Models and Payment Options of In-Home Care Providers

Private Duty/Private Pay Services

Private duty/private pay services are usually paid directly by the patient or his or her family members. Long-term care insurance, workers’ compensation and some armed services funding may cover private duty/private pay services if the agency qualifies for reimbursement under the policies, and if the recipient has the policies.

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. A full staff means no lapses in care due to sick days and vacations. In addition, all staff are screened for skills and thoroughly vetted. 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 to clients and patients who need home care. However, registries place the responsibilities of managing and supervising the worker on the patient, a family member, or a family advisor. Supervision, monitoring, government mandated taxes, and workers’ compensation coverage usually fall on the consumer and oftentimes the workers are not trained.

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. Examples are care for a wound (dressing changes), injections, monitoring of health conditions like diabetes or blood pressure or heart disease, assistance with medical equipment like dialysis, assistance with an indwelling catheter, assistance with a naso-gastric (NG) tube feeding or a ventilator.

Home Health Care can also provide physical, respiratory, or speech rehabilitation therapy. These might include: exercises to improve range of motion of arms and legs, physical therapy following an injury to improve functioning of the injured body part, speech therapy or help swallowing which might be due to a stroke, Parkinson’s disease 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:

  • The patient must need intermittent (and not full time) skilled nursing care, physical therapy, speech/language pathology, or continuing occupational therapy.
  • The patient is homebound—normally unable to leave home and leaving home is a major effort. When the patient does leave home, it must be infrequent and for a short time. The patient may attend religious services. The patient may leave the house to get medical treatment, including therapeutic or psychosocial care. The patient can also get care in an adult day-care program licensed or certified by a state or accredited to furnish adult day care services. NOTE: If patients are too tired when they get to a facility for treatment (rehab) or testing (blood tests) or education (diabetic teaching class) to do the work, then home health care is covered to bring treatment to them. It is important to remember that the reason for the patient to be homebound (arthritis, paralysis, etc.) may not be the main focus of care (wound care, monitoring medications after hospitalization for cardiac problems, and the most popular—treatment for Congestive Heart Failure).
  • The care must be referred by a doctor and medically reasonable and necessary. It must be related to the problems encountered and the care plan must address realistic outcomes. The plan and care needed must show potential for an improvement in the patient’s health/activities of daily living.
  • 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 and home health aide services
  • Physical therapy/speech therapy/occupational therapy
  • Medical social services
  • Medical supplies
  • Durable medical equipment, such as wheelchairs, hospital beds, oxygen and walkers

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. Hospice is generally depicted as end-of-life care and can be in a home or a hospital setting, but it is usually required that someone be with the dying patient at all times. How a family accomplishes this is up to the individual and the family. Hospice entails a range of services from nurses and mental health professionals to spiritual advisors.

Hospice coverage is offered by most private insurance providers, through Medicare nationwide, and as an optional Medicare service covered by most states. Hospice has a limited number of 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.

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. In order to access Medicaid services, the client must be assessed by a state agency charged with evaluating each situation to determine if they are qualified. The agent also makes the determinations to either approve the patient for a specific number of hours of home care or to offer an equivalent voucher.

Medicaid is funded by a Federal/State partnership. Coverage criteria and covered services are determined by each state. 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. the mandatory traditional home health benefit, and two optional programs
  2. the personal care option
  3. home- and community-based waivers]

Depending on the state, the vouchers can be used to pay individuals, agencies or registries.

Geriatric Care Management

Geriatric Care Management entails managing a client’s 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.