There comes a point where having assistance with activities of daily living is crucial. Some Medicare beneficiaries may need the appropriate guidance when dealing with things like showering, getting dressed, or even organizing their medications. Assisted living facilities provide a great deal of services aside from those mentioned, the harsh reality of these facilities that may drive beneficiaries in the opposite direction is the cost. Weighing out all possible options may help when considering the best plan for you.
Does Medicare Cover Costs for Assisted Living?
The short answer is, “No. Medicare does not cover the costs of assisted living.” The reason is that assisted living facilities are residential settings that provide custodial care, not medical care.
Medicare is to assist patients with their medical costs, not to pay for them to have custodial care that is provided by an assisted living facility. The facilities charge for room and board and custodial care. Not for providing medical treatment to the residents.
Does Medicare Cover Costs of Assisted Living for Those Diagnosed with Dementia?
It would seem that those diagnosed with dementia and who need custodial care because of their medical diagnosis would have Medicare coverage for the necessary stay in an assisted living facility. But Medicare simply provides no coverage for any type of custodial care no matter what the diagnosis.
Will a Medicare Supplement Plan Cover Costs of Assisted Living?
Medigap plans do not cover the costs of assisted living. Medigap plans are just what they sound like. To fill the gap between what Medicare pays for services and what you are expected to pay. For whatever medical services you receive, Medicare pays its part first. Then, your Medigap plan steps in and pays its portion of your medically necessary care.
Do Medicare Advantage Plans Cover Assisted Living?
Generally, the Advantage Plans do not provide coverage for assisted living. Some plans provide benefits for supplemental home services. These benefits allow a person to stay in their own home and live independently. But no Medicare Advantage Plan pays for room and board at an assisted living facility.
Not all Advantage Plans offer this in-home assistance, so check carefully if you think you will need it sometime in the future. The plans promote ageing at home and although the Plan may have some benefits to help you at home, there are rules and restrictions that you must become familiar with to avoid a surprise later when you may think you have coverage for some home modification but find out it is not covered under your specific plan.
Will Medicare Still Provide Medical Coverage for Those in Assisted Living Facilities?
If you are in an assisted living facility, although Medicare will not pay for non-skilled assistance, or non-medical care received at an assisted living facility, Medicare will still provide you the same medical benefits it provides when you live at home which may include the following:
- Doctor visits
- Surgeries
- Hospitalization
- Prescription drugs
- Durable medical equipment
Does Medicare Cover Home Health Care?
Medicare also provides some home health benefits related to your medically necessary needs for skilled nursing care or skilled therapy services that can be provided to you at your home. This does not include any custodial-type services such as cooking, assisting with getting dressed, or 24-hour nursing care.
Will Medigap Still Provide Coverage for Medical Expenses?
Your Medigap plan will also provide you the same coverage for these medical services that it provides when you live at home and not in an assisted living facility.
Does Medicare Provide Coverage for a Skilled Nursing Facility?
Medicare does provide coverage for short-term care in a skilled nursing facility. The difference is that an assisted living facility is a residential setting that charges for room and board. A skilled nursing facility is a clinical setting that provides medical care.
Medicare defines care in a skilled nursing facility as “health care given when you need skilled nursing or skilled therapy to treat, manage, and observe your condition, and evaluate your care.”
It covers essentially all services you will need that are determined to be medically necessary. This includes your meals, a semi-private room, your medications, all types of therapy from speech therapy to physical therapy, dietary counseling, and more.
To have this coverage, there are rigid requirements. The following may apply:
- You must first have been in the hospital for at least three days for a qualifying medical condition. The day you leave the hospital is not counted. So, if you are in the hospital for two days, and are discharged on day three, you have not met the three-day hospitalization requirement.
- You must still have hospital days left for your current benefit period.
- Your physician must determine that the care in the skilled nursing facility is medically necessary.
- The reason you need skilled nursing care is related to the reason you were hospitalized. This means either because you need more care for your original condition, or because of something that arose while you were in the hospital, such as a hospital-acquired infection.
- You must receive the skilled services in a Medicare-certified skilled nursing facility.
As of 2022, the coverage may include:
- $0 coinsurance for the first 20 days.
- Up to $194.50 coinsurance is required per day from days 21 to 100.
- No coverage for any days after day 100.
If you have a Medigap Plan, you may have assistance with the coinsurance cost. This is the coverage provided for each benefit period. The same applies to a Medicare Advantage Plan. These plans are required to provide at least the same benefit you have with Original Medicare. These requirements may also apply after each benefit period.
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