What do you mean Medicare doesn’t pay for that?!
One of the most common misconceptions about senior care is that Medicare will pay for whatever care a person needs, whether at home or in a facility. Families are often left scrambling when they find out this is not the case.
Picture this: you are a caregiver for your elderly mother. Your mom lives home alone and is managing okay on her own. Maybe you stop by once a week to check on her and help out a little around the house, but that’s about all she needs.
One day, she has a fall and ends up in the hospital with a broken hip. She has surgery and recovers in the hospital for several weeks, then goes to rehab at a skilled nursing facility, where she receives meals, physical therapy, nursing services, and assistance with getting on and off the toilet, showering and getting dressed. She stays in rehab for a month and then goes home with visiting nurse services.
A nurse, home health aide, occupational therapist, physical therapist, and social worker provide care and monitor her recovery at home. Mom may be on the mend, but is no longer able to do many of the things she could before the fall.
Throughout this experience, you are told that Medicare is paying for everything — and so far this has been true. However, after 6 weeks, the nurse discharges your mom from visiting nurse services, and informs you that she, the physical therapist, occupational therapist, social worker, and home health aide will not be coming to see your mom anymore.
Your reaction is likely something like this — “Excuse me? What do you mean the services are going to stop? She has Medicare. Won’t Medicare pay for help at home?” Unfortunately, the answer is no. This is usually the point where you, the caregiver, look at the nurse like she has 5 heads.
So, what is Medicare?
Medicare is a health insurance program for Americans age 65 and older, who are typically retired and no longer receive health insurance from an employer. Medicare was passed in 1965 by President Lyndon B. Johnson as an amendment to the 1935 Social Security program.
Although the Social Security program provided income for retired seniors, it was still nearly impossible for seniors to afford decent private health insurance. Healthcare costs were a huge economic burden because, as people age, their healthcare costs tend to increase as their income generally decreases. Prior to Medicare, a little over half of Americans aged 65+ had hospital insurance, and only a subset of that group had coverage for surgery and out-of-hospital costs.
The passing of Medicare created a comprehensive health insurance program for all Americans age 65+, which covers health care costs like doctor’s visits, hospital stays, surgery, lab tests, prescriptions, etc. Medicare pays for nursing home and home health care sometimes, but only as it relates to a “skilled” medical need (requiring a licensed professional, such as a nurse, doctor or therapist), primarily after a hospitalization, and typically for a relatively short amount of time.
Everyday care, like help showering, getting dressed, or filling a pill box is called “custodial” care, and is not considered skilled care covered by Medicare. This is why Medicare does not pay for things like ongoing homecare or assisted living facilities, since no skilled medical care is being provided.
“Medicare does not pay for things like ongoing homecare or assisted living facilities, since no skilled medical care is being provided.”
Well, if Medicare isn’t paying, what can I do?
Let’s get back to our story. Your mom is being discharged from the VNA and you have likely not thought about other options for care. You may work full time and have a family of your own. You cannot provide as much assistance as she needs to live safely at home. What do you do?
Your plan may depend on your mom’s financial situation. If she has a significant amount of financial assets, you can hire paid help. Home health aides, through an agency or working privately, can assist with personal care needs, like bathing and dressing, and other tasks around the house, such as cooking, cleaning, and laundry. The national median cost of a home health aide is $22/hour — in many major urban areas the cost is higher than $30/hour.
“The national median cost of a home health aide is $22/hour — in many major urban areas the cost is higher than $30/hour.”
Many homecare agencies also have four hour minimums. So even if you just need someone to come for an hour and help your mom shower and get dressed in the morning, you will probably find yourself paying for 4 hours of homecare, which could mean close to $120/day. As you can imagine, this cost can add up quickly.
Many states have government-subsidized services for lower income seniors. To learn more about these programs and eligibility requirements, you can contact your local Area Agency on Aging (AAA). Your local Council on Aging (COA) is another good resource that may be able to connect you with support services.
Many COAs and AAAs also have staff who can help you figure out if your mom qualifies for Medicaid, which is a state and federal government-funded health insurance program for low-income Americans. There are income and asset eligibility guidelines for Medicaid that vary by state. For an individual to qualify for Medicaid, the requirement is generally that they make no more than about $1,000 per month (around $1,400 for a married couple) and have no more than $2,000 in assets ($3,000 for a married couple).
Medicaid will often pay for homecare services, and many states have comprehensive programs, like PACE (Program of All Inclusive Care for the Elderly), that cover an array of home-based services (typically in a managed-care model) for seniors who qualify for both Medicare and Medicaid.
Medicaid is also the largest payer of long-term care in nursing homes. As mentioned earlier, Medicare only pays for short-term rehab in nursing homes. Often times, seniors must spend down their assets by paying out of pocket for homecare or nursing home care until they qualify for Medicaid coverage.
But what if your mom isn’t rolling in enough cash to pay hundreds of dollars a week for homecare out of pocket, and she makes too much money to qualify for state programs? This is the place where a growing number of seniors find themselves.
If she is one of the lucky few who own a long-term care insurance policy, now would be the time to review her coverage. There are many different kinds of policies, with varying elimination periods, benefit periods, covered services, benefit structures, etc. Stay tuned to our blog for a separate post about how to better understand your long-term care insurance policy! In the meantime, you can contact the insurance company to learn more about her policy. Some local insurance brokers may also be willing to review it with you.
If you have exhausted the options above, there are still a few things you can try. You could hire an aging life care professional (also called geriatric care manager). These professionals, usually social workers or nurses, specialize in coordinating and managing care for seniors. The cost of a geriatric care manager ranges widely, from $50-$200/hour, depending on where you live and what services they are providing. However, a GCM will have knowledge of local options and resources to support your mom at home and may be able to come up with a more affordable plan of care. To easily find a GCM near you, you can check out the Aging Life Care Association (ALCA) website. Explore their site to learn more about what GCMs do. We will also be posting an interview with a local GCM, and the president of the New England chapter of ALCA, so keep an eye out for that!
Any last suggestions for me?
“The best way out of this situation is to plan for it way in advance, which most people do not do.”
You’ve made it to the end of this article and may still be thinking, “None of these options will work for my family.” I wish I had an insider secret I could share with you: some little-known loophole that would allow your mom to live safely at home with an endless supply of affordable services for as long as she needs. But no such loophole exists. The best way out of this situation is to plan for it way in advance, which most people do not do. Often times, families need to be creative, and end up patching together a network of support that includes neighbors, friends, family members, volunteers, and local community resources, to make sure their loved one gets the care he/she needs.
About the author: Marissa Levenson, MSW, LICSW has her master’s degree in Social Work and bachelor’s degree in Gerontology. She has worked with seniors in a variety of community (state homecare, outpatient geriatric psychiatry, hospice, adult day health, and guardianship) and facility-based settings (continuing care retirement community and nursing home) for 10 years.
