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Does Medicare cover assisted living? Assisted living can mean different things to different people, even within the same state. Medicare coverage can depend on the services involved.

Does Medicare Cover Assisted Living?

Medicare covers certain products and services that may relate to assisted living. These products and services are covered by Part A of Medicare, which provides coverage for hospital inpatient care, skilled nursing care, nursing home care that isn’t custodial or long-term care, home health services, and hospice care.

It is important to note that Medicare does not pay for assisted living that involves only custodial care.

Hospital Care

Hospital care can be covered under Medicare for inpatient facilities. Inpatient care includes acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, inpatient mental health facilities, inpatient care as part of clinical research studies, and long-term hospitals. The benefits for these types of stays can include:

  • Semi-private rooms (and even private rooms when deemed medically necessary)
  • Meals
  • General nursing
  • Any medication as part of inpatient treatment
  • Hospital supplies

Skilled Nursing Facility (SNF) Care

Part A of Medicare provides coverage for care received in a skilled nursing facility as long as:

  • You have Part A and days left for use in your benefit period
  • You have a qualifying hospital stay
  • The services are deemed necessary by your doctor
  • You receive these services in a Medicare-certified skilled nursing facility
  • Your medical condition is either a hospital-related condition treated during your qualifying 3-day inpatient hospital stay, or it is a condition that began while you were in receipt of care in the skilled nursing facility for a hospital-related condition. 

The benefits for skilled nursing facility care can include (but are not limited to):

  • Semi-private room
  • Meals
  • Medication
  • Medical supplies and equipment
  • Physical, occupational, and speech therapy
  • Dietary counseling
  • Ambulance transportation (under certain circumstances)

Home Health Services

If approved, Medicare can help pay for some home healthcare services. While Medicare will not pay for 24-hour care or meals delivered to the home, it can provide coverage for:

  • Part-time skilled nursing care and home health aide services
  • Physical, occupational, and speech therapy
  • Medical social services
  • Certain medical injection medications

Hospice Care

image of stethoscope

Hospice care can be covered by Medicare for care received at home or at an inpatient hospice facility. Depending on the type of terminal illness or related conditions, benefits can include:

  • Items and services for pain relief and symptom management
  • Medical, nursing, and social services
  • Prescription drugs for pain management
  • Durable medical equipment for pain relief and symptom management
  • Aide and homemaker services
  • Other covered services for pain management and other symptoms
  • Spiritual and grief counseling for the patient and family members

How Much Does Medicare Pay for Assisted Living Costs for Seniors?

For covered services, Medicare will pay for patient’s medical costs based on the type of care received and the amount of time receiving such care. All costs are subject to change annually.

For hospital care, a deductible is required for each benefit period. The amount of this deductible is $1,556 as of 2022.1

  • For the first 60 days, there are no coinsurance requirements. But beginning on day 61, a coinsurance of $389 per day is required. After 90 days, that coinsurance requirement jumps to $778 per day.1
  • Patients have 60 total lifetime reserve days to use beyond the initial 90-day stay. When those 60 days are exhausted, the patient is responsible for all costs.

For skilled nursing care, Medicare patients will pay nothing for the first 20 days of the benefit period. Days 21 to 100 will require a daily coinsurance payment that totals $194.50 in 2022.2

  • After 100 days, the patient is responsible for all costs.

Home health care services are covered in full for approved benefits. Only a 20% coinsurance payment is required for any needed durable medical equipment.

Hospice care is also covered in full by Medicare for approved benefits. Patients may be asked to pay copayments of no more than $5 for prescription drugs and 5% coinsurance for respite care.

Outpatient physical therapy is covered by Medicare Part B. Patients are responsible for paying 20% of the Medicare approved-amount.

Eligibility Requirements for Assisted Living Benefits

Just as with costs, the eligibility for coverage through Medicare depends on the type of service. The eligibility requirements include:

Hospital Care

Eligibility for covered hospital care requires each of the following to be true:

  1. The patient has Medicare Part A.
  2. A doctor orders a patient to receive medically necessary inpatient treatment, and the hospital formally admits the patient. 
  3. The hospital accepts Medicare. 
  4. In some cases, the hospital Utilization Review Committee approves the patient’s stay.

Skilled Nursing Care

For skilled nursing care coverage, all of the following must be true for eligibility:

  1. The patient has Medicare Part A and has some days remaining in their benefit period. 
  2. The patient had a qualifying hospital stay of at least three days. 
  3. A doctor determines that skilled nursing care is needed.
  4. The facility is certified by Medicare.
  5. The medical condition requiring the skilled nursing care is either related to the patient’s previous hospital stay or to a condition that began during the stay at the skilled nursing facility.

Home Health Services

Medicare coverage for home health care services requires all of the following to be true:

  1. The patient has Medicare Part A and/or Medicare Part B.
  2. The patient must be under the care of a doctor and receiving services according to the doctor’s plan.
  3. A doctor must certify that the patient needs either intermittent skilled nursing care, physical therapy, occupational therapy, or speech-language pathology. 
  4. The home health company providing treatment must be certified by Medicare. 
  5. The patient must be certified as homebound by a doctor.

Hospice Care

Benefits for hospice care are available when each of the following is true:

  1. The patient has Medicare Part A.
  2. The patient is designated as terminally ill by both a hospice doctor and regular doctor
  3. Life expectancy is estimated at six months or less.
  4. The patient accepts palliative care instead of care designed to cure the illness. 
  5. The patient signs a statement to forego treatment of the illness in favor of hospice care.

Long-Term Care Alternatives to Medicare

There are a number of supplemental insurance plans that cater specifically to people in need of extended or long-term care. 

Long-Term Care Insurance

Long-term care insurance can be provided for people who can’t perform basic tasks on their own, including bathing, dressing, and restroom usage. HealthMarkets can help you find a plan that will cover long-term care services at home or in an assisted living facility. 

Hospital Confinement Insurance

Hospital insurance can provide patients with a direct cash benefit when they are in the hospital. These benefits can help with the unexpected medical expenses that often accompany long hospital stays, as well as everyday living expenses.

Critical Illness and Cancer Insurance

If limited by a critical illness or cancer, patients with this type of insurance can receive direct cash benefits to help pay for childcare, household groceries, and normal living expenses including rent and utility bills.

Disability Insurance

Similar to hospital confinement or critical illness insurance, disability insurance can allow for direct cash benefits to help compensate for everyday living expenses and medical expenses that are not otherwise covered.

Assisted Living, Medicare, and Your Options

As you may have been able to notice, the answer to the question ‘Does Medicare cover assisted living?’ can vary.

HealthMarkets can help you find the Medicare plan for you. Just answer a few quick questions about your insurance needs, and we can help you compare your options.

Start comparing Medicare plans online today, or call (800) 439-6916 to speak to a licensed insurance agent.


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References:
1.”Inpatient hospital care.” Medicare.gov. Retrieved from https://www.medicare.gov/coverage/inpatient-hospital-care Accessed December 15, 2021. | 2. “Skilled nursing facility (SNF) care.” Medicare.gov. Retrieved from https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care Accessed December 15, 2021. 

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