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Paying for In-Home Services Using Medicare Advantage

Page Reviewed / Updated - November 21, 2019

The Benefit of In-Home Services

For many seniors and families, aging in place isn't just about enjoying the ability to embrace the security and familiarity of home, but it's also a financially economical option. According to the U.S. Department of Housing and Urban Development, aging in place saves money, particularly for seniors who own their homes outright and are no longer paying on a mortgage. Older adults who own their homes spend less on living expenses and are able to access their home's equity to pay for in-home mobility devices and personal care services.

However, seniors who own their homes outright are the minority; approximately 80% of adults between the ages of 65 and 84 still pay for housing or do not own the home they reside in, limiting their access to funds. When paired with monthly mortgage or rent payments, the increasing cost of in-home care is burdensome for many. According to Genworth's 2019 Cost of Care Report, non-medical home care services cost $4,290 per month on average and home health care services cost $4,385 per month. For those who need skilled nursing, a single visit costs $87.50. Even retirees who enjoy financial security may struggle to afford the services that they need to continue safely living at home.

Fortunately, Medicare can assist beneficiaries in covering necessary in-home services. Through the recently expanded Medicare Advantage plans, seniors may qualify to receive coverage for personal care assistance, non-medical transportation and in-home meal delivery.

Choosing the Right In-Home Services

For some seniors, living at home requires a helping hand with some activities of daily living. In these cases, home care provides a balance between preserving privacy and independence and having needs met efficiently. Home care can range between highly specialized care, such as visits from a neurologist, to generalized care and companionship. It can be broken down into three categories, including home health care, non-medical home care and in-home services.

Home Health Care

Home health care, which may also be referred to as home health aide services, addresses the needs of seniors who require regular health monitoring. Home health aides, also called geriatric aides, certified nursing assistants or nurse aides, are certified or licensed to provide specialized care such as checking patients' respiration, pulse and temperature. They may also provide assistance with medical equipment like braces or ventilators, provide wound care, change catheters and administer medications. Along with skilled nursing services, home health aides may provide personal care services like help with bathing, dressing and toileting.

Home health care also encompasses medical supplies that are used at home, such as durable medical equipment like manual and electric wheelchairs, walkers, ventilators and nebulizers. Some injectable drugs, like osteoporosis drugs, may be included in home health care.

In most cases, home health aides bill on an hourly basis, and because they are subject to a high degree of government regulation, they are typically hired through an agency. Under traditional Medicare, home health care services are covered in full only for beneficiaries who require skilled nursing care, though any personal care services must be covered out-of-pocket. Durable medical equipment is typically covered at 80% of the Medicare-approved cost. Seniors who do not need skilled care but only require personal care services are not eligible to have home health care services covered under traditional Medicare.

To qualify for home health care coverage under traditional Medicare, seniors must be under the care of a doctor and be getting services under a plan created and reviewed regularly by their doctor. Their doctor must certify that they need intermittent skilled nursing care or physical, speech or occupational therapy services. Their doctor must also certify that they're homebound.

Home Care

Home care services, also called personal care, attendant care, companion care or non-medical care, is limited to helping with the activities of daily living. Some care services provided by non-medical home care attendants include housekeeping, transportation for errands and medical appointments, meal planning and preparation, toileting and grooming.

Like home health aides, home care attendants bill on a per-hour basis. They may be retained either through a home care agency or through private hire. On average, seniors pay $21.50 per hour for homemaker services for personal care attendants who are hired through a home care agency. However, unlike home health aides, personal care attendants have virtually no government oversight. Seniors may save money by hiring private individuals to provide homemaker services, but these personal care attendants are not required to obtain certifications, purchase insurance coverage or go through background checks.

In contrast to home health care, home care services don't require a prescription from a doctor; it's left to the senior and their family members to determine what level of care is needed. Seniors can decide for themselves what tasks they need assistance with and how many hours per week they'd like to have home care services.

Under traditional Medicare, there is no coverage for non-medical care, and any personal care services are paid for in full by the one receiving them. However, under the recently expanded Medicare Advantage program, seniors may be eligible to have some services covered.

In-Home Services

The in-home services option is the most customizable of the three, allowing the senior to select which services they would benefit from and finding their own providers for each service. Instead of depending on a single agency to do everything, as is the case with home care and home health care, seniors have the freedom to choose the services that provide the most practical solutions for their needs. For example, older adults with severe asthma or allergies may benefit from professional house cleaning or carpet cleaning services. Those who do not cook may have healthy meals delivered regularly. Other types of in-home services may include transportation to health-related services, such as to a doctor's office or pharmacy, adult day care services, health and wellness programs and prescription drugs.

In-home services may be covered under Medicare Advantage plans, which may also be called Medicare private health plans or Medicare Part C. By law, these plans must provide the same benefits of traditional Medicare, such as coverage for hospital stays, doctor's office visits and stays in skilled nursing facilities, but they may also include additional coverage as well. Similar to traditional Medicare, Medicare Advantage plans are only available to those aged 65 and over.

Using Medicare Advantage to Pay for In-Home Services

In October 2018, the Centers for Medicare and Medicaid Services approved new Medicare Advantage guidelines that allowed a greater degree of flexibility for enhanced quality of life, including expanded coverage for home care. The purpose of this is to allow seniors to continue living at home as long as possible. Previously, coverage for home health care services was limited to skilled nursing care. Now, some Medicare Advantage plans cover services like housekeeping and laundry, meal delivery, ride-share for medical appointments and aides to help with the activities of daily living.

Unlike home care services that are generally retained through an agency, in-home services may be provided by a professional caregiver or even a family member or friend. Some covered services are preventative in nature, such as healthy meals or wellness programs, which may allow the enrollee to avoid future health problems. Generally speaking, benefits like these are limited to a certain number of hours of care in a calendar year.

The first step in having in-home care covered is to enroll in a Medicare Part C plan instead of the traditional Medicare Part A or Part B plans. It's important to note that unlike traditional Medicare, in which the government pays the healthcare providers for services, Medicare Advantage programs are provided by Medicare-approved private health insurance companies. Therefore, coverage, restrictions and costs differ widely from one plan to another.

The process for finding a Medicare Advantage plan is similar to that of purchasing any other private health insurance plan. The enrollee should consider what services they need and seek a plan that provides coverage for them. Seniors should also ensure that the plan they choose provides coverage for their preferred healthcare provider.

Claims for covered services are filed directly with the Medicare Advantage plan. Because Medicare pays these private insurers a set amount every month to manage and administer benefits, beneficiaries do not need to file a separate claim with Medicare. The claims process varies from one provider to another.

Determining Eligibility for Medicare Advantage

To qualify for Medicare Advantage, applicants must be eligible for traditional Medicare, and they must live within the service area of the plan they choose. In most cases, with the exception being seniors with very low income, enrollees pay the Medicare Part B monthly premium. Depending on the plan they choose, they may also pay an additional premium.

A senior's eligibility for Medicare Advantage plan options depend on what plans are offered in their geographic area. The CMS reported that as of 2019 and 2020 about 300 plans expanded their coverage by providing one or more supplemental benefits. An enrollee's access to these benefits is based on which benefits are implemented by the private health insurance companies offering plans in their area.