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Medicare Does Not Cover The Cost of Long Term Senior Care, But There Are Other Options

Over the last several decades, the choice for senior living and care has greatly expanded to meet the needs and expectations of older adults. It is critically important for your senior loved one’s health and well-being to find the right option for senior living or care. This article explores the differences between assisted living facilities, nursing homes, and skilled nursing facilities and the coverage (or lack thereof) provided by Medicare/Medicaid. April is Medicaid Awareness month, so it’s a great time to discuss. Let’s dive in!

What Is An Assisted Living Facility?

Assisted living facilities (ALFs) provide medical and personal care in a home-like, social setting to seniors who require extra help. ALFs prioritize the individual’s independence and are less focused on nursing or health care. Assisted living maximizes the quality of life while providing a more independent lifestyle, so it is usually the preferred care option over nursing home care where possible.

Most ALFs have care aides or certified nursing assistants (CNA)s and nursing care available. They generally employ a Licensed Vocational Nurse (LVN), as opposed to a Registered Nurse (RN), and typically the nurse is only in the building Monday through Friday for eight hours a day, and they may be “on-call” for emergencies.  

Some ALFs may also have a “Medical Director,” a doctor who has a contract with the facility to provide physician visits onsite so that residents don’t have to leave the facility for medical care, except for emergencies or specialty medical services. The cost of the medical director is generally covered by Medicare and your insurance, just as it would be at a doctor’s office. 

Some of the traditional services Assisted Living Facilities offer are:

• • Daily housekeeping of  the individual’s suite
  • Meal preparation
  • Assistance with Activities of Daily Living (ADLs) such as grooming, bathing, and dressing
  • Transportation to medical appointments, grocery stores, social programs, pharmacies, etc.

What Is A Nursing Home?

Nursing homes are designed for seniors who require around-the-clock care, monitoring, or medical assistance. A nursing home assists with ADLs, such as grooming, bathing, feeding, and any required medical care such as blood pressure or diabetes monitoring and prescription management. Many nursing homes have entry requirements that require a prescription from their physicians, a physical examination, and in some cases, state approval. If an individual does not meet the criteria, they may be referred to an assisted living facility.

Nursing homes ensure the safety and comfort of their residents. In addition to assisting with ADLs for their residents, they offer a variety of support and medical care:

• Meals that must meet the daily nutritional requirements of each resident
• Management of  prescription administration and injections
• Continual palliative and preventative long-term care
• Rehabilitative services, such as occupational, physical, speech, cognitive, vocational, and respiratory therapy
• Emergency and routine dental services
• Increased safety features and security benefits, including ADA accessible areas, grab bars, and alarmed doorways
• Offer skilled nursing care where trained medical personnel can provide specialized treatment to gravely ill residents
• Provide socialization activities for residents

What Is A Skilled Nursing Facility?

A major difference between nursing homes and skilled nursing facilities (SNFs) is the depth and range of available medical services. Doctors, nurse practitioners, registered nurses, and other medical staff (physio and speech therapists, for example) can commonly be found at SNFs. In contrast, you may never see a doctor at a nursing home.

One of the main reasons someone would go to an SNF is following a hospital stay as they would receive specialized care following any of the medical issues they may have experienced:

• Serious memory issues       
• Stroke recovery
• A medical condition that demands around-the-clock care
• Wound care
• Rehabilitation following an operation or illness
• Terminal illness

Additionally, medical staff at SNFs help seniors with daily living tasks such as grooming and feeding, just like they would receive at a nursing home. An SNF is meant for short-term care, where the patient would typically return to their home, assisted living, or nursing facility once they recover.

Now That We Know The Differences Between The Types of Facilities, Let’s Talk About Coverage

If you or a loved one requires care, we strongly encourage you to check out this page, where we have gathered many resources to help you learn more about senior care costs, current data trends, and projections and to find financial assistance for the type of care required.

Assisted Living Facilities

Most Assisted Living Facilities in the United States are “private pay.” Meaning you pay out of pocket. Medicare does not pay for assisted living. However, financial assistance is available through Long Term Care Insurance policies, VA Pensions, and in some rarer cases, Medicaid. 

In Texas, Medicaid is offered to offset the cost of ALFs to those who meet the criteria. As long as you are eligible for Medicaid and prove that assisted living is medically necessary for you, you likely qualify for the STAR (State of Texas Access Reform) +PLUS Waiver services. This is a newer program offered in Texas that pays for home and community-based services, including assisted living facilities. However, there is limited enrollment, so there may be a waiting list. If you require this service or a loved one does, you can contact the Texas Dept. of Health and Human Services.

Nursing Homes

Medicaid will cover the costs of nursing homes so long as they are deemed medically necessary by a physician. A physician must document the patient’s medical requirements and prescribe skilled nursing care, including shots, treating bedsores, changing wound dressing, or inserting catheters or feeding tubes. The physician must certify the patient’s condition every six months for Medicaid to continue coverage.

Nursing care is expensive. The national average monthly cost of a private nursing room is $8,460 (over $100,000/year), so most people can not afford to pay for their care. If you qualify for Texas Medicaid, their coverage does include nursing homes. People who automatically qualify for Medicaid include SSI recipients and participants in Texas’ Temporary Assistance to Need Families (TANF) program. People who are 65 years or older, those with disabilities or are blind can qualify for Medicaid so long as they meet income and resource limits. Based on 2019 data, the monthly income for a single person cannot exceed $2313, and if married, the combined income cannot be more than $4326. However, Texas allows individuals to place extra income in a trust to qualify for Medicaid. You can find out more about trusts at this link.

Skilled Nursing Facilities

According to a 2020 Cost of Care Analysis, the average cost of services rendered by a skilled nursing facility in Texas is $4950 for a semi-private room and $6300 for a private room. As with everything else in our economy, the prices for skilled nursing care are expected to rise, with projections estimating the annual cost of a semi-private room will reach $125,000 by 2030.

Skilled nursing must be ordered by a physician and must meet very specific guidelines for Medicare to pay for it. Private pay, as well as long-term care options, are available, however, it is quite expensive.

For further information about skilled nursing qualifications, check out this page. 

Find The Care You Or Your Loved One Needs Today

We understand that the choice to place someone in care, whether in assisted living, at a nursing home, or a skilled nursing facility, is a difficult decision and a costly one. However, in most cases, it is the only choice for families. If you or a loved one needs care, please reach out to us today, and we will happily answer any questions you may have.

Disclaimer: Due to the changing nature of government assistance programs, Tribute does not guarantee the information in this article is the most current data. We encourage you to reach out directly to assistance programs directly for the most current eligibility requirements.