Why does Medicare stop at the front door?
Medicare buys treatment. The surgeon, the hospital bed, the physical therapist, the prescription. What an assisted living community sells is a room, three meals, and somebody who notices at seven in the morning that your mother has not come out of hers. Medicare calls that custodial care, and has never covered it.
California draws the same line twice, in its licenses. A six bed board and care home and a hundred apartment community on Ventura Boulevard hold the same license, a Residential Care Facility for the Elderly from the Department of Social Services. Skilled nursing is licensed by the Department of Public Health. Social services on one side, health on the other, and Medicare pays into the health side. Care homes sit in the CCLD Care Facility Search, nursing facilities in Cal Health Find.
- CCLD Care Facility Search, California Department of Social Services, Community Care Licensing Division
- Cal Health Find, California Department of Public Health, Center for Health Care Quality
What does Medicare actually pay for, then?
Four things, and three can happen inside an assisted living community, which is why families think it covers part of the bill.
| Care or service | Pays | Does not pay | Where families get caught |
|---|---|---|---|
| Skilled nursing after a hospital stay | Short term skilled nursing or therapy | A long stay, or unskilled help | Rehab with an end date |
| Hospice | Hospice team, nurse visits, medications, equipment | Room and board wherever she lives | Hospice comes to her apartment. The rent still arrives |
| Home health | Part time skilled visits, homebound and certified | Around the clock care, meals, housekeeping, dressing | A nurse who visits, not a caregiver who stays |
| Doctors, hospital, prescriptions, equipment | All of it, unchanged | The rent and care fee, the whole bill | Medicare follows the person, not the address |
No dollar amounts here. Medicare resets those each January.
When does Medicare cover a skilled nursing stay?
Part A covers one only when all of these hold at once, and the second catches people.
- She was admitted as an inpatient for at least three days in a row. The admission day counts. The discharge day does not.
- Those were inpatient nights. Emergency room and observation time does not count, so four nights asleep in a hospital can still fail this.
- She moves in within a short time of leaving, generally thirty days.
- A doctor determines she needs daily skilled care, and she is getting it from or under skilled nursing or therapy staff.
Why does the coverage end sooner than everyone expects?
A hundred days was never an allowance. Part A caps coverage at 100 days in a benefit period, and the cost climbs inside it: nothing daily through day 20 beyond the Part A deductible, a coinsurance from day 21, everything from day 101.
What ends it is rarely the calendar. Coverage runs while she needs daily skilled care and is receiving it, so it can stop on day eighteen, with two days of warning.
Here is the part almost nobody is told. Coverage does not depend on her getting better. Jimmo v. Sebelius, a federal settlement approved in 2013, established that, and Medicare has said since that skilled care is covered when it is needed to maintain her condition or slow her decline, not only when she is improving. If you are told the benefit is ending because she has plateaued, that reason on its own is not the standard.
You also get a written notice before coverage stops, called a Notice of Medicare Non-Coverage, and it tells you how to ask for a fast review. Follow the instructions printed on it rather than improvising, because the deadline is noon the day before the date on the notice and it goes quickly. Ask her doctor to record why skilled care is still needed, whether to improve her or to hold the ground she has. Many families never ask for the review at all, because they were told she stopped improving and assumed that settled it.
Some of it only works beforehand. Ask the hospital whether she is admitted or under observation before she leaves. It cannot be fixed later. Ask the facility for its expected last covered day. On Medicare Advantage, ask the plan. Look her facility up in Cal Health Find before a transfer, because the discharge planner has a bed to fill by Friday and you are the only person in the room still living with this in March.
- Cal Health Find, California Department of Public Health, Center for Health Care Quality
If not Medicare, then what pays for it?
Start with the real number. A licensed board and care home runs $3,500 to $6,000 a month, a larger community $4,500 to $8,000, memory care $5,500 to $9,000. These are typical Los Angeles market ranges rather than prices we set or quote, and they move with care level, room type, and neighborhood.
Medi-Cal generally does not pay room and board in assisted living, though the Assisted Living Waiver covers care services for eligible enrollees at participating Los Angeles facilities.
If your father served, VA Aid and Attendance adds to the VA pension for wartime veterans and surviving spouses who need daily help from another person, paid to him, not the facility. Amounts are on the VA Aid and Attendance and Housebound benefits page, free help to file at the VA accredited representative and VSO finder.
And if a long term care policy sits in a drawer, ask the carrier in writing whether a licensed Residential Care Facility for the Elderly is covered at all. Many older policies named nursing homes only. More on reading a policy before you rely on it.
Where can I check this myself?
If the facility will not produce that notice, or a home worries you, CDSS resources for residents and families is where complaints and the Long Term Care Ombudsman live.
Her coverage is the one thing nobody else can check for you. Call the number on her card and ask what a benefit period means for her.
- CDSS resources for residents and families, California Department of Social Services
How is Senior Placement Agency LA paid?
When a family we introduced moves in, the home pays us from the budget it would otherwise spend advertising that room. You pay nothing, and nothing is added to your rate.
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You have a number to solve. Start there.
Tell us her monthly income and what she needs help with, and we will tell you honestly whether it works here.
Questions families ask us
- Does Medicare pay for assisted living?
- No. Help with bathing, dressing and getting through the day is personal care, not treatment, and Medicare has never paid for it. Her doctors and prescriptions carry on.
- Does Medicare pay for a nursing home?
- Only a short skilled stay, and only when a three day inpatient admission, a move in within about thirty days, and a doctor certifying daily skilled care all hold at once. Long term care there is Medi-Cal's.
- How many days will Medicare cover in a skilled nursing facility?
- Part A caps it at 100 days in a benefit period, a ceiling rather than an allowance. It runs only while she needs daily skilled care, so it often ends in week three.
- Does Medicare pay for memory care?
- No. The line follows the type of care, not the diagnosis, and memory care is supervision and a secured building. Her neurologist and prescriptions stay covered.