How Much Does Medicare Cover for Assisted Living?
Demystify Medicare's role in assisted living. Discover what services are covered and the significant costs you'll pay out-of-pocket.
Assisted living facilities offer a residential option for individuals needing assistance with daily activities but not continuous skilled nursing care. Medicare, a federal health insurance program for those 65 or older and certain younger people with disabilities, has a limited and often misunderstood role in covering assisted living costs. This article clarifies the specific services Medicare covers within assisted living, focusing on medical care rather than long-term residential support.
Understanding Medicare’s Purpose
Medicare primarily covers medical care and rehabilitation services, distinguishing it from programs for long-term custodial care. Medical care involves services from healthcare professionals, such as hospital stays, doctor visits, and skilled nursing care for recovery. These services are medically necessary and for a defined period.
Custodial care, in contrast, involves assistance with daily activities (ADLs) like bathing, dressing, eating, and medication management, along with supervision and room and board. This care supports personal needs and is often performed by non-licensed caregivers. Assisted living facilities predominantly provide this custodial care, which Medicare generally does not consider medically necessary.
Medicare Part A and Assisted Living
Medicare Part A, or Hospital Insurance, covers inpatient hospital stays, skilled nursing facility (SNF) care, certain home health services, and hospice care. SNF care is short-term, medically necessary care for rehabilitation or recovery following a qualifying hospital stay.
Medicare Part A does not cover the residential costs of an assisted living facility, including room and board or personal care services. However, if an assisted living resident requires medical services covered by Part A, such as a short-term home health visit or physical therapy, those specific services may still be covered.
Medicare Parts B, C, and D in Assisted Living
Medicare Part B, or Medical Insurance, covers doctor visits, outpatient services, preventive care, and durable medical equipment. Assisted living residents can use their Part B benefits for these medical services, including physician appointments, medical screenings, or equipment like wheelchairs.
Medicare Part D covers prescription drugs. Residents in assisted living facilities can use their Part D plans for approved prescriptions. Medicare Part C, or Medicare Advantage, offers an alternative way to receive Medicare benefits through private companies. These plans cover all services in Parts A and B, and often include additional benefits. While some Medicare Advantage plans may offer supplemental benefits, they generally do not cover the primary costs of assisted living, such as room and board or custodial care.
Assisted Living Costs Not Covered by Medicare
Medicare generally does not cover the core expenses of residing in an assisted living facility. These non-covered costs include room and board, which covers living space and daily meals.
Medicare also does not pay for personal care assistance, which involves help with activities of daily living (ADLs) like bathing, dressing, eating, and medication management. Other non-covered services include 24-hour supervision, emergency call systems, housekeeping, laundry services, and organized social and recreational activities. These expenses are paid out-of-pocket by residents or through other financial arrangements.