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When Does Medicare Pay for Assisted Living?

Over 3.5 million seniors live in Assisted Living homes or facilities in the U.S. Find out if Assisted Living is covered by Medicare.

5 mins read
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Seniors who require non-medical assistance with daily tasks but do not require full-time nursing care can live in an environment of support in assisted living. It’s a type of care that offers a variety of services to improve the quality of life for senior citizens and those with certain disabilities. 

A frequent question is whether Medicare covers the cost of assisted living. While original Medicare (Part A and Part B) does not cover assisted living, there are various other ways to get coverage for such services. Let’s explore these options and the concept of assisted living in detail. 

Understanding Assisted Living

Assisted living facilities house senior citizens and people with disabilities who may have difficulty living independently but do not require the intensive medical care provided by nursing homes. These facilities provide individualized care plans to cater to the particular needs of their residents. They encourage independence while assisting with daily activities like bathing, dressing, medication, and meal preparation. Assisted living facilities can comprise single rooms, shared rooms, or entire apartments.

Services and Amenities Provided in Assisted Living Facilities

The goal of assisted living facilities is to give their residents a comfortable and enjoyable living space while taking care of their non-medical needs. Common services and amenities they offer typically include:

  • 24-hour staff availability for assistance and emergencies
  • Nutritious meals that take care of individual needs
  • Housekeeping and laundry services
  • Social and recreational activities to promote socialization and mental stimulation
  • Transportation services for medical appointments and other outings
  • Medication management and assistance with self-administration

Differentiating Assisted Living from Other Care Options

To make informed decisions about yourself or the care of a loved one, you must know the differences between assisted living and similar care options. Here’s how they compare with nursing homes and home healthcare: 

  • Assisted Living vs. Nursing Homes: Assisted living places a greater emphasis on helping residents with non-medical daily activities. In contrast, nursing homes offer skilled nursing care for people with more demanding medical needs.
  • Assisted Living vs. Home Healthcare: Home healthcare provides medical services and assistance to a patient at their place of residence, whereas assisted living offers a communal living environment with round-the-clock support.

Medicare Coverage Options for Assisted Living

Medicare Part A (Hospital Insurance) or Part B (Medical Insurance) do not cover the cost of assisted living because these services are not considered medically necessary. As a result, Original Medicare does not cover the cost of assisted living, long-term care, custodial care, or in-home care.

Original Medicare may, however, cover costs for short-term home health care or care received at a skilled nursing facility as long as they happen after a “qualifying hospital stay.” This is defined as staying at a medical facility where you spend at least three days as an inpatient. Medicare will cover these costs only after it determines that the stay was medically necessary and skilled medical professionals provided care. 

Medicare Part A Coverage for Skilled Nursing Care

Medicare Part A pays for skilled nursing care services provided to residents of an assisted living facility. 

The eligibility requirements for coverage are as follows: 

  1. A person must be admitted to an assisted living facility after a qualifying hospital stay of at least three days to be eligible for Medicare Part A coverage for skilled nursing care. 
  2. The qualifying hospital stay had to have been as a result of an underlying medical condition, or as a result of picking up a condition such as an infection during a hospital stay. 

Coverage Limitations and Duration

Medicare Part A will cover the entire cost of skilled nursing care for the first 20 days. For days 21 and 100, the beneficiary will have to pay a 20% co-payment.  After 100 days, they will be responsible for the entire cost of skilled nursing care. 

Medicare Part B Coverage for Medical Services

Medicare Part B covers a wide range of medical services, some of which are relevant to residents of assisted living facilities.

Covered Medical Services in Assisted Living 

Medicare can help cover some costs if a doctor determines that an individual needs specialized nursing or rehabilitation. This is only possible after at least three days in a hospital as an in-patient and up to 100 days in a Medicare-certified skilled nursing facility.

This type of coverage applies only if you were formally admitted to a hospital for three days or longer. It does not apply if you were only in the hospital for diagnosis or testing. This also does not apply to assisted living facilities, which do not provide skilled nursing or intensive medical care.  

Medicare Part B covers medically necessary services such as doctor visits, outpatient therapy, diagnostic tests, and certain medical equipment.

Medicare Reimbursement for Specific Services 

Medicare typically reimburses the assisted living facility directly when a resident receives covered medical services. Make sure to check in advance with the facility if they accept Medicare assignments.

Medicare Part C Coverage for Assisted Living

Private insurance providers with Medicare-approved status provide Medicare Part C or Medicare Advantage plans. These plans offer several extra benefits in addition to Original Medicare, and some cover assisted living services.

Overview of Medicare Advantage Plans 

Medicare Advantage plans include all of the benefits of Original Medicare (Parts A and B) as well as Medicare Part D (Prescription Drug Coverage).

Availability of Assisted Living Coverage 

Medicare Advantage plans did not originally cover the cost of assisted living. In recent years, however, the Centers for Medicare and Medicaid Services (CMS) have loosened regulations to permit Medicare Advantage plans to offer additional supplemental benefits. They include:

  • Non-skilled in-home care services
  • Daycare for adults
  • Adjustments to the home
  • Non-emergency transportation
  • Services for Telehealth

Planning Ahead: Options for Financing Assisted Living

Here are some additional options you can look at to cover the cost of assisted living. 

Long-Term Care Insurance 

Long-term care insurance can be an excellent resource for covering the costs of assisted living. This type of insurance covers a wide range of long-term care services, such as assisted living, nursing home care, and in-home care.

Veterans Benefits and Assistance Programs

The Department of Veterans Affairs (VA) offers benefits and assistance programs to veterans and their spouses. Veterans who qualify for these benefits may be able to get the care they require, including assisted living services.

Personal Savings and Financial Planning for Assisted Living

Individuals can reduce the burden of paying for long-term care by planning ahead financially and setting aside money for assisted living costs.

Medicare and assisted living are both complex issues that can be difficult for Medicare beneficiaries and their families to navigate alone. Find the right coverage for your needs with CoverRight. Reach out today to locate the perfect Medicare plan.

Frequently Asked Questions

Can Medicare cover the cost of room and board in an assisted living facility?

Medicare does not cover the cost of assisted living facility room and board. Room and board expenses are considered personal expenses and are the individual’s or their family’s responsibility.

Are there any income or asset limitations for Medicare coverage of assisted living?

Medicare has no specific income or asset limits for assisted living coverage. Medicare coverage for assisted living services, however, is restricted to particular situations and services, with its primary focus being on skilled nursing care.

How can I determine if Medicare covers my specific assisted living facility?

Contact the facility directly to check if they accept Medicare. Confirm which of their services, if any, are covered by Medicare. If you are looking for coverage under Medicare Part A for particular services, make sure the facility is Medicare-certified for skilled nursing care.

Richard Chan

Richard is the Founder of CoverRight and based in New York. He is passionate about empowering consumers to take control of their health and finances. Prior to starting CoverRight, Richard had extensive experience working in financial services with over 8 years' experience in consumer lending and investment banking.

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