Allentown Senior AdvisorDoes Medicare pay for a personal care home or assisted living in Pennsylvania?
No: Medicare does not pay for room, board or personal care in a personal care home, assisted living residence or dementia unit, because it covers medical care and short-term skilled care, not long-term help with daily activities.
Medicare can still pay for services delivered to a resident there: doctor visits, home health visits, hospice, therapy and prescriptions under Part D.
When does Medicare pay for a nursing home stay?
Medicare Part A pays for up to 100 days in a certified skilled nursing facility per benefit period after an inpatient hospital stay of at least three days, if the patient needs daily skilled nursing or therapy: the first 20 days in full and days 21 to 100 with a daily copayment.
Observation days in the hospital do not count toward the three days, so ask Lehigh Valley Hospital or St. Luke's staff whether your parent is formally admitted. Medicare Advantage plans may waive the three-day rule but usually require prior authorization.
What does Medicare's home health benefit cover?
Medicare covers intermittent skilled nursing, physical, occupational and speech therapy, and some home health aide time for a homebound patient under a doctor's plan of care, at no cost to the patient, but not 24-hour care or homemaker services alone.
CMS lists 24 Medicare-certified home health agency offices and 9 hospice offices in the three counties, most of them in Allentown and Bethlehem; agencies serve clients well beyond their office address. Home health can visit a parent in a personal care home as well as in a private house.
What does Medicare's hospice benefit cover?
Medicare's hospice benefit covers comfort-focused care for a patient with a life expectancy of six months or less who chooses hospice: nursing visits, aide visits, medical equipment, medications related to the terminal illness, social work, chaplaincy and respite.
Hospice does not pay for room and board in a personal care home or nursing home, and it does not provide round-the-clock caregivers except during short crisis periods.
Where can Lehigh Valley families get free Medicare counseling?
PA MEDI, Pennsylvania's free Medicare counseling program (formerly APPRISE), runs through each county's Area Agency on Aging: Lehigh 610-782-3200, Northampton 610-829-4540 and Carbon 610-824-7830.
Counselors compare Medicare Advantage and supplement plans, check Part D formularies and screen for Extra Help and Medicare Savings Programs. The annual open enrollment period runs October 15 to December 7.
At a glance
| Medicare pays for | Medicare does not pay for | |
|---|---|---|
| Nursing homes | Up to 100 skilled days after a 3-day admission | Long-term custodial stays |
| At home | Intermittent skilled home health | Hourly non-medical caregivers |
| Residences | Medical services delivered there | Personal care home or ALR rent and care |
Sources include 55 Pa. Code Chapters 20, 2600 and 2800, Pennsylvania DHS, Department of Health and Department of Aging pages, CMS, VA and CareScout rate tables as cited above; see our editorial standards.
