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Memory care facilities provide housing, care, and therapies for seniors who have Alzheimer’s disease or other forms of dementia in an environment designed to reduce confusion and prevent wandering.

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Medicare, Medicaid, and Long-Term Care

Kara Lewis
By Kara LewisSeptember 14, 2021
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Many seniors and families search for ways to make long-term care more affordable. In some cases, Medicare and Medicaid can help by financing senior health services and some types of senior living. Though not everyone qualifies for these programs, many individuals do — potentially reducing their senior care costs.

As many as 6 million eligible Americans don’t apply for or don’t use their benefits each year, according to the Centers for Medicare and Medicaid. Many causes contribute to this staggering number, notes Letha Sgritta McDowell, an elder care attorney who practices at Hook Law in Virginia.

“It’s really about comprehending the rules,” explains McDowell, who also serves as president of the National Academy of Elder Law Attorneys (NAELA). “Many people don’t understand the intricacies of how public benefits work.”

Whether Medicaid and Medicare will help with your family member’s senior living costs depends on several factors, such as your loved one’s age, income, and required level of care. It also depends on communities themselves, as some accept Medicaid as a payment method, while others require private pay.

Read on to learn about Medicaid and Medicare eligibility, resources for seniors, and if these benefits can help pay for senior care.

What are Medicare and Medicaid?

Medicare and Medicaid are two federal programs designed to provide health care coverage to vulnerable populations, or to people who might not otherwise have health insurance.

  • Medicare extends federal health insurance coverage to Americans 65 and older and people with end-stage renal disease.
  • Medicaid, currently the largest source of health insurance in the U.S., covers low-income individuals or people with significant medical expenses. Since Medicaid is a partnership between individual state governments and the federal government, requirements vary significantly based on an individual’s state of residence.

Medicare in particular has multiple, complex components:

  • Part A, Hospital Insurance, which helps pay for inpatient care in a hospital or a skilled nursing facility, as well as some home health care and hospice care
  • Part B, Medical Insurance, which helps pay for doctors’ services and many other medical services and supplies
  • Part C, Medicaid Advantage, which offers separate plans in many areas through private health care companies
  • Part D, Prescription Drug Coverage, which helps pay for medications prescribed by seniors’ physicians or specialists

While most people don’t pay a premium for Part A, Medicare’s other forms of coverage come with monthly costs for seniors.

Who’s eligible for Medicare and Medicaid?

“The requirements are going to be similar, but they are going to be state-specific,” McDowell says in regards to Medicare and Medicaid eligibility markers.

Here’s an overview of federal guidelines:

  • Medicare recipients must be age 65 or older. Individuals receiving Social Security or Railroad Retirement Board benefits are also eligible, along with people who’ve received Social Security or Railroad Retirement Board disability benefits for at least two years. Kidney transplant patients and people undergoing kidney dialysis treatment are also eligible. The Social Security website is a resource that can help seniors review requirements and start the Medicare application process.
  • Medicaid recipients must meet certain income thresholds and asset limitations based on their state of residence. Though income requirements vary in each state, they’re typically based on being within 133% of the poverty level. States can also deem individuals “medically needy,” meaning they exceed the standard income but have significant medical expenses. If your family member is planning to apply for Medicaid, it’s a good idea to contact your state medical assistance office for more details. Depending on where you live, Medicaid programs may be referred to as auxiliary grant, elderly waiver, or frail elderly waiver programs.

Public payment options for independent living

Does Medicare pay for independent living?

Seniors in independent living are usually healthy and active and choose this care type for benefits like housekeeping, lawn maintenance, and social activities. Since Medicare covers health care services and senior communities in general, it doesn’t pay for independent living.

Does Medicaid pay for independent living?

Medicaid helps low-income and medically needy individuals access medical care. Because independent living doesn’t encompass medical services, Medicaid doesn’t cover this care type.

Public payment options for assisted living

Does Medicare pay for assisted living?

Generally, Medicare pays for short-term, intensive care for seniors who have experienced an injury or for seniors who are in the end-of-life stage. In contrast, assisted living provides care to seniors who are largely independent but could benefit from assistance with activities of daily living (ADLs) and who need increased supervision, as well as older adults who desire more opportunities for socialization. Given this more limited range of care, Medicare doesn’t cover assisted living.

Will Medicaid pay for assisted living?

Medicaid typically pays for some — but not all — assisted living services. Families and seniors can expect help with costs related to medical treatments and personal care services, reducing their overall bill. However, Medicaid often won’t cover the total price of room and board in an assisted living community. In most states, Medicaid can be used to pay for the following:

  • Help with ADLs like toileting, mobility, and dressing
  • Home health services, which may be provided in an assisted living community
  • Physical, occupational, or speech therapy
  • Medication management

Public payment options for memory care

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Does Medicare cover memory care?

Much like with assisted living, Medicare won’t pay for rent or board in memory care facilities. However, Medicare does cover many costs associated with dementia treatment, such as equipment and supplies designed to counter common dementia safety risks. Seniors with dementia generally experience a loss of balance and coordination in the early and middle stages of the disease, and Medicare pays for resources like walkers and grab bars.

Under some Medicare Advantage plans (Medicare Part C), families can receive cost assistance with GPS trackers for elderly loved ones, devices which help avoid the dangers of wandering and disorientation either in a community setting or at home.

Medicare Part D, which provides prescription drug coverage, also assists with common dementia care costs. Though there’s no FDA-approved medication known to cure Alzheimer’s or other forms of dementia, Medicare Part D helps pay for medications that may stave off the condition’s progression.

Does Medicaid pay for memory care?

Though not all communities accept Medicaid, the program does pay for 24-hour dementia care in many memory care facilities as well as memory-related care in skilled nursing communities. This usually includes all costs associated with room and board. Under Medicaid policies, seniors must forfeit most of their available income — including Social Security checks — toward their care and can retain only a small monthly “personal allowance.” Allowance amounts differ by state but typically are less than $75.

Public payment options for nursing homes

Does Medicare pay for nursing homes?

“The number one misconception about Medicare is that it will pay for your long-term care,” says McDowell. “It will only pay for a rehabilitative stay.”

Seniors who need care in a skilled nursing facility due to an injury can receive Medicare coverage for up to 100 days. It comes with the following costs:

  • Older adults pay nothing for days one through 20 of a nursing home stay, with Medicare covering the entire bill. This covered nursing home stay is available to seniors after a three-night inpatient stay in a hospital.
  • Medicare pays for nearly all nursing home costs for days 21-100 of a nursing home stay, but seniors are responsible for a daily coinsurance. This coinsurance payment is approximately $170.50 per day.
  • After 100 days, Medicare will not pay any nursing home costs.

Medicare also pays for the entirety of hospice and palliative care in a skilled nursing community.

Does Medicaid pay for a nursing home?

Medicaid pays for long-term care in a nursing home for seniors who meet the program’s requirements. Seniors must relinquish any income — aside from a limited monthly “personal allowance,” usually under $75 — to be eligible for Medicaid coverage, which will then cover nearly all associated costs, including a senior’s room and health care services.

Public payment options for home care and home health care

Can families rely on Medicare to cover home care costs?

Medicare doesn’t pay for long-term home care costs or 24-hour assistance. Similar to Medicare’s nursing home coverage, Medicare contributes to short-term home health care services. Medicare Part A and Part B entitle seniors to fewer than eight hours of care per day for a 21-day period. A doctor must prescribe this care and recommend a Medicare-certified agency to arrange and facilitate it.

Medicare primarily pays for treatments that help seniors recuperate from an injury or stroke, such as:

  • Physical therapy
  • Occupational therapy
  • Speech-language pathology services

Many families hire a home caregiver to give their loved one companionship or to reduce their at-home responsibilities, like chores and meal preparation. In these cases, Medicare can’t serve as a payment method.

Medicare doesn’t pay for these aspects of home care:

  • 24-hour supervision
  • Meal preparation or delivery
  • Daily tasks like personal shopping, cleaning, and laundry
  • Personal care services like bathing and toileting

Does Medicaid pay for home care?

Seniors can hire a caregiver from a Medicaid-approved agency using their Medicaid benefits. First, a doctor has to determine the senior is in need of medical care, usually at such a high level that they would otherwise move into a nursing home. In most states, Medicaid Home and Community-Based Services (HBCS) waivers provide financial assistance to seniors who require these services:

  • In-home medical care, including physical therapy
  • Assistance with ADLs
  • Help with cooking, cleaning, and laundry
  • Transportation
  • Assistance with medical devices

Low-income seniors can expect Medicaid to absorb nearly all the costs associated with these services.

Navigating Medicare, Medicaid, and long-term care

Determining eligibility for Medicare or Medicaid — as well as considering how these programs affect long-term care access and costs — poses a challenge for most seniors. Shifting requirements in different states mean one-size-fits-all advice rarely applies to each family’s unique situation. If seniors are eligible for other cost assistance, such as VA benefits, the process can be complicated further.

“Doing your own research and then talking to an expert is so critical,” urges McDowell. “In the same way a financial advisor would talk to someone about how to reduce their taxes, that’s how an elder care attorney would help someone decide the best option for their long-term care.”

Seniors can find a qualified elder care attorney in their area, including one who specializes in Medicare and Medicaid policies, by using NAELA’s up-to-date database.

Sources:

Centers for Medicaid & Medicare Services. Eligibility.

Centers for Medicaid & Medicare Services. What’s Medicare?

Centers for Medicaid & Medicare Services. Medicare Coverage of Skilled Nursing Facility Care.

Centers for Medicaid & Medicare Services. Home Health Services.

Kara Lewis
Author
Kara Lewis

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