Is assisted living one of the options you have for yourself or your loved one? One of the things that you need to ponder over to make an informed decision is the cost of housing. There is a horde of factors that influence how much you pay for the house including the amenities available, the location living space, is it an apartment or just a room, and the services offered. You need to know how you will pay for it.
There is a common notion that Medicare takes care of the bills for long-term care for the elderly aged 65 and above and younger people with disabilities. However, Medicare does not pay for all assisted facility costs.
Where Does Medicare Come In?
Medicare is the chief healthcare insurance for seniors, but its involvement with paying the bills for assisted facility costs is somewhat not direct. This federal health insurance program has designed a separate financial plan to cater for assisted facility costs rather than pay directly. For instance, Medicare will not pay the rent for the assisted care facility, or the fees for non-skilled services, which comprise of help with daily activities such as grooming, clothing and mealtime assistance. The resident and the family will have to take care of such bills.
In assisted facilities, Medicare will be involved in offsetting the cost of preventive care and that of daily medicine prescriptions. It is the program that takes care of the extra money that the residents would have to pay in a nursing home. If residents in assisted facility need a skilled practitioner such as a doctor or other medical professional that rehabilitates from a slip-and-fall, the health insurance part B will cater for the bills.
Generally, Medicare makes life in assisted facilities bearable for the residents allowing them to live there for longer.
Medicare as a Health Insurance Program
When you enroll for Medicare, the federal government expects that you will pay long-term care service fees from your income or your savings. These include fees for nursing home care and assisted living, or personal care at home. This is clearly outlined in the Medicare Handbook .
Consumers will benefit with skilled nursing facility and post-acute home care; and this is where all the confusion with Medicare’s role in assisted facility comes in.
Post-Acute Care and Your Health Insurance
Post-Acute Care falls in secondary health care. Here, a patient receives short-term treatment for an injury or an episode of illness, post-surgery or for an urgent health condition. Considering this in medical terms, acute care is the exact opposite of chronic care; the former means short term and the latter means long term.
The acute care services that the insurance caters for are attended to by medical professionals and may be medical or surgical in specialty. While undergoing post-acute care, you will be required to stay in a hospital’s emergency department, urgent care center, or even ambulatory surgery center and any other short-term medical facility.
Post-acute care also comes in form of therapy services or skilled nursing where the patient may need outpatient care while in assisted facilities. The cover could be in terms of a nurse visiting to tend your wound or for therapy sessions after surgery. Long term care services will not be covered by the insurance; these are daily activities in the assisted facility such as help with bathing and eating, managing prescriptions, any other daily service that the assisted facility and memory care facilities offer.
What is covered by Medicare?
To stop the confusion, it is important for one to understand exactly what is covered by Medicare during the period that seniors are in assisted facilities. Qualified or skilled healthcare costs while seniors, 65 years and above, or young people living with disabilities are in assisted facility will be taken care of by the insurance. Any skilled healthcare that the assisted facility offers will be paid for by the insurance. However, the costs do not cater for on-going daily and monthly long-term care services that the assisted facility offers, including help with toilet use.
Understanding the Basics of Medicare
Put simply, Medicare is a health insurance program offered by the federal government. It is for the seniors aged 65 years and above and also for the young who are living with disabilities and may, therefore, need the services of an assisted facility. The program features three parts each of which seniors in assisted facilities can mince benefits from for health care while in assisted facilities.
Part A of the program covers in-patient healthcare while Part B covers outpatient health care, doctor visits and a couple of other skilled care costs. Part D of the program cares for prescriptions and drugs.
Part A
Part A is the hospital insurance part. Here, a resident is covered for hospital admission fees, hospice or skilled nursing facility, irrespective of whether they are staying at home or in an assisted facility. This, however, has to be short-term admission. This cover also takes care of home healthcare services. The insurance program will take care of therapy visits and skilled nursing for those who cannot leave their home. For these services to be paid for by the insurance, a doctor has to certify them.
In some scenarios, home health benefit offered by the insurance program caters for long term care that touches on health aide visits while at home. The visits are meant to offer personal assistance to people who are eligible for professional visits.
Only 17 percent of home health visits account for the 11 percent of home healthcare spending from the insurance program. According to AARP , visits from a health aide are temporary and not long-term. After at least three days of stay in a hospital, a patient may be offered up to 100 days of nursing facility care cost payments.
While in an assisted facility, the insurance program takes care of the costs for:
• Semi-private room
• Meals
• Skilled nursing care
• Therapy
• Medical social services
• Speech and language pathology assistance
• Medications
• Dietary counselling
• Medical supplies
• Ambulance transportation
Part B
No matter where you live, Part B of the insurance program will take care of your bills when you call for outpatient care. This is the part that pays when you visit a doctor or for preventive care such as cancer vaccination and screening. This is where medical supplies such as blood sugar strips are covered. Part A and Part B of the insurance program only differ with the needs of assisted facility residents. Part A of Medicare can be limited and may not cover extensive injuries resulting from slips and falls. Medicare Part B applies when seniors need outpatient care. While Part A of the insurance pays for services such as the hospital bed after the initial deductible, you will be required to pay at least 20 percent of the costs after the initial deductible with outpatient care.
Part A and Part B of the insurance program will require initial application from the seniors. However, railroad workers and those with ALS and permanent kidney problems are covered without the need for an application. One needs to register before they are 65; otherwise, coverage will delay. Part A does not require one to pay, but Part B require premiums depending on one’s income.
Medicare Part D
This is the part that covers for prescription drugs while in assisted facility. Seniors need to register for this part when they are about to turn 65 and pay premiums. Besides premiums paid monthly, there are drug deductibles, and there is a list of drugs accepted by this part of the insurance.
This part takes care of drugs and prescriptions that B does not take care of, thereby reducing costs while living in assisted facility. If your doctor chooses drugs that are not covered, you will have to pay for them. Part D offers additional safety between Part B and paying for assisted facility services yourself.
Part D services vary greatly depending on administrator and premiums paid. There is confusion between Part D plan and Medicare Advantage plans, which act as a supplementary for those with Insurance part A and part B.
Medicare and Seniors Coverage
Seniors qualify for Medicare Part A the moment they hit 65 years of age; they do not have to pay anything besides registering. Costs of enrolling for the three parts, however, differ greatly and will depend on the need of the assisted facility resident. You can get more help from the Center for Medicare and Medicaid .
End Note
It is important to understand how Medicare works and its relation to assisted facility living if you are to plan for your senior years or that of your family member. There are health conditions not covered such as dental and vision care, and there are those that are covered such as diabetes and glaucoma. Some drugs are not covered while others are covered. Of importance to those living in assisted facilities is to understand that rehabilitation, visits to doctors, short-term admissions, therapy, and meals are taken care of, but any medical care that involves a long-term admission is not part of the Medicare cover.
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