Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
Typically, you have options for Medicare coverage of medically necessary skilled care delivered while you’re in assisted living, but Medicare does not cover room and board or custodial care in assisted living facilities. The care provided at an assisted living facility is not considered skilled like you get in a nursing home or Skilled Nursing Facility (SNF).
Although most people who need assisted living have Medicare health insurance, Medicare does not cover room and board or custodial care at an assisted living facility. Your long-term care insurance may have benefits for assisted living, and you may be eligible to get help with expenses from Medicaid, Veterans Affairs, or Social Security through Optional State Supplements.
When Does Medicare Cover Assisted Living?
Generally speaking, Original Medicare does not cover assisted living because it is not considered medically necessary skilled care. However, it is very common for Medicare beneficiaries to need assistance with personal care and alternative living arrangements versus living independently at home. Medicare’s website offers an outline of possible long-term care choices here.
If you reside in an assisted living facility, Medicare will continue to cover services you require, such as hospitalization and medically necessary outpatient care and supplies, but not assisted living expenses.
Which Parts Of Medicare Cover Assisted Living?
- Part A (hospital insurance). Part A does not cover assisted living; however, you still have access to your Part A benefits if you reside in an assisted living facility. For instance, Part A will help cover your expenses if your health condition requires hospitalization. You can also choose to receive hospice care in an assisted living facility.
- Part B (medical insurance). Part B does not cover assisted living; however, you still have access to your Part B benefits if you reside in an assisted living facility. For instance, Part B will help cover your medically necessary outpatient services, like doctor’s visits, lab tests, ambulance transport, durable medical equipment (DME), and preventive care.
- Medicare Supplement Insurance (Medigap). Your Medigap policy only covers some out-of-pocket costs from your Original Medicare services. There is no additional coverage for assisted living.
- Medicare Part C (Medicare Advantage Plans). Medicare Advantage Plans, as an alternative way to receive your Medicare Part A and B benefits, do not cover assisted living. Most Medicare Advantage Plans offer supplemental benefits such as transportation to doctor’s appointments, adult day care, and meal deliveries. These benefits can help you stay at home longer.
- Medical Savings Account (MSA). An MSA Medicare Advantage Plan combines a high-deductible Advantage Plan with a savings account. The savings account is for qualified medical expenses not covered by Medicare. If you use your MSA funds for non-qualified expenses, such as room and board for assisted living, it does not count toward your deductible and is taxed as income.
- Dual Eligible Special Needs Plan (D-SNP). Another type of Medicare Advantage Plan, a D-SNP combines Medicare Advantage and Medicaid. Medicaid helps pay for most out-of-pocket expenses, including room and board for an assisted living facility. Check here to see if a D-SNP is offered in your area.
- Part D Prescription Drug Coverage. Medicare Part D drug coverage will help pay for your prescription medications whether you are at home or in assisted living.
Should You Consider Long Term Care Insurance Along With Medicare For Assisted Living?
Long-term care insurance policies may help cover assisted living costs. For instance, you may receive a daily dollar amount for room and board until your lifetime maximum allowance is reached. Policies vary, but most require that you meet two criteria before your policy pays:
- Benefit triggers determine if you are eligible for benefits. These are typically based on your inability to perform activities of daily living or your compromised cognitive function.
- The elimination period is the time between when you are deemed eligible for benefits and when your policy pays. You must pay for costs during the elimination period, much like you have to pay a deductible on an insurance plan first.
On average, if you are 65 years old, you have a 70% chance of needing some time of long-term care or support as you age. According to longtermcare.gov, 13% of people may need assisted living for up to a year.
You need to decide on long-term care insurance before you need it. You may not get an affordable policy if you wait until you are older and have health concerns.
The American Health Care Association (ACHA) and National Center for Assisted Living (NCAL) provide consumers with helpful information about assisted living and how to pay for it. If you want to make a plan for assisted living, consult your local Agency on Aging or speak with your insurance agent.
Learn More From Our Sources
- ACL.gov | Longtermcare.gov | Last accessed November 2022
- ACL.gov | Longtermcare.gov: How Much Care Will You Need? | Last accessed November 2022
- AHCANCAL | Resources for Consumers | Last accessed November 2022
- AHCANCAL | Paying for Assisted Living | Last accessed November 2022
- Eldercare.acl.gov | Find Your Local Area Agency on Aging | Last accessed November 2022
- Medicaid | Contact Information for Your State | Last accessed November 2022
- Medicare | Long-term Care Insurance | Last accessed November 2022
- Medicare | Long-term Care Choices | Last accessed November 2022
- NIH | National Institute on Aging: Assisted Living Facilities | Last accessed November 2022
- SSA | Social Security Administration: Information about Optional State Supplements | Last accessed November 2022
- VA | U.S. Department of Veterans Affairs and Long-term Care: Assisted Living | Last accessed November 2022