What Medicare will and won’t pay for when it comes to care in a facility and at home
Medicare Coverage in an Assisted Living or other Facility
Medicare does NOT pay for people to live in an assisted living facility. In fact, Medicare does not cover room and board or ongoing personal care in any facility.
The only circumstance in which Medicare will cover any type of room and board and personal care assistance in a facility is when a doctor authorizes a rehab / skilled nursing facility (SNF) stay, following admission to the hospital for at least 3 nights.
Even in this circumstance, Medicare has strict coverage limits. Medicare typically pays 100% of the cost of a rehab/SNF stay for the first 20 days. From the 21st-100th day (assuming eligibility requirements continue to be met), Medicare usually pays for 80% of the cost. The remaining 20% is covered by secondary insurance (if the patient has such a policy) or is the patient’s out of pocket responsibility (if no secondary insurance exists).
Medicare Coverage at Home
Medicare does not pay for ongoing care at home, even when people need assistance with personal care, like bathing, dressing, grooming, toileting, etc.
In fact, the only time Medicare will pay for any assistance with personal care is when there is also a need for skilled services (physical therapy, occupational therapy, speech therapy or nursing services)—typically following a rehab or hospital stay. When the skilled services stop (usually after several weeks), Medicare’s coverage of in-home personal care also stops.
[Read more about Medicare’s coverage of skilled services at home]Note about Medicare Advantage: Medicare Advantage policies are provided by private health insurers who contract with the government. These plans often offer “perks” like transportation and home delivered meals, but don’t typically provide more services or coverage, than Original Medicare, when it comes to care in a facility or at home.
[Find out more about the differences between what Original Medicare and Medicare Advantage cover]
Understanding the limits to Medicare’s coverage for ongoing care in a facility and at home, it would be a good idea to start thinking about how you will pay for your future care.
More on this to come, but in the meanwhile, you may want to read about buying long-term care insurance and whether it would make sense for your circumstances.
