The question “Does Medicare pay for assisted living for dementia?” has two aspects to it. First and foremost, if your loved one is suffering from dementia, they need to be in memory care and not assisted living.
As far as Medicare covers assisted living, unfortunately, it won’t cover all expenses but some specific costs associated with dementia care.
In this article, we will discuss what types of services are covered by Medicare and how to determine eligibility.
What is assisted living?
Assisted living is a residential community for older adults needing assistance with daily tasks but does not require the level of medical care provided in a nursing home. It offers a balance between independent living and access to staff assistance 24/7.
In an assisted living facility, residents live in private apartments and have the freedom to maintain their independence while also receiving help with daily activities such as bathing, dressing, and medication management.
So, instead, memory care is the one that is better equipped and has trained staff for seniors with dementia or Alzheimer’s.
What is Medicare?
Medicare is a federal health insurance program providing coverage for individuals aged 65 and older if they have worked and paid Medicare taxes for at least 10 years.
It usually covers the cost of medical care, including hospital stays, doctor visits, and prescription drugs. Medicare has multiple plans and add-ons to help seniors and other beneficiaries.
Let’s look at each to have an understanding of what costs can medicare cover for seniors with dementia.
Medicare Part A
Medicare Part A covers inpatient care at a skilled nursing facility, such as a rehabilitation center or nursing home.
It pays for room and board, medical services, and other care for treating an illness or injury. In certain cases, Medicare may cover up to 100 days of care in a qualified facility for individuals with dementia and Alzheimer’s.
Additionally, it covers hospice and home health care.
Medicare Part B
Medicare Part B is an important component of the Medicare program that provides coverage for a wide range of medical services and supplies. It helps pay for services from doctors and other healthcare providers, outpatient care, home health care, durable medical equipment, and preventive services.
Coverage under Part B includes doctor visits, lab tests, x-rays, mental health services, and preventive screenings such as mammograms and flu shots. It also covers outpatient surgery, ambulance services, and durable medical equipment like wheelchairs and walkers.
Medicare Part A and Part B are the original Medicare created with the intent to give the most basic coverage.
Medicare Advantage (Part C)
Medicare Advantage plans, also known as Medicare Part C, offer a comprehensive alternative to Original Medicare (Part A and Part B) coverage. These plans are offered by private insurance companies as per the guidelines of Medicare.
Medicare Advantage plans combine the benefits of Part A and Part B into a single plan. They also often include coverage for prescription drugs, known as Medicare Part D. This means you can get all your Medicare coverage, including hospital stays, doctor visits, preventive care, and prescription drugs, all in one plan.
The plan offers various options: health maintenance organization (HMO), preferred provider organization (PPO), and private fee-for-service (PFFS) plans. Each type of plan has its own network of providers and different rules regarding in-network and out-of-network care.
It’s important to note that if you choose a Medicare Advantage plan, you will not be eligible for Medigap. Medigap plans are designed to fill the gaps in
Medicare Part D
Medicare Part D is also offered through private insurance companies. It covers medications, including recommended shots and vaccines. Medicare Part D can be added to Original Medicare or received through a Medicare Advantage plan that includes drug coverage.
It can be a great relief for individuals with chronic conditions or those who require regular medication management. Whether one has Original Medicare or a Medicare Advantage plan, the option to include Medicare Part D ensures comprehensive coverage that includes prescription drugs.
Medigap
Medigap can help “fill gaps” in the Original Medicare plan by covering copayments, coinsurance, and deductibles.
It is important to note, however, that Medigap policies do not cover the costs of long-term care or private-duty nursing. While Medigap can provide financial relief for medical expenses, it does not extend to services such as assisted living for individuals with dementia or other chronic conditions.
Does Medicare pay for assisted living for dementia?
Unfortunately, Medicare typically does not cover the cost of assisted living, regardless of the individual’s cognitive condition. Medicare’s coverage primarily focuses on acute care and short-term stays in skilled nursing facilities.
It may cover services such as inpatient hospital care, medication management, and certain therapy services, but long-term care in an assisted living facility is generally not covered.
However, there are exceptions to this rule. If an individual with dementia or Alzheimer’s requires skilled nursing care, Medicare may cover a portion of the cost for a limited period.
Additionally, if an individual is enrolled in a Medicare Advantage Plan, they may have additional coverage options for long-term care.
What assisted living services does Medicare cover?
Medicare coverage typically will not cover custodial care. However, the exception is if a senior has a certain medical condition and needs skilled nursing care.
The care has to be provided by a certified nursing professional or a doctor. The coverage includes the cost of services like physical therapy or changing sterile dressings. So, if an assisted living facility also provides skilled nursing care, there is a possibility.
In general, assisted living only provides custodial care and supervision. You may want to try Medicaid if you are looking for financial help with assisted living costs.
Who is eligible for Medicare coverage for dementia care?
Medicare coverage may cover medical and care costs for seniors with dementia if they are 65 years old or above. However, it covers inpatient hospital care and a portion of the doctors’ fees and other medical items. You may need Medicare Part D to cover prescription drugs.
Additionally, it will cover up to 100 days of skilled nursing home care under certain circumstances. For hospice care, Medicare will pay if delivered in the home, a nursing care community, or an inpatient hospice setting if a doctor determines the senior is near the end of life.
