PLANNING AHEAD: How Medicare services at home differ from at-home Medicaid

When asked how they would like to receive long-term care services many consumers, probably most, indicate they would like to receive them at home. Expectations for extensive help at home with government support often exceed what is available and this, considering shortages in available health care workers and limited funding is likely to continue. However, knowing the differences between what is offered under Medicare versus Medicaid is extremely helpful.

If the concern is to obtain short term “rehab” after hospitalization, Medicare is the program most often used and it does not depend on complicated applications or review of assets and income. However, the time frame under Medicare is limited to up to 100 days.

Another program under Medicare — the hospice program — does provide longer term Medicare support at home and, importantly, does not depend on lower income or assets. However, hospice requires a physician’s certification that the patient has a life expectancy of six months or less. Some patients do receive care longer than six months and can be recertified to continue on the program.

On the other hand, Medicaid can often provide longer term support but is available only to those with lower income and lower assets. This may be referred to as the “Aging Waiver” program or Community Health Choices. Medicaid, under the Medicaid Aging Waiver program, which is for individuals age 60 and older, may offer help for non-medical at home health care for a longer period of time but it is severely limited in Pennsylvania to applicants with gross incomes including but not limited to gross Social Security not to 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 rehabilitative help either at home or in skilled nursing for a limited period after hospitalization but longer term government supported non-medical home health care assistance is largely out of reach for vast numbers of Pennsylvanians.

There are some limited alternatives but, generally speaking, consumers pay privately for at home help instead. Under the Medicaid Aging Waiver program in Pennsylvania it does not matter how much care costs for you. What matters for approval is your gross monthly income from all sources and your total non-exempt assets.

If you need additional help after hospitalization, Medicare may be the answer for a limited period. This ignores, by the way, the issue of whether you might have other private insurance long-term care insurance or through a current or former insurer where there might be additional at-home assistance.

Here are some descriptions of the types of help under Medicare (not Medicaid) available for rehab and what they can or will not offer.

Medicare Assistance After Leaving the Hospital — OT, PT and Home Health Care

The terms in the field are OT (Occupational Therapy), PT (Physical Therapy), and Home Health Care.

Although “occupational therapy” seems to imply it is intended to provide recovery so you can return to work, that is not necessarily the case. Actually, recipients of OT may be and often are retired or homemakers or disabled and not intending to relearn employment skills.  Occupational therapy has to do with being able to perform basic tasks such as dressing and showering. It is task related. Physical therapy, on the other hand, concerns regaining strength and capacity. You could be lifting weights or stretching. Some services may overlap. Think about what is it you would like to do but are unable to perform because of your temporary disability and then discuss this with your occupational therapist.

Visits by Nurses

If your physician’s or hospital’s orders include home visits by neighborhood nurses, you might expect periodic visits to have your vital signs taken such as blood pressure, heart and so on. Where appropriate, you may receive instructions on diet and medication.  Your nurse might check on wound care or give injections. Nurses who visit the home do not provide non-medical services but can be covered under Medicare.

Non-medical home care

Non-medical at home care other than the above is not covered by Medicare. It can involve feeding, dressing, bathing, assisting with toileting, but also running errands, taking you to the doctors or providing companionship. It is paid by you privately or through some long term care insurance policies. Seek help if you need to know more.

Janet Colliton is a Certified Elder Law Attorney by the National Elder Law Foundation and a member of the Pennsylvania Association of Elder Law Attorneys. She limits her practice to elder law, life care, special needs and retirement planning, Medicaid, estate planning and estate administration and guardianships and is located at 790 East Market St., Suite 250, West Chester, 610-436-6674, colliton@collitonlaw.com. She is also, with Jeffrey Jones, CSA, co-founder of Life Transition Services LLC, a service for families with long term care needs.