Medicare, Medicaid or Hospice for At-Home Care
If you are seeking at-home care assistance for a family member that is paid either in full or in part by the government you can find that the system is complicated and, unless your loved one fits within one of the designated categories, you may be limited to paying from your family member’s asset or your own. Here are some of the differences and criteria.
Medicare. Medicare at-home other than hospice is essentially for rehabilitation, very often after hospitalization, and is generally limited in time – up to 100 days and often much less. It can cover services at home following a hospital stay. Medicare also can provide these services in a skilled nursing facility, a rehab facility or what is referred to as a “step down” unit. Medicare rehab in these environments is time limited up to 100 days. One good point is that Medicare services are not dependent on your income. Therefore, it is not necessary to go through the details of your income and assets to qualify for Medicare benefits. You do not need to worry about “lookback,” gifting or transfer of assets to qualify. Your family member or someone on her/his behalf, for instance a spouse, paid into the system during the working years. This is why the Medicare benefit is now available. The downside is that it is limited. It does not pay for longer term assistance, for instance, in a nursing home or at home.
Medicaid. Medicaid is a different system. It does depend on calculations regarding assets and income as well as need. Under the Community Health Choices Program (previously the Medicaid Aging Waiver Program) which is for individuals aged 60 and older, an individual might receive help for a longer period of time but qualification is severely limited. In Pennsylvania applicants with gross incomes including but not limited to gross Social Security, pension and other regular income sources cannot exceed $2,829 per month based on the 2024 figures.
Differences between the Medicare program and the Medicaid program usually mean that many Pennsylvanians eligible for Medicare may have rehabilitation help either at home or in skilled nursing for a limited period after hospitalization up to 100 days or less but longer term government supported non-medical home health care assistance can be out of reach for vast numbers of Pennsylvanians often because their income exceeds the limit. Generally speaking, you pay privately instead. Under this program in Pennsylvania it does not matter how much care costs for you. Qualification depends on your gross monthly income from all sources.
Note that a non-governmental alternative can be coverage under a previously purchased long term care insurance policy. Also there are a few programs that can provide help but availability is limited. One of these is the Options program.
Hospice. Hospice is a Medicare program. This means that, like Medicare for rehab after hospitalization, it does not depend on your assets or income. Therefore, there is no need to be concerned about gifting or a five year lookback. Qualification depends on being covered by the Medicare program which again generally means that either you or someone on your behalf such as your spouse, paid into the system. The primary limitation for hospice is you must meet the medical criteria.
To qualify for hospice your doctor needs to certify that you suffer from a life-limiting condition with a prognosis for six months or less if the disease runs its normal course. If you have a life ending condition, hospice does not have financial limitations such as required by Medicaid at home care. It is regularly available through community sources. Hospice can be renewed and there are many patients who do outlive the six month projection. Generally speaking the care is very helpful and hospice should be considered wherever a family member fits the criteria.
Summary. One of the great confusions when seeking access to government health benefits is the similarity between the words “Medicare” and “Medicaid.” Even seasoned professionals in the field sometimes slip and use one word instead of the other. There are major differences between the two programs and one area where this becomes very clear is in the provision of home care services. If you are not sure whether your family member qualifies for any of these benefits and he/she is in need of at-home services you should ask questions and seek help from professionals who do know the answer.
About the Author Janet Colliton
Esquire, Colliton Law Associates, P.C. Janet Colliton has practiced law for over 38 years, 37 of them in Chester County, Pennsylvania, a suburb of Philadelphia. Her practice, Colliton Law Associates, PC, is limited to elder law, Medicaid, including advice, applications and appeals, and other benefits planning including Veterans benefits, life care and special needs planning, guardianships, retirement, and estate planning and administration.