Medicare generally doesn’t cover the cost of residing in assisted living communities, which are facilities that offer housing and custodial services — such as laundry, cooking and managing medications — for older adults. However, it does cover care received at skilled nursing facilities, which are equipped to provide more medical care than assisted living communities, when certain requirements are met.
If you move to an assisted living community, Medicare will still cover your approved prescriptions, surgeries, doctor’s appointments, screenings and medical equipment, just as it did when you lived at home.
Assisted living community vs. skilled nursing facility: What’s the difference?
Assisted living communities, which are in residential settings, aren’t the same as nursing homes or skilled nursing facilities, which are in clinical settings.
Nursing homes offer a greater level of medical care and may be eligible for Medicare coverage in certain cases. Assisted living communities generally focus on providing custodial care, such as bathing, eating, meal preparation, getting dressed or using the bathroom. Original Medicare (Part A and Part B) doesn’t include coverage for custodial care when it’s the only care you need.
In some cases, a company might operate both an assisted living community and skilled nursing facility in the same building or a neighboring one, under the same name. The coverage you receive through Medicare depends on which care you’re receiving and whether you meet certain requirements.
In order to get Medicare coverage for skilled nursing care:
You must have just had a qualifying hospital stay and not used up all your covered hospital days.
Your doctor must determine that you need this care.
Your current condition is either the reason you were just hospitalized, or it developed as a result of your being in the hospital (for example, an infection you picked up while hospitalized).
This skilled nursing care must be considered medically necessary.
If you meet all these conditions, you would be 100% covered for the first 20 days in residential care, then be responsible for $185.50 per day in coinsurance for days 21 through 100. After 100 days Medicare doesn’t provide any coverage for this type of care.
What about Medicare Advantage?
Medicare Advantage (Medicare Part C) must cover at least as much as Original Medicare. But since Medicare Advantage is private insurance contracted through the government, the specific benefits of each policy are unique.
That said, Medicare Advantage doesn’t typically cover assisted living or any other long-term custodial care, although it continues to cover your eligible medical expenses like prescriptions, surgery, doctor’s appointments, screenings and equipment if you move to an assisted living facility. It may also provide some additional benefits such as transportation to your medical appointments, vision and hearing coverage and gym memberships.
Also like Original Medicare, your costs may be covered if you need short-term care at a skilled nursing facility immediately following a hospitalization.
Assisted living costs and how to pay
The national median cost for residential care at an assisted living facility was $51,600 per year in 2020, according to a survey from Genworth, a major provider of long-term care insurance.
In general, if you have long-term care insurance, your policy will usually cover these costs if you meet certain requirements. If you don’t have this type of coverage, you may have to tap into savings or home equity to cover costs.
When to enroll in assisted living
Moving to an assisted living community is a huge step, both financially and emotionally. If you’re unsure about whether this is an appropriate option, here are a few clear signs that assisted living might be right for you:
It’s getting hard to care for yourself. Cooking, eating and after-meal cleanup may feel like so much work that your nutrition suffers and you experience unhealthy weight loss. Maybe you’ve been skipping showers due to fear of falls, not washing clothes as often as you should because the laundry basket is too heavy, or having difficulty bending to put on socks and shoes.
It’s getting hard to care for your home. Perhaps it feels too strenuous to vacuum, scrub and declutter, and your house isn’t meeting your standards of cleanliness anymore.
It’s difficult to get around, even at home. Getting in and out the bathroom, up and down the stairs, or even out of bed in the morning may have become an issue.
Assisted living communities also may have minimum age requirements; for example, some are limited to residents 62 and older.
Before choosing an assisted living community, be sure to confirm that it’s properly licensed and reputable. Many state websites have online tools that allow you to look up assisted living communities in your area, check licenses and read inspection or investigation reports.