It can be difficult for families to begin to think about placing our loved ones into assisted living. Why consider assisted living?
For some, this consideration comes out of necessity to guarantee the needs of the elderly person are being met. Others, it is because the family member lived on their own and can no longer do for their self anymore. There are numerous reasons why to consider assisted living and it is a difficult task for all involved. Caregivers must identify the needs that need to be met of the individual, decide if Medicaid can pay for assisted living, and what can the family do to get the cost covered.
Assisted Living for Senior Citizens
An assisted living facility provides nursing care, housekeeping, snacks, and prepared meals as necessary. Assisted living for senior citizens is a residence that provides care long term. Facilities range in size and location. Some facilities may be a typical suburban home in a residential neighborhood with an extremely low resident count. Other facilities could be compared to a large hospital and could house several hundred residents. While there are facilities that offer a home-like atmosphere, there are also facilities that give residents a resort-like experience. In these resort-like facilities, residents have state-of-the-art amenities like exercise rooms, swimming pools, full salons, movie theaters, and fine dining.
Choosing Assisted Living
Choosing which facility that can meet the needs of the individual may be difficult. There are different assessments that can be taken to help choose what kind of facility is appropriate, based on needs. Besides personal choice, the facility must be able to manage and care for the specific conditions the individual has. This would include dementia, is they have suffered a stroke, Alzheimer’s, Parkinson’s Disease, or general physical disabilities. It is also important to consider the services and amenities offered at the assisted living residence. If basic services such as laundry, meals, and assistance with simple daily tasks like dressing are all that is offered then that facility would not be appropriate for someone who needs full care and/or supervision.
Look Into the State’s Standards
State regulations, laws, licensing procedures, and inspection procedure/requirements will vary by state. The type of assisted living facility is also based on the category the state decides to place it in. With the variations in standards, it can be very difficult to understand the type of facility insurance will cover or if the facility is properly regulated. Looking into the state laws and regulations of the state of residency will help in guiding individuals to the appropriate facilities. Speaking to an insurance representative will also help in finding the appropriate facility.
Payment and Costs of Assisted Living
Can Medicaid pay for assisted living? The short answer to this is yes. Guidelines and requirements that a state must have in place are set by the federal government. However, each state may add their own guidelines or requirements into effect for how insurance companies may cover or assist individuals looking to reside in an assisted living facility. There are several ways the state may pay for assisted living. One of these is through different waivers in the Medicaid program and the other is payment using regular Medicaid, also known as State Plan Medicaid.
- Have a higher income eligibility.
- There a limited amount of spaces available and may lead to waitlists.
- The person must have a nursing home level of need.
State Plan Medicaid Information:
- Very limited income in the amount of $750.
- Entitled to benefits so there is no enrollment cap or waitlists to worry about.
- Less restrictive of the care requirements needed to qualify.
None of the fifty states is required to pay for housing or room requirements of any individual. The majority will cover medication and its administration, cleaning, cooking, laundry service, nursing care, Bathing, grooming, toileting assistance, and recreational services. Social Security may help in providing housing and/or room cost requirements. It is also possible to get assistance for food preparation and serving of the food, but not the food cost itself. Consideration in the number of facilities that accept Medicaid is also a factor. So, can Medicaid pay for assisted living? It does pay some towards the cost of assisted living for senior citizens.
Primarily Medicare will not cover the cost for assisted living facilities. Some qualified healthcare costs are covered while an individual is in certain types of facilities. Medicare will more often pay for skilled nursing facilities or home health, although these do have limitations on the amount of time they will cover.
The national median yearly rate for a one-bedroom unit in an assisted living facility is about $42,000. Monthly that works out to be approximately $3,500. It makes the question: Why to consider assisted living if it costs so much. It is because some things are necessary to meet the needs of senior citizens.
Special Payment Methods
There are other ways to cover the high cost of assisted living. Some facilities have payment programs to help families with the expense. It is also possible to apply for Medicaid to try to get assistance with cost. For some individuals, applying for Social Security will aid in some of the expenses associated with assisted living. Checking with local organizations it may be possible to find assistance as well. There are waivers, grant, and other programs available in the community with assisted living costs.
Income Based Facilities
Another avenue would be to find a facility who helps with the cost based on need. Some facilities are income based and offer a sliding scale for payment. If all of the above options do not work, then seeking a different type of facility may be necessary. Assisted living is defined differently across the many states. Depending on what a particular state defines assisted living or other care facilities will determine what is covered and how.
Understanding Insurance Options
Medicaid is a federal and state government program that helps individuals with limited income to have medical care. Medicaid provides health insurance to families, pregnant women, elderly, and people with disabilities. Benefits last as long as the individual or family meet the income guidelines. There are federally mandated benefits that states must offer to Medicaid recipients. Mandatory Benefits Include:
- Inpatient/Outpatient Hospital Services
- Screening, Diagnostic, and Treatment Services
- Nursing Facility Services
- Home Health Services
- Physician, Nurse Practitioner, and Nurse Midwife Services
- Transportation to Medical Care
- Rural Health Clinic Service
- Family Planning
- Laboratory and X-ray Services
- Federally Qualified Health Center Services
Not All States May Offer These Services
Some medical services may not be covered in all states. This list will vary state-to-state and some benefits may be covered if a doctor sends a referral to the insurance company explaining the need for the service. Optional Benefits Are:
- Prescription Drugs (majority cover with at least a copayment)
- Clinical Services
- Physical and/or Occupational Therapy
- Speech, Hearing, and Language Disorder Services
- Podiatry Services
- Optometry Services
- Dental and Denture Services
- Chiropractic Service
- Private Duty Nursing
- Case Management
- Health Homes for Enrollees with Chronic Conditions
- Inpatient Psychiatric Services for Individuals Under 21
Some individuals are able to be covered for the above optional services. It is a process that can take several days or several weeks. Insurance companies have a list of criteria that must be met to be able to qualify for any optional benefits to be covered.
What About Medicare?
Medicare is also a federal program, but supplemental plans may vary by individuals states. The qualifications to get Medicare is different from Medicaid. Once a person is within their birth month at the age of 65 they are able to qualify for Medicare. A second way to qualify, even if under 65, is if a person receives Social Security Disability Insurance or SSDI for more than 24 months. Medicare Part A and Part B are contracted through private insurance companies. Then there are two different Medicare that a person must decide between. Original Medicare is the standard Part A and Part B. Part A is hospital insurance and Part B is medical insurance. Medicare Part A Covers:
- Inpatient Hospital Care
- Skilled Nursing Facility Care
- Inpatient Care in a Skilled Nursing Facility (not long-term)
- Hospice Care
- Home Health Care
Medicare Part B Covers:
- Clinical Research
- Ambulance Services
- Durable Medical Equipment
- Mental Health: Inpatient, Outpatient, and Partial Hospitalization
- Second Opinions Before Surgery
- Limited Outpatient Prescription Drugs
Medicare is not a completely free program. In general Medicare Part A does not have any monthly premiums if the individual or their spouse paid Medicare taxes for a certain amount of time. If by chance you do not qualify for premium-free Part A, expect to pay up to $437 a month. Should you decide to pay for Part A then you must also Pay for art B. A premium is required for Part B and must be paid monthly with Part A if you do not have premium-free. Part B will typically cost you $134, but depending on your annual income that is reported on your income tax this amount could be as high as $460.