Models and Payment Options of In-Home Care Providers

Primer on In-Home CarePrivate Duty/Private Pay Services

Private duty/private pay services are usually paid directly by the patient or his or her family members, or by long-term care insurance, workers’ compensation and some armed services funding.

Private duty services are usually mostly “non-medical” services and can range from companionship to housekeeping, transportation, personal care, dementia care to 24-hour or respite care.

  • Full service agencies provide non-medical care by employees of the agency who are screened, trained, monitored and usually bonded and insured. There is far more safety in this model, and far less potential liability for the care recipient than with a nursing registry.
  • Nursing registries/healthcare registries act as a “matchmaker” service, assigning workers (often untrained) to clients, placing the responsibilities of managing and supervising the worker on the patient, a family member, or a family advisor, as well as government-mandated taxes and workers’ compensation coverage.

Hospice Care

Hospice care is a special concept of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments, in a home or a hospital setting, usually requiring that someone be with the dying patient at all times.

Hospice coverage is widely available—offered by most private insurance providers and through Medicare nationwide, and as an optional Medicaid service covered by most states. Also, hospice sometimes has grants allocated to supplement Hospice Medicare provisions which cover some private duty services. These services are funded by public funds, are not considered private duty, and are geographically specific. Querying each hospice location is needed to determine if these services are available.

Additionally, most hospices will provide for anyone who cannot pay using money raised from the community or from memorial or foundation gifts.

Home Health Care

Home health care is skilled nursing care and certain other health care services one receives in a home setting for the treatment of an illness or injury, such as care for a wound, injections, monitoring of health conditions like diabetes, assistance with medical equipment like dialysis or with an indwelling catheter, naso-gastric tube feeding or ventilator.

Home health care can also provide rehabilitation services, such as exercises to improve the range of motion of arms and legs, speech therapy or help swallowing which might be due to a stroke or ALS, and respiratory therapy.

Medicare pays for some of the care in a patient’s home only if all four of the following conditions are met:

  1. The patient needs intermittent skilled nursing care, physical, speech or occupational therapy.
  2. The patient is homebound—normally unable to leave home and leaving home is a major effort.
  3. The care must be referred by a doctor and medically reasonable and necessary.
  4. The home health agency caring for the patient must be approved by the Medicare program.

If the conditions for eligibility are met, Medicare will pay for the following services in the patient’s home when they are medically reasonable and necessary: intermittent skilled nursing/home health services; physical/speech/ occupational therapy; medical social services/supplies; durable medical equipment.

Medicaid Home and Community-Based Care

Medicaid Home and Community-Based Care is intended to provide services for those who cannot afford to pay for care with the goal of keeping the person out of a nursing home. Recipients do not need to be homebound or ill to receive the services. To access Medicaid services, the client must first be assessed by a state agency that gate-keeps the program and be approved for a specific number of home care hours or given a voucher for a certain amount of care.

Medicaid is funded by a Federal/State partnership. If the patient is mutually eligible, both Medicare and Medicaid can be payment sources with Medicare usually the primary payer and Medicaid secondary. Medicaid payments for home care are divided into three main categories:

  1. Mandatory traditional home health benefit, and two optional programs
  2. Personal care option
  3. Home- and community-based waivers

Geriatric Care Management

Geriatric care management entails personal, daily money as well as household management that falls outside of the services of a direct care provider. Other services care managers provide fall into categories that bridge the gaps between direct care and ongoing care needs, which may include coordinating medical and other care providers, family communication, or assisting a move into another living arrangement and the closing up of a household. Payment is generally out of pocket for professional services, invoiced by the hour or by the project.

Every patient’s situation is different. At Home Independent Living will gladly assist in determining which payment option would best suit a person’s specific situation. Contact us today!

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