by Ron Pollack
(Editor's Note: Ron Pollack is the executive director of Families USA, the national organization for health care consumers.)
Have you started to experience challenges with living on your own? Do you need help with medical care or daily activities? A nursing home may seem like your only option. But there are good alternatives, including home care and assisted living. However, it's important for you to learn what kinds of services Medicare and Medicaid will and won't cover. (Medicaid is the nation's health insurance program for low-income individuals and families — including seniors — and for people with disabilities.)
What is home- and community-based care?
You may have access to services such as Meals on Wheels, visiting and shopper services, and adult day care programs. But what if you need other kinds of assistance?
Home health services (also called home- and community-based care) help seniors who need additional support so they can safely stay in their homes or who are recovering after a hospital stay. These services include short-term nursing care and rehabilitative care (like physical therapy). Registered nurses, physical therapists, occupational therapists, speech pathologists, home health aides, and medical social workers provide home health care.
Medicare pays for a limited number of one-hour home health visits, but only for medical care. Medicaid may pay for other types of home care, depending on your situation and the state you live in.
You may be able to find other non-medical services in your community through your local Area Agency on Aging.
What is assisted living?
Assisted living facilities (or assisted living homes) bridge the gap between independent living and nursing homes. These facilities typically provide services like assistance with personal care and medications, and they give residents more freedom and privacy than nursing homes. They range in size from small houses that serve a few residents to very large facilities with hundreds of residents.
Assisted living facilities cost less than nursing homes but are still very expensive, costing an average of $3,300 a month.
What do Medicare and Medicaid pay for nursing home care and nursing home alternatives?
Many people are confused about what Medicare and Medicaid cover.
Nursing Home Care
Medicare does not cover most nursing home care. Medicare pays only for certain skilled nursing or rehabilitative care, and only after a hospital stay. The duration of this coverage is limited. To learn more about coverage limits, visit the Medicare web site, www.medicare.gov/coverage/skilled-nursing-facility-care.html.
Medicaid covers most nursing home care if you have a low income. Each state sets its own income eligibility level for Medicaid coverage of nursing home care. In many states, you must also have limited assets to have Medicaid cover your nursing home care.
Alternatives to Nursing Home Care
Medicare covers very little of this care. For example, Medicare won't pay your rent for an assisted living facility, but it will cover some health care you receive while you are in assisted living.
Medicaid pays for some assisted living costs for people with low incomes in several states. Every state has at least one Medicaid program that will pay for other alternatives to nursing facility care, and most have multiple programs. Each state's program is different. Plus, individuals must meet the eligibility rules for that particular program. For example, some programs focus on individuals with particular health care needs. And some programs are limited to a certain number of people, which creates waiting lists.
Many people end up paying the full cost of assisted living entirely out of their own pockets.
To Learn More
To learn more about Medicare and Medicaid coverage of nursing home care, assisted living, and other options, contact your State Health Insurance Assistance Program, or SHIP. SHIPs offer free counseling and assistance by phone and in person. Find the SHIP in your state online at https://shipnpr.acl.gov/shipprofile.aspx.
Also, the Eldercare Locator connects older Americans and their caregivers with information on senior services. Find it online at www.eldercare.gov/eldercare.net/Public/Index.aspx.