Does Medicare cover assisted living?

Does Medicare pay for assisted living?

No. Assisted living facilities are one of the places, along with your home, the community and nursing homes, where people get non-medical long-term care. Long-term care (also called custodial care or long-term services and support) includes medical and non-medical care for people who have a chronic illness or disability, and most of it helps with basic personal tasks of everyday life, like dressing, bathing and using the bathroom.

Medicare and most health insurance, including Medicare Supplement Insurance (Medigap), don't pay for long-term care services, including care in a nursing home or in the community. You pay all costs for non-covered services, including most long-term care.

What can Medicare cover while I live in assisted living?

Medicare can still cover some care for a person who lives in an assisted living facility, if the person meets Medicare's rules for that care:

• Hospice care (Part A): you can usually get Medicare-approved hospice care in your home or another facility where you live, like an assisted living facility or a nursing home. See how Medicare covers hospice.
• Home health care (Part A and Part B): in some cases, as explained below.
• The GUIDE Model for dementia care: people with dementia who live in a residential care community, which includes an assisted living facility, may qualify for GUIDE services if they meet all other eligibility criteria and the GUIDE participant has an approved partnership with the facility. Residents can get most GUIDE services but aren't eligible for GUIDE respite services, though their caregivers can still get GUIDE caregiver education and support. People living in a memory care unit aren't eligible for GUIDE.

When does Medicare cover home health care in assisted living?

Under CMS's home health rules, a person who lives in an assisted living facility (also called a personal care home or group home) may be considered “confined to the home” for Medicare home health coverage if the facility isn't primarily engaged in providing these services to inpatients: diagnostic and therapeutic services for medical diagnosis, treatment, care of injured, disabled or sick people, rehabilitation or other skilled services, or skilled nursing care. If the facility isn't primarily engaged in providing those services, Medicare will cover reasonable and necessary home health care furnished to its residents.

Under the same rules, claims for home health services that duplicate services the assisted living facility is required to provide under state licensure requirements should be denied. You must also meet Medicare's usual home health rules: you need part-time or intermittent skilled services, you're homebound, a provider sees you in person and orders the care, and a Medicare-certified home health agency provides it. See how Medicare covers home health care.

How do people pay for assisted living?

People pay for long-term care in assisted living in a few ways:

• Medicaid: your state's Medicaid program may help cover services in an assisted living facility, depending on your needs and the state you live in, and home- and community-based services like at-home care, home-delivered meals, home modifications and adult day care, if you qualify. Contact your state Medicaid office. See how Medicare and Medicaid differ.
• Long-term care insurance: policies vary widely; some may only cover nursing home care, while others may cover a range of services, like adult day care, assisted living, medical equipment and informal home care. Check whether a policy could limit coverage because of a pre-existing condition, and buy from a company licensed in your state.
• Your own money: you can pay the costs of long-term care yourself.
• Subsidized senior housing: state and federal programs help pay for housing for some seniors with low to moderate incomes, and some also offer help with meals and activities like housekeeping, shopping and laundry.

Does Medicare Advantage or Medigap cover assisted living?

Medigap doesn't pay for long-term care services. Medicare Advantage plans must cover all medically necessary services that Original Medicare covers, and some offer extra benefits; rules and costs vary by plan, so check with a plan before you join to find out exactly what it covers. If you're in a Medicare Advantage plan and start hospice care, Original Medicare covers everything you need related to your terminal illness, even if you stay in your plan.

Where can I get help planning for long-term care?

If you're in a hospital or nursing home, or working with a home health agency, you can talk to a discharge planner, a social worker, or an organization in a “No Wrong Door System,” like an Aging and Disability Resource Center, Area Agency on Aging or Center for Independent Living, for help understanding your long-term care options or arranging care. The Administration for Community Living has long-term care planning resources, the Eldercare Locator has information on group living arrangements, and your State Medical Assistance (Medicaid) office can tell you whether you qualify for long-term care coverage through Medicaid.