Can You Have Medicare Advantage if You Live in an Assisted Living Community?
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Assisted living is a great option for seniors who need help with some daily living activities like dressing, grooming and eating but want to preserve privacy and independence as much as possible. Unfortunately, this type of senior care is costly. According to the Genworth Cost of Care Survey 2020, the average American pays $4,300 per month for assisted living. Some states offer financial aid programs for seniors in assisted living, but many do not, leaving seniors and their families with burdensome out-of-pocket expenses.
For many seniors, a Medicare Advantage plan is a practical option for funding some services provided in assisted living. However, while many Medicare Advantage plans cover some senior care services, they don’t cover everything. In this guide, we provide an overview of how Medicare Advantage works, what types of assisted living costs may be covered and some of seniors’ most frequently asked questions about Medicare Advantage.
The Basics of Medicare Advantage
In contrast to Original Medicare, which is provided by the federal government and offers the same coverage at the same cost to every beneficiary, Medicare Advantage plans are provided by private health insurance companies. While these plans are legally required to provide the same coverage as Original Medicare Parts A and B, many plans offer additional benefits like dental and vision coverage and non-medical in-home care services, making them an attractive option to many retirees.
What Does Medicare Advantage Cover?
Health insurance companies that offer Medicare Advantage plans are required to cover the same services and benefits that are included in Original Medicare, and they cannot charge a co-pay or coinsurance for services that are covered 100% under the standard Original Medicare policy. Some medical services that are covered include:
- Hospital care
- Skilled nursing care
- Outpatient surgery
- Lab tests
- Screenings for depression, cancer and diabetes
- Medical equipment and mobility aids
- Emergency transportation services
In addition to these standard services, many Medicare Advantage plans cover additional benefits, such as:
- Prescription drugs
- Gym memberships
- Routine dental, hearing and vision care
- Non-medical in-home care services
- Therapeutic massage
- Adult day health care
What Does Medicare Advantage Cost?
In most cases, Medicare beneficiaries with Original Medicare don’t pay for Part A coverage but have a monthly premium for Part B coverage. In 2021, the standard Part B premium is $148.50. Seniors with Medicare Advantage plans are also required to pay this monthly premium and may also have an additional monthly premium for their specific plan. On average, Medicare Advantage premiums are $21 per month in 2021, and nearly half of enrollees have no additional premium.
Who Is Eligible for Medicare Advantage?
Medicare Advantage plans are available to seniors age 65 and over who are either enrolled in Original Medicare or are eligible to do so. To be eligible, seniors must be legal U.S. citizens or legal residents and have lived in the country for at least five consecutive years. Additionally, they must live within their plan’s service area.
What Assisted Living Costs Does Medicare Advantage Cover?
In 2019, Medicare Advantage plans were able to offer non-skilled in-home care, a benefit unavailable prior to that due to the Centers for Medicare & Medicaid Services’ policy against covering “daily maintenance” types of care. In-home care benefits vary from one plan to another and may include things like:
- Nutrition services
- Home modifications
- Adult day healthcare
- Telehealth services
- Personal care services, including tasks like preparing food, dressing and bathing
- Transportation to medical offices
In many cases, these benefits are limited. For example, non-emergency transportation may only be available a certain number of times per year or within a certain period of time following hospitalization, depending on the policy.
It’s also important to note that Medicare Advantage plans don’t explicitly cover assisted living. In fact, the purpose of many of the additional benefits offered by Medicare Advantage plans is to promote aging in place. However, if it can be established that a senior’s home is an assisted living facility, in-home services provided by the facility may be covered.
What Assisted Living Costs Does Medicare Advantage Not Cover?
Despite the expanded coverage options available through Medicare Advantage plans, seniors cannot receive assisted living coverage through these plans. Room-and-board fees, activities fees and meals are not eligible for coverage under Medicare Advantage.
Frequently Asked Questions
Is Assisted Living Considered Inpatient Care?
In most cases, assisted living is not considered inpatient care, which is why it’s not covered by Medicare Part A. Following a qualifying inpatient hospital stay, Medicare covers a stay in a skilled nursing facility for up to 100 days, after which the patient is responsible for 100% of the costs. In some cases, skilled nursing services may be provided in an assisted living facility. In this instance, these services would be covered by Medicare Part A and Medicare Advantage.
How Much Do Medicare Advantage Plans Cover for Assisted Living?
Medicare Advantage plans only cover the costs of qualified medical care that seniors receive while they are residing in an assisted living facility. For example, inpatient and outpatient care are covered just as it is for seniors who reside in their own homes. However, Medicare Advantage plans do not pay for the cost of the assisted living facility itself.
How Do I Know If My Medicare Advantage Plan Covers Services Provided in Assisted Living?
Nationwide, there are thousands of Medicare Advantage plans, each with their own unique coverage options, costs and additional benefits. Finding a Medicare Advantage plan that covers non-skilled in-home care requires some legwork but, in the end, may provide significant cost savings. To find out what in-home services are covered, seniors should review a copy of their plan’s “Evidence of Coverage” notice, which outlines everything the plan covers and to what degree eligible services are covered.
Is an Assisted Living Facility Considered a Beneficiary’s Home?
Different health insurance companies may have different criteria for what qualifies as a beneficiary’s home, which impacts what types of non-skilled in-home care Medicare Advantage plans cover. However, in instances in which an assisted living facility is considered a home, the facility could receive reimbursement from a resident’s Medicare Advantage plan for certain types of care, such as transportation services and personal care services.
How Do I Pay for Assisted Living Services Not Covered by Medicare Advantage?
At this time, Medicare Advantage doesn’t cover assisted living costs, and no intent to do so has been publicized. Instead, seniors have several other options for paying for long-term care, including state-funded programs like Medicaid and Medicaid waiver programs, long-term care insurance, asset liquidation and selling a life insurance policy for cash.