Medicare versus Private-pay Home Care

Serenity Senior Care, LLC is a private-pay, in-home care provider. Private-pay home care is different than the Medicare-covered home care, which is short term (less than 60 days), intermittent (for a few hours each week), rehabilitative (physical therapy or speech therapy), and medically necessary (care that must be provided by a Registered Nurse). Medicare-covered home care does not provide services that are considered long term or ongoing, around-the-clock (evening hours or 24-hour in-home care), or non-rehabilitative (homemaker, meals, or transportation). These in-home services, that are not paid for by Medicare, are called private pay home care, because Medicare does not cover them and they are an out-of-pocket expense or paid for by long term care insurance. Most people who need additional care or assistance (that isn’t covered by Medicare) choose to hire a private pay home care provider, OR they move into an assisted living or nursing home.

Who can get the Medicare Benefit?

Medicare A is available to persons who are:

  • entitled to social security
  • Railroad Retirement at age 65
  • ESRD
  • disabled
  • hospital inpatient, hospice, homebound

Note: There is no out-of-pocket expense for Medicare A recipients

Medicare B is available to persons who are:

  • eligible for Medicare A
  • requires physician services, ambulance, DME, outpatient

Note: With Medicare B the recipient pays or their insurance pays a monthly premium, typically 20%

How do you qualify for the Medicare Benefit?

  • Meet the benefit requirements above.
  • Have a need for services that are Medically necessary.
  • Meet the homebound criteria
  • Services are ordered by a qualified physician.
  • Care is intermittent or part-time care and rehabilitative so that there is a predictable end point.
  • There is a need for at least one skilled service.

How do you know if someone is homebound?

  • They have a normal inability to leave home.
  • Going to religious practice or doctor’s appointments is possible, but it requires considerable and taxing effort.
  • Absences from home are infrequent and of short duration.

Where can I receive the Medicare Home Care benefit?

Wherever you call home

  • Own dwelling
  • Apartment
  • Relative’s home
  • Senior Housing
  • Assisted Living
  • Group Homes

Must a person have a hospital stay to have services ordered by a Physician?

No. If you meet the Medicare criteria, your primary physician can order Medicare Home Care services.

What is intermittent or part-time care that is rehabilitative?

Medicare pays for care that’s primary goal is to improve a person’s current health condition so that they can live independently again. Therefore it is intermittent (a few days per week, less than 24-hours per day) and short-term (it has an end point that is less than 60 days). Medicare does not pay for long-term or ongoing care that ultimately will not improve someone’s current health condition. If a person is not rehabilitating, Medicare will generally stop paying for services. Medicare services, in total, cannot exceed 8 hours per day, 6 days per week. Medicare services cover nursing and therapy needs, not homemaker, meals, or transportation. Generally, Medicare services are completed in less than 60 days. If a person continues to be homebound, shows signs that they are rehabilitating, and the physician will order Medicare services be continued, it is possible for services to go beyond 60 days, but this is rare.

It is a requirement that a person must have at least one skilled service need to initiate the Medicare Benefit, what is a skilled service need?

A physician must order that the person needs services related to one of the following three skills to receive the Medicare benefit. The person can receive services in more than one area, if necessary.

  • Medicare Nursing (examples: assessment, teaching and training of medications, direct nurse procedures)
  • Physical Therapy (examples: therapeutic exercises, gait training, range of motion, maintenance therapy, other modalities)
  • Speech Language- Pathology (examples: Diagnosis and treatment of dysphasia, communication disorders, diagnosis and treatment of speech and language disorders)

Are there additional Medicare Benefit Services that a person has access to?

Yes! Once a person has one of the skilled needs mentioned above and those Medicare services begin, the person has access to the following services:

  • Occupational Therapy Services (example: upper body therapeutic programs)
  • Social Services (examples: to resolve social or emotional problems, make community service referrals, etc.)
  • Home Health Aide Services (Examples: bathing, oral hygiene, changing bed lines, assistance that supports the skilled therapy or nursing services)

What can a person typically expect if they qualify for the Medicare Benefit?

Typically, a person will have a visit 2-4 times per week from a Nurse, Physical Therapist, or Occupational Therapist depending on the skilled need that opened the case. The person will receive therapy or nursing services, based on their needs, during those visits. A Home Health Aide will visit 1-3 times per week for 1-2 hours to provide for a bath or other needed personal care. The Home Health Aide does not assist around the house with housekeeping, meals, or provide transportation. A Social Services Worker will make a visit to assess if there is a need for emotional or social health services and/or make referrals for other services in the community. Generally, in 30-60 days the person receiving Medicare services is “rehabilitated” by Medicare standards because they no longer meet the homebound criteria. The amount of visits, number of services rendered, and time spent with the recipient varies per case and Medicare Agency.

What Home Care services are not covered by Medicare?

  • Generally, any services that are on-going beyond 60 days.
  • 24-hour care and assistance
  • Rides for doctor’s appointments
  • Assistance running errands, getting household supplies, or grocery shopping
  • Meal Preparation
  • Housekeeping
  • Social Outings
  • Around-the-clock assistance with ADL’s, mobility, personal care, bathroom assistance, grooming, etc.
  • What if a person needs additional assistance beyond what Medicare covers?

    This is where Serenity Senior Care, LLC a private-pay, in-home care service steps in to make it possible for almost any senior, at any age, in any health condition, to continue living life at home. The same care and assistance that is provided in assisted living and nursing homes can be provided at home! Private-pay home care can be assistance from a few hours a week to 24-hour care that supplements Medicare Home Care or begins when Medicare coverage ends.