Do Medicare and Medicaid Pay For Adult Day Care?
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Do Medicare and Medicaid Pay For Adult Day Care?

If you are caring for a loved one with Alzheimer’s disease or another form of dementia, it’s paramount to understand your available options. Many caregivers want to know whether Medicare or Medicaid will cover adult day services, for example.

There is no short answer to this question, as there are many guidelines, eligibility requirements, and alternative options. At Town Square, our incredible senior day care services are offered on a private-pay basis, but there are a variety of benefits that may be available to you or your loved one that could defray the cost. For more information, contact us today, or read further to learn the details on insurance coverage for senior day care.

Types of Medicare

Medicare is a federal health insurance program that provides coverage for eligible individuals, primarily targeting people aged 65 and older. Medicare consists of different offerings, each of which has distinct coverage and benefits. These are known as Part A, Part B, and Part C.

Medicare Part A (Hospital Insurance)

Medicare Part A, also known as Hospital Insurance, offers coverage for inpatient hospital care, skilled nursing facility care, nursing home care, hospice care, and home healthcare services. Most individuals qualify for premium-free Part A, but some may have to pay a premium based on their specific circumstances.

Medicare Part B (Medical Insurance)

Medicare Part B, also known as Medical Insurance, covers certain doctor’s services, outpatient care, medical supplies, and preventive services.

If individuals are already receiving Social Security or RRB benefits at least four months before becoming eligible for Medicare and reside in the United States (excluding Puerto Rico), they are automatically enrolled in both premium-free Part A and Part B.

Individuals who are not receiving Social Security or RRB benefits are not automatically enrolled in Part B and must actively enroll during specific enrollment periods.

Part B eligibility rules depend on whether an individual is eligible for premium-free Part A or if they must pay a premium for Part A coverage. Those who are eligible for premium-free Part A are also eligible to enroll in Part B once they are entitled to Part A.

Medicare Advantage (Part C)

Medicare Part C, also known as Medicare Advantage (MA), offers an alternative to Original Medicare (Parts A and B) for health and drug coverage. Medicare Advantage plans are comprehensive plans provided by private insurance companies contracted and approved by Medicare. These plans must offer the same basic coverage as Medicare Parts A and B but often include extra benefits such as dental, vision, hearing, fitness memberships, and more. Medicare Advantage plans that include prescription drug coverage are referred to as Medicare Advantage Prescription Drug (MAPD) plans.

To be eligible for Medicare Part C, individuals must meet the following requirements:

  • They must be enrolled in both Medicare Part A and Part B.
  • They must be a resident of the Medicare Advantage plan’s service area.
  • They must be a U.S. citizen or permanent legal resident for at least five consecutive years.

Additionally, individuals must meet at least one of the following criteria for Medicare eligibility:

  • They are 65 years of age or older.
  • They are permanently disabled and have received disability benefits for at least two years.
  • They have been diagnosed with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease).

Does Medicare Cover Adult Day Care Services?

In most cases, Medicare does not pay for adult day care, but the full answer is more complex.

Medicare provides coverage for various medical services. However, when it comes to adult day care services, Medicare has certain limitations. Let’s take a closer look at what Medicare does and does not cover:

Medicare Coverage for Adult Day Care Services

Unfortunately, Medicare does not cover non-medical custodial care, including adult day care services. Adult day care involves providing a safe and supervised environment for older adults or individuals with disabilities, offering social activities, meals, and assistance with daily living tasks. As Medicare primarily focuses on medical care, adult day care falls outside its coverage scope.

Limited Coverage for Mental Health Treatments

Although Medicare does not cover regular adult day care services, it may provide coverage for specific mental health treatments offered through an adult day care center. These treatments may include the administration and monitoring of medication, recovery from a medical crisis when prescribed by a physician, and outpatient mental health services provided by a clinic that offers adult day care.

Medicare Advantage (Part C) Coverage

Some Medicare Advantage plans may offer partial coverage for adult day care services as part of their comprehensive home care services.

It’s important to note that not all Medicare Advantage plans provide coverage for adult day care services. The inclusion of adult day care coverage in Medicare Advantage plans is not mandated by Medicare, so it varies from plan to plan. If you have a Medicare Advantage plan or are considering enrolling in one, it’s crucial to review your plan’s specific details and benefits to determine whether it includes adult day care coverage.

What About Medicaid?

Medicaid is a health insurance program designed for low-income individuals of all ages. It plays a significant role in providing coverage for long-term care services, including adult day care, to people with dementia. Let’s explore how Medicaid differs from Medicare and how it can support individuals in accessing adult day care services.

Medicaid and Medicare: Understanding the Differences

While Medicare is a federal health insurance program available to all Americans aged 65 and older, regardless of their income, Medicaid is specifically aimed at assisting low-income Americans with their healthcare needs. Medicaid eligibility criteria vary by state, with recipients typically required to have monthly income and countable assets below a certain threshold. The income limit in 2023 is around $2,742 per month, and the asset limit is usually $2,000. However, these figures may vary depending on the state, as Medicaid is managed at the state level.

Unlike Medicare, which primarily covers medical needs such as doctor visits, hospitalization, and medications, Medicaid provides coverage for many long-term non-medical services and supports that individuals with Alzheimer’s or other dementias require. This makes Medicaid a crucial resource for accessing the necessary care and services for those with dementia.

Medicaid Coverage for People with Dementia

Medicaid offers a range of services that can benefit individuals with dementia. While most Medicaid beneficiaries with dementia are also eligible for Medicare, Medicaid serves as a secondary payer, covering services that Medicare may not fully cover or certain long-term services and supports (LTSS) needs.

States participating in Medicaid are required to cover specific services while also having the flexibility to provide additional services at their discretion. Some of the mandatory Medicaid services relevant to people with dementia include inpatient and outpatient hospital services, lab and x-ray tests, nursing facility services, home health aide services, physician services, and non-emergency medical transportation.

In addition to the mandatory services, Medicaid offers optional services supporting individuals with dementia. These services may include prescription drugs, physical therapy, speech-language and occupational therapy, private duty nursing, personal care services, hospice care, case management, adult day health care programs, and respite services.

Moreover, through the Affordable Care Act (ACA), states can offer Community First Choice, which provides attendant care services and supports with enhanced federal matching funds. Some states have taken advantage of this option to target services specifically for people with dementia, such as offering health home services that include case management, care coordination, and health promotion.

Many states offer adult day care as part of their regular Medicaid program, ensuring that individuals with dementia can access this form of care and support. Adult day care is often included as a benefit under the Home and Community-Based Services (HCBS) waivers available through Medicaid. Keep in mind that enrollment caps and waiting lists may exist for waiver services due to the high demand.

How Do People With Dementia Qualify For Medicaid?

People with dementia may qualify for Medicaid through various means, including age-related, disability-related, and LTSS pathways. Medicaid eligibility criteria differ by state, but they must adhere to certain federal minimum requirements.

What Steps Should I Take To Determine If My Loved One Is Eligible For Medicare Coverage Of Adult Day Care?

The following steps can help you understand the coverage guidelines and find the best fit for your needs.

Step 1: Gather Information About Your Loved One’s Medicare Coverage

Start by reviewing your loved one’s Medicare coverage. Determine whether they have Original Medicare (Part A and Part B) or a Medicare Advantage (Part C) plan.

Step 2: Review Specific Coverage Guidelines

Next, carefully review the specific coverage guidelines for adult day care under your loved one’s Medicare plan. Medicare typically covers medical care but does not pay for non-medical custodial care like adult day care. However, there are limited circumstances where Medicare may cover services offered through an adult day care center, such as mental health treatments or outpatient services related to recovery from a medical crisis.

Step 3: Check Eligibility for State or Local Programs

In addition to Medicare, some state or local programs may provide coverage for adult day care. These programs often have their own eligibility requirements and guidelines. Check with your local Area Agency on Aging or Department of Social Services to explore potential programs that could offer additional coverage for your loved one’s adult day care needs.

Step 4: Contact Medicare or a Medicare Counselor

If you’re unsure about your loved one’s eligibility or have questions about their Medicare coverage, reach out to Medicare directly or consult a Medicare counselor. Medicare representatives or counselors can provide valuable assistance in understanding the specific coverage options available and guide you through the eligibility determination process.

Step 5: Explore and Evaluate Coverage Options

Once you have gathered all the necessary information and determined your loved one’s eligibility, it’s time to explore and evaluate the coverage options for adult day care. Consider the specific needs of your loved one, including any specialized care requirements related to dementia or other conditions. Compare the benefits, costs, and quality of care offered by different adult day care centers or programs. It’s important to find a facility or program that aligns with your loved one’s needs and provides a supportive and engaging environment.

Discover the Best-Fit Care Option for Your Loved One

By following these steps, you can navigate the Medicare coverage options for adult day care and make informed decisions regarding your loved one’s eligibility and the best fit for their needs. Remember to stay informed, ask questions, and seek assistance when needed to ensure your loved one receives the care and support they deserve.

Town Square’s innovative adult day care offers our members therapeutic reminiscence, social connection, creativity, learning, and pure fun, helping improve mental and physical well-being. We are proud to be a key resource for dementia care for seniors and their caregivers across the country. Find your nearest Town Square center or contact us today to learn more about what makes us the best adult day care option.