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Michael T Braden March 13, 2024 GENERAL MEDICARE
DOES MEDICARE PROVIDE FOR ASSISTED LIVING FACILITIES?
No, Assisted living facilities are often referred to as Long Term Care Facilities. These facilities cater to individuals requiring non-medical custodial care and aid with daily activities that they can not perform on their own, unassisted. These ADL (Activities of Daily Living) consists of Dressing, Bathing, Medication Management, Getting in and Out of a Chair or a Bed, Walking independently, Going to the Restroom, and Eating.
Many individuals have a separate Long-Term Care Policy that they plan to use to cover the projected costs of Assisted Living down the road. That is because Medicare does not pay for assisted living, and honestly, it was never designed to. It was envisioned as Health Insurance, not Custodial Care.
Medicare usually pays for any of your Medical needs while you are a resident of any Assisted Living Facility/Long Term Care Facility. However, Medicare will not provide any assistance for the cost/rent to stay at an Assisted Living or Long-Term care Facility.
For those who need assistance with the cost of staying in a Long Term Care/Assisted Living Facility, you can contact your state's Medicare Department.
Care centered around helping with the activities of daily living is not considered medically necessary when it does not result from a medical condition. Thus, it falls outside the scope of the federal health insurance program.
ISN'T EVERYTHING THE SAME WHEN IT COMES TO ASSISTED LIVING?
In general, Nursing Homes or Skilled Nursing facilities are appropriate for individuals with complex medical needs that require constant monitoring and medical supervision. These patients are expected to recover in short order at which time they will be released and can return to their own homes and skilled nursing care and are expected to recover to full functionality in relatively short order.
Assisted Living is defined as a location where residents cannot perform all of the seven Activities of Daily Living. In ALF (Assisted Living Facilities) the residents only receive non-medical assistance and personal care. Most typically, the only thing that prevents the majority of ALF residents is the fact that they are unable to execute each of the seven Activities of Daily Living independently and on their own. These are the tasks that prevent the beneficiary from living on their own safely and independently.
WHAT YOU CAN EXPECT MEDICARE TO PAY FOR?
MEDICARE PART A
We all know that Medicare Part A is the portion of Medicare that covers Hospital inpatient care. Medicare Part A extends coverage to include restricted coverage for minor/brief recovery periods in both SNF's (Skilled Nursing Facilities). You must meet the minimum standards set forth by Medicare. You needed to have been in the Hospital for at least 3 days and have your Doctors and/or Hospital Administration attest to the fact that you require Skilled Nursing Care or Rehabilitative services as a part of your recovery. if additional Occupational, Speech, or Physical/Occupational therapy is required, Medicare will pay for it.
MEDICARE PART B
Typically, we refer to Medicare Part B as the Out-Patient side of the Medical coin. Medicare Part B covers Durable Medical Equipment, Preventative Care, Intravenous Drug Therapies in a Clinic, Hospital or Doctors Office, Lab Work, Imaging, Outpatient Services, and Preventative Services. Generally, all of these Part B benefits will follow the Medicare beneficiary if they end up residing in an Assisted Living facility.
Here is a brief image of how this might work:
An example of some things I have seen and witnessed could be an Assisted Living Community collaborating with an Independent Home Health Care Company/Organization/Agency that could offer physical therapy services, or they might be able to schedule visits from a doctor on-site. In certain situations, they might administer injections for residents with diabetes or handle bandage changes. These medical services would typically be covered by Medicare.
MEDICARE BENEFITS IN ASSISTED LIVING COMMUNITIES MAY INCLUDE ANY OF THESE ITEMS BELOW:
Durable Medical Equipment such as wheelchairs, oxygen, and walkers. There is an option for a battery-powered/Electric Wheelchair, however, the Medicare Beneficiary must meet with the Doctor in person at the Doctor' Office to discuss.
Physical Therapy, Speech Therapy, and Occupational Therapy.
Intermittent or Part Time Skilled Nursing Visits.
Social Services outreach to help beneficiaries adjust and cope with any issues that have come from an illness or accident.
Caregivers who can offer assistance with non-skilled assistance in executing the Activities of Daily Living, which is arguably the biggest reason people are in a Non-Skilled Care Facility/Assisted Living environment. In some cases having someone from an agency like Visiting Angels or Home With Help might be the difference between staying at home or residing in a facility. Vital, non-skilled assistance with daily activities, which we all realize is usually the biggest part of assisted living care, is not covered by Medicare. This is why the general answer to, “Does Medicare pay for assisted living?” is no. However, if you transition to an assisted living community, Medicare will continue to cover your prescription medications and any other medical services that were previously covered under your plan while you were living at home.
WHAT IS THE LITMUS TEST TO QUALIFY FOR ASSISTED LIVING?
ADL'S (ACTIVITIES OF DAILY LIVING)
Individuals who have difficulty or need help with activities such as bathing, dressing, grooming, toileting, eating, and mobility are often good candidates for assisted living.
INSTRUMENTAL ACTIVITIES OF DAILY LIVING Living (ADL's)
These are more complex activities, such as managing medications, handling finances, cooking, housekeeping, and transportation. If a person requires support with these tasks, assisted living can be suitable.
SAFETY ISSUES
Seniors who face safety risks living independently due to issues like falls, memory problems, or physical impairments may benefit from the supervised and secure environment of an assisted living facility.
BECOMING ISOLATED FROM SOCIETY
Assisted living can be beneficial for individuals who feel isolated or lonely living alone and would benefit from the social interaction and community engagement provided by the facility.
LACK OF DESIRE OR WILLINGNESS
The individual should be willing to move into an assisted living community and feel comfortable with the idea of receiving assistance and care in a communal setting.
PROS AND CONS OF LIVING IN AN ASSISTED LIVING COMMUNITY
Overall, assisted living facilities offer a supportive and social environment, providing help with daily activities and ensuring safety and security. The trained staff offers care and assistance, and residents can enjoy recreational activities and transportation services.
However, the cost can be a drawback, and it may involve adjusting to communal living and a potential loss of independence. Medical care is limited, and the quality of facilities varies. You should make a decision based on your needs, preferences, and available options.
ARE THERE DIFFERENT LEVELS OF AN ASSISTED LIVING COMMUNITY?
The highest level of assisted living is often referred to as “memory care” or “special care units.” Memory care is a specialized form of assisted living designed to meet the unique needs of individuals with Alzheimer’s disease, dementia, or other memory-related conditions.
Memory care units typically provide a higher level of supervision, security, and specialized care to ensure the safety and well-being of residents with memory impairments. The staff in memory care facilities undergo additional training to understand the challenges faced by individuals with memory loss and how to provide appropriate care and support.
In memory care personal care units, the physical environment is often adapted to help residents navigate their surroundings more easily. They may have secured access to prevent wandering, memory prompts, and specific design elements to reduce confusion and anxiety. Activities and programs are tailored to engage and stimulate residents’ cognitive abilities, promote social interaction, and maintain a sense of familiarity and routine.
Medicare does not pay for room and board or personal care services, but it will usually cover some of the medical costs residents may encounter. Typically, Medicare coverage is for outpatient care under Medicare Part B.
Due to the specialized nature of memory care and the increased level of care provided, memory care units may have higher costs compared to standard assisted living facilities. Families seeking memory care for their loved ones should carefully evaluate the facilities, staff qualifications, and available services to ensure they meet the specific needs of their family member with memory impairment.
HOW DOES ASSISTED LIVING WORK/INTERACT WITH MEDICARE PART C?
Some Medicare Advantage plans provide additional benefits that can help with care-giving needs such as adult day care, care giving support, limited meals at home, and transportation to medical appointments. The specific services covered, benefits, and limitations vary a lot from plan to plan. Not all Medicare plans are the same. The only way to know for sure is to read the benefits in your particular plan's SOB (Summary of Benefits).
If you do not already have a local Medicare Broker, I would suggest looking some up nearby. You can ask for their help in researching your exact plan's benefits and they may have better options for you moving forward. It is in EVERY Medicare beneficiary's best interest to work with an Independent, Licensed Medicare Broker.
NEITHER MEDICARE SUPPLEMENT PLANS NOR MEDIGAP COVER ASSISTED LIVING
Medigap plans only pay the co-pays, deductible, and coinsurance of Medicare Part A and Medicare Part B. Assisted living coverage is not included in Medicare or a supplement.
Even though Medicare Supplement Plans and Medigap Plans do not cover Assisted living, we at Braden Medicare believe that the best option for complete, comprehensive healthcare is Original Medicare with Medicare Supplement Plan G or Medigap Plan F, period and it is not even close.
DO ASSISTED LIVING FACILITIES ADMIT DEMENTIA PATIENTS?
Assisted living communities are not covered even for individuals who need Dementia care. However, there is an option called the Program for All-inclusive Care (PACE) designed for the elderly who are eligible for both Medicare and Medicaid.
WHAT DOES IT COST TO STAY AT AN ASSISTED LIVING FACILITY FOR A YEAR?
The average cost of assisted living is close to $130 per day and $3,900 per month. However, some assisted living facilities charge as much as $5,000 - $10,000 per month, with this being considered on the lower end of the price range.
WHAT ARE PAYMENT OPTIONS FOR ASSISTED LIVING FACILITIES?
Most individuals pay for a stay at an assisted living facility through private funds, relying on personal savings or income. Other common methods of financing include Medicaid, which provides health care assistance to those with limited income and resources, and private long-term care insurance. Additionally, some people use financial instruments like reverse mortgages, life insurance options, retirement accounts, and annuities to cover the costs associated with assisted living.
ARE THERE ANY OTHER PROGRAMS THAT ARE ASSOCIATED WITH OR COVERED BY MEDICARE?
Medicare Part A offers coverage for skilled nursing care, but only under specific circumstances and for a limited duration. The care must be provided less than seven days a week or less than eight hours a day, lasting for no more than 21 days, with some exceptions.
OTHER CARE OPTIONS THAT COULD BE COVERED BY MEDICARE:
HOME-BASED CARE LIKE HOME HEALTH AIDES
However, Medicare does not cover daily 24-hour care at home, meals delivered to your home, or homemaker or custodial services if those are the only services needed.
HOSPICE AND RESPITE CARE
Hospice provides care and support for terminally ill individuals, while respite care offers short inpatient stays for hospice patients, allowing their caregivers to rest.
PACE PROGRAMS - ALL-INCLUSIVE CARE FOR ELDERLY SENIORS (PACE)
It’s a Medicare/Medicaid program that supports people in meeting their healthcare needs within their own community, reducing the need for care facility placements. It covers services like prescription drugs, doctor visits, transportation assistance, home care, and necessary nursing home stays.
ADDITIONAL OPTIONS FOR ASSISTANCE
LONG TERM CARE IS NOT PAID FOR BY MEDICARE OR THE VA
Your Medicaid coverage will depend on where you live and which specific Medicaid assistance you receive. Depending on your medical condition or income, you might qualify for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). Social Security also offers “compassionate allowances” for people with certain serious conditions to help them get disability benefits more quickly.
Long-term care insurance plans are offered through private insurance providers and may cover several types of long-term care.
For those Medicare Beneficiaries who have served in the Military and have VA Benefits, Tri-Care or Champ VA there may be additional programs to assist you with Assisted Living Benefits directly from the VA. We recommend that you contact your local Veterans Administration office to see if there are additional benefits you can apply for or are entitled to receive.