Is Assisted Living Covered by Medicare or Medicaid?

David Bolton

/

August 24, 2020

Retirement Communities
Is Assisted Living Covered by Medicare or Medicaid? | Retire Fearless

As family members age, assisted living often becomes a necessity. Many seniors struggle to pay for their assisted living on top of their medical bills. Many seniors don't want to rely on their families to cover the portion of expenses that they can not. Assisted living is expensive, with costs driven by both residency and the skills necessary for staff to provide the care needed. Costs are also impacted by what services an assisted living facility provides.

Many seniors are left wondering if Medicare or Medicaid will cover some or all of the expenses that are associated with living in an assisted living facility. So, in this article, we will find out what an assisted living facility is and whether assisted living is covered by Medicare or Medicaid. If you are looking for a comprehensive source of information to learn all about these plans, you have come to the right place.

So, let's get started.

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Table of contents

What is an Assisted Living Facility?

Assisted living is a broad term that can refer to a wide variety of services. An assisted living community is designed for people who need access to daily medical care, but don't require that care to be continuous. Housing in an assisted living community can range from full, individual apartments, to individual rooms. Many people who live in an assisted living facility need help with custodial care, which means help with some of the activities of daily living or the kind of health-related care that most people can do themselves.

Some examples of custodial care include:

  • Non Medical care that can be safely and reasonably provided by a non-licensed caregiver
  • Can take place at home or in an assisted living facility in your area
  • Includes help with daily personal activities such as bathing and dressing
  • Includes help with daily household duties such as cooking and laundry

The services that are often provided by an assisted living facility include:

  • Help with daily tasks such as bathing, grooming, dressing, and housekeeping
  • Exercise programs and classes
  • Meal services, which can include bringing ingredients for the senior to prepare, delivery of prepared meals, or providing meals in a cafeteria setting
  • Social and recreational activities
  • Transportation services to public events, grocery shopping, or personal appointments

Do Either Medicare or Medicaid Cover Assisted Living?

If you are looking to enter an assisted living home, the original Medicare will not help you pay for it. Medicaid coverage might help you pay for it, but it varies from state to state. Federal Law states that there are certain minimums of what a state must provide through its Medicaid program, though there are no rules around the issue of assisted living.

There are individual states that choose to cover assisted living, although this is the exception and not the rule. The states that do offer some form of assisted living are as follows:

  • Massachusetts: In some situations, Massachusetts will subsidize assisted living costs. This is available through its Group Adult Foster Care program and is available for low-income seniors on Medicaid.
  • New York: Certain assisted living facilities are licensed by the state of New York to accept Medicaid. Seniors must meet certain criteria to qualify for this program.
  • North Carolina: The state of North Carolina allows patients to qualify for assisted living room and board expenses. This is done through the states Special Allowance Program.
  • Ohio: Ohio will cover the costs of an assisted living facility for patients provided they are sufficiently low income.
  • Colorado: For patients who cannot afford to pay for their long-term care privately and do not have any long-term care insurance, Colorado's Medicare may help offset the costs.
  • Indiana: Indiana offers a Home and Community Based Services Medicaid waiver program that helps seniors remain living independently.

Other states may offer some funding that offsets the cost of an assisted living facility, without being explicitly for assisted living situations. The best way to find out what your specific state covers is to call your local Medicaid office.

Wasn't Medicare Created to Meet the Needs Of Seniors?

Medicare is a national health insurance program and is funded by the government. It is an insurance that is intended for Americans to receive when they reach the age of 65. Since Medicare was developed and is intended for senior care, you might expect it to cover all of a senior's expenses, but unfortunately, that isn't the case.

Medicare only covers costs that are associated with care that is short term. This means that Medicare will cover short term stays at a nursing home, after being in the hospital and will pay for limited rehab and in-home therapies.

This means Medicare will not pay for the following:

  • Assisted living
  • Long term care at a nursing home
  • Residential care homes
  • Any other long-term care needs

Medicare does not cover the cost of residing in an assisted living home or the costs associated with activities such as bathing or dressing. However, they do cover some benefits that the individual might need while residing in the facility, as long as they are for the short term. While a patient is living in an assisted living facility, they can still receive their Medicare Part A and Part B benefits, provided they are enrolled in the programs. This differs from when you are in a nursing home and no longer qualify for Medicare Part A and Part B benefits.

What if I Require Long Term Care?

Medicaid is the leading program for long term care among seniors. While this is a government-assisted program, what is covered can vary greatly state by state. This is because Medicaid is administered cooperatively by the federal and state governments. The federal government provides most of the funding and allows the states to have discretion in its individual rules, regulations, and requirements.

Unfortunately, not all American seniors are going to qualify for Medicaid. In order to be eligible for Medicaid you must:

  • Have almost all of your assets going toward your care
  • Be a low-income earner, or have medical expenses that exceed your income
  • Reside in the state that you are receiving benefits
  • Permanent resident of the US, or have US Citizenship

The factors above can vary based on the additional factors listed below:

  • The type of care required
  • The medical diagnosis of the senior
  • The state the senior resides in
  • The marital status of the senior

In addition, the senior must have a doctor certify that the need for care in an assisted living facility is medically necessary. Assuming that a senior can meet all of the above requirements, they must now find an assisted living facility that accepts Medicaid as a payment. Since many facilities do not accept Medicaid as a payment option, finding somewhere with space can be difficult. Even when a facility does accept Medicaid, they may only offer a limited number of spaces for people who are being funded by Medicaid.

Medicaid Is the Safety Net for Seniors in America

Medicaid is an essential benefit for Americans who need care that they are not able to afford. While Medicare and Medicaid may seem similar, Medicaid is far more inclusive in the services that they provide. Medicaid is also not automatically granted to all seniors once they reach the age of 65. All programs through Medicaid need to be applied for.

Medicaid Programs

Some states break down the programs that are available within the umbrella of Medicaid. One of these programs is PACE or Program of All-Inclusive Care for the Elderly. Pace covers all the care for a senior, as well as their medical needs, through one contracting agency. This allows people who would have traditionally ended up in a nursing home to stay at home with the supports they require.

Who Should Consider an Assisted Living Facility?

Assisted living facilities are great options for older adults who are mostly independent but need some help with the basic tasks of daily living. Another reason someone might choose to live in an assisted living facility is for the convenience and freedom of no longer having to do those activities. For some people, living in an assisted living facility is a way to have a community around them and not feel isolated.

Assisted living facilities are great for any older adult who wants or needs assistance with the following:

  • Doing laundry
  • Preparing and cooking meals
  • Taking medications
  • Showering
  • Dressing

If the older adult has needs that extend beyond those things, such as requiring regular supervision, complicated medication administration, memory care, and other in-depth services a nursing home tends to be a better option.

What Other Names Can an Assisted Living Facility Be Referred to As?

An assisted living facility can go by many different names. This is important to know when you are looking for an assisted living facility to reside in. Some of the different names include:

  • Adult Foster Care
  • Board and Care Homes
  • Residential Care
  • Group Homes
  • Personal Care Homes
  • Memory Care Facilities
  • Congregate Care
  • Adult Care Home
  • Adult Group Home
  • Alternative Care Facility
  • Extra-Care Housing

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