More and more older people are choosing to stay in their homes after they lose physical skills as a result of an illness or accident. Relatives and friends often help out so people who wish to do so can remain in their homes. But often, more help is needed. Home care is available to help the person stay at home, rather than having the person move into an institution. If you are going to hire a home health care worker, there are many things you will need to consider. This Guide will help you to figure out your options.

Who Provides Home Health Care?

Home health care services may be provided by home care organizations, which include home health agencies, hospices, homemaker and home care aide agencies, and staffing and private-duty agencies. Independent providers may also provide home care.

What Is A Home Health Agency?

The term "home health agency" often means that a home care provider is Medicare certified. A Medicare certified agency has met federal minimum requirements for patient care and therefore Medicare and/or Medicaid will pay for covered home health services. People who need skilled nursing home care services usually receive their care from a home health agency. Skilled nursing includes services such as wound care, giving injections and other care that cannot be performed by a nonmedical person. If a person needs care from more than one specialist, a home health agency can coordinate a team of caregivers to provide services. If you use a home health agency, the agency will hire and supervise the workers that come into your home. The agency assumes full liability for all care. Also, the workers are employees of the agency, and the agency is responsible for all employee taxes and benefits.

What Is Hospice Home Care?

Hospice care involves skilled professionals and sometimes volunteers who provide care for the terminally ill and support for patients and families. It is based primarily in the home, and allows families to remain together. Most hospice care home providers are Medicare certified and licensed according to state requirements.

What Are Homemaker and Home Care Aide Agencies?

Homemaker and home care aide agencies hire homemakers or chore workers, home care aides, and companions to help patients with meal preparation, bathing, dressing, and housekeeping. Some states require these agencies to be licensed and meet minimum standards established by the state. Most homemaker and home care aide agencies hire, train, and supervise their employees and are responsible for the care their employees provide. They are also responsible for all employee benefits and taxes.

What Are Staffing And Private-Duty Agencies?

Staffing and private-duty agencies generally are nursing agencies that provide individuals with nursing, homemaker, home care aide, and companion services. Most states do not require these agencies to be licensed or meet regulatory requirements. These agencies recruit their own employees and responsibility for the employee and patient care rests with each agency.

What Are Registries And Independent Providers?

"Registries" are basically employment agencies for home care nurses and aides. They match home care workers with patients and collect finder's fees. These organizations are not usually licensed or regulated. In many states, registries are not required to screen or do background-checks on the home care workers. "Independent providers" are nurses, therapists, aides, homemakers, chore workers, and companions who are privately hired and employed by patients. Aides, homemakers, chore workers, and companions are generally not required to be licensed or to meet government standards. If you hire a worker referred by a registry or hire someone on your own, the responsibility for hiring and supervising the worker rests with you. Therefore, as discussed below, you may very well have to comply with all applicable state and federal labor, health, and safety laws and regulations, including payroll tax and social security withholding requirements.

Who Pays For Home Care Services?

Home care services can be paid for directly by the patient and his or her family members or through a variety of public and private sources. The two primary public payors are the Medicare and Medicaid programs.

How Do I Qualify For Home Health Coverage Under Medicare?

To qualify for Medicare home health coverage, you must meet all four of the following conditions:

• Your doctor must have determined that you need medical care in your home, and the doctor must prepare a plan for your care at home. Your doctor and home health agency personnel must review your plan every 60 days or more; and
• You must need at least one of the following: intermittent (not full-time) skilled nursing care, or physical therapy or speech language pathology services, or continue to need occupational therapy; and
• You must be homebound. Your home can be a house or apartment, a relative's home or even a home for the aged. But a hospital or other facility that mainly provides skilled nursing or rehabilitation services does not qualify as a home. You may be considered homebound if you leave home only with considerable effort. Absences from home must be infrequent, or of short duration, to get medical care or to attend religious services.
• The home health agency caring for you must be approved by Medicare.

How Can I Find An Approved Agency?

You can find a Medicare-approved agency by asking your doctor or hospital discharge planner, senior community referral service, or other community agencies involved with your health care.

Note, Medicare managed care plans are health care choices in some areas of the country. In most plans, you can only go to doctors, specialists, or hospitals on the plan's list. Medicare managed care plans must cover all Medicare part A and part B health care, including home health care.

If you belong to a Medicare managed care plan, you can only choose a home health agency that works with the managed care plan. Call your managed care plan if you have questions about the plan's home health care rules, coverage, appeal rights, and your costs. If you get services from a doctor or a home health care agency that doesn't work with the managed care plan, neither the plan nor Medicare will pay the bill.

What Home Health Services Will Medicare Pay For?

If you meet all four of the conditions to qualify for home health care, Medicare will pay for:

• Skilled nursing care either on an intermittent or part-time basis, not full-time. This is limited to care that can only be provided safely and effectively by a licensed nurse.
• Home health aide services either on an intermittent or part-time basis, not full-time. These services include assistance with personal care such as bathing, using the toilet, and dressing.
• Physical therapy as often and for as long as it is medically necessary and reasonable. Physical therapy includes exercise to restore and maintain movement and strength to an injured arm or leg, and training in getting into and out of a wheelchair or bathtub.
• Speech language pathology as often and for as long as it is medically necessary and reasonable. This type of therapy includes exercises to restore speech.
• Occupational therapy as often and for as long as it is medically necessary and reasonable, even if you no longer need other skilled care. Occupational therapy helps you to achieve independence in daily living by learning new techniques for eating, dressing and performing other routine tasks.
• Medical social services to assess the social and emotional factors related to your illness, counseling based on this assessment, and searches for available community resources.
• Medical supplies like wound dressings.
• Some Medical equipment like wheelchairs, walkers, and oxygen equipment. Medicare pays 80% of the approved amount for the equipment. You are responsible for the remaining 20%.

What's Not Covered By Medicare?

Medicare does not cover the following:

• 24 hour care at home;
• Prescription drugs;
• Meals delivered to the home;
• Homemaker services such as shopping, cleaning and laundry, except that home health aides may do a small amount of these chores when they are providing covered services; and
• Personal care provided by home health aides, such as bathing, toileting, or providing help in getting dressed, if this is the only care you need. This type of care is called "custodial" care. Medicare does not pay for custodial care unless you are also getting skilled care such as nursing or therapy and the custodial care is related to the treatment of your illness or injury.

How Long Will Services Continue?

Medicare will pay for covered home health services for as long as they are considered medically reasonable and necessary. However, the skilled nursing care and home health aide services are paid for only on a part-time or "intermittent" basis. This mean there are limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services.

To decide whether or not you are eligible for home health care, Medicare defines "intermittent" as "skilled nursing care that is needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less)."

Hour and day limits can be increased in special cases when the need for more care is limited and can be planned ahead.

Once you are getting home health care, Medicare uses the following definition of part-time or intermittent to make decisions about your coverage: "skilled nursing or home health aide services combined to total less than eight hours per day and 28 or fewer hours each week."

How Do I Qualify For Home Health Coverage Under Medicaid?

Medicaid is a joint federal and state program that helps with medical costs for some people with low incomes and limited resources. To qualify for Medicaid, you must have a low income and few savings or other assets.

Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not paid for by Medicare. Medicaid has programs that pay some or all of Medicare's premiums and may also pay Medicare deductibles and coinsurance for certain people who are entitled to Medicare and have low income.

For more information about what Medicaid covers for home health care in your state, call your State medical assistance office. If you need the telephone number for your State, call 1-800-MEDICARE (1-800-633-4227 TTY/TDD or 1-877-486-2048, for the hearing and speech impaired).

Are There Other Programs That Pay For Home Health Care?

In addition to the Medicare and Medicaid programs, there are also funds available to pay for home care through the Older Americans Act, the Department of Veterans Affairs, and Social Services block grant programs. Some community organizations, such as local chapters of the American Cancer Society, the Alzheimer's Association, and the National Easter Seal Society, also provide funding to help pay for home care services. For information on state and local programs to help with home care, contact your local Area Agency on Aging.

What Will My Responsibilities Be If I Hire A Home Care Worker Myself?

That depends on whether the person providing the care is considered to be an independent contractor or an employee. The difference between independent contractors and employees can be a gray area. The legal definition hinges on the degree of independence the worker has, and the amount of supervision required for the work to be performed.

• An employee generally carries out instructions received from the employer, and is usually paid at a weekly or monthly rate.
• An independent contractor decides when, what and how work is to be done, carries out tasks agreed to with the employer without direct supervision, and usually is paid at a per diem or hourly rate.

It is generally better to hire a person as an independent contractor rather than an employee. There should be a written statement, signed by both parties, stating the terms of employment and specifying that the worker understands that he or she is an independent contractor and will be responsible for Social Security payments, insurance, taxes, etc.

In the event of some real problem, however, there is no guarantee that a court or the Internal Revenue Service will find the independent contractor status to be valid. If a court should find the worker to be an employee, you would be required to pay his or her Social Security and Medicare tax.

You should contact the Internal Revenue Service (IRS) regarding any necessary reporting requirements or forms. The IRS will also give you information on how to complete forms and when and where to file them. You can also contact your local taxing authority for information on applicable taxes in your locality.

Other Questions?

If you have any other questions, call your AARP Legal Services Network (LSN) attorney. For a complete list of LSN attorneys, call 800-424-3410, or check the LSN section of AARP's website at www.aarp.org/lsn. To locate other local support resources for older persons, contact the Eldercare Locator at 800-677-1116 or visit their website at http://www.aarp.org/legalsolutions/selfhelp/http//www.eldercare.gov.

Other Self-Help Guides

You can request copies of these Self-Help Guides from your Legal Services Network attorney.

Consumer:

A Credit Card is a Loan Card

A Mistake in Your Bill

Before You Buy Anything, Stop and Think

Buying a Home

Having Problems with a Loan?

Home Modification

How to Deal with Mail Order Problems

Selling a Home

What to do When You Can't Pay Debts

You Can Get Out of Home Improvement Contracts - Here's How to Do It

Estates:

Financial Powers of Attorney

Personal Bank Accounts, What's Best for You?

Support for Widows and Widowers

What is a Will?

Family:

Financial Exploitation

The Older Couple and Divorce

Health Care:

Health Insurance Portability & Accountability Act of 1996 (Group Plans)

Hiring a Home Health Care Worker

Is a Life Care Contract for You?

Paying for Long-term Nursing Home Care

Landlord and Tenant:

Renters, Know Your Security Deposit Facts

Note: While we strive to keep this legal information up to date, the law is constantly changing, and we do not guarantee the accuracy of any information contained herein. If you should find any inaccuracies, errors or omissions in this document, please e-mail suggested changes to cjanicko@aarp.org or mpotter@aarp.org.

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