Private Pay or Medicare - Which covers what?

by Central Texas Caregivers
Sep 12, 2013

You may be wondering why so many families pay out of their pocket for home health services instead of receiving financial assistance in the form of Medicare benefits.  Well, the truth is that Medicare covers very specific things for specific periods of time – and depending on your needs, it may not work for you at all.

On the surface, Medicare Home Health appears to offer many of the same features as private-pay care. Its nurses or other qualified practitioners administer medication and other nursing functions, while its home health aides help with such basic tasks as bathing, brushing teeth and getting dressed. But the resemblance pretty much stops there.

One major difference is that Medicare Home Care is a temporary measure designed to help disabled individuals recover, rehabilitate and return to everyday functionality. Care is typically less than an hour visit and intermittent throughout the week. Most significantly, the service ends after 60 days unless the person is recertified under the four criterion required by Medicare.  In order to qualify for Medicare Home Health, the patient must be a Medicare recipient, must have a physician’s order, a qualifying diagnosis and must be homebound. The homebound criteria are often the most misunderstood, but it basically means that it is a “taxing effort” for the individual to leave the home for any reason.  Patients may leave the home environment for doctor’s appointments and limited outings.  (Hospice criterion is different than that of Home Health.)

Goals are established at the start of care and once the patient achieves those goals or plateaus, he or she will be discharged.  Once the need for a skilled service (i.e. nursing care, physical, occupational or speech therapy) ends, Medicare will no longer pay for the home health aide to perform visits for personal care and bathing.

A private-pay home health service, on the other hand, helps you as long as you need help, even if ultimate recovery is not in the picture. If you need round-the-clock and/or daily assistance, you need a private-pay provider. Private-pay providers also perform a lot of extra services not covered by Medicare Home Care, such as running errands around town, housekeeping, cooking and transportation to medical appointments. And with private care you have no qualification hoops to jump through – you can have any of the services you pay for, anytime, with no questions asked.   It is important to determine if the private-pay agency can perform certain tasks if there are higher levels of care required.  Some agencies are only able to assist with companion type care.  Others can help with medication administration and tasks that must be performed by a nurse.

There are two Medicare Home Health benefits: Home Health and Hospice.  Both are invaluable services and many patients receive these services covered by Medicare and supplement their care with private-pay services.

The chart below from AARP shows the costs of  nursing home care vs home health care as compared to household income. As you'll see, Austin has the 3rd lowest percentages for nursing home costs and the lowest costs for home health costs.

Private Pay Affordability of Long-Term Services and Supports for Texas: