Does Medicare Cover the Cost of Assisted Living?
Navigate Medicare's complex relationship with assisted living expenses. Discover what Medicare covers for medical care and explore other funding solutions.
Medicare, a federal health insurance program, provides coverage primarily for individuals aged 65 or older, and for some younger people with disabilities. It is often misunderstood, particularly regarding its coverage of long-term care services like assisted living. Many individuals and their families inquire about Medicare’s role in covering the substantial costs associated with assisted living facilities. This article aims to clarify Medicare’s coverage limitations and explore alternative funding options.
Medicare and Assisted Living Costs
Medicare generally does not cover the non-medical costs associated with assisted living. These costs include room, board, and personal care services, often referred to as “custodial care.” Custodial care involves assistance with daily living activities such as bathing, dressing, eating, and using the restroom. Medicare’s design focuses on acute medical care rather than long-term daily living assistance.
Assisted living facilities primarily offer support with these activities in a residential setting. Therefore, Medicare does not cover the expenses for daily living assistance provided in these facilities. The significant portion of assisted living costs, including rent and meals, remains the responsibility of the individual.
Medicare Coverage for Medical Care
While Medicare does not cover the residential aspects of assisted living, it does cover medically necessary services for individuals residing in these facilities. Medicare Part A covers inpatient hospital stays, skilled nursing facility stays for rehabilitation, and some home health and hospice care. If an individual in an assisted living facility requires a hospital stay, Part A covers those inpatient services.
Medicare Part B covers outpatient care, including doctor visits, preventive services, and durable medical equipment. Doctor appointments, medical tests, and certain medical supplies prescribed by a physician are covered under Part B, even if the person lives in an assisted living facility. Examples of covered durable medical equipment include wheelchairs, walkers, and oxygen equipment.
Medicare Part D helps cover the cost of prescription drugs. Individuals in assisted living can use their Part D coverage for their prescribed medications. Additionally, Medicare Part A may cover short-term home health care services, such as skilled nursing care or therapy, which could be provided to a resident within an assisted living setting.
Assisted Living Versus Skilled Nursing Facilities
Understanding the distinction between assisted living facilities and skilled nursing facilities is important for Medicare coverage. Assisted living facilities provide assistance with daily activities and medication management in a residential environment. These facilities are generally less clinical and offer a more home-like atmosphere.
Skilled nursing facilities (SNFs), conversely, provide a higher level of medical care, including 24/7 nursing care and rehabilitative services. Medicare Part A can cover short-term stays in a Medicare-certified SNF for rehabilitation purposes, but only after a qualifying inpatient hospital stay of at least three consecutive days. This coverage is limited to 100 days per benefit period, with a coinsurance requirement after the first 20 days.
Paying for Assisted Living Beyond Medicare
Given that Medicare does not cover the residential costs of assisted living, individuals and families often explore alternative payment methods. Private funds, including personal savings, pensions, and investments, are common ways to cover these expenses. Long-term care insurance policies are designed to help cover the costs of services like assisted living, home care, and skilled nursing care.
Medicaid, a joint federal and state program, can also provide financial assistance for long-term care services for individuals with limited income and assets. While Medicaid generally does not cover the room and board portion of assisted living, many states offer Home and Community-Based Services (HCBS) waivers that can cover personal care and other supportive services within an assisted living setting. Eligibility for Medicaid and its specific coverage varies by state, often requiring applicants to meet financial and functional criteria, such as needing a nursing home level of care. Veterans may also be eligible for benefits through the Department of Veterans Affairs (VA), such as the Aid and Attendance Pension, which can help offset the costs of assisted living for eligible wartime veterans and their surviving spouses who require assistance with daily living activities.