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 the second best time 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 household chores, nursing services and personal care. And with 10,000 baby boomers a day turning 65 between now and 2030, the need for home health care will only increase.
Those who plan early may buy insurance policies that cover home-care benefits. That could be long-term care insurance, or a life insurance policy with a rider for long-term care, sometimes called hybrid policy.
That's if they can afford long-term care coverage. When 2012 premiums for a couple who are both age 60 are adjusted to 2019 dollars, the most recent available information from the American Association for Long-Term Care Insurance, the cost averages almost $3,800 a year.
Plus one in 5 applicants younger than age of 60 are declined, and the proportion rises with age, according to 2019 industry data from the same trade group.
Those without long-term care insurance often start out relying on an unpaid family caregiver, but eventually many need to turn to paid help. And that can be expensive, too: According to insurance company Genworth's 2018 survey on the cost of long-term care, the national average bill for a home health aide is $4,195 a month.
"I think it's a crisis,” says Jennifer VanderVeen, president of the National Academy of Elder Law Attorneys. “Getting reliable home health care is not as available and affordable as it should be."
Paying out of pocket
"For the most part, the clients who have home care are private pay,” says Jerry Love, a CPA in Abilene, Texas, and a frequent lecturer on financing retirement and long-term care for the American Institute of Certified Public Accountants.
Many cobble together a care budget from multiple sources, among them:
- Savings and investments
- Life insurance policies that can be used for qualified home-care expenses through cash value or an accelerated death benefit
- Borrowing, for example by taking out a reverse mortgage or home equity loan
Using your house to provide cash for long-term care is risky: You could run out of equity in your home and still need long-term care. It's important to research reverse mortgages to see if they are right for you and take advantage of reverse mortgage counseling.
Hiring a worker directly, rather than through an agency, may be cheaper. But being an employer comes with responsibilities, Love says.
"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."
You can get help paying for in-home care if you don't have insurance coverage for long-term care and can't afford to pay out of existing financial resources.
Start by searching the federal government's Eldercare Locator to find your local Area Agency on Aging.
Those offices are “the first place to look,” VanderVeen says. “They have resources on home health care, and they are the gateway to Medicaid, which pays for home services.” You can also check the National Council on Aging's BenefitsCheckUp to find out what programs you may qualify for.
Help with home-care bills may be available through Medicaid if the care recipient has a low income or limited assets. Medicare can also pay for home health services in some circumstances, and the Department of Veterans Affairs (VA) offers home-care support for former service members. People who pay for caregiving also can qualify for tax breaks.
Original Medicare can cover the full cost of medically necessary home health care on a limited basis for beneficiaries who are unable to leave home without assistance. That could include:
- Skilled nursing care
- Occupational, physical and speech therapy
- Home health aide services — for example, help with daily activities such as bathing and dressing and basic medical care such as checking vital signs and dressing wounds — if the recipient also needs therapy or skilled nursing
Medicare will cover home care only on a part-time or intermittent basis, and only if a doctor orders it as part of a broader plan of care. It will not pay for full-time home care or for personal and homemaker services if that is the only help you need.
The joint federal-state program does pay for in-home care, some residential and assisted living care, and nursing home care. More than half of all Medicaid spending on long-term care goes toward home- and community-based services.
Home health services are less limited under Medicaid than with Medicare, but each state runs its Medicaid program differently, and eligibility and benefits vary.
Eligible former service members may qualify for one of several VA programs that help pay for care at home, including Aid and Attendance benefits, Housebound benefits, Veteran Directed Care, and Homemaker and Home Health Aide Care. Contact your regional VA benefits office for information.
If you're hiring and paying for home care for medical reasons, you may qualify for a federal tax deduction, just as if the loved one were in a nursing home, Love says.
An adult child serving as a caregiver for a live-in parent also can get a tax break by claiming the parent as a dependent. But the child must meet certain criteria, including providing more than half of the care recipient's financial support.
A lesser-known option: PACE
Programs of All-Inclusive Care for the Elderly (PACE) is a small but growing Medicare and Medicaid initiative aimed at keeping frail seniors out of nursing homes. About 45,000 people were enrolled as of May 2019 through more than 100 organizations offering PACE programs in 31 states.
Among other things, PACE covers in-home care, adult day care, checkups, hospital and nursing home stays, prescriptions and some transportation for medical purposes. It can also pay for training, support and respite for family caregivers.
Local PACE organizations work with medical providers who form the recipient's health care team. If the team decides your loved one needs care that Medicaid or Medicare doesn't provide, PACE still may cover it.
To be eligible, someone must be:
- 55 or older
- In need of nursing home-level care as certified through your state
- A resident of an area with a PACE organization
- Able to live safely in the community with help from PACE. People with Medicare, Medicaid or both can qualify although if you have Medicare only you might be charged a monthly premium. Those not covered through either program can pay for PACE privately.
Editor's note: This article, originally created in 2016, has been updated with more recent information. Stephanie Mansfield contributed additional reporting.