Understanding Medicare in Senior Home Care – with Tyrone Carr and Chris Zayid

In this special podcast interview, Independent Medicare Insurance Agent Tyrone Carr in conversation with Affinity Senior Care CEO Chris Zayid, deep dives into Senior Home Care and the role of Medicare in Senior Adult Care.

Tyrone Carr is a personal Medicare Advisor and a member of the Senior Compass Group. He is dedicated to educating and empowering senior adults and their family members make informed decisions about Medicare. Tyrone also hosts a podcast ‘Unlocking Medicare with Tyrone Carr’ with the purpose of equipping the senior members of the community with the tools to feel confident in their Medicare decisions.

Get your Medicare questions answered in a free, no-obligation one-on-one consultation with Tyrone Carr.

Contact
Phone: 810. 623.9262
Email:tyrone@tcarrassociates.com
Website: Tcarrassociates.com

Read the edited podcast transcript below.

Tyrone: Often, we find that individuals think that Medicare is just going to cover the cost of a nursing home, assisted living, and are surprised when they learn that it doesn’t. Can you walk us through, in your experience, what that cost looks like, the services that are needed when it comes to home care?

Chris: Sure. This is a great a question. Home Health care is two branches. There is home health that is covered by the insurance, and you have a doctor that has a script. And he is the captain of the ship in that type of scenario, where he is going to be able to find out what’s going on with this person and then find out what if they actually need a Registered Nurse or a therapist. And this is called Medical Home Health Care and that’s covered by your insurance. 

A lot of family members get that screwed up because there’s also a Private Pay option which is called Caregiver Services. And that’s called Private Duty in the health care world but really in layman terms it’s caregiving and that’s more private pay. So, home health care when it is covered by your insurance typically the one that’s going to make that call is your physician writing a script and saying that you are going to be qualified for that.

And then two is that the home health care has to accept your insurance. So, if you have Medicare for example, all Medicare covers a 100%, so you should be able to have your home health care covered through Medicare. So, leaving the hospital, the rehab, or if you are at home and you want a nurse to come in or a therapist, your insurance should cover that but it’s always good to ask when you select a home care company, if they accept your insurance and they should do an insurance verification. And then they could tell you if they are sometimes your in-network or not, or maybe you might have a co-pay, and sometimes home health care companies cover those co-pays to get you covered 100%. Say you have a 100 – 200 dollars on there, some companies will work with you on that to get it covered by insurance.

So, home health care typically is covered by insurance but make sure that you check with the home care provider and let your doctor do your due diligence, make sure that home care provider covers your insurance.

Tyrone: Do you see a difference between original Medicare and someone who’s got a medigap policy – do you see the differences in coverages versus somebody who has a Medicare advantage. Because we are seeing more and more people that are leaning towards the Medicare advantage versus traditional Medicare to Medigap policy. From your perspective can you give us some insight.

Chris: Medicare Advantage is now becoming more aware that home health care is prevalent and so they curated plans out there to be able to customize family member if what type of condition that they have. So, Medicare traditionally, and all the Medicare Advantages – they’ve always covered home health care pretty well. But Medicare Advantage is becoming a little more aggressive on it because they realize that activities of daily living care are becoming more prevalent. People have Alzheimer’s and Dementia and Parkinson’s and MS, like they need more care. Medicare Advantages customizes them depending on their condition. If someone needs more daily care and wants someone to stay a little bit longer, when it’s time for enrollment, you should talk to Tyrone. And what Tyrone will do is, he’s going to figure out what you’ve got going on in your life. As time goes on, you might need Medicare advantage to customize that you need care for longer periods of time, because traditional Medicare does only cover home health care for intermediate care – for an hour a nurse comes in or a therapist and they’re done, and they are regulated by the insurance company by how many visits that they can go. Medicare advantage, they recognize that someone needs more long-term care depending on your chronic condition. When you do get at that age and you have to decide on the type of Medicare plans to take, you have to consider your diagnoses, what’s the possibility that you might need a longer-term care, and that’s when you customize Medicare advantage plan and that’s what they are trying to do in the future moving forward.

Tyrone: Someone who is transitioning into Medicare, let’s say they are turning 65 and they have at that stage of the game, regardless of their health issues, has the availability of traditional Medicare along with the Medigap policy versus a Medicare Advantage. If someone has a lot of underlying health issues that is probably going to need some home health care services, would you be more inclined from your position deal with the insurance carriers and services that you guys offer and provide to the community – are you saying that the advantage provides greater level of care with less restrictions if you’re the right one of course, compared to original Medicare and a Medigap Policy.

Chris: Michigan is getting there, but other states have gotten there already. We get these calls all the time, “Does Medicare cover caregiving services?”, and the is answer is, now in Michigan it doesn’t, not yet. Other states they do, so you will hear that Medicare Advantage when it comes to Michigan, they are going to cover more of long-term basis care, for someone to stay 4,6,8,12 hours, whatever they qualify for, they will tell you how many hours you are qualified for. So we will see in Michigan that more home care health providers will accept Medicare Advantage.

Home health care will always be there as an option for you, but I would say in combination soon, instead of privately paying for caregiving services, insurance like Medicare Advantage and Medigap … just like Medicaid. Medicaid has been doing this for decades and they said that we will send a nurse then we will say that you are going to have 10 hours or 100 hours a month covered and then that number of hours is utilized for your care. Or you can just have your loved one provide the care and Medicaid will pay you. 

Medicare Advantage is going through an approval process soon Michigan, well it’s just not there yet but they do have home health care advantages and you would say you have both. You could have the caretake, and the nurse, and the therapist all coming in at one time, now you are getting integrated wellness care and getting it covered by more insurance-wise and then the private pay starts to be a little bit less. Now, they are not going to cover it all, even when your nurse or therapists leave and the insurance covered it, you still are left two options, which is your family and friends and your support system is going to help you or you are going to private pay and get some covered but not all and then you are still going to have that gap where you still have to have some kind of coverage, it just depends.

Tyrone: The original Medicare covers the intermediate care, the skilled nursing care. But can you expand as far as on the home health care, those specific services that Medicare isn’t going to cover, that that person no matter what class you are in, that they are going to be responsible for because that’s what we want. We want people to understand what their exposures are, what they should do to prepare, so that way they are making the best-informed decision as they transition.

Chris: When you are at home health care, a lot of family members say why did the care stop, we want to continue, and why can’t we continue. So in the case of Dementia and Parkinson’s what happens is that if you cannot remember to do your daily routines and if a therapist comes in and you still cannot remember then Medicare stops their visits, so even if you’re qualified for 30 days, it used to be 60 now it’s 30 days, between the 20th and 30th day if our team and home health care team and the doctor – they say listen you have reached your goals, and the patient cannot remember to be able to continue on their own, we’re going to educate the family but we can’t continue because they don’t qualify to the point of reaching their goals. Goals are so important in home health care and so there are certain conditions where it’s not qualified.  Now you’re moving forward into getting your hip and knee surgeries done and typically the insurance says, hey listen you know you get your need on and you need to go back to outpatient need to be independent again. So, you don’t have to have Medicare you can have any type of insurance, and the insurance still will cut you off and they’ll say hey listen two weeks therapy that’s the average in the united states, you need to go to outpatient therapy and so usually the doctor makes that decision in a certain period of time where you continue to receive care or you don’t and sometimes family members get mad about that and they say why can’t we extend the care and the only one that could extend your care is your doctor writing a script of necessity.

Tyrone: Is that for any particular service as far as writing a prescription for home care or does it have to be like each service that’s rendered. Like if you’re coming into the home to provide a service whether it be administering medications, whether it’s assisting with food or transferring from a bed to a chair to a chair to a toilet, getting dressed. Does each itemized service have to be written out in that prescription order for it?

Chris: That’s called caregiving services.  A nurse and a therapist, sure they’re going to be humanistic and compassionate; they’re going to come in and help you, but they only stay for an hour at a time. And the bathing, the dressing, the medication reminders, the meal preparation, the lighthouse keeping, transferring your bed bound loved one if they’re incontinent or if they are urinating and making bowel movements in the bed and wearing adult diapers – this is called private duty caregiver services, we call it home care. It is separate than home health care, it’s a whole other type of care. Medicare doesn’t cover that and that’s a private pay option. So, your nurse will be compassionate, they’ll do as much as they can though when they’re there. That’s why home health care is called intermediate care where the doctor is coming in for medical care, for a specific scope to reach a goal for you to be independent so you can go on with your daily living. Caregiving, home care, private duty services, the private pay option which I’m talking about now, there you might not reach independence anymore, where you slowly, progressively decline and that’s where you need more assistance if you’re a fall risk and you’re at home and or if you’re bed bound, that difference is a big thing right now. But people, they hear home care and then they classify home health care as being the same.

Tyrone: Does affinity senior home health care help determine what’s going to be covered underneath. Let’s say we refer a client to your agency, do you help determine what’s going to fall underneath Medicare, their Medicare Advantage and then versus this is what they’re going to pay private duty costs so that way they have a realistic idea of what that cost is going to be whether it be on a monthly, six months basis or even a year. Do you help with that process?

Chris: When you think you need it, what we do is we send out a nurse and do an assessment and the nurse can’t come in unless the doctor writes a script and also if they think that you need caregiving services then our team does that too, we have that same service on hand and so that way the nurse and the caregiver can train each other and talk to each other about the daily routine that needs to be done and that’s really the scope of really what’s important. We can provide both care. If the nurse comes in or the therapist feels like they need a little bit more assistance then we’ll do a separate assessment, it’s still a different assessment, you will talk to our caregiving team because we have to ask you different questions regarding what is going on in a daily life so that way we can incorporate that and the main goal is to keep them safe in their home and if they want to go all the way to the end of life care and stay in their homes then there has to be a plan and that’s what we do.

Tyrone: One of the things I do as far as an agency, first I’ll ask what questions you have, we want to make sure that we address those. In addition to that these are some of the additional questions that you should be asking. Especially for the people that have a loved one that needs home health services, what are some of the questions, some of the things that they should avoid as they’re looking into this next chapter of life.

Chris: Be patient with your loved one and take initiative to understand what your long-term goals are and set up the right team and collaborate with guys like me and Tyrone and we have a senior resource group, and educate about what’s out there, develop a relationship with care providers so that way one day when you have to make a decision, the most stressful situation is when you have to make a decision on the fly and that’s why I would advise the family members to develop relationship with people in the community that you can trust so that way you can have your questions answered. And set it up right when you’re leaving the hospital. That’s one thing I would just advise right now, if you have surgery set up, if you have rehab center and you’re about to go home, don’t wait to go home to even set up any care or talk to a professional about it when you’re in the moment. I always say, the first day that you know that possibly you’re going to need more assistance in the home that’s when you start researching. Don’t wait for it and being at home you have to set it up and write too as well, you have to make it safe, you have to have home modifications, you have to make sure your insurance is going to be right to cover everything before you know, that’s why you meet with your Medicare specialist when it’s time for enrollment. What a lot of people do is that they don’t have the right insurance and then they’re searching for the right home care company and the one in their community might even not accept their insurance and that a lot of family members I see get hurt on that, they’ll call us and say hey we want to use you guys, we check their insurance and we don’t accept it and then they have to go use some other company we’re not aware of. So do your due diligence and make sure you start ahead of time.

Tyrone: I think it’s important that you know as an agent advisor you’re not only asking the questions that pertain to what their life looks like right now but understand the family history as well, because that could be telling to what their future may hold and what types of additional exposures they could have potentially just by understanding what the family history is and just bringing certain things to their attention so that way they’re more informed and educated about what may transpire in the future that may be greater cost to them that they can be prepared for and then unfortunately that something does happen.

Some of the questions Chris that some clients had sent in – are there state requirements for home care providers and do most agencies do background checks?

Chris: If you’re home healthcare you have to be licensed by the state, that’s just how it is. You usually have your JCAHO approved, your chapter proof or the state of Michigan comes in and every three years they come in and they audit the chart. If you are home health care it’s mandatory, if you’re private duty caregiver services in Michigan, it’s not mandatory to be licensed. Background checks and drug screens I surely hope that if you’re going to hire a company that you ask that question because they have to. Now there’s companies that don’t, steer away from them. That should be one of the mandatory questions on how to choose a home care company.

Tyrone: Now there are certain questions they should ask, so let’s say someone you know outside of any senior care and home care, are there questions that you would tell somebody this is what they should be asking an agency if they’re looking to do business with them just to be aware that doesn’t have to be disclosed?

Chris: Yes, we have a guide, we give it for free to everyone and it’s how to choose a home care company. You don’t have to choose us, we don’t care if you do, but you do need to ask the right questions when you’re out vetting and some of them are, if they drug screen, do they hire their employees virtually or do they hire them in person, do they have 24/7 access to the to the home care company, if they call the contact number are they going to answer, that’s important and it doesn’t matter what company it is they should be able to get your questions answered in a critical situation. Are they licensed is important, but if they’re not licensed that’s fine, if they’re a caregiving company, most aren’t? But if they don’t have a license, do they have a registered nurse on staff to answer questions? And then their skill sets – ask what type of employees they hire and what are the requirements when they hire them. You want to know what the process is, to be part of an organization. For us, we set a standard, we’re family owned and we’re not going to settle for less. And if there is care that’s not provided right it’s not going to happen for very long because we’re super involved, we make sure that customer service and clients are happy and as well as our employees too. If they’re not happy we tackle it right away and we figure out a solution. That’s important, you want to know the culture of the organization – go on their website, go see what they’re doing, if they’re super involved in the community and I don’t think that anybody wants to be embarrassed of their reputation, so if you could see a company that’s out there and doing things that means that they’re willing to put their name on the line.

Tyrone: Another question we have from a client – do you need to use a hospice company or will home care companies provide it?

Chris: You’ll find some home health care companies also have a hospice wing and so if you do then your home health care and your hospice could be intercorrelated with each other. Now there’s lots of hospice companies that are stand alone, that are just hospice, and then there’s some hospice companies that have palliative care in hospice. It just depends, usually when you transition, typically when you have home health care and if you have a chronic condition then we recommend the hospice company.

Tyrone: Can you speak to the difference between, to your level of knowledge, hospice, home care, and palliative care, so that way people understand the difference between the three?

Chris: We talked a lot about home health care. In home health care your doctor is involved, he writes a script, it’s short-term care reaching goals and a nurse, and a therapist, and therapists and home health aides could be covered by insurance. 

Hospice care – the word is more freely explained now and not as bad as talking about someone passing away with hospice. You don’t have to be passing away tomorrow or next month to be qualified for hospice, but insurance does cover it all, your medical supplies cover it, and typically what happens is you can’t seek care at that point in time which is you can’t seek treatment. In fact when you’re seeking treatment that’s when they start to see like you do qualify for hospice, let’s make your life comfortable as possible and your doctor does write a script for that, so insurance is involved and the doctor is involved and typically right when you transfer to a hospice company they also have a physician on board, a director of nursing on board and your care now starts to be transitioned with their physician and their nurses to make sure that you have a good quality of life and the care that’s needed.

But with palliative care it’s one step before hospice and you can still seek treatment at palliative care but you have a nurse practitioner that’s going to be on board with you, you still have the director of nursing, you have the whole hospice support and insurance does cover it as well too, but it’s a little bit less leniency where they’ll say hey listen you’re not taking chemo anymore, not taking treatment to be able to fix that chronic condition that you have. That’s the difference between palliative care – it’s more comfortable keeping you comfortable and they do add a little bit of caregiving services as well too. The aid comes in, helps with the meals, dressing, and bathing and all that and so making you comfortable is possible but the insurance is a little bit less stringent on the qualifier.

Tyrone: Who determines what’s home care versus palliative care?

Chris: The best is your doctor. You have a good relationship with him and the hospice company you’re going to choose, or the physician, or primary doctor, or an oncologist, whatever condition that you have, there’s a great relationship with him obviously and he should guide you in the right direction. They’re very knowledgeable of it, they do it all the time, and they should be able to know what stage you are at this point in time, and obviously you have your family involved. If there’s family with power of attorneys and they’re involved as well have them have a meeting with your physician and decide, like this is our decision, we have to make a choice. And it’s okay to go from palliative to hospice, and a lot of people transition, you can go back and forth too even with home health care. People can graduate from hospice, and you know they’ve done treatment, they receive the care through hospice but then they say hey listen looks like there’s going to be a long-term lifespan now, let’s graduate from hospice and let’s have more therapy services. Because usually hospice doesn’t offer the therapy and the range of motion and exercises, you can actually graduate, go back to hospice, your doctor can write you a home health care script and go back to having therapy come in. A lot of people don’t know that, but you can you actually can go back.

Tyrone: When you think of hospice, I always understood the term like yeah, you’re just, you’ve passed away, like your days are numbered essentially. But the more I learned about it, that definition is very broad in the sense of what it really actually means.

Chris: You don’t have to be passing away. It may be a chronic condition that you currently have on you and a lot of people go back in remission or there’s miracles, there’s tons of miracles in life where people actually start to go, this is not a condition where you’re actually going to pass away, you can live for few more years and you don’t have to be on hospice anymore, and you don’t have to be on all those meds that they recommend for hospice, and you can go back to being on home health care and your primary care doctor can work with you on your treatment.

Tyrone: I just find this so fascinating and it’s helpful as well. Here’s a question we have from a viewer or a client – is there a limit on how long you can be in hospice before insurance will no longer cover it?

Chris: No. Hospice will take you to end of life and also all your supplies Medicare will cover medical supplies and it’s good to know like what medical supplies because you definitely don’t want to get that walker and then you never got the hospital bed, and you have to privately pay for the hospital bed. But when you go on hospice there’s a lot of advantages to that too as well, all that expense to you, most hospice companies will cover it all for you and make sure that they give you everything that you need during that period of time.

Tyrone: With affinity do you just focus on the home care? Do you also provide palliative care? Do you have hospice service or just strictly home care?

Chris: Home health care and private duty caregivers is our niche.

Tyrone: What would you say is the average cost for home care private duty?

Chris: You can do the math. It’s 30 per hour if you get standard care, it’s 25 if you want around the clock care. If you want 4, 6, 12, or just 24/7 care, you just times it by the rate. If it’s 30 dollars, if you need our minimum amount of care, it’s three days a week for our minimum shifts and then that would be just your bare minimum and that’s times the rate. 

When we talk to family members about long-term care insurance policies, we let them know that we’re carriers and we can make sure that we work with the carrier, and you get the care covered. If you’re a veteran, we can help you with your veteran benefits that helps cover caregiving services, you’re involved in an auto accident, this covers any type of care depending on the situation and working with a case management group. For hospice we would refer that out but we work with very preferred providers and make sure you’re taken care of and also with home health care. I’m not here to say that it’s important to use us, we have great partners that if we can’t cover services then we would recommend you to.

Tyrone: The services that you provide – will you do a free consultation?

Chris: Completely free. That’s one question you need to ask too when you’re vetting companies – did they charge you for a consultation? We don’t charge you to answer your questions.

Tyrone: If someone has a specific budget, are you willing to work with inside that budget as far as what’s conducive to what they can afford and maybe a certain care may be better served to have this taken care of versus maybe not having this service necessarily met?

Chris: I really tell family members about this one is that we’re going to make a humanist decision as if it’s our own family member. I always tell them I’m transparent with them, they call and say hey I want round the clock here, do you know how much that costs? Let me ask you one question – does your loved one sleep at night? Are they a fall risk? Are they sleeping throughout the night, and everything is fine? Then you don’t need night care. That’s 12 hours a day that possibly if you have someone there with them that you could save on that, and I would gradually start with 8 to 10 and gradually go over time to see if you need more of that care. You have to look at the condition of your loved one, you have to look at are they at risk, do they have bowel movements and urinate in the middle of the night, do they try to get up, are they a fall risk, are they wandering throughout the night? They like to wander with Alzheimer’s and dementia, that happens all the time, so there’s periods of the day where they’re safe, then you don’t need care as long as somebody is there and understands what care they need, and what their daily needs are.

Tyrone: One of the things that I always suggest during the Medicare Seminars is – education, education, education! When we’re thinking of Medicare we’re thinking of oh I’m going to choose a drug plan or you traditional Medicare with the Medigap or I have to decide if I want to choose a Medicare Advantage, not realizing that Medicare is like a spider web or there’s a bunch of tentacles and it touches so many different areas of life you know like your assets and if you don’t have that basic foundation in place you can’t even begin to wrap your head around the idea of what type of exposure you have and if you’re not educated, you’re not informed, then you can’t make an educated decision. So one of the things that we always emphasize is to make certain that you understand what Medicare covers or what it doesn’t cover in the sense of a home care, nursing home, or assisted living facility, because people just naturally assume. So, there’s things that you can do to protect yourself in the event that something does happen, an unfortunate event, or you’re diagnosed with some disease, or maybe you have a family history of something that’s hereditary and that later in life you might be exposed to that. That’s a real-life situation. Now you’re paying out of pocket for something if you were just prepared properly you could have avoided paying all this money and it would be a lot easier to manage that way.

Chris: A good scenario I would say for you is, if you’re meeting with Tyrone and you need Medicare, find out who are the Medicare providers in your local area and vet them and make sure that that’s what you want because you might have an HMO or PPO and you might be in a network and you can’t use certain home care companies or blue care network, coffinity, aetna, humana. There’s a lot of healthcare providers that don’t accept that insurance or if you have an HAP you have to use a home care provider that has to be with HAP. The company that you truly want and the insurance that you pick, matters.

Tyrone: It does and it’s the same even when it comes to physical therapy or chiropractic coverage, I mean depending on what care you may be using now. Currently people just aren’t asking the right questions and unfortunately a lot of agent advisors are not sharing a lot of the information that you need to be aware of. 

Again, those are the things that we do, make sure that we’re addressing the questions, concerns that you have and then saying these are the additional questions that you need to be asking so that way you’re properly educated, informed to make an empowered decision.

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