In-Home Care Costs and Ways to Pay
Many older adults say they’d prefer to stay in their home for as long as possible in their later years. If you want to support an aging parent or other loved one in this choice, you may be considering hiring someone to help them out at with daily tasks at home. This arrangement is called in-home care. This is different from home health care, which includes medical care at home prescribed by a physician.
There are different options for in-home care depending on what your aging parent needs. You may be looking at paying an adult to live in the home, do the housekeeping, prepare meals, act as a companion, and help your loved one when they need assistance. If your aging parent needs medical assistance or care through the night, you could be looking at a more advanced and expensive level of in-home care.
About 40 hours per week of in-home care costs about $48,000 on average, according to Genworth’s 2018 Cost of Care Survey. By comparison, assisted living costs $4,000 per month on average. Since costs can vary widely based on your location and the amount of care needed, it’s important to do your research to get a good feel for how much you can expect to spend.
Understanding In-Home Care Costs
Professional in-home caregivers – whether through an agency or independent operators – typically provide assistance with activities of daily living such as dressing, bathing, medication management, light housework and running errands. With a live-in caregiver, some of the salary may be offset by things like room and board, food, or allowing access to a vehicle for personal use.
For those who need medical care at home, home health care nurses or trained health professionals are available. Home care can be pricey, and in some cases costs more than care in an assisted living community.
Before hiring a live-in caregiver, you need to determine if he or she will be able to provide the services you need. And that will vary depending on the state regulations for personal care aides or certified nursing assistants.
In some states CNAs can perform a wide range of tasks, but in others, a live-in helper will be there only for companionship and ADLs, or activities of daily living. These include:
- cooking meals
- transportation or running errands
- light housekeeping
- medication reminders
- and sometimes blood pressure checks
In some states, CNAs can take care of things such as administering medication, giving injections, blood sugar checks and emptying catheter bags.
If your aging loved one has needs that align more closely with nursing care and doesn’t live in a state where these additional services are allowed, it may make more sense to hire both a live-in caregiver and nurse. This can end up being cost-prohibitive.
Hiring Through Home Care Agencies
One way to avoid problems down the line is to do your homework up front. Because there is such high demand for in-home care, including live-in care services, new companies are popping up all over. Beware of agencies that haven’t been in business for very long or of services that cost well below market value.
When you reach out to an agency, be sure to ask for specifics about their financial policies. You should fully understand how they handle billing, services and fees, and if they offer financial assistance such as payment plans.
Caring.com Family Advisors can provide information on different in-home care agencies near your loved one and connect you and your loved one with agencies that might be a good fit. From there, the agency will work with your loved one and his or her family to better understand their care needs and to set up an initial meeting.
Most people want to stay home, and if they can afford to do it, they will. But it’s important to realize that it’s going to be a management challenge, especially if you’re juggling more than one caregiver at a time. Because the pay is relatively low for caregivers, expect this position to be transitional. People move on to other careers and the rate of turnover is high.
Ways to Pay for In-Home Care
Before you commit to in-home care, it’s important to consider how you will pay for it. You may have more options available to you than you might otherwise expect. These include reverse mortgages, annuities, Medicare, collective sibling agreements; private insurance (covered in the next section) such as life insurance and long term care insurance; and public programs (covered in the last section) such as Medicaid and Veterans benefits.
Collective Sibling Agreements
If you’re worried about Mom or Dad living alone, other family members may be worried, too. Working together, families can come up with a plan in which those who can’t help out because of geography or work demands pay siblings who do have that availability and flexibility to be with their parents on a daily basis.
In another strategy, siblings who have available funds can pay in-home caregivers or senior home care agencies now with the understanding that they’ll be paid back for their contribution from the siblings’ collective inheritance or the proceeds of the house after the parents’ death.
Either of these agreements needs to be spelled out very clearly to avoid tension, resentment, or dissension down the line. If a sibling acts as caregiver, she should have a set hourly wage and should keep close track of hours and any expenses incurred, such as gas or groceries, just as an employee would do. If a sibling pays for in-home care with the expectation of reimbursement, she should keep clear records in the form of invoices and receipts or canceled checks. It’s also a good idea to have something in writing to show the executor of the will, or even to put a clause in the will explaining the plan.
Reverse mortgages were developed by the government specifically for the purpose of helping seniors (originally widows) stay in their homes until the end of their lives.
With a reverse mortgage, seniors can use the value of the equity in their home to get cash now, either all at once or in monthly payments. But instead of borrowing a set sum, the loan balance increases over time. A reverse mortgage allows your loved one to stay in the home until she dies, even if by that time the loan balance exceeds the home’s worth. But at that point, the home must be sold to repay the loan balance.
Reverse mortgages do have limitations: Your loved one has to be 62 or older, and she has to own her home, either outright or with little debt left on the original loan. (The bank that holds the original loan must be paid back before payments are made on the reverse mortgage.) The bank decides on a value based on the home’s worth and also based on your loved one’s age, since that affects the length of time the payouts must cover.
While a reverse mortgage may be the perfect solution to your in-home care dilemma, it also comes with strict rules regarding homeowners’ insurance, mortgage insurance, and home maintenance, making it easy to default. Choose a reputable mortgage broker or bank and read the entire contract carefully. (According to the Consumer Financial Protection Bureau, reverse mortgage scams and foreclosures are on the rise, often because of high fees or clauses that make it easy to lose the home.)
Annuities are designed to help seniors turn retirement savings or a pension into a steady, guaranteed income stream that pays out until death or for a set number of years. The money can be used to pay for in-home care or, eventually, for assisted living if necessary. An annuity is like a cross between an investment fund and an insurance policy; the money is invested at a fixed or variable interest rate, and then, after an agreed-upon maturation date, you can begin making withdrawals.
Annuities have become controversial because of unscrupulous representatives who take advantage of vulnerable seniors. So help your loved one find a reputable financial institution and representative to consult regarding an annuity purchase.
Another benefit of an annuity is that the sum invested isn’t considered an asset when applying for Medicaid. The government counts the income paid out from the annuity, but not the amount originally invested.
It’s not easy to get Medicare coverage for in-home care, and when you do it’s strictly limited. That said, it can be a godsend when you’re faced with a sudden medical crisis or downturn in your loved one’s condition. Medicare coverage is most common when your loved one is being discharged from the hospital or a rehabilitation facility. You’ll contract through a Medicare-certified agency for a period of skilled nursing care and therapy that’s tied to a certain period of expected recovery.
The good news is that Medicare coverage is easier to get than it used to be, and sometime in 2013 it should become easier still. Thanks to the settlement of a lawsuit, Medicare coverage for skilled nursing care and occupational and rehabilitative therapy — either at home or in a nursing home — can’t be limited by whether or not the patient’s condition is improving. Prior to the lawsuit, Medicare criteria would cover treatment only if the patient’s condition showed improvement, which meant that people with chronic conditions like COPD, heart failure, Parkinson’s, and Alzheimer’s lost coverage after a certain period of time.
Look in our directory of government insurance counselors to find a counselor in your area who can help you with Medicare eligibility.
Private Insurance Options for In-Home Care
Be sure to explore these options to help pay for in-home care. Unfortunately, you’re likely to get little help from private health insurance. Although most health insurance policies cover some doctor-prescribed in-home care for acute health issues, usually following a hospital or skilled nursing facility stay, no health insurance policy — whether through a retirement health plan, a spouse’s work or a Medigap policy to supplement Medicare — covers long-term in-home care.
Nonetheless, you should check your private health insurance to understand what is and is not covered, and then consider other private insurance options you may have, such as the following.
If your loved one has a long-term care (LTC) insurance policy, it may cover some costs of in-home care. Some LTC policies only pay home care benefits to a licensed home care agency or other licensed provider; others pay a set daily amount to the insured person who qualifies for the benefits (which means your loved one can spend that money on any caregiver he or she chooses, including family members).
Read through the LTC policy itself to see if there’s coverage for in-home care and what the payment terms are: when someone qualifies, for how much, and how the benefits are to be paid.
If your loved one has a life insurance policy, you may want to look into whether it could provide money now to help pay for care instead of going to family members later. Cashing in a life insurance policy can sometimes provide a substantial amount of money to pay for in-home care.
Certain life insurance policies can be cashed in with the insurance company itself for 50 to 75 percent of the policy’s face value, though some policies permit these “accelerated benefits” or “living benefits,” as they’re called, only if the policyholder is terminally ill.
If these accelerated insurance benefits aren’t available, you can investigate whether a “life settlement” (also called a “senior settlement”) may be possible. This involves selling the policy to a life settlement company (different from the insurance company that issued the policy) for a lump sum.
The exact amount of the payment — 50 to 75 percent of the policy’s face value — depends on the policy benefit amounts, the policy’s monthly premiums, and your loved one’s age and health. After buying the policy, the settlement company keeps paying the premiums until your loved one dies; then the life insurance benefits are paid to the settlement company rather than to a family member or whoever was the policy’s original beneficiaries.
Using Medicaid Toward In-Home Care
The fact that your aging parent may have very little income doesn’t rule out in-home care. Check out following benefit programs to see if they will pay even a limited amount for providing in-home care.
Medicaid covers short-term in-home care for acute conditions, usually following a stay in a hospital or rehabilitation or skilled nursing facility. Also, some (but not all) state Medicaid programs cover a limited amount of long-term in-home care for those who qualify.
However, even in those states that provide long-term home care coverage, Medicaid rules often limit it to people whose physical or mental condition is severe enough that it would qualify them for Medicaid nursing home coverage. Also, Medicaid will only pay for in-home care if provided by a Medicaid-certified home care agency, not by an independent paid caregiver or family member (but learn about Cash and Counseling, below, regarding whether you or other family members might get paid).
To find out about Medicaid eligibility and coverage for in-home care in your state, contact the state’s Medicaid agency by going to the online directory for state Medicaid agencies or to your local Area Agency on Aging.
Note: Neither traditional Medicare nor Medicare Advantage plans cover long-term in-home care, but both do cover short-term in-home care for acute conditions, usually following a stay in a hospital or rehabilitation or skilled nursing facility.
Home and Community-Based Services (HCBS) Waivers
All states provide some kind of long-term care for certain people, including the elderly, who live at home and who would require nursing home care if they didn’t receive these services. These programs aren’t technically part of Medicaid but are funded by Medicaid through waivers of normal Medicaid rules, which is how they get their designation as Home and Community-Based Services (HCBS) “waiver” programs.
Unlike Medicare coverage of home care or regular Medicaid home care coverage, these programs aren’t limited to medical care and their coverage doesn’t run out when a person’s medical condition stabilizes. (The purpose of these waiver programs is to keep people out of nursing homes for as long as possible.)
Home and Community-Based Services programs can provide:
- In-home healthcare, including nursing care and physical therapy.
- Personal care services to help with the normal activities of daily living (ADLs), such as eating, bathing, and dressing.
- Homemaker services, such as simple cooking, cleaning, and laundry.
- Meal delivery.
- Adult day services participation (care, companionship, and activities at an adult day services center).
- Transportation assistance to and from medical care or other services.
- Assistive devices, medical equipment, and supplies.
- Minor home modifications (such as widening a doorway to accommodate a wheelchair, or installing a safety railing in a bathtub).
Eligibility for an HCBS waiver program has two parts. The first involves the need for care. The program must evaluate the applicant’s need for medical care and/or assistance with activities of daily living. Usually, the applicant’s need for care must be extensive enough that without in-home services, he or she would have to move into a nursing home.
The second part of eligibility is financial. An applicant must have low income and few assets, but these asset and income eligibility levels are usually significantly higher than for regular Medicaid coverage. In most states, an individual can have countable income (for a discussion of countable income, see How Medicaid Works) two or three times higher than for regular Medicaid eligibility. Similarly, an individual usually can have considerably more in assets — the value of the person’s home doesn’t count at all — than for regular Medicaid coverage. Also, in some states, income and assets resting solely in a spouse’s name aren’t counted.
The exact income and assets eligibility rules and amounts vary from state to state.
If someone qualifies for HCBS coverage of in-home care, in some states there are also programs that can pay a family member to provide some of this home care.
To find out exactly what Home and Community-Based Services are available in your state, and what the eligibility rules are, contact a local office of your state’s Medicaid program. To find a local Medicaid office, go to the federal government’s Benefits.gov website and choose your state. This takes you to a page with contact information for your state’s Medicaid program and information about local offices.
The relatively new Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive home and community care for frail elders who would otherwise require nursing home care. PACE is only available in certain areas of some states, and eligibility is restricted to low-income seniors, usually those eligible for both Medicare and Medicaid. To see if there’s a PACE program operating where you live, and, if so, how to contact the program, see the National PACE Association’s online list of PACE programs.
If your senior loved one was a veteran, you may be in luck when it comes to financial assistance — but you’ll have to be assertive and persistent to get it. Veterans who served more than 90 days of active duty, with at least one day during a wartime period, with an honorable discharge, may be eligible for the Veterans Pension. Veterans who need long-term help with the activities of daily living — or whose spouses need such help — may be entitled to monthly disability payments known as “aid and attendance” by the VA.
This type of veterans benefit requires documentation from a doctor and is calculated using a complex rating system based on how disabled your loved one is. Many people become daunted by the complexity of the qualification process, but once veterans benefits are established they can be extensive and continue until the end of life. According to the Senior Veterans Service Alliance, only 5.4 percent of veterans who are eligible for these benefits actually receive them, because so few veterans know about the benefits and how to qualify.
Help is available from Veterans Service Organizations (VSOs), a list of which is available in a PDF that can be downloaded from the Department of Veterans Affairs website. Legally, VSOs are not allowed to charge for help with veterans benefits applications. If a service requests payment for this help, look for another organization. If you’re having trouble finding a VSO, there are financial concierge services that can help. Elderlife Financial is one such service with a network of VSOs.
Cash and Counseling (payment to family members)
If your family is like most, it’s you and other family members who provide most of your loved one’s in-home care. But what if you or other family caregivers have to give up paid work in order to provide that care? The Cash and Counseling program may be able to help.
In some states, Medicaid or another state agency runs a program that pays elders directly to cover at least part of their in-home care. (Note that some states run similar programs under different names.) The amount the program pays depends on the program’s assessment of the person’s care needs. If your loved one qualifies for the program (the standards, in some states, are slightly easier to meet than for regular Medicaid coverage), he or she can then use the cash benefits to pay you or other family members, or independent home care workers, to provide care.
To find out about a Cash and Counseling or similar program in your state, contact the state Medicaid agency online or contact your local Area Agency on Aging.
Tip: Get free help with Medicaid, Medicare, PACE, or Cash and Counseling programs. If you need help with questions about Medicaid, PACE, or Cash and Counseling coverage of in-home care in your state, you can get free, expert counseling at a local office of the [State Health Insurance Assistance Program (SHIP) or Health Insurance Counseling and Advocacy Program (HICAP).