Does Medicare Cover Assisted Living in Washington State? What You Need to Know

According to the National Council on Aging, Original Medicare does not cover the cost of assisted living. For Washington state residents, understanding if Medicare covers assisted living in Washington state is a crucial part of planning for senior care, and the details often differ from common assumptions.

Quick Summary

Medicare typically doesn't cover assisted living because it is considered custodial rather than skilled medical care, but Washington's Medicaid program, Apple Health, is a primary resource for eligible residents. This guide clarifies the specific coverage limitations of Medicare and explores state-specific options, including Medicaid programs and the WA Cares Fund, for financing assisted living costs.

Key Points

• Medicare Excludes Assisted Living: Original Medicare (Parts A & B) does not cover the costs of assisted living, as it is considered non-medical, custodial care.

• Medicaid is Key in Washington: Washington's Medicaid program, Apple Health, is a primary funding source for assisted living services for eligible, low-income seniors.

• WA Cares Fund Offers Benefits: The state's public long-term care insurance program, WA Cares Fund, provides flexible benefits for various care options, including assisted living, for vested residents.

• Alternative Funding is Essential: Many families rely on private savings, long-term care insurance, or veterans' benefits to pay for the costs not covered by government programs.

• Assess Eligibility Carefully: Accessing state programs like Apple Health requires meeting specific income, asset, and functional need criteria through an application and assessment process.

• Plan Ahead for Costs: Given Medicare's limitations, early planning and exploration of state-specific resources are crucial for financing assisted living in Washington.

Understanding Medicare's Role in Senior Care

Medicare is a federal health insurance program for people 65 or older, and certain younger people with disabilities. It is primarily designed to cover medical costs, not long-term care services like assisted living. Assisted living facilities provide residents with a supportive living environment that includes help with daily tasks, often referred to as 'custodial care.' This typically includes assistance with bathing, dressing, eating, and medication management. The core of the issue is that Medicare does not pay for this type of long-term custodial care, regardless of where the care is received.

What Medicare Parts Cover

• Medicare Part A (Hospital Insurance): Part A covers skilled nursing facility stays, but only for a limited period (up to 100 days) following an inpatient hospital stay. This is for short-term rehabilitation, not long-term residence, and applies only to a Medicare-certified facility, which assisted living facilities typically are not.
• Medicare Part B (Medical Insurance): Part B covers doctor visits, outpatient services, and other medical supplies. It does not cover the personal care services or room and board that are the main components of assisted living.
• Medicare Advantage (Part C): These are private plans that must offer at least the same coverage as Original Medicare. Some may offer additional benefits, but generally do not cover the residential costs of assisted living. Some special needs plans (SNPs) may cover certain non-medical services for individuals in assisted living, but these are not the norm and do not pay for the full scope of assisted living.
• Medicare Part D (Prescription Drugs): This covers prescription medications, which seniors living in an assisted living facility can still use to help with their drug costs.

Washington State Options for Assisted Living

Since Medicare's coverage is limited, Washington residents must look to state-specific programs for financial assistance with assisted living. The most significant resource is the state's Medicaid program, known as Apple Health.

Washington's Medicaid (Apple Health) and Waivers

In contrast to Medicare, Washington is one of the few states where its Medicaid program directly contracts with certain assisted living facilities to pay for eligible individuals' care. Several programs can assist seniors with costs:

• Medicaid Personal Care (MPC) Program: This program offers assistance with activities of daily living for low-income seniors who need support but do not require a nursing home level of care. While it doesn't cover room and board, it can significantly offset personal care expenses within an assisted living setting.
• Community First Choice Option (CFCO): This state plan program offers services to those requiring a nursing home level of care but choosing to remain in a community setting, such as an assisted living facility. It provides a wide range of services to support independent living.
• Community Options Program Entry System (COPES) Waiver: This is a Medicaid waiver program that provides supportive services to eligible individuals in their own homes or assisted living facilities, helping to prevent nursing home placement.

The WA Cares Fund: A New Long-Term Care Program

Washington introduced a new public long-term care program called the WA Cares Fund, providing eligible residents with flexible benefits to pay for care. Funded by a payroll premium, it offers a lifetime benefit amount that can be used for a wide range of services, including assisted living. This fund is an important new resource for those planning for future care needs.

Other Funding Sources

Besides state-specific programs, other options can help finance assisted living:

• Long-Term Care Insurance: Private insurance policies can cover long-term care services, including assisted living, that Medicare does not.
• Veterans' Benefits: Some veterans may qualify for programs like the VA's Aid and Attendance benefit, which can provide financial assistance for assisted living.
• Private Pay: Many seniors use personal savings, retirement funds, or the proceeds from selling a home to pay for assisted living.

Comparing Assisted Living Payment Options

Aspect	Medicare	Washington Medicaid (Apple Health)	WA Cares Fund	Private Pay & LTC Insurance
Covers Assisted Living?	No (covers limited medical services)	Yes (through specific programs and contracted facilities)	Yes (offers benefits for assisted living and other services)	Yes (depends on policy/savings)
Primary Care Type	Short-term skilled medical care	Long-term custodial and personal care for low-income individuals	Flexible benefits for various long-term care services	Varies based on funds or policy
Key Requirement	Age 65+ or specific disabilities	Low income and asset limits, plus a functional assessment	Payroll contributions and eligibility criteria	Personal assets or private policy coverage
Funding Source	Federal taxes and premiums	Joint federal and state funding	Washington state payroll tax	Individual savings, insurance premiums

The Application Process in Washington

For those interested in Apple Health, the application process involves a financial review and a functional assessment to determine the level of care needed. Resources like the Department of Social and Health Services (DSHS) can guide seniors and their families through the process. A Medicaid planning specialist can also help navigate the complex financial requirements and prepare the necessary documentation.

The Bottom Line for Washington Residents

While the simple answer to 'Does Medicare cover assisted living in Washington state?' is no, that does not mean residents are without options. The robust network of state-specific programs, particularly Washington's Medicaid (Apple Health) and the new WA Cares Fund, provides critical financial avenues for those needing assisted living. It is essential to research all available options and assess individual financial and medical needs to find the best possible path for senior care in Washington. For further information and resources, it is recommended to visit the official Washington State Department of Social and Health Services (DSHS) website.

Final Thoughts on Planning for Assisted Living

Proactive planning is the most effective way to address the future costs of assisted living. Understanding the distinction between Medicare, which handles medical care, and other programs that address long-term custodial care is the first step. By exploring Washington's specific Medicaid programs, the WA Cares Fund, and private pay options, families can create a comprehensive financial strategy that ensures quality care for their loved ones. Consulting with a financial planner or elder care specialist can provide tailored guidance based on your unique circumstances.

Frequently Asked Questions

What is the primary reason Medicare doesn't cover assisted living?

The main reason is that Medicare is designed for short-term, medically necessary care, while assisted living provides long-term 'custodial care' for daily tasks, which is not covered.

Will Medicare ever pay for a short-term stay in an assisted living facility?

No, Medicare does not cover any residential stay in an assisted living facility. It may cover a short-term stay in a skilled nursing facility under certain conditions, but this is a different level of care and facility.

Can Washington Medicaid (Apple Health) help with assisted living costs?

Yes, for eligible low-income seniors. Washington is one of the few states where Apple Health contracts with facilities to directly pay for some assisted living services. Several programs, like the MPC and CFCO, can help.

How does the WA Cares Fund help pay for assisted living in Washington?

The WA Cares Fund is a state-run long-term care insurance program. Eligible, vested Washingtonians can receive a lifetime benefit to pay for services, including assisted living, in their later years.

What are the income and asset limits for Washington's Medicaid programs for assisted living?

Eligibility for Washington's Medicaid programs requires meeting strict income and asset limits, which can vary depending on the specific program. It is best to contact the Department of Social and Health Services (DSHS) or use the resource links for current, detailed information.

Does a Medicare Advantage plan cover assisted living?

Generally, no. While Medicare Advantage plans are offered by private companies and can have expanded benefits, they still do not cover the room and board costs of assisted living. Some may offer limited non-medical services, but full assisted living coverage is rare.

What if I need both medical and personal care in an assisted living facility?

In an assisted living setting, Medicare will continue to cover any medically necessary services, such as doctor visits or therapies, just as it would if you lived at home. However, the facility's custodial care costs remain uncovered by Medicare.