Medicare and Assisted Living Coverage

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What kind of extended care benefits options exist through Medicare?

Does Medicare cover assisted living? Yes and no.

Assisted living can mean different things to different people in different locations, even within the same state. Medicare covers some services associated with extended care in various types of assisted living facilities. But there are a number of assisted living services Medicare does not cover.

At most facilities offering long-term or short-term care services, Medicare does not cover the cost of the stay. But it does cover some medical expenses during your stay.

For instance, Medicare might not cover the bill from an assisted living facility for occupying a room, but it might help cover benefits such as basic care from the staff, prescription medication, doctor’s appointments, medical equipment, including walkers and wheelchairs, transportation to doctor’s offices and hospitals and more.

Additionally, Medicare also covers some extended-stay services that are similar to assisted living but that are not designed for long-term care like assisted living. These include care received in skilled nursing homes, hospice, home health services and extended hospital stays.

If you want to know how you can get supplemental insurance outside of Medicare to help pay for the extra costs of long-term care for a loved one, just read on. We’ll break down the different components of Medicare benefits as they relate to assisted living and other long-term care coverage that HealthMarkets has to offer.

What Medicare Covers

Medicare is made up of four different parts: A and B (Original Medicare), C (Medicare Advantage) and D (prescription drug coverage). Part A is for hospital insurance and skilled nursing care. Part A of Medicare provides coverage for:

Hospital Care

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

  1. Semi-private rooms (and even private rooms when deemed medically necessary)
  2. Meals
  3. General nursing
  4. Any medication as part of inpatient treatment
  5. Hospital supplies

Skilled Nursing Facility (SNF) Care

Part A of Medicare provides coverage for care received in a skilled nursing facility as long as the services are deemed necessary by your doctor. The benefits for skilled nursing care includes:

  1. Semi-private room
  2. Meals
  3. Medication
  4. Medical supplies and equipment
  5. Physical, occupational and speech therapy
  6. Dietary counseling
  7. 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 will provide coverage for:

  1. Part-time skilled nursing care
  2. Physical, occupational and speech therapy
  3. Medical social services
  4. Medical supplies and equipment

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:

  1. Services administered by doctors and nurses
  2. Hospice aide and homemaker care
  3. Prescription drugs
  4. Medical equipment and supplies
  5. Physical, occupational and speech therapy
  6. Dietary counseling
  7. Social work services
  8. Grief and loss counseling for the patient and family members
  9. Short-term respite care

Costs

A Medicare patient’s costs for extended care will vary based upon the type of care received and the amount of time receiving such care. All costs are subject to change each year and the figures below are for the 2016 calendar year.

For hospital care, a deductible is required for each benefit period. The amount of this deductible is $1,288 in 2016.

For the first 60 days, there are no coinsurance requirements. But beginning on day 61, a coinsurance of $322 per day is required. After 90 days, that coinsurance requirement jumps to $644 per day.

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 totaled $157.50 in 2015 and $161 in 2016.

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

Home health care services are covered in full for approved benefits. Only a 20 percent coinsurance payment is required for any needed 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 percent coinsurance for respite care.

***A benefit period is measured from the first day you are admitted as an inpatient in a hospital or skilled nursing facility to the 60th consecutive day without receiving any inpatient care.

Eligibility

Just as with costs, the eligibility for extended care coverage through Medicare depends on the type of service. For each type of care, it is required to be enrolled in Medicare Part A. The additional requirements include:

Hospital Care

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

  1. A doctor orders a patient to receive medically necessary inpatient treatment that requires at least two nights of stay and the hospital formally admits the patient.
  2. The type of treatment needed can only be provided in a hospital.
  3. The hospital accepts Medicare.

Skilled Nursing Care

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

  1. The patient 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 approved 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 must be under the care of a doctor and receiving services according to the doctor’s plan.
  2. A doctor must certify that the patient needs either intermittent skilled nursing care, physical therapy, occupational therapy or speech language pathology.
  3. The home health company providing treatment must be certified by Medicare.
  4. 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 is designated as terminally ill by both a hospice doctor and a regular doctor and life expectancy is estimated at six months or less.
  2. The patient accepts palliative care instead of care designed to treat the illness.
  3. 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 eating, bathing and dressing. 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 confinement insurance can pay patients a daily cash benefit for every day they are in the hospital. These payments can help with the unexpected medical costs 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 daily cash benefits to pay for childcare, household help and normal living expenses including rent and utility bills.

Disability Insurance

Similar to hospital confinement or critical illness insurance, disability insurance allows for daily cash payments to compensate for everyday living expenses and medical costs that are not otherwise covered.

When it comes to finding Medicare coverage for assisted living, it all comes down to what specific services a patient needs and from which type of facility they receive care.

In order to best figure out which extended care coverage options are best for you or your loved one, speak to one of the 3,000-plus licensed agents at HealthMarkets today. We have sold more than two million policies to date and can help you find the best insurance plan for your assisted living needs.

Call us today at (800) 360-1402.

About the Author: Luci Lopez

Luci is a visual storyteller (10 years!). Baker. Dog lover. Proud UTPA and UNT alumna. Curious about the unknown.

HMIA002296

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Sources:
"Inpatient hospital care | Medicare.gov." 2012.
"Medicare May Cover the Cost of Home Care Following ..." 2011.
"Medicare Hospice Benefits - Medicare.gov." 2012.
"What Part A covers | Medicare.gov." 2012.
“Your Medicare Coverage - Inpatient Hospital Care.” Medicare.gov 2015.|
“Your Medicare Coverage - Skilled Nursing Facility (SNF) Care.” Medicare.gov 2015.
“Your Medicare Coverage - Home Health Services.” Medicare.gov 2015.
“Your Medicare Coverage - Hospice & Respite Care.” Medicare.gov 2015.
"Skilled nursing facility (SNF) care | Medicare.gov." 2012.
"Medicare and Home Health Care (PDF). - Medicare.gov." 2012.
“How Hospice Works - Medicare.gov.” 2012.
 

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