More than 800,000 adults in the United States live in a senior living or nursing community. There are more than 30,000 such communities across the country, all with different programs, services, and payment options.
Many people wonder if Medicare, the federal program that provides senior healthcare coverage, will pay for services in senior living communities. This answer is complex and depends on many different factors.
This article explains what those are. Keep reading to learn more about Medicare coverage for senior communities. The information below will help you determine if it applies to your situation.
Medicare is a federal program that offers health coverage for people 65 years of age and older. It is also available for certain younger people with disabilities or suffering from end-stage renal disease.
Medicare covers a wide range of medical services. These include hospital care and doctor visits. It also can cover home health care and related medical equipment. It has many different elements to it, some of which enrollees can choose.
Medicare Part A is hospital insurance. It covers inpatient hospital stays and, under certain conditions, skilled nursing community care. It also covers some home health care, as well as hospice care.
Medicare Part A is not optional and does not require any premiums. People who are over 65 and receiving Social Security benefits are automatically enrolled in it.
Medicare Part B is medical insurance. It covers doctor visits, including specialists.
Part B also covers many outpatient hospital services and preventive services. These include screenings and vaccinations. It also can cover some home health care and medical equipment, like wheelchairs or oxygen tanks.
Medicare Part B is optional, although enrollment is often automatic for people receiving Social Security benefits. It does require a monthly premium.
Medicare Part C is also known as "Medicare Advantage." It includes health insurance plans offered by private companies that Medicare has approved. Like other private insurance plans, enrollees must live in an area where a particular insurer offers coverage.
These plans will have all of the benefits and services offered under Medicare Part A and Part B, combined into a single plan. Part C often includes prescription drug coverage as well. It also often has additional benefits, such as vision, dental, hearing, and wellness services.
Medicare Part C has premiums and is optional. To sign up for it, individuals must have both Medicare Part A and Part B. Then, they choose a Medicare Advantage plan during the open enrollment period.
Medicare Part D is prescription drug coverage. It too is offered through private insurance companies approved by Medicare. People can opt for Part D as a stand-alone plan if they are enrolled in Medicare Part A and Part B, or if as part of a Medicare Advantage (Part C) plan.
Medigap is a supplemental insurance plan sold by private companies. It is not purchased through the Medicare program but, as the name suggests, it is designed to cover gaps in original Medicare plans. These include out-of-pocket costs, such as deductibles, copayments, and coinsurance.
There are many "healthcare" categories that Medicare usually does not cover. These include custodial care, most dental services, dentures, and eye exams related to prescribing glasses. It does not cover cosmetic surgery, hearing aids, acupuncture, or routine foot care,
In terms of Medicare coverage for senior communities, it usually does not pay for long-term care or any non-medical services. For instance, most senior living homes offer amenities and services like those related to recreation, socialization, and entertainment.
When someone lives in one of these communities, they are paying for room and board, libraries, dining, laundry, and assistance with daily living. In most cases, these are excluded from Medicare coverage.
The next obvious question is, "What about medical services offered by senior living communities?" This is where things get complicated.
In general, yes, Medicare should cover medical services offered by a senior living center. A good rule of thumb is that, if those services would be covered outside the community, then Medicare should pay for them. Specifically, here are the types of Medicare services for seniors you may find in these communities:
Original Medicare (Part A and Part B) and many Medicare Advantage plans will cover temporary stays in a short-term skilled nursing community. In most cases, this requires that it follow hospitalization.
Your Medicare plan may also cover longer stays, depending on the circumstances. They may require a per-day coinsurance payment. Note that some Medigap insurance plans may help pay for these additional costs.
In most cases, original Medicare benefits for senior living will not cover services like assistance with activities of daily living (ADL), meal preparation or delivery, and transportation to and from medical appointments. However, some Medicare Advantage plans might. This will depend on your specific policy and the services it covers.
Most Medicare plans cover services for people with Alzheimer's disease or other forms of dementia. These include cognitive assessments, skilled nursing care, and home health care. Medicare Part D also should cover medications.
This coverage usually translates to a nursing or assisted living home setting. You can expect Medicare to pay for many of the services provided in a memory care community. However, they could be excluded if they fall under "long-term care."
The same is true for hospice care. A Medicare senior community will have coverage for end-of-life services.
Now that you understand the basics of Medicare coverage for senior communities, there will be no surprises down the road. The most important thing you can do is discuss this with prospective senior living homes. Reputable ones will be upfront with you about costs, including Medicare eligibility for senior care services.
Addington Place of Fairfield provides exceptional comfort, convenience, and an elevated senior living experience. Our community offers resident-focused lifestyle services and programs, including quality dining and daily social activities.
Reach out to us today to learn more.