Medicare in a Senior Care Setting and What to Expect

February 12, 2024

Understanding how Medicare works and what it does and does not cover is not easy. It’s a complicated, often subjective system with myriad conditions, stipulations, and no one-size-fits-all situations. “Medicare can be boiled down into two words: it depends,” quipped Robin Smith, a New England-based licensed insurance advisor and board-certified patient advocate, who works with senior citizens.

While all U.S. citizens who have worked for at least 10 years are eligible for Medicare once they turn 65 (and some disabled people under 65), it’s important to bear in mind that each individual’s circumstances are unique, and benefits can vary widely. That said, here are some general questions and answers about Medicare and Medicaid as they relate to a senior care community or home healthcare.

Does Medicare pay for assisted living/personal care?

The short answer is no, a fact that is surprising and distressing to many seniors. But first, let’s define what assisted living and personal care are. Often, the two terms are used interchangeably and mean largely the same thing. At Barclay Friends, assisted living is referred to as personal care. It involves help with non-medical daily activities, such as dressing and bathing, for people who are still relatively active and independent. This type of care is also referred to as “custodial care,” which the Centers for Medicare and Medicaid (CMS) defines as any non-medical care that can take place at home or in a senior care community. According to the CMS: “Medicare does not cover facility-based care if the only care a patient needs is help with activities of daily living (ADLs).

Does Medicare pay for skilled nursing care?

Yes, but there are several conditions and stipulations, and it does not cover an indefinite period of time. First, be aware that skilled nursing (nursing home care in a Medicare-approved facility or home healthcare agency) is defined by the CMS as medically necessary care that can only be provided by, or under the supervision of, skilled or licensed medical personnel.

The need for skilled nursing care must be predicated by an “admitted” hospital stay of at least three days or longer, and admittance into post-hospital care must occur within 30 days of the hospital stay. Medicare benefits are focused on “rehab,” not indefinite long-term care.

Post hospital stay, Medicare covers the full cost of medically necessary skilled care for the first 20 days (including a semi-private room – private rooms are paid out-of-pocket – meals, medications, therapies, etc.). After that, if a patient is approved to stay beyond 20 days, their co-pay from day 21 to 100 is $185.50 per day, as of this writing. After 100 days, Medicare coverage stops, and the beneficiary is responsible for 100 percent of the cost. (Note: if a care facility describes itself as exclusively “private pay,” it means it does not accept Medicare or Medicaid reimbursements.)

This 100-day cap can be reset in some situations if at least 60 days pass between occurrences that require a hospital stay.

• Not all patients receive the full 100 days of care. The patient must continue to make progress in rehabilitation during the stay. If their condition plateaus, Medicare coverage of the rehab stay usually ends.

Who pays for assisted living/personal care?

The custodial care (non-medical help with ADLs) provided in assisted living or personal care settings are paid predominantly by the residents themselves, their family members, charitable funds provided by donors to a not-for-profit community.

What are the different parts of Medicare, and what do they cover?

Most likely, we’ve all heard the letters associated with Medicare: Parts A, B, C and D. Less likely is that we all understand what each entails. Briefly, here is a rundown of the four parts and what they generally cover:

• Original Medicare (Parts A and B) – Part A is for inpatient stays in a hospital, mental health facility or skilled nursing facility, hospice care and medically necessary home healthcare. Part B covers outpatient care, medically necessary care, some preventive care, some lab tests, vaccines, screenings, therapies and medical supplies.
• Medicare Part C – Also referred to as a Medicare Advantage plan, Part C is offered by private insurance companies that have been approved by Medicare. Part C includes all the benefits of Parts A, B and D as well as additional services, such as dental, hearing and vision. Costs and coverage vary by each plan. Part C does not cover assisted living or personal care.
  • The state of Pennsylvania has seen robust growth in Medicare Advantage plans, with 45 percent of beneficiaries enrolled in Part C over Original Medicare.
  • 66 private insurers in Pennsylvania offer supplemental insurance plans.
• Medicare Part D – Easily remembered as D for “drugs,” Part D covers prescription medications, regardless of where one lives. Note: If one does not enroll in Part D when they’re first eligible (read about Medicare enrollment periods here), they may have to pay more to get this coverage at a later time.

Do I need supplemental insurance with Medicare?

Many older adults purchase supplemental health insurance plans to fill the gaps on the unlimited 20 percent of medical expenses not covered by Medicare A and B and other out-of-pocket expenses. These include copayments, coinsurances, deductibles, and other costs. Often referred to as Medigap, supplemental health insurance is sold by private providers and must be purchased within one’s home state. A word to the wise: with the exception of four states (Pennsylvania not being one of them), if a person does not purchase supplemental insurance when they are first eligible for it, they are subject to health questions that may affect cost and eligibility later on.

What is the difference between Medicare and Medicaid?

Medicare is a federal program, with standardized eligibility requirements, while Medicaid is state-administered, and eligibility varies from state to state. Medicaid is designed for low-income residents who have exhausted their financial resources.

Are there any other government-funded programs that pay for senior care?

Many are not aware that the Office of Veterans Affairs’ Aid and Attendance Program can help cover some of the costs of senior care for veterans with limited assets and their surviving spouses. Eligibility generally requires that the veteran was honorably discharged and served a minimum of 90 days on active military duty, one of which was during war time. The applicant must also be in a skilled nursing facility, be confined to a bed, legally blind, or have a documented need for assisted living/personal care services. Like Medicaid, this program incurs a lookback analysis to ensure that patients’ assets weren’t given away in an attempt to qualify for VA benefits.

Where can I get help navigating Medicare?

Many people find that a certified Medicare counselor is a good resource in helping them navigate the murky waters of government-funded healthcare. Medicare’s State Health Insurance Program (SHIP) is a free counseling service, offering one-on-one, unbiased advice from trained volunteers. In Pennsylvania, helpful resources include, but are not limited to:

• APPRISE is a free Medicare/Medicaid and long-term care insurance counseling program.
  • PACE, PACENET and PACE Plus offer assistance to Pennsylvania Medicare beneficiaries who need help paying for prescription medications.
  • Medical Assistance is a statewide program for Medicare beneficiaries who cannot afford their premiums or deductibles.
  • Pennsylvania Senior Medicare Patrol is a program that helps combat Medicare abuse by educating seniors and caregivers about Medicare Advantage scams and other fraudulent activity that can lessen quality care and increase costs.
  • Other valuable resources are the Older Pennsylvanians Legal Assistance Program, as well as the Pennsylvania Health Law Project.