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Medicare Rules for Assisted Living

Medicare, the federal program that assists elderly citizens of the United States (those over 65 years old), covers many medical services, including those for people living in supervised or assisted living facilities. Certain rules govern how services for assisted living are provided. You should learn these rules to avoid any confusion if you or a family member needs to go into an assisted living facility.

  1. Defining Assisted Living

    • Medicare treats individuals who receive some medical care at an assisted living facility exactly the same as those receiving assistance in their own home. Medicare does not pay rent for assisted living facilities nor do it pay for routine services provided by the assisted living home. Medicare pays only for medical services. To receive this medical assistance, however, a person must exhibit considerable difficulty carrying out basic activities of daily living (eating, bathing, using the bathroom, transferring from bed to chair) without help and must require assistance when leaving the home. These individuals must be considered "homebound."

    Exceptions for Homebound

    • Medicare uses the definition of "Homebound" to determine if a person is eligible for home health service. If a person is able to leave the home without assistance, Medicare will assume that the person could get outside medical help and so could deny home health coverage. Medicare recognizes two exceptions to this rule: attending religious services and adult day care outside the home. If the individual otherwise meets the definition for "homebound," Medicare will still pay for authorized medical services in the person's home or in an assisted living facility.

    Services Covered

    • Medicare will cover only "medically-necessary part-time or intermittent treatments" (as determined by a physician), speech therapy and occupational therapy. Medicare may also cover "medical social services, part-time or intermittent home health aide services, durable medical equipment and medical supplies for use at home." Medicare pays only for medical services. It does not pay for general, daily activities, such as bathing and other unskilled nursing services.

    Doctor Authorization

    • A licensed physician must order the service and a Medicare-authorized health-care provider must carry out the service. The services cannot be considered full-time or life-sustaining activities.

    Costs

    • There is no cost under Medicare for approved services, but Medicare-covered equipment is subject to a 20-percent payment of the Medicare-approved amount. Also, Medicare Part B deductibles still apply.

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