Medicare recipients who reside in assisted living facilities most commonly leave because they need a higher level of health and custodial care. For many, this means moving into a skilled nursing facility where they can get help with their daily living activities and have access to around the clock nursing care.
In some assisted living homes, seniors are relatively independent and do not get help with dressing, bathing, or eating. As they age, many seniors find it more difficult to live alone. Loss of mobility or sight, a decline in cognitive function, or strength and balance issues can all contribute to a need for more regulated care.
While living in an assisted care facility your Medicare benefits are, for the most part, the same as when you live at home. But if you move to a nursing home, your Medicare coverage may change. Here is a look at what differences you should expect in your Medicare coverage if you are leaving an assisted living facility and moving into a long-term care facility.
Does Medicare coverage change when you leave assisted living?
If your move into a nursing home is short-term because you need skilled nursing care after a hospital stay, your Medicare Part A (hospital insurance) benefits cover 100 percent of the first 20 days (per benefit period) of your stay. For days 21-100, you must pay a $176.00 coinsurance charge for each day per benefit period. After 100 days, you are responsible for all costs.
For short-term stays, Medicare does not pay for any custodial care you receive while in a nursing home. Your coverage includes medically necessary care and supplies, room, and meals.
If you move into a nursing home as a long-term care option, Medicare does not cover the cost of nursing home care or residency. It does, however, continue to pay for hospital care, doctors’ services, and medical supplies for as long as you stay there and continue to have Medicare Parts A and B.
If you move out of assisted living and return home, Medicare Parts A and B cover home health services like the following:
• Intermittent or part-time skilled nursing care
• Physical, occupational, and/or speech-language therapy
• Medical social services
• Personal care on a part-time or intermittent basis through home health aide services
• Injectable osteoporosis drugs
If you get care at home, Medicare coverage does not include around the clock care, meal delivery, homemaker services, or custodial care.
Does Medicare Advantage coverage change when you leave assisted living?
Medicare Advantage plans are required to provide the same Part A and Part B benefits as Original Medicare. If you have a Medicare Advantage plan, like an HMO or PPO, your plan may include additional coverage for nursing home or in-home care. Generally, most Medicare Advantage plans do not include nursing home coverage unless there is a contract between the home and insurance company, but you should ask for details of your coverage before moving.
Depending on your plan, you may have coverage for in-home care services such as housekeeping, meal delivery, and help with daily custodial care. Again, check with your insurance provider to ensure you have this coverage before you make plans to move.
Does prescription drug coverage change when you leave assisted living?
If you already have prescription drug coverage with a stand-alone Part D plan or through a Medicare Advantage plan, you can keep that plan when you leave your assisted living facility even if you move into a nursing home or other similar type of institution. At the nursing home, you get your prescriptions from the long-term care pharmacy they have a contract with.
Medicare recipients are automatically enrolled in a Part D plan if they do not have prescription drug coverage at the time they move into a Medicare-affiliated nursing home.
If you are moving from your assisted living facility into a Medicare or Medicaid-certified nursing home, you can change your Medicare Part D plan when you move or at any time you are living in the nursing home. If you do not have the ability to make changes to your prescription drug plan on your own, you can have your authorized representative do it for you.
If you are in a skilled nursing facility on a short-term basis, your prescription drugs are covered by Original Medicare Part A.