En español | Planning for in-home care is a lot like the Chinese adage about planting a tree: The best time was 20 years ago, and second best is today.
Older Americans determined to stay in their own homes are likely to need help at some point — for a few hours a day or 24/7 — with personal care, household chores and nursing services.
"There's advanced planning, and there's crisis planning," says Hyman G. Darling, an estate attorney in Springfield, Mass., and president-elect of the National Academy of Elder Law Attorneys.
Those who plan ahead often buy long-term care insurance policies with home care benefits if they can afford them and qualify for them. Those without it often start out relying on an unpaid family caregiver.
"It's tough," Darling says.
About 1 in 3 people caring for someone at home (as opposed to a nursing home), said they had hired paid help in the past year, according to a 2015 survey by the AARP Public Policy Institute and National Alliance for Caregiving.
The median cost nationwide for either homemaker or home health aide services is upward of $125 a day, assuming 44 hours of care per week. The median cost for assisted living is comparable to 44 hours of home care a week (though far less than a nursing home), according to the Genworth 2016 Cost of Care Study. Costs vary by region, number of hours and level of care needed.
Here are tips for how you can afford home care, whether you're planning ahead or need help soon:
If you can plan ahead
If you're in your 50s, hooray! You're in your prime for advance planning to hire a home care worker when the time comes. You can invest, check out long-term care and life insurance policies with in-home care benefits — perhaps through an employer — and other products to cushion the high costs of home care.
"It's important for a person to purchase these policies when they're in good health and younger," says Rod Perkins, vice president of insurance regulation with the American Council of Life Insurers. "You don't want to wait until you need it."
The average age for purchasing long-term care insurance used to be in the 60s but has dropped to 57, Perkins said.
"Baby boomers have seen their parents have long-term care needs and weren't prepared," he says. "And it's not just an old-age product. You could need in-home care as a result of an accident."
Policies may include an elimination or waiting period before long-term benefits start, but it's wise to think of policies in the long run. The average claimant on a long-term care policy is 80+. Since you may pay premiums for decades, take time to compare policies and get the benefits you think you'll need and can afford in the long term.
Policies are changing to meet current demands, such as long-term care insurance benefits attached to life insurance policies.
"In the past, most long-term care policies were nursing-home only," Perkins says. But today, most long-term care policies are comprehensive and cover care in a variety of settings.
Download the free "A Shopper's Guide to Long-Term Care Insurance," by the National Association of Insurance Commissioners, the organization of state insurance regulators. Note: Do your homework to figure out if long-term care insurance is right for you. Some people, such as those with a pre-existing condition, are not able to afford or qualify for long-term care insurance.
If you need help now
If you're older and need help paying for in-home care sooner rather than later, you can search for services by location on the federal site eldercare.gov. See also benefits.gov and the National Council on Aging's BenefitsCheckup.org to find out what programs you qualify for.
You can also search for services by location using the Eldercare Locator on eldercare.gov.
Homemaker services cover help with such tasks as eating and bathing, cooking and cleaning, and running errands. Home health aides provide a range of nonskilled or skilled medical services, from checking vital signs to nutrition therapy and wound care.
Medicare pays for medically necessary home health care on a limited basis but not for homemaker services. Medicare supplemental plans and health insurance through an employer generally do not cover home care.
Medicaid, the joint federal-state program for low-income people (or in some cases those with high costs), does pay for in-home care, some residential and assisted living care, and nursing home care. Each state runs its programs differently, however, and eligibility and benefits vary.
Eligible veterans may qualify for several Department of Veterans Affairs programs — Aid and Attendance, Housebound, Home and Community Based services — that help pay for care at home.
One little-known option: Program of All-Inclusive Care for the Elderly (PACE), a small but growing Medicare and Medicaid program aimed at keeping frail seniors out of nursing homes. It covers in-home care, checkups, dental and doctor care, hospital and nursing home stays, prescriptions and some transportation.
To be eligible, someone must be 55 or older, be certified by the state as in need of nursing home-level care (as certified by your state) and live in an area with a PACE organization. People with Medicare or Medicaid, or both, can qualify; some may be charged a monthly premium. Those not covered by Medicare or Medicaid can pay privately.
Although PACE has been around for decades, only about 40,000 people were enrolled as of Jan. 1, 2016. More than 110 organizations offered PACE programs in 32 states as of March.
Individual or group life insurance policies may have cash value the owner can use toward qualified home care expenses. With an accelerated death benefit, the company pays actual charges for long-term care up to a certain amount per day or month. It's typically capped at 50 percent of the death benefit.
A reverse mortgage could provide cash for home care, but the homeowner remains responsible for taxes, upkeep and other bills. Experts warn that you could run out of equity in your house and still need care. It's important to research reverse mortgages to see if they are right for you and take advantage of revere mortgage counseling.
"For the most part, the clients who have home care are private pay," says CPA Jerry Love, of Abilene, Texas, a frequent lecturer on financing retirement and long-term care for the American Institute of Certified Public Accountants.
People cobble together a budget from savings, long-term care and life insurance and annuities, reverse mortgages or home equity loans.
It may be cheaper to hire a worker directly, rather than through an agency, but being an employer comes with responsibilities, Love warns.
"First you have to be sure you're paying the minimum wage," he says. "And if the person is working more than 40 hours a week, you must pay overtime."
Covered are workers who are family and friends, those paid privately or with Medicaid funds or some other combination.
If you're hiring and paying for home care for medical reasons or because the recipient is in the early stages of Alzheimer's or dementia, you may qualify for federal tax deduction, just as if the loved one were in a nursing home, Love says. An adult child may get a tax break if the parent can be claimed as a dependent. (The adult child must meet certain criteria, including that the family caregiver must be providing over half of the care recipient's financial report.)
Private payers should also look into community support
"Tap into anything in the community you can apply for," Love says. Don't overlook churches, synagogues, the United Way, the local Area Agency on Aging office and senior centers.
They may steer you to adult day care, meal delivery programs, and grants for home modification, weatherization and assistance with heating bills. Such assistance may be enough for you or your loved one to remain independent and at home.
If you're the family caregiver, you may be eligible for a voucher to pay a neighbor or friend to help out.
Respite care vouchers are funded by the federal government as well as by private organizations, such as Easter Seals, the Alzheimer's Association and the ALS Association.
In Virginia, for example, a family caregiver who lives with the care recipient may apply for a federal respite grant voucher of up to $400 through the Virginia Division for the Aging. About 200 families a year, many of whom do not receive Medicaid, receive the grants.
"It's a chance for the caregiver to take a break and rejuvenate," says Liz Havenner, Division of Aging human services program director. "They may just want to take a nap."