Does Medicare Cover Assisted Living in Texas?

Understanding Assisted Living Costs

Assisted living facilities offer a residential option for older adults who need help with daily activities but do not require extensive medical care like nursing homes. These communities typically provide various services, including meals, housekeeping, personal care, and social activities. The significant costs often lead individuals and their families to explore potential coverage from programs like Medicare.

Medicare and Assisted Living Coverage

Medicare, the federal health insurance program for individuals aged 65 or older and certain younger people with disabilities, generally does not cover the costs of assisted living facilities. This is because Medicare primarily covers medical care, deeming assisted living, which focuses on custodial care, as not medically necessary. Custodial care involves assistance with Activities of Daily Living (ADLs) such as bathing, dressing, eating, and supervision, distinct from skilled medical care.

Medicare Part A, known as Hospital Insurance, covers inpatient hospital stays and, under specific conditions, short-term, medically necessary skilled nursing facility (SNF) care. To qualify for SNF coverage, an individual must have had a qualifying hospital stay of at least three consecutive days and require daily skilled nursing or rehabilitation services. This coverage is for rehabilitation, not long-term residential care in an assisted living setting.

Medicare Part B, or Medical Insurance, helps cover doctor visits, outpatient services, and durable medical equipment. This includes services like ambulance transportation, chemotherapy, laboratory tests, and some preventive services. While residing in an assisted living facility, Medicare Part B will continue to cover these medically necessary services. Medicare Part D, the prescription drug coverage, helps lower the cost of outpatient prescription medications.

Medicare Advantage Plans, often called Part C, are offered by private companies and must cover everything Original Medicare (Parts A and B) covers. While these plans may offer some supplemental benefits, such as transportation to medical appointments, meal delivery, or limited personal care services, they typically do not cover the core costs of assisted living facilities. These additional benefits are generally supplemental and do not encompass the room, board, and comprehensive personal care services that constitute the primary expenses of assisted living. The fundamental costs of living in an assisted living facility, including room, board, and personal care services, are not covered by any part of Medicare.

Texas Medicaid Programs for Assisted Living

While Medicare does not cover the residential costs of assisted living, Medicaid, a joint federal and state program, can be a significant financial resource for eligible individuals. Medicaid provides healthcare coverage and may offer assistance for long-term care services for those who meet specific income, asset, and functional eligibility requirements. These programs are distinct from Medicare and have their own application and approval processes.

In Texas, the STAR+PLUS Waiver is a primary Medicaid program that can assist with services in assisted living facilities for eligible adults aged 65 or older, or those with disabilities. This waiver allows individuals who require a nursing facility level of care to receive services in community settings, including assisted living residences. The STAR+PLUS Waiver covers a range of services such as personal care assistance, adult day care, and adaptive aids.

Eligibility for the STAR+PLUS Waiver involves meeting specific financial criteria, including income and asset limits. For instance, in 2024, a single applicant for STAR+PLUS in Texas generally must have a monthly income below $2,829. Beyond financial requirements, individuals must also demonstrate a functional need for assistance, typically assessed as requiring a nursing facility level of care. This assessment considers an individual’s ability to perform Activities of Daily Living (ADLs) like transferring, mobility, eating, and bathing. While the STAR+PLUS Waiver covers the services provided within an assisted living facility, it generally does not cover the full cost of room and board.

Other Funding Sources for Assisted Living

Given that Medicare typically does not cover assisted living, and Medicaid has strict eligibility criteria, individuals often rely on various other funding sources. The most common method involves using personal financial resources, including personal savings, investment portfolios, pension payments, and Social Security benefits to cover the monthly fees.

Long-term care insurance is a private insurance product specifically designed to cover the costs of long-term care services, including assisted living, home care, and skilled nursing facilities. Benefits from these policies are typically triggered when a policyholder is unable to perform a certain number of Activities of Daily Living (ADLs), such as bathing or dressing, or has a cognitive impairment. Policies vary, and it is important to understand the daily or monthly benefit amounts and the length of coverage.

Veterans and their surviving spouses may be eligible for the Aid and Attendance benefit, a special monetary allowance from the Department of Veterans Affairs. This benefit can help offset assisted living costs for those who meet specific service requirements, income and asset limits, and require the aid and attendance of another person for daily activities. This non-service-connected pension can provide financial support for eligible individuals.

For short-term financial gaps, bridge loans offer a temporary solution, providing funds to cover immediate assisted living costs while waiting for other assets to become available. These loans are typically short-term, ranging from six to twelve months, and can provide quick access to capital for urgent transitions. Reverse mortgages allow homeowners to convert home equity into cash for assisted living expenses. The loan is repaid when the home is sold or the homeowner moves out permanently.