What is Medicare?
Medicare is a federal health insurance program for those 65+ and for those who are younger and are living with certain disabilities or medical conditions. Part A is hospital insurance that helps cover inpatient hospital care, short-term skilled nursing centers, hospice care and some home health services. Part B is medical insurance that helps cover physician visits, ambulance services and durable medical equipment. 100% of costs are not usually covered, so many seniors purchase additional or supplemental insurance to cover what Medicare doesn’t – usually 80%.
Medicare Benefits for Senior Care
Since most senior living is paid for privately, many families are surprised when they find out Medicare doesn’t pay for senior living. Because Medicare is a health insurance program, it typically only covers medically necessary care. However, in some cases, medically necessary care may be covered while a person is living in a senior living community.
What Does Medicare Cover?
While Medicare does not cover assisted living, it will continue to pay for all approved services under Parts A and B—such as hospital stays, doctor visits, procedures, and screenings. Medicare Advantage (Part C) allows you to receive your Medicare Parts A and B coverage through private health plans. Learn more
Skilled Nursing and Rehabilitation
Should short-term rehabilitation in a skilled nursing and rehab center be necessary, Medicare will pay for a portion of the first 100 days of rehab, provided required conditions are met. The first 20 days are covered in full. A co-pay is then required for days 21-100.
Many older adults require home health care services following a hospital stay for an illness, injury or surgery. Medicare will pay for that care, which includes skilled nursing care, as well as physical, occupational and speech therapy, if care is provided by a Medicare-certified agency. It’s also important to note that home is wherever the person lives – a private residence or an independent living or assisted living community.
Remember that while Medicare will cover (at least in part) medically necessary home health services that are provided in a senior living setting, it does not cover the cost of room and board.
What is Medicaid?
Medicaid is a public insurance program that provides health coverage to low-income families and individuals, including seniors and people with disabilities. It is funded jointly by the federal government and the states.
Medicaid Benefits for Senior Care
To qualify for Medicaid wavered services, seniors must meet the Medical Assistance guidelines in their state. In addition to meeting financial requirements, most states also require a demonstrated need for skilled nursing level care.
Nursing homes and Skilled Nursing Facilities (SNFs) serve those with more complex, continuous health care needs and frequently provide rehabilitation services following surgery or hospitalization. Medicaid often covers these services – and the cost of room and board – if care is provided in a nursing facility licensed and certified by the state as a Medicaid Nursing Facility. Services are paid for only when other payment options are unavailable – which means assets must be spent down before financially qualifying for Medicaid.
However, not everyone who needs long-term care necessarily needs 24/7 skilled nursing care and may have their needs better met in an assisted living community.
The good news for those seniors: many states will cover health care services that are provided in assisted living communities if they are needed intermittently. Care and support must be provided in communities that are Medicaid certified in their state. Medicaid does not cover room and board but may include various care services including:
- Personal care
- On-site therapy
- Medication management
- Outpatient hospital services not covered by Medicare
- Home health services
- Prescription drugs
- Eyeglasses and hearing aids
- Hospice care
- Co-pays for hospitalization and skilled nursing care not covered by Medicare
Applying for Medicaid
Understanding Medicaid and applying for it can be complicated. Each state has its own eligibility guidelines, benefits and application process. It’s a good idea to check with your local Department of Aging, Department of Elder Affairs or social service agencies who may be able to assist you. Find your local state resources here
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