Assisted living is one of the most difficult parts of elder care. Expensive, with costs driven by both residency and the skills involved with this care, assisted living leaves many seniors struggling to pay for it. Does Medicare pay for assisted living? For seniors and families on Medicare or Medicaid seeking answers, here’s what you need to know.
What Is Assisted Living
First, it’s important to understand that assisted living can refer to a relatively wide variety of services.
An assisted living community is housing designed for people who need access to permanent medical care without needing active care at all times. This can range from seniors who simply need to have nursing staff available to those who need occasional treatment. Housing at an assisted living community can range from full apartments to individual rooms or even (sometimes) shared quarters.
This differs from a nursing home in the overall nature of care. Residents of a nursing home need full time care and health monitoring. In this case, residence has elements of active hospitalization. Residents of an assisted living facility, on the other hand, are individuals who anticipate needing help at times but not permanently. For example, it could be the difference between someone who needs frequent doses of powerful medication vs. someone who simply needs help organizing their medication on a daily basis.
Does Medicare Pay For Assisted Living?
As a general rule, original Medicare does not pay for assisted living. This means that the program will not cover costs such as room, board and general treatment services.
This is because Medicare explicitly does not cover what the program terms “custodial care.” Custodial care is defined as “help with activities of daily living [or] the kind of health-related care that most people do themselves.” This is one of the primary services which assisted living facilities provide, and a key difference between assisted living and nursing home care.
Does Medicare pay for assisted living outside designated facilities? In a way.Medicare can cover skilled nursing home care when medically necessary, however you must actively need professional treatment for the entire duration of your stay. It will not cover these costs indefinitely.
Does Medicare pay for assisted living expenses? While custodial care is out, seniors in assisted living do still have access to the traditional array of Medicare services. If, during their stay, a senior has an expense that would otherwise be covered by Medicare the program will pay. For example, a resident may be able to charge necessary medical equipment or outpatient services that the program would have covered if they lived at home.
Does Medicare pay for assisted living if you have Medicare Part C? No. It has been reported in some areas that Medicare Advantage plans will begin paying for assisted living. This is not true, but Medicare Advantage plans do a certain degree of discretion in this area. Advantage plans can sometimes pay for more elements of a patient’s stay in an assisted living facility but still will not cover the core costs of room and board.
Does Medicaid Pay For Assisted Living?
Medicaid coverage changes from state to state. This can include coverage for assisted living.
While federal law imposes certain minimums on what a state must provide through its Medicaid program, it remains silent on the issue of assisted living. The federal government does require that states fund nursing facilities for Medicaid recipients who need full time medical care, and home health aides for similarly qualifying patients.
Individual states may choose to cover assisted living under conditions set by the state, however this is rare. Specifically, the following states offer some form of coverage for assisted living:
Massachusetts: Through its Group Adult Foster Care program, Massachusetts will sometimes subsidize assisted living costs for low-income seniors on Medicaid.
New York: The state licenses certain assisted living facilities to accept Medicaid through its Assisted Living Program. Seniors must qualify for this program.
North Carolina: In some circumstances, patients can qualify for assisted living room and board expenses through the states Special Assistance program.
Ohio: For sufficiently low-income patients, Ohio will cover some of the costs of an assisted living facility.
For more information, this NOLO page has details on each state’s specific rules regarding Medicaid and long term care.
The Bottom Line
Assisted living can be expensive and more so in some states than others. Researching the median costs on a national basis, then looking at the costs of care in your state can give you perspective on what you might pay for care as you age.
Taking steps now to plan. That could mean purchasing long-term care insurance or creating a separate savings cushion. Either can help keep the costs from burdening your financial future.
Consider talking to your financial advisor about the implications of saving and paying for assisted living. Finding the right financial advisor that fits your needs doesn’t have to be hard. SmartAsset’s free tool matches you with financial advisors in your area in 5 minutes. If you’re ready to be matched with local advisors that will help you achieve your financial goals, get started now.
If you’re considering long-term care insurance or a hybrid life insurance/long-term care policy, shop around with different insurers to compare premiums and coverage amounts. SmartAsset’s life insurance guide can tell you how much you’ll need and provide quotes. Like other types of life insurance, long-term care insurance is typically more affordable the younger and healthier you are when you buy it.
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