Medicare, Medicaid, HMO? Here's how it works.

October 27, 2014

It is rare that I meet with a caregiver who is eager to move their loved one into a nursing home.  What I usually get instead, are questions about what kind of help can be arranged at home so they can keep them there longer, and potentially avoid a nursing home altogether.

Here is the best information I can give you about your options for getting help for your loved one at home:

The term “home care” includes skilled nursing care and rehabilitation services as well as what is referred to as custodial care. 

Medicare, HMO’s, and your States Medicaid plan will all cover home care services.  Of course, you can always get home care by paying for it yourself through a private agency.

Medicare:  Part A, B, and C, and HMO’s cover part-time skilled nursing care and rehabilitation services at home as long as the need is considered temporary, the services are approved by a doctor, and the person receiving the care is considered “home bound” (home bound means that the person can not leave the house without assistance and does not mean they must be confined to bed.)  The benefit is designed to assist people as they are recovering from an injury or illness and will end once the person is considered to be stable.

Skilled nursing care is provided by an RN who will visit, a maximum of once per day, to help with something like a daily injection, a dressing for a wound or surgical site, or set up and run an IV (yes, this can be done at home).  Rehabilitation services such as physical, occupational, or speech therapy, are also considered skilled needs, and are a provided by therapists who make visits to the home as determined necessary and covered by Medicare, probably 2-3 times per week.  A home health aide can also visit, up to 20 hours per week to help with personal care like showering, grooming, meal preparation.

Medicare Part A covers this home care when the person is being discharged from a hospital or nursing home stay that was paid for by Medicare and was a minimum of 3 days long.

Medicare Part B covers home care when there has been no hospital stay and services are typically arranged by your doctors office.

Medicare Part C (Medicare Advantage Plans) cover extra services and will likely have different co-pays.  You can click the link for more information about Medicare Advantage Plans and their services.  http://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/medicare-advantage-plans.html

HMO’s will have individual benefits for home care services so you will need to read the policy carefully.  Most HMO’s base the services they offer on the Medicare model that we have been outlining above.

But please remember:  Once your loved one is considered well enough to no longer need the skilled services e.g. the wound is healed or can be managed by a family member, the IV days have completed, the therapy is finished; the home care case will be over and all of the assistance stops.  For more information on Medicare coverage for home care go to: http://www.medicare.gov/coverage/home-health-services.html

This brings us to:

Medicaid and “custodial care”:

When Medicare home care ends but your loved one still needs someone to assist them, or would not be safe if they were left alone,  Medicaid can offer increased home attendant services on an ongoing basis (not temporary like Medicare/HMO’s.)  Medicaid is a Federal benefit for healthcare and every State runs it’s own program.  To be eligible for Medicaid you must have low income and limited assets.

At this point in conversations with families, I am usually asked about owning a home, because lots of folks do!  You ARE allowed to own your home – this is factored into the application process.

It is important to keep in mind that not everyone will be eligible for Medicaid benefits, or if they are, they could have a surplus of income that must be paid into the Medicaid system in order to receive the benefits.  I recommend using an elder law attorney if your financial situation feels complicated to you.

To learn about the specific Medicaid eligibility requirements for your state go to: http://www.benefits.gov/benefits/browse-by-category/category/MED

Of course, there is so much more to talk about when it comes to getting help for your loved (and you!)  Stay tuned for more discussion about making home care work for you, other resources, and tips to handle your stress!  And by all means, share your experiences with me and and let me know what you need more of!

Warmly,

Christine

 

 

 

 

 

 

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