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Will Medicare Pay for Assisted Living?

Medicare pays for a limited amount of skilled nursing home care – provided that custodial care is not the only type of care that the patient needs. Medicare does not, however, pay benefits for care in an assisted living facility.

Assisted living facilities provide help with activities of daily living. Some help with care such as taking medication, getting dressed, getting in and out of the bathtub or shower, and / or assistance with transferring from a chair into bed are considered to be basic daily activities.

Residents of assisted living facilities oftentimes will live in their own room or apartment within a building or group of buildings. In some assisted living facilities, the residents will have all of their meals together. Social and recreational activities are also usually provided.

Some assisted living facilities will have health services on site, although not all of these facilities will provide the same types of services. In most instances, residents of an assisted living facility will pay a regular monthly rent, and then they will pay additional fees for the services that they receive.

In order to be eligible for Medicare skilled nursing home facility benefits, an enrollee must meet all of the following conditions:

  • They must have Medicare Part A (Hospital Coverage), and they must have days remaining in their benefit period
  • They must have a qualifying hospital stay of at least three midnights
  • Their doctor must have decided that the individual requires daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. (If the individual is in the skilled nursing home facility for skilled rehabilitation services only, then his or her care will be considered daily care, even if the therapy services are offered only five or six days per week – provided that the patient requires and receives the therapy services each day that they are offered
  • The patient gets the skilled services in a skilled nursing facility that is certified by Medicare
  • The patient needs the skilled services for a medical condition that was either a hospital-related condition, or a condition that began while he or she was getting care in the skilled nursing facility for a hospital-related medical condition.

It is important to note that your doctor may order observation services to help decide whether or not a patient needs to be admitted to the hospital as an inpatient or can be discharged. During the time that the patient is getting these observation services in the hospital, they are considered to be an outpatient, and therefore, they may not count this time towards the three-day inpatient hospital stay that is required for Medicare to cover their skilled nursing facility stay. An inpatient stay will actually begin on the day in which a person is formally admitted to a hospital with a doctor’s order. In addition, the day of a person’s discharge does not count as an inpatient day.

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