Decoding differences in senior care and what’s covered

(Aging Untold) — When you’re searching for senior care, the options can be overwhelming.

Home care, assisted living and skilled nursing serve different purposes, and their costs vary.

The biggest misconception families face

Sam Cradduck, a gerontologist, said there are a lot of misconceptions in senior care, and the biggest is that Medicare pays for everything.

“I think the biggest misconception out there is that what you need the most is a covered benefit, and it’s not,” Cradduck said.

“What you need the most oftentimes is home care, and that’s the activities of daily living — that’s your bathing, your dressing, your meal preparation. They do light housekeeping, companionship, nonmedical. And that is a private-pay unless you already had taken out a long-term care policy."

Katherine Ambrose, an aging-well coach, said it is important for people who do have those policies to know what they cover.

“If you do have those kinds of policies, you want to have somebody help you decipher it so you know for sure if you do have coverage, because that would be glorious, because otherwise it is out of pocket,” Ambrose said.

She explained that home care goes by many names — private duty, nonmedical, companion care — but they all mean the same thing: help with activities of daily living where you are.

Understanding the difference between home care and home health

“We tend to mix — I know myself and a lot of people because we don’t know — we will interchange home care and home health care thinking they’re the same thing," Dr. Rhea Rogers, a board-certified physician, said.

“So, home care is the private pay, hands-on care. And then home health is Medicare,” Amy O’Rourke, an aging expert, explained. “That’s how you should think about it.”

Cradduck added another layer:

“The home health when medically necessary and doctor ordered is covered under Medicare. Or if you don’t have Medicare, maybe your private insurance if you’re younger,” Cradduck said.

Cradduck said that skilled care can be private pay if it is a long-term situation, but if it’s medically necessary, Medicare or insurance may cover it for a certain number of days for rehabilitation and getting you back on your feet.

“What I want the viewer to know is it’s not ongoing every day for the rest of your life when you need the care — Medicare is not going to pay for it,” O’Rourke said.

Care based on your needs

Cradduck emphasized that care decisions are based on need.

“If you need home health, if you’re needing a nurse to come in for maybe it’s just wound care, but you can handle all your other ADLs, all your other activities of daily living — you can do your dressing, your bathing, your meal prep — then you don’t need home care," Cradduck said.

However, Cradduck noted that in situations like hospice care, “you’re almost always going to need extra support, which will come into that home care.”

“It’s based on what you need,” Cradduck said. “And then oftentimes it’s based on what benefit you have or the amount that you can afford.”

Four key takeaways

1. Medicare doesn’t cover most long-term care needs

The most common need — help with daily activities like bathing, dressing and meal preparation — is typically not covered by Medicare. This type of care, called home care or private duty care, is usually an out-of-pocket expense unless you have a long-term care policy or VA benefits.

2. Home care and home health are not the same

Home care refers to private pay, hands-on assistance with activities of daily living. Home health is medical care provided at home that’s covered by Medicare when medically necessary and doctor-ordered.

3. Skilled care can be covered, but only temporarily

Medicare or private insurance may cover skilled care for rehabilitation purposes, but only for a limited number of days while medically necessary — not for ongoing, long-term care.

4. Housing and care are separate decisions

Don’t confuse where you live with the type of care you receive. Assisted living, memory care and skilled nursing are housing options, most of which are private pay unless you qualify for Medicaid or VA assistance.