHER PROGRAMS THAT ARE ASSOCIATED WITH OR COVERED BY MEDICARE?

Medicare Part A covers skilled nursing care, but only under specific circumstances and for a limited duration. Care must be provided fewer than seven days a week and fewer than eight hours a day, for no more than 21 days, with some exceptions.

OTHER CARE OPTIONS THAT COULD BE COVERED BY MEDICARE:

HOME-BASED CARE LIKE HOME HEALTH AIDES

However, Medicare does not cover 24-hour in-home care, meals delivered to your home, or homemaker or custodial services if those are the only services needed.

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.

PACE PROGRAMS - ALL-INCLUSIVE CARE FOR ELDERLY SENIORS (PACE)

It’s a Medicare/Medicaid program that helps people meet their healthcare needs in 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.

ADDITIONAL OPTIONS FOR ASSISTANCE

LONG-TERM CARE IS NOT PAID FOR BY MEDICARE OR THE VA

Your Medicaid coverage depends on where you live and the specific benefits 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 severe conditions to help them get disability benefits more quickly.

Private insurers offer long-term care insurance plans and may cover various types of long-term care.

For those Medicare Beneficiaries who have served in the Military and have VA Benefits, TRICARE, or CHAMPVA, there may be additional programs to assist you with Assisted Living Benefits directly from the VA. We recommend contacting your local Veterans Affairs office to determine whether there are additional benefits you can apply for or are entitled to receive.