Assisted Living for Qualified Seniors

Policy Proposal: Medicare Coverage for Assisted Living Costs for Seniors

Policy Overview

The goal of this policy is to extend Medicare coverage to include assisted living costs for eligible seniors, ensuring that they can access necessary long-term care services in a residential setting. Assisted living provides critical support for seniors who require help with daily activities but do not need the full-time medical care provided in a nursing home. By offering this coverage, we aim to improve the quality of life for seniors, reduce hospital readmissions, and provide a more cost-effective solution for long-term care.

1. Eligibility Criteria

To qualify for Medicare coverage of assisted living services, the following conditions must be met:

  • Age: The individual must be 65 years or older or under 65 with a qualifying disability.
  • Medicare Enrollment: The individual must be enrolled in Medicare Parts A and B, or be eligible for Medicare Advantage plans.
  • Level of Care: The senior must require assistance with at least two of the following activities of daily living (ADLs):
    • Bathing
    • Dressing
    • Eating
    • Toileting
    • Transferring (moving in and out of bed/chairs)
    • Continence
  • Non-Medical Facility: Assisted living must be provided in a state-licensed facility that is not a skilled nursing facility or a hospital. The facility must offer personal care services, such as help with ADLs, but not provide full-time medical care.

2. Coverage Components

Medicare will cover a portion of the assisted living costs for eligible seniors. Coverage will include:

  • Basic Personal Care Services: Assistance with ADLs, including bathing, dressing, grooming, and mobility.
  • Room and Board: Payment for the room and basic board in an approved assisted living facility.
  • Medication Management: Assistance with medication reminders and management as part of basic care services.
  • Transportation: Non-emergency transportation to medical appointments, necessary social activities, or other community services.
  • Care Coordination: Services to ensure proper care management, including regular visits by care managers to monitor health status and needs.

3. Exclusions

Medicare will not cover:

  • Skilled Nursing Services: Medicare will continue to cover skilled nursing care, rehabilitation, and therapy services, but only when provided in a certified nursing facility or hospital.
  • Social or Recreational Activities: While social activities may be available at assisted living facilities, they are not covered under Medicare.
  • Custodial Care for Non-Qualifying Needs: If an individual does not meet the eligibility requirements for assisted living coverage, custodial care services will not be covered.

4. Payment and Reimbursement

  • Medicare Payment Structure: Medicare will reimburse a set daily rate to the assisted living facility, which will be based on the average cost of providing personal care services in the local area. The reimbursement will vary based on the level of care required.
  • Co-Payments: Beneficiaries may be required to pay a co-payment for assisted living services. The amount will be based on their income, with lower-income seniors receiving reduced co-payments or subsidies.
  • Income-Based Sliding Scale: Seniors with higher incomes may need to pay a larger portion of their assisted living costs, while those with lower incomes could receive assistance from Medicaid, if eligible, to cover the remaining balance.

5. Coordination with Medicaid and Other Programs

  • Dual Eligibility: For those who qualify for both Medicare and Medicaid, Medicaid will cover the difference between Medicare’s payment and the full cost of assisted living services.
  • State Partnership: States will be encouraged to collaborate with Medicare to streamline the process for covering assisted living costs and to ensure that seniors are aware of and able to access available programs.
  • Care Management: A partnership between Medicare, Medicaid, and other social services will provide a comprehensive care management approach to ensure seniors receive the appropriate level of care and services across multiple providers.

####6. Implementation and Oversight

  • National Pilot Program: Initially, the policy will be rolled out as a national pilot program in select states or regions to assess the impact on both costs and quality of care.
  • Quality Standards: Assisted living facilities will need to meet federal and state quality standards to participate in the Medicare program. Regular inspections and assessments will be conducted to ensure these standards are met.
  • Program Evaluation: The effectiveness of the policy will be reviewed annually, with adjustments made to ensure that it remains cost-effective, efficient, and provides adequate care for beneficiaries.

####7. Policy Benefits

  • Increased Access to Care: By expanding Medicare coverage to include assisted living, seniors will have better access to the care they need in a less institutionalized setting.
  • Cost-Effectiveness: Providing coverage for assisted living services could reduce hospital readmissions and long-term care expenses by keeping seniors in a less expensive, community-based environment.
  • Improved Quality of Life: Seniors will have a better quality of life, receiving assistance in a setting that encourages independence, community engagement, and well-being.
  • Support for Family Caregivers: This policy helps alleviate the burden on family caregivers by ensuring that their loved ones have professional support, while still offering a home-like environment.

8. Funding and Budget

Funding for this policy will come from a combination of:

  • Medicare Trust Fund: A portion of the Medicare Trust Fund will be allocated to assist in covering the new services.
  • State and Federal Partnerships: States may contribute funds to cover the cost of assisted living for low-income seniors who are also eligible for Medicaid.
  • Savings from Reduced Hospitalizations: The implementation of this policy may result in savings from reduced hospital stays, emergency room visits, and the need for skilled nursing care.

Conclusion

This Medicare policy to cover assisted living costs represents a necessary evolution in senior care, reflecting the growing need for long-term, affordable, and quality care options. By extending Medicare coverage to include assisted living, we can improve the health outcomes, well-being, and dignity of our aging population, while also addressing the financial challenges faced by seniors and their families.

Your proposal sounds a lot like a long-term care insurance policy. I absolutely believe we need to do more as a nation to help with the cost of living as we age and become more and more disabled. Many assisted living facilities as they stand now do not provide many of the services described in your proposal. They usually provide:
Shelter
Meals/snacks
Electricity
Water
Light house keeping once / week
Laundry done once / week (resident has to know enough to know what day it is, to put laundry out)
Social activities
Help with meds or showers is available on a tight schedule and at additional $300-400/month each.
One has to employ private sitters/companions to handle many of the everyday tasks if not at first, eventually. 24hour private sitter care can run $8-12k/month depending on who and where. This is in addition to the $4-10k/month just to live in the assisted living facility. My family has a lot of insight in this area. I want in on this discussion.