Is comfort keepers covered by Medicare?

1. Overview

Unfortunately, the vast majority of Comfort Keepers’ services are of a private duty nature. This means that there is little to no Medicare coverage for these services. The services that Comfort Keepers provide could best be categorized under a long-term care service called custodial care. In order for any type of custodial care services to be covered by Medicare, the recipient of care must already be receiving benefits from Medicare Part A or Part B. Also, they must receive the custodial care services from a home health agency that is Medicare-certified. As Comfort Keepers provides private duty services and is not a home health agency, it is implied that their services are not eligible for Medicare coverage.

Comfort Keepers provides an array of services for people needing assistance, from in-home care to long-term care in facilities. They serve adults and seniors, and their private duty services include companionship, meal preparation, light housekeeping, grocery shopping, incidental transportation, laundry, recreational activities, and more. Comfort Keepers states that their caregivers, or Comfort Keepers, are “special people” and that they “bring more to clients than just care and assistance.” They strive to “elevate the human spirit” and positively impact the lives of those whom they serve.

1.1. Introduction to Comfort Keepers

Comfort Keepers has a large team of agents and local nurses to serve the in-home health care needs. Agents are guided by Client Care Coordinators and Registered Nurses to create clear and concise individual plans. They believe that a plan of care is the most important part of home health care. Without it, there is no direction and the aid provided would be aimless. They understand that the plan of care must be consistently updated to meet the clients’ changing needs. Comfort Keepers also have an exclusive partnership to offer Personal Emergency Response Systems through Safety Choice HealthCare. The company is knowledgeable about veterans’ benefits for those who need in-home care and is familiar with long-term care insurance. Comfort Keepers’ agents are available 24/7 and can be trusted to provide the best in-home health care. [1][2][3][4][5][6][7][8][9][10]

Comfort Keepers is a home health care company that operates all across North America and can serve those in need of aid in both the US and Canada. Comfort Keepers are a direct link from family to family in regards to in-home health care. Comfort Keepers’ directors and agents have categorized the people in need of in-home health care into two distinct groups: the first group is titled ‘Primary Care Needs’, which is for those who need some level of assistance above the domestic level and are looking to retain independence in their homes. This group also aims to help the elderly avoid deteriorating health. The second group is called ‘Interactive Caregiving’, which is a fresh and innovative approach to in-home care with the goal of fully aiding and engaging those who require full-time care. This type of care aims to provide a higher standard of living, improve the clients’ health status, and provide peace of mind to the family. It is aimed at chronic conditions care, transitioning home from facilities, end-of-life care, and private duty nursing.

1.2. Medicare Coverage

In general, home care is not paid for by Medicare. However, all insurance is subject to change and it is difficult to give hard and fast answers regarding coverage. Medicare’s website puts it this way: Medicare doesn’t routinely pay for services not billed by a provider, including most non-medical home care services. This puts the personal care into a grey area, and Comfort Keepers are licensed as a non-medical home care agency. While Medicare only pays a limited amount for non-skilled home care – those who are homebound and are already receiving Medicare and participating in a pre-approval process from a doctor and requests home care. Surveillance of personal care clients’ health status or changes in health status are a skilled service and can be billed to Medicare through the home health care benefit. Clients are often confused about this benefit and expect Comfort Keepers to become caregivers paid for by Medicare. Medicare typically will not pay, in fact, for any service that is not specifically ordered by a physician, the responsibilities of a case manager, or those provided by a traditional home care or home health care agency. This includes any housecleaning, meal preparation, transportation, or companionship type services. For this type of service to be covered, there must be an acute need, and the service must be performed by a provider who is also licensed to perform skilled services and billing. If a Medicare recipient is asked to pay out of pocket for a service, it is often found that they will stop receiving Medicare skilled home care in order to avoid the costs. Providers often look to avoid placing these burdens on clients. [11][12][13][14][15][16]

2. Medicare Coverage for In-Home Care

A patient is considered homebound if they require the aid of supportive devices such as crutches, canes, walkers, or wheelchairs to leave the home, or if leaving home is medically contraindicated. According to Medicare, a person may leave home for medical treatment or short, infrequent absences for non-medical purposes such as attending religious services. Additionally, a patient on home health care is still considered homebound if the absences from home are infrequent or of relatively short duration, or are due to the need to receive therapeutic and/or intermittent skilled nursing care in an outpatient setting.

For people eligible for covered services, Medicare provides in-home care following an initial assessment by a doctor that deems the service medically necessary. Personal care to assist with activities of daily living such as bathing, dressing, using the toilet, transferring, and eating are all covered services. Medicare will also cover the cost of medical social services and certain intermittent skilled nursing and home health aide services. However, the patient must be homebound and the in-home care must be from a Medicare-certified home health agency.

Medicare is a health insurance for those 65 years or older in the United States. To be eligible for coverage, the recipient or their spouse must have worked for a minimum of 10 years in Medicare-covered employment. Those under 65 must meet the criteria for disability set forth by Social Security. The patient must also be a U.S. citizen or permanent legal resident.

2.1. Eligibility Criteria

Patients must meet the following conditions in order to be eligible for home health care from Comfort Keepers: – They must be confined to the home. – They must be receiving home health services (does not have to be skilled nursing care). – They must be under the care of a doctor who has an active role in their care and who provides the home care agency with orders for the patient’s care (this is not the same as simply having a primary care physician). – The patient must be receiving services under a plan of care. This means their care is not of a “shift” nature (8 hours or so of care with the patient receiving a discharge when the shift is over) and there should be a foreseeable end to the care. This does not mean that services cannot be resumed at a later date. Comfort Keepers can take care of a patient for as long as necessary, but Medicare coverage is based on a plan of care and a plan of care is by nature finite in duration. It can always be renewed and is expected to be in this case.

2.2. Covered Services

In situations where a health event or injury has occurred, Medicare does cover in-home care for a limited time. To be eligible, the patient must: (1) be currently receiving benefits from Part A and/or Part B, (2) be homebound, and (3) be under the care of a doctor with a care plan set in place. With these conditions met, Medicare will cover: (1) skilled nursing care or (2) physical, occupational, and/or speech therapy. It is important to note that Medicare will only cover the types of in-home care that are deemed medically necessary for treatment of the patient’s condition and will not cover the long-term custodial services. [17][18][19][20]

The second step is to understand what Medicare services are covered. Many seniors are disappointed to learn that there aren’t many long-term care services covered by Medicare. A common misperception is that Medicare covers the ongoing in-home custodial services, and this is simply not the case. If some other type of care triggered the need for in-home care, such as an injury covered by Workers’ Compensation or automobile insurance, the in-home care services might be covered by the other benefit programs and specific insurance policies. A Medicare supplement insurance (Medigap) policy can help pay for services that Medicare only partially covers, as well as copayments and deductibles.

2.3. Limitations and Exclusions

There is a downside to Medicare coverage for in-home care. If you fall under the eligibility criteria for in-home care and have a doctor’s orders stating that you are in need of medical care provided in your home, you may well receive coverage for services. However, there are limitations to this coverage. Step one must be an assessment to establish whether or not a patient is deemed homebound. The homebound condition is met if a patient can’t leave their dwelling without help. They may leave the dwelling for medical treatment or quick, infrequent absences for non-medical reasons. The patient can still obtain coverage if they attend adult day care. If these conditions are met, you’ll receive coverage. Be aware that it’s not going to be whole coverage. In this case, you will require a Medicare Advantage plan or Medigap coverage to fill in the gaps and assure that you obtain full coverage. Step one is normally a physical or occupational therapy plan for a particular illness or sickness. People who are in need of skilled nursing care can also qualify. A physician or provider must see the patient regularly to evaluate whether or not these home health services are working. If all of these conditions are met, coverage will likely be extended for said services until the patient no longer requires them. Anything that isn’t covered under these conditions won’t be covered under standard Medicare.

3. Alternatives to Medicare Coverage

Finally, financial PCS is available in many states to provide HCBS to adult Medicaid recipients who are inpatients in a hospital, NF, or ICF. The PCS services must be established in a state plan, and a separate rate has to be negotiated for PCS. Adult recipients in settings qualified to receive PCS shall not receive services through a Section 1915(c) waiver.

The next Medicaid HCBS provider is the state plan. States may offer HCBS provided under a state plan if the service is offered to persons who are eligible based on categorically needy or most if a state allows waiver and are in institutional care.

Medicaid is a joint federal and state-run program. It is not a mandatory program and offers multiple ways to cover services at home. In 2001, very few states provided HCBS through Medicaid waivers compared to today. There are three primary ways Medicaid offers HCBS: through Section 1915(c) waivers, through the state plan option, and financial PCS. Section 1915(c) waivers are an optional program providing states the flexibility to develop and implement creative alternatives to institutionalization. Waiver programs have a vast array of allowed services and can accommodate various target populations, for example, frail elderly or individuals with intellectual/developmental disabilities. States often have more than one waiver program. HCBS provided under a waiver must be cost-neutral or cost less to the state than institutionalization and provide service to a specific number of individuals in a certain time period (ideally services should be provided to alleviate or prevent the need for institutional care).

3.1. Medicaid

With the recent increase in Home and Community Based Services (HCBS) under Medicaid, there are many changes and more opportunities for individuals receiving long term care services to utilize Medicaid to pay for services received at home. Now more than ever, there are various Medicaid programs that have services directed at keeping individuals out of nursing homes and in the community. This is an option people can look into if they are beginning to research long term care options and want to remain in the comfort of their own home.

Currently, there is wide variation in Medicaid programs among the states. The eligibility and coverage can be different for people in similar circumstances, depending on the state where they live. The financial eligibility requirements and covered services are set by each individual state within federal guidelines. Many states have several Medicaid programs, tailored to the specific needs of separate groups of people, such as the aged, disabled, or families with children. Therefore, the answer to whether Comfort Keepers services can be covered by Medicaid depends on the rules in the specific state and the specific Medicaid program in question.

Medicaid is a joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid also offers benefits not normally covered by Medicare, like nursing home care and personal care services. In some states, Medicaid has a program that will pay for some long-term care services that are received at home to help people remain independent and avoid institutionalization.

3.2. Private Insurance

Private insurance is perhaps the least preferred option for covering in-home care because most elderly persons qualify for Medicare, do not have private supplemental insurance, and private insurance typically covers only short-term, intermittent skilled care. The decision to keep elderly persons with chronic disabilities in the community, rather than admit them to nursing homes, will most likely depend on family ability to pay for needed supportive services since Medicare, private insurance, and out-of-pocket costs for most elderly persons will not cover such services. If an alternative to nursing home care is to be realized for the many disabled elderly persons and their families who cannot afford to pay for supportive services, it will be necessary to develop public payment mechanisms and funding levels that will cover these services.

3.3. Out-of-Pocket Payment

It is important to note that Medicare coverage does not apply to the hire of independent providers. Before engaging a provider of home care services, it is best to fully check their qualifications, do a background check, and carefully screen their previous work experience. Of course, the client or family who is paying with their own “out-of-pocket” resources will want to consider price.

Usually agency rates for providing out-of-pocket home care are competitive with those charged by independent providers. This has led some clients and families to ask how the “quality of care” compares between agency providers and independent providers. This is a very unsubstantiated view. The quality of care is the same. Usually an agency provider is a RN, LPN, or certified health care aid. This is far more qualified than someone obtained independently through a newspaper ad or from someone who is simply sitting with the client to provide an insufficient level of care.

There are cases where clients might not have Medicare, Medicaid or insurance coverage but need home care. These clients or their families would then have to pay for home care services “out-of-pocket.” This means using the client’s or family’s own financial resources to cover the costs of home care. This can be done by using hourly, daily or monthly agency services and can be for a short or long period of time. Many clients or families usually use this type of payment when the care is for short term respite, around the clock live-in, or to supplement the care that is being received from another source such as family.

References:

[1] [1] L. R. Archbald-Pannone, D. A. Harris, K. Albero, et al., “COVID-19 collaborative model for an academic hospital and long-term care facilities,” Journal of the American Medical Directors Association, vol. 21, no. 7, pp. 939-942, 2020, Elsevier. nih.gov

[2] N. M. Stall, C. Farquharson, C. Fan-Lun et al., “A hospital partnership with a nursing home experiencing a COVID‐19 outbreak: description of a multiphase emergency response in Toronto, Canada,” Journal of the American Geriatrics Society, 2020, Wiley Online Library. nih.gov

[3] S. Ward-Miller, E.M. Farley, L. Espinosa, M.E. Brous, et al., “Psychiatric mental health nursing in the international year of the nurse and COVID-19: One hospital’s perspective on resilience and innovation-Past, present and future,” Journal of psychiatric nursing, vol. 2021. Elsevier, 2021. nih.gov

[4] S. S. Dickerson, S. G. N. Khalsa, K. McBroom, et al., “The meaning of comfort measures only order sets for hospital-based palliative care providers,” in Scand. J. of Qualitative Health Res., vol. 2022. Taylor & Francis, 2022. tandfonline.com

[5] K. M. Chu, E. M. Jones, J. R. Meeks, A. P. Pan, “Decade‐long nationwide trends and disparities in use of comfort care interventions for patients with ischemic stroke,” Journal of the American Heart Association, 2021, Am Heart Assoc. ahajournals.org

[6] S.L. Mitchell, A.E. Volandes, R. Gutman, et al., “Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial,” JAMA Internal Medicine, vol. 180, no. 1, pp. 107–115, 2020. jamanetwork.com

[7] JG Ouslander, DC Grabowski, “COVID‐19 in nursing homes: calming the perfect storm,” Journal of the American Geriatrics Society, vol. 68, no. 10, pp. 2153-2162, 2020, Wiley Online Library. snpalliance.org

[8] N. Lalani and Y. Cai, “Palliative care for rural growth and wellbeing: identifying perceived barriers and facilitators in access to palliative care in rural Indiana, USA,” BMC palliative care, 2022. springer.com

[9] Y. Lin, Y. Zhou, and C. Chen, “Interventions and practices using Comfort Theory of Kolcaba to promote adults’ comfort: an evidence and gap map protocol of international effectiveness …,” Systematic Reviews, 2024. springer.com

[10] K. Philips, A. Uong, T. Buckenmyer, M.D. Cabana, “Rapid implementation of an adult coronavirus disease 2019 unit in a children’s hospital,” in The Journal of …, 2020, Elsevier. jpeds.com

[11] C. Allick, “Indigenous Long-Term Supports and Serivces–Elders, Traditional Knowledge, and Tree Rings,” 2024. proquest.com

[12] E. E. Griffith and R. F. Patterson, “COVER ARTICLE,” 2024. aapl.org

[13] T. A. López, “… Valley Healthcare and Nursing Careers Pathways Program Final Report Submitted to Espanola Valley Healthcare and Nursing Careers Pathways Program …,” 2021. lanlfoundation.org

[14] S. IBRAHIM-DOST, “… the success of an Indigenous community based healthcare clinic: the hands on health Australia’s community clinic, and its program—Aboriginal health in …,” 2022. rmit.edu.au

[15] D. Rind and T. L. Square, “Re: Draft Scoping Document for KarXT in Schizophrenia,” 2024. icer.org

[16] L. F. Clarke Jr, “Community Heritage: A Source of Health/Medical Aspirational Capital for Black Males,” 2022. usf.edu

[17] R.T. Konetzka, D.H. Jung, R.J. Gorges, et al., “Outcomes of Medicaid home‐and community‐based long‐term services relative to nursing home care among dual eligibles,” Health Services Research, vol. 2020, Wiley Online Library, 2020. nih.gov

[18] R. M. Zimbroff, K. A. Ornstein, et al., “Home‐based primary care: A systematic review of the literature, 2010–2020,” Journal of the American Geriatrics Society, vol. 2021. Wiley Online Library. bvsalud.org

[19] K. G. Volpp, S. M. Diamond, and W. H. Shrank, “Innovation in home care: time for a new payment model,” Jama, 2020. jamanetwork.com

[20] J. G. Burgdorf, T. M. Mroz, and J. L. Wolff, “Social vulnerability and medical complexity among Medicare beneficiaries receiving home health without prior hospitalization,” Innovation in Aging, 2020. oup.com