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Assisted Living FAQs

Because many people have questions about assisted living, we are providing answers to the most asked Assisted living FAQs in the post below.

What is an assisted living facility:

Assisted living facilities provide individuals assistance with the ADLs (activities of daily living).  These activities include; meal preparation, bathing, dressing as well as medication management to name a few.  All these activities are categorized as custodial care.

Click here to learn more about the activities of daily living

What is the difference between Medicaid and Medicare in assisted living coverage:

There are definitely difference in how Medicare and Medicaid provide coverage for assisted living.

1.  Medicare does not provide any coverage for assisted living facilities. Although it does short-term stays in a skilled nursing facility for rehabilitation purposes as long as specific requirements are met.  This criterion includes the exclusion of the need for long-term care.
2. In some states, qualified Medicaid enrollees may receive help from a waiver program they provide with the costs for personal care as well as some other support services beneficiaries receive in an assisted living setting.  This assistance can reduce the total cost of assisted living quite a bit.  However, Medicaid does not offer help with the costs of room and board in an assisted living facility.

Click here for more details on Assisted living coverage

Is there a way to get financial assistance for assisted living:

As stated above, several states provide help with assisted living costs for anyone who has limited financial resources and qualifies for help such as Medicaid.

Veterans may qualify for help through programs offered through their local VA.  These programs and VA benefits may offer help with the costs of assisted living.

Although Medicare does not cover assisted living facilities, it will cover cost for medical treatment provided by doctors or hospitals as well as some approved skilled nursing facility care. If prescription drugs are needed, they are covered by Medicare Part D.

Medicare rules for physical therapy

If you are like many people, you may need physical therapy at one time or another.  Physical therapy (P.T.) can be a lengthy and expensive process.  If you are a Medicare beneficiary, you might ask about the Medicare rules for physical therapy coverage.

Why do you need physical Therapy:

Physical Therapy is provided to evaluate and treat injuries or diseases that impede your ability to function.  The goal of P.T. is to either improve or maintain current function as well as to slow the decline.

When it comes to physical therapy and Medicare coverage, in most cases, it is covered by Medicare Part B.  Medicare Part B covers outpatient services, including medically necessary physical therapy, occupational therapy, and speech-language pathology services.

In some cases, Medicare Part A covers Physical therapy if it is received as inpatient rehabilitation.  This is usually connected to an inpatient hospital stay.

Please note: members of Medicare Advantage plans need to check their evidence of coverage for benefit and coverage information.  If you do not have a copy, call the member services number located on the back of your ID card to get coverage details.

Physical therapy eligibility and medical necessity:

Although Medicare Part B covers physical therapy, it is important to understand that not all therapy sessions are eligible for reimbursement. Medicare requires that the therapy services are medically necessary to address a specific condition or injury.  Additionally, your doctor or healthcare provider must prescribe and oversee the therapy sessions.

Caps and Exceptions:

In the past, Medicare put annual therapy caps in place to limit the benefit amount members could use. However, as of 2018, Medicare has removed these caps.  This is because of MACRA (Medicare Access and CHIP Reauthorization Act). This change gives beneficiaries access to necessary therapy services without the stress of being cut off due to an arbitrary cap.

Although these days there is an annual “soft cap” in place, all this means is, providers must track their patients’ progress and state that the Pt is medically necessary, and coverage will be provided.  Once a patient gets close to the threshold, providers must use a KX modifier when submitting claims to prove services are medically necessary.

In 2023, the threshold is $2,230 for PT and SLP services combined.  For OT services it is $2,230.  This is a total annual coverage amount even if a patient seeks therapy for several different conditions during the course of the benefit period.  All services count toward that patient’s threshold. This threshold (soft cap) is not intended to prevent Medicare patients from obtaining medically necessary care.  It is just in place to avoid abuse of the system and track a patient’s progress to ensure the medical necessity.

Please note; as long as your physical therapy is medically necessary there is not limit on outpatient therapy services in one year.

What is the cost for physical therapy:

Under Medicare Part B, most beneficiaries pay an annual deductible. Once you meet your deductible, you must pay the 20% of the Medicare-approved amount for covered therapy services. If you have a Medicare Supplement plan, that plan pays the 20% left after your deductible is met and Medicare pays its part.  It’s important to verify that your therapy provider accepts Medicare assignment, which means they agree to accept the amount that Medicare deems reasonable for their services as payment in full.

Requirements for therapy providers:

To make sure Medicare covers the services you receive, your physical therapy must be provided by a qualified healthcare professional who meets Medicare’s standards. This rule applies to licensed physical therapists (PTs), licensed occupational therapists (OTs), as well as licensed speech-language pathologists (SLPs).

Documentation and Progress Reporting:

In order to receive continued coverage of physical therapy sessions, your provider must document your progress regularly.  Documenting helps justify the medical necessity of ongoing therapy as well as provides insight into your functional improvements. It is also important to attend all recommended therapy sessions and actively participate in your treatment plan.

Once you know the rules and requirements for Medicare coverage for physical therapy, you can move forward with your recovery without having to worry about any possible financial strain your treatment may cause. It is imperative that you communicate with your healthcare provider and therapy team to maximize the benefits of Medicare’s coverage and work towards achieving your health and wellness goals.

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