Assisted Living

Does Medicare Pay for Assisted Living?

Do you have senior parents who require assisted living arrangements? When loved ones require a move into an assisted living community, a significant price tag is usually attached. 

Because Medicare is the preferred coverage for a large portion of American seniors, many of their children have the question of whether Medicare pays for assisted living services.

Medicare does not cover the cost of room and board during stays in an assisted living community. However, it does pay for some expenses like hospital care, physician payments, and additional medical-related items.

This article will discuss cases when Medicare does cover assisted living and which plans might be best for your parents or loved ones.

Contents

What Medicare Parts or Plans Cover Assisted Living? 

Certain Medicare plans cover specific portions of assisted living costs. The following section outlines which plan covers these designated expenses.

Medicare (Part A)

Medicare Part A is considered hospital insurance. This coverage will cover the following expenses:

  • Inpatient stays at a hospital
  • Inpatient stays at mental health facilities
  • Stays at skilled nursing facilities (nursing homes)
  • In-home hospice care
  • Additional home healthcare

Medicare Part A will not cover the custodial services involved with assisted living, such as assistance with bathing, dressing, and other tasks. 

Medicare (Part B)

Medicare Part B is traditional medical insurance. This coverage provides payment for the following services:

  • Outpatient care
  • Necessary medical services
  • Certain preventative measures of care

Additionally, Medicare Part B covers the following medical procedures that may be involved during the process of assisted living:

  • Lab tests
  • Vaccines
  • Screening for certain diseases
  • Cancer screening
  • Physical therapy after injuries
  • Dialysis supplies and services
  • Diabetic supplies
  • Chemotherapy

Medicare Advantage (Part C)

Medicare Advantage is another form of Medicare that may provide additional coverage for different types of services.

Medicare Advantage is a form of coverage provided through private insurance carriers. This specific coverage includes the same coverages as Medicare Parts A and B. Additionally, certain prescription coverages are also provided for recipients.

Otherwise known as Part C, Medicare Advantage covers the following services:

While Medicare Advantage does not cover daily maintenance or custodial care services in assisted living facilities, it does cover them during in-home care situations. These services may include the following:

  • Home changes to accommodate recipients
  • Adult daycare
  • Meal services
  • Telehealth services
  • Personal care and grooming
  • Transportation to and from appointments

A Medicare Advantage plan also covers the following non-home medical expenses:

  • Hospital and skilled nursing care
  • Surgery
  • X-rays and lab tests
  • Screening for various illnesses
  • Various medical equipment and mobility assistance devices
  • Emergency transportation services

During rare occasions, Medicare will also cover non-emergency transportation. Certain plans for some individuals also cover the following:

  • Gym memberships
  • Prescriptions
  • Routine dental, vision, and hearing appointments
  • Therapeutic massage

What Coverage Is Not Provided by Medicare During Stays at Assisted Living?

The following list provides information regarding the services that Medicare won’t cover during your loved one’s stay at one of these communities.

Room & Board

Medicare does not cover the cost of room and board expenses during your loved one’s stay at an assisted living facility. This would be considered a “rent” expense, as it covers the actual living space in these communities.

Custodial Care Services

No part of Medicare covers any custodial care services. Custodial services include non-medical services such as bathing, dressing, and any other tasks recipients are unable to provide for themselves.

Nutritional Expenses

Additionally, any nutritional expenses will not be covered by Medicare. This includes all three meals and any supplements or additional food items during their stay. 

What Is Medigap?

Medigap, otherwise known as supplemental insurance coverage, covers certain gaps that aren’t covered by a normal Medicare policy. These gaps include:

  • Deductibles
  • Co-payments
  • Co-insurance

Basically, Medigap covers additional expenses that Medicare Parts A and B won’t cover. For example, when Medicare only pays for services up to a certain amount, Medigap kicks in and covers the rest of these expenses.

Medigap may also provide coverage on certain expenses if you travel outside of the United States. However, Medigap will not cover costs associated with dental, vision, or hearing care. 

Which Medicare Plan Is Best for Your Loved One?

When you’re assisting your loved one or parents to decide on an appropriate form of Medicare, you must ask several questions to make the most effective decision. You should make a list of all of their medical needs and their healthcare providers and any medical equipment or prescription medications they require.

It also helps to calculate all of the out-of-pocket expenses they are currently experiencing. This will help you decide on the most appropriate form of coverage that gives them the best chances to reduce a large majority of these costs.

Together with your parents or loved ones, you should discuss the following questions:

  • Are you satisfied with your current primary care physician, or do you think you may want to switch in the future? 
  • Do you think your medical needs will require the services of any type of healthcare specialist? If so, do you have any specific providers in mind? 
  • Are you comfortable with choosing your providers from an HMO? Is having fewer providers an acceptable option if it means you could potentially save money? 
  • Do you require any type of dental, vision, or hearing coverage? What is the maximum your budget will allow to pay for these services if you do? 
  • What is the highest amount your budget will allow you to pay out of pocket for your medical costs every year? 
  • What’s the most you can afford to pay when it comes to premiums each month?

When you’re reviewing different options for plans with your loved ones, the most efficient plan is to include all of the possible options, including original Medicare plans. Many people assume that Medicare Advantage is automatically the most appropriate option.

However, original Medicare Parts A and B may provide the coverage needed at the most affordable price for some individuals. Even if they choose Medicare Advantage, there are still several specific forms of coverage they’ll have to decide on.

Different plan options under Medicare Advantage plans include the following: 

Healthcare Maintenance Organizations (HMO)

HMO plans allow your loved ones to pay lower premiums. However, they can only choose from a specific collection of providers. If they use a provider that is outside of the network, they will be required to pay out of pocket.

Preferred Provider Organizations (PPO)

When your loved ones use a PPO plan, they will receive a discount for choosing a provider within the network. You can choose a provider out of the network; however, your co-pays will be more expensive.

Special Needs Plans (SNP)

Special needs plans are made for individuals with specific requirements involving a certain disability. This is reserved for individuals who require residential care. However, you must choose from providers within the network.

Medicare uses a rating system based on a certain number of stars. You should narrow your choices down to only plans that are rated five stars.

Once you narrow down your number of choices, you should review the following elements:

  • Monthly premiums
  • Co-pays
  • Maximum out of pocket expenses
  • Covered services
  • Whether plans cover medications your loved ones or parents need

After deciding on the best plan, it’s important that you are informed of the sign-up process.

Enrolling a Parent in Medicare

The following list of steps provides information regarding the Medicare signup process. 

How to Enroll

The easiest way to sign your parents up is online through the Social Security website. 

Enrollment Requirements

Your parents can sign up three months before they turn 65. Additionally, they must be United States citizens and have been residing in the United States for at least the last five years. 

Contact for Medicare Enrollment

For questions regarding Medicare sign-ups and coverage options, call 1-800-MEDICARE (800) 633-4227).

Still Have Questions About Medicare Coverage? 

We understand how tricky it can be to navigate Medicare for the first time. For additional questions about what is and isn’t covered under Medicare, you can always speak to a member at Varenita. While we do not control what is and is not covered by Medicare, we can help you understand what coverage you will receive and what you’ll have to pay for independently.

We believe understanding Medicare can greatly help you and your family as you navigate financing senior living for a loved one. Feel free to contact Varenita online.