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Medicare Coverage as it Relates to Assisted Living

Healthcare Insurance
Healthcare Insurance

Are you considering assisted living for yourself or a loved one? The cost of senior housing is the most persuasive elements in the decision process for consumers. The factors that affect the price and expenses are the location, amenities, services, and the living space like an apartment or a room. The first step is to figure out how to pay for it.

Most Americans believe that Medicare, the federal health insurance program for people age 65 and older and some younger people with disabilities, pays for long-term care like assisted living. It does not.

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 augments 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 mealtime. So, most costs involved with an assisted living facility are by the resident and his or her family.

Instead, Medicare offsets 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. It enables residents to remain in assisted living facilities by increasing a quality of life.

Medicare is a Health Insurance Program, Not a Long-Term Care Insurance Program.

The official Medicare handbook states that Medicare enrollees must pay for long-term care services (such as personal assistance at home, assisted living, and nursing home care) entirely from their income and savings. Get a copy of the Medicare handbook.

Consumers' confusion about Medicare and what it covers originates from a misinterpretation of coverage by Medicare's "post-acute" home health care and skilled nursing facility benefits.

What is Post-Acute Care?

Medicare does not pay for assisted living.
Understand Medicare's role with Assisted Living

It is a branch of secondary health care where a patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery. In medical terms, care for acute health conditions is the opposite from chronic care or longer-term care.

The acute care services, delivered by teams of health care professionals, range in medical and surgical specialties. It may require a stay in a hospital emergency department, ambulatory surgery center, urgent care center or another short-term facility.

Another description of "post-acute" services relates to skilled nursing and therapy services some when patients need hospital or outpatient treatment. These could be a skilled nursing visit for wound care and physical therapy after hip surgery. It does not cover long-term care services and supports like personal assistance with daily activities: bathing, using the toilet and managing medications.

What does Medicare Cover?

It's important that individuals understand Medicare to explain the confusion. Medicare covers qualified healthcare costs while the individual (over the age of 65) is living in an assisted facility. So, again Medicare can and may cover costs associated with an assisted living resident's healthcare, but NOT the ongoing monthly cost of long-term residency at an assisted living facility.

What is Medicare?

Medicare is the federal health insurance program (health insurance, not long-term care insurance) for people age 65 and older and some younger people with disabilities a medical insurance for its different parts. There are three parts to the Medicare program that seniors in assisted living facilities can take advantage of for their health care:

Medicare Part A which covers inpatient hospital care,

Medicare Part B, which focuses on outpatient hospital care and doctor visits and most other care,

Medicare Part D, which covers prescription drug benefits.

Medicare Part A

Part A - called hospital insurance part of traditional/original Medicare. Most people enroll when turning age 65. Part A covers the cost if admitted to a hospital, skilled nursing facility, or hospice, no matter where your home is, including an assisted living facility - for a limited time only. Medicare Part A also covers some home health services.

Medicare's home health care benefit pays for intermittent skilled nursing and therapy visits for people who are homebound. A doctor certifies the need for the services.

In some cases, the home health benefit pays for long-term care that applies to home health aide visits. These visits provide personal assistance to people eligible for skilled visits. Know the limits and coverage stipulations of aide visits. Only 17% of Medicare home health visits account for 11 percent of home health spending. Visits from home health aide is a significant portion of temporary, not long-term, needs for personal assistance. - From AARP

Medicare Part A (Hospital Insurance) covers skilled nursing care in a skilled nursing facility under certain conditions for a limited time. The conditions are: up to 100 days of skilled nursing facility care, but only after a hospital stay of at least three days.

Medicare Part A Covered Services include:

  • Semi-private room (a room you share with other patients)
  • Meals
  • Skilled nursing care
  • Physical and occupational therapy*
  • Speech-language pathology services*
  • Medical social services
  • Medications
  • Medical supplies and equipment used in the facility
  • Ambulance transportation to the nearest hospital
  • Dietary counseling

*Medicare covers these services if they're needed to meet your health goal.


Medicare Part B

Part B is a medical insurance that covers outpatient care no matter where you call home. It pays for visits to a doctor's office, tests, and preventive health care like cancer screenings and vaccines. It also covers some medical supplies, like blood sugar test strips, therapeutic shoes, etc.

Medicare is confusing and you need to understand what it covers and what it does not cover. This article intends to help clear up the Medicare health insurance confusion. It is health insurance not a long-term care insurance.

Medicare Part A versus Medicare Part B

The primary difference between Medicare Part A and Medicare Part B is the type of care that assisted living facilities residents require. There are limits to the Part A coverage of 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 paid 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 before turning 65 or coverage delays. Most people will not have to pay for Part A and therefore in-patient care premiums. Part B coverage requires a premium, but this depends on one's income.

Medicare Part D

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 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 are 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.

Costs of Medicare

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. However, it's important to note that there is more than one option for Part D coverage, and these vary significantly among drugs. The Center for Medicare and Medicaid Services offers a helpful resource for choosing among them.

What Isn't Covered by Medicare

Some vision and dental care covers 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.

Dental care of most varieties are not 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 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.

Carol Marak
Carol Marak

After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.