Home Care and In-Home Care: What's Covered, What's Not?

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Home care can be helpful in supporting individuals of all ages to safely live at home for as long as possible and/or to recover from an unexpected health crisis. Additionally, home care can be a welcome source of support when family members can no longer provide care alone. These care providers are available for anything from simple household chores and companionship to complex care. But what exactly is meant by the terms “home care” and “in-home care," and what will your insurance cover?


Sharon Roth Maguire, M.S., R.N., gerontological nurse practitioner-BC, and the chief clinical quality officer at BrightStar Care®.
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Meet our home care and in-home care expert

Sharon Roth Maguire, Master of Science, registered nurse, is the chief clinical quality officer at BrightStar Care®, a company that offers home care services. Sharon has an extensive healthcare background with more than 35 years of experience working with seniors. Sharon has helped HealthCentral educate readers about medication management for seniors, as well as how to prevent and care for pressure sores, so we asked her to provide insight into how home care and in-home care work. Here are Sharon’s tips.


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Terminology matters when it comes to insurance coverage

The terms home care and in-home care are used to describe different types of services provided in the home. Additionally, state regulation and licensing entities follow certain definitions for care provided in the home and these definitions can vary from state to state. Federal programs like Medicare have their own specific definitions, and insurance companies that provide coverage for in-home care will also have their own definitions as related to what they will cover and what they will not.


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Ask questions so you know what’s offered and what to expect

It’s important to ask questions so that you are well informed, especially in regard to what services are covered at all, and for what percent or dollar amount of covered services you will be responsible. Consumers also need to explore unique options that may be available to them, including special programs for the poor and for veterans. Some programs have age restrictions while others do not.


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Non-medical, custodial care is likely private pay

Most non-medical, custodial in-home care services will need to be paid for out-of-pocket. Unfortunately, this daily, hands-on care is the type of care that most caregivers are looking for, so discovering that this care is not covered can be a blow. Most Alzheimer’s care will fall under this category, which explains why Alzheimer’s and dementia caregivers can spend so much out-of-pocket. Some long-term care policies will cover a prescribed number of hours, but traditional insurance rarely does.


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These services fall into the custodial category

Support for activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are rarely covered by insurance. ADLs include bathing, dressing, grooming, toileting, and assistance with movement, such as walking and transferring from one surface to another, like bed-to-chair or wheelchair-to-toilet. IADLs include managing medications, shopping, laundry, housekeeping, meal preparation, and transportation.


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No medical order is needed for non-covered, custodial care

You might hear the term “custodial care” or “non-medical care” used when someone is speaking about ADLs and IADLs. You don’t need medical orders from a licensed prescriber to hire these services for yourself, or your friend, or loved one. These services may also be referred to as home care, in-home care, private duty, private pay, or non-medical, versus home health services, which refers to medical services ordered by a provider.


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A medical order is needed to have skilled services paid for

Some in-home care services are defined as skilled or medical. These services are typically referred to as home health services. Skilled or home health services will generally require an order for a specific service from a licensed prescriber, such as a physician or nurse practitioner. Skilled services tend to be short-term, episodic, and rehabilitative in nature. In fact, this is the definition used for Medicare home health services, which additionally require that the individual be home-bound.


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Skilled services must be provided by a licensed professional

Skilled services are provided by licensed professionals, who are educated and experienced in the type of services ordered. This type of care would include injections; infusions, advanced wound care; ostomy care; medication administration; and prescriber-ordered physical, occupational, or speech therapy regimens. Some limited prescriber-ordered home health aide services may be included, but if skilled services extend beyond a rehabilitative nature, the client may need to pay out of pocket.


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All home care companies aren’t alike

Home care companies can provide a wide variety of services. Some specialize in skilled home health, others in non-skilled/private duty/private pay, and still others may have the capacity to do it all. It is important for consumers to inquire and make the choice that best meets their needs. I want to emphasize that you want to make certain that you are clear on what services are covered by insurance and what are not, because if you aren’t, you could be in for an unexpectedly large bill.


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Is the company licensed?

Many home care companies seek licensure in the states in which they operate. This may or may not be required and would depend on the services they are performing. For example, most states require licensure for skilled services, and all states require licensure for services covered/reimbursed by Medicare. Some home care companies seek accreditation from external third parties as a means of validating their claims of quality care.


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How are care providers trained?

Accredited home care providers are required to follow specific guidelines, for example adherence to national patient safety goals, like fall prevention and medication safety, that non-accredited home care companies are not. Consumers should also be mindful of how care providers are trained. Are they competency-tested? If so, by whom are they supervised and at what frequency are they tested? This can vary widely, especially in unlicensed private-duty/private-pay home care agencies.


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Takeaway

Home care and in-home care are valuable assets, but consumers need to educate themselves on the variables as well as the quality of the company providing care. Interview companies thoroughly so you know who you are hiring and what this care will cost you. Older adults and caregivers too frequently hire help thinking that what they need help with is covered by Medicare only to see after-the-fact that it’s not. Take advantage of these services, but first do your research so you know the score.