This guide on Medicare focuses on how to leverage government healthcare to maximize quality of life even if you need some personal assistance. Keep in mind that as in any financial or health situation, it is often necessary to include a number of different complementary pieces in order to best fit your needs.
There are three parts to the Medicare program that seniors in assisted living facilities can take advantage of for their healthcare: Medicare Part A which covers inpatient hospital care, Medicare Part B which focuses on outpatient hospital care and doctor visits and most other care, and Medicare Part D which covers prescription drug benefits.
While nearly all seniors qualify for Medicare Part A which is also known as hospital insurance, it's important to recognize that those costs can differ greatly due to the structure of costs, co-pays and deductibles. Medicare Part D asks for an initial monthly premium which covers up to 95 percent of drug costs. That's especially important because the donut hole in prescription drug coverage between $750 and $4,550 in 2010 has been limited and will be phased out.
However, it's important to note that there is more than one option for Part D coverage, and these can vary significantly among what drugs are covered. The Center for Medicare and Medicaid Services offers a helpful resource for choosing among them here: https://www.medicare.gov/find-a-plan/questions/home.aspx
The primary difference between Medicare Part A and Medicare Part B is the type of care that assisted living facilities residents require. Part A coverage is limited to inpatient hospital care for extensive injuries due to slips and falls or serious illnesses. In that case, Medicare covers the costs of surgical care and other inpatient costs such as hospital beds after paying an initial deductible.
In other cases, such as outpatient care like doctors visits, Medicare Part B applies. The reason it's critical to know the difference is that outpatient services require you to pay 20% of all services after the deductible, while all Part A services are paid for by Medicare outside of the initial deductible.
Medicare Part B and Part A both require initial applications, except for railroad workers, those with ALS or permanent kidney failure. Note that you need to sign up to receive benefits prior to turning 65 or coverage can be delayed. Most people will not have to pay for Part A and therefore in-patient care premiums. Part B coverage generally requires a premium, but this depends on one's income.
Medicare Part D, or prescription drug coverage, is a group of plans that seniors can sign up for as they are about to turn 65. In addition to a monthly premium, there are also deductibles for certain drugs. Keep in mind that there are different formularies, or lists of drugs that are accepted by a given Part D plan.
What Part D offers is the ability to limit the cost of some prescription drugs that otherwise wouldn't get covered by Part B. For example, a 20% co-payment is available for some drugs under Part B if prescribed on an outpatient basis, but your doctor may choose another medication that isn't covered. Part D plans offer an additional safety net that can help in between self-paying and Part B coverage.
Keep in mind that Part D coverage can vary depending on the plan's administrator, and that it may also vary depending on the premiums that you pay. There may be some overlap as well between Medicare Part D prescription drug plans and Medicare Advantage plans, which offer augmented healthcare coverage for those who have Parts A and B.
The principal benefit of health care reform for Medicare patients in assisted living facilities is an emphasis on preventive screenings. While the doctor's visits are subject to the 20 percent co-pay of Medicare Part B, the costs of the screenings themselves, including those for cardiovascular disease are free. Similar fees are carried for bone mass density for those at risk of osteoporosis and similar conditions. The Centers for Medicare and Medicaid Services has established guidelines for the frequency of these preventive care measures, generally every few years. Patients requiring more tests may qualify for them based on medical necessity.
On the other hand, most services now carry a 20 percent co-pay. This can include everything from insulin pumps and therapeutic shoes to diabetes self-management training. Assisted living facility residents are also required to pay 20% of the cost of diagnostics or x-rays performed in an outpatient setting, but blood work and other diagnostics are fully covered. For 2011, services such as dialysis at home, as well as training and self-management are also subject to the 20 percent deductible. This also extends to dialysis equipment for use in a room at an assisted living facility. Other similar changes are available online.
While some vision and dental care is covered, especially preventive care for disease screening like glaucoma, regular visits and check-ups are not always covered by either Part A or Part B. So visits to optometrists are not covered by either Part A or Part B, except if they relate to another condition such as diabetes, glaucoma or macular degeneration.
In that vein, dental care of most varieties isn't covered, and that includes everything from checkups to extractions and dentures. Again, Medicare covers in-hospital care or for more complicated or orthodontic procedures, but standard care isn't part of the equation. And Medicare Part B does not cover insulin for diabetics who inject using syringes or needles, nor does it cover ancillary supplies like cleaning materials.
Also important to those in assisted living facilities is the fact that some services such as rehabilitation services from therapists must be prescribed as a result of an in-patient visit to a hospital, and those transitioning to nursing homes will require a hospital stay of at least three days to verify the need for further care.
While Medicare and its various components tend to constitute the chief healthcare insurance for many seniors 65 and older, its role for assisted living facility residents is somewhat different. Rather it should be seen as an augmentation of a separate financial plan designed to cover the costs of assisted living.
As an example, the rent for an assisted living facility resident is not covered by Medicare, nor are so-called non-skilled services. These include assistance with daily activities including grooming, clothing oneself and assistance at meal-time. So most of the costs involved with an assisted living facility must be borne by the resident and his or her family.
Instead, Medicare can be used to offset the cost of preventive care and regular prescriptions, and can also be used to augment care that spans the gap between assisted living facilities and nursing homes. For example, a "skilled" practitioner such as a licensed physical therapist or other medical professional involved in rehabilitation from a slip and fall would count towards Medicare Part B care. This can enable residents to remain in assisted living facilities by increasing quality of life.
While the different parts of Medicare can assist with healthcare there are other options that can be used to help offset the costs of rent and personal assistance at an assisted living facility. Assistedlivingfacilities.org will be covering these in our overview for senior insurance coverage, as well as guides to other options. They include long-term care insurance, the CLASS act, MediGap and investment options, each of which you can find in our guides on the subjects.
Medicare Parts A, B and D, as well as private offerings through Medicare Advantage may help to limit the costs of healthcare while in an assisted living facility. Keep in mind that other costs such as rent will need to be borne out in different fashions. More importantly, be sure to review the different plans and guidelines with your doctor and a financial adviser if you have one. You may not be able to forecast future ailments or injuries, but you may be able to maximize the time you have for a measure of independence in an assisted living facility.