Home Care ... Is It Covered?

by Cheryl Nemanic

Nearly one out of every four U.S. households (23 percent, or 22.4 million) provides care to a relative or friend aged 50 or older. The majority of these caregivers are baby boomers. In the twenty-first century the demands placed on family and other informal caregivers are likely to escalate, affecting nearly every American family. Since most persons prefer to stay in their own homes and live independently for as long as possible, this column addresses questions and concerns regarding these issues.

Q After suffering a stroke my mother was briefly hospitalized and then transferred to a rehab facility. She will soon be discharged and sent home, where she lives on her own. The social worker at the rehab facility has arranged home care visits which consist of a person to help her bathe and a physical therapist each stopping in two or three times a week. We are concerned that these visits won’t be enough. My mother will need someone to stay awhile with her, to help her get around, and with personal care and meals. The social worker says that this type of home care is not covered. We are confused since mother has Medicare and a supplemental insurance policy that says home care is covered. Are there different types of home care?

A Home Care is a term that is greatly misunderstood and usually does mean visits by Home Health Aids, RNs, or therapists. These visits are set up per Doctor’s Order for a period of time usually after someone has been discharged from a healthcare facility. The visits are covered by private health insurance and Medicare, but these folks will stop in briefly when it fits their schedule.

For folks who need more in-home care, funding coverage is very limited, although anyone can pay out of pocket for the services since there is no Doctor’s Order needed. Services that provide in-home care can schedule people for the days and times that care is needed.

Sources that may cover in-home basic care are long term care insurance, and a variety of programs offered through the Medicaid program or the local Area Agency on Aging. Private pay services are also available and can be combined with covered services.

Though it would generally cost less than care in a residential or nursing facility; funding coverage for services in an individual’s home is very limited. Since most persons prefer to stay in their own homes and live independently for as long as they can, there is a great need for sources that will cover care and services in those settings.

The following offers some basic guidelines about what may covered by various payment sources. Note that this is general information and coverage will always depend on an individual’s arrangements with the payment source.

Private Health Insurance

· Including MediGap policies, Managed Care Plans (HMOs), Group Plans through employers, American Association of Retired Persons (AARP), etc.

· Some home health services, when prescribed by a physician may be covered. Generally basic personal care, custodial care and home chore services are NOT covered.

email consumer@ins.state.pa.us

http://www.insurance.state.pa.us

Pennsylvania Department of Insurance toll-free Consumer Hotline at 1-877-881-6388

Medicare

· Covers those age 65 and older and those who have been receiving Social Security disability benefits for at least two years

· Coverage is limited to a number of short (usually 1 hour or less) visits per week for a period of time prescribed by a physician.

http://www.medicare.gov

Long Term Care Insurance

· Purchased privately or may be through employer.

· Coverage for in-home basic personal care and/or a stay in a long term care facility. Per day maximums and time limits may apply. Check the policy or the insurance company that issued the policy to find out what is actually covered.

email consumer@ins.state.pa.us

http://www.insurance.state.pa.us

Pennsylvania Department of Insurance toll-free Consumer Hotline at 1-877-881-6388

Local Area Agency on Aging

· Federal and state government agencies have collaborated to develop a variety of special programs that will arrange for extended care and services to be provided in home and community-based settings. Whether or not you are eligible for these programs will depend on your income and resources; your need for care; and the availability of funds. A newer cost sharing program is also available.

http://www.aging.state.pa.us

Department of Public Welfare Information Helpline 1-800-692-7462

Local Area Agencies on Aging are listed by county in your phone book

Medicaid

· For persons with low to moderate income and limited resources.

· Coverage for a limited amount of care and services in the home if prescribed by a physician and approved by the Department of Public Welfare as an alternative to residential or nursing home care.

http://www.dpw.state.pa.us

County Assistance Office http://www.dpw.state.pa.us

"Department of Public Welfare Information Helpline 1-800-692-7462

Private Pay (Also Referred To As Patient Pay or Out-Of-Pocket)

· Any individual or family member may contract services to be paid out-of-pocket without requirements such as doctor prescription or financial qualifications. Care to supplement covered services can also be arranged.

· Companion/Nurse Aide, LPN, or RN level services can be contracted through private duty nursing services. Light housekeeping, laundry, and meal prep as well as basic personal care and medical services are usually offered.

Some services may also be providers for your covered sources, such as insurances or the local Area Agency on Aging, making it easy to combine service or to continue with the same caregiver on a private pay basis when coverage runs out.

Cheryl Nemanic, CCM, is the General Manager of Private Duty Services for Liken Health Care, Inc., a private duty nursing service in the Pittsburgh area since 1974. If you have a question, Cheryl can be reached by phone at (412) 816-0113, by email at cnemanic@likenhealthcare, or visit the website at www.likenhealthcare.com.