Medicare vs. Medicaid: Why Your Insurance Doesn’t Pay for Long-Term Home Care

The "Medicare Myth"

If you are currently caring for an aging parent, you’ve likely spent hours on the phone with insurance companies. The most common question we hear at CareOasis is: "My parent has Medicare—will that pay for family caregiving and long-term care services?"

It is a painful discovery for many families: Medicare generally does not cover on-going long-term, non-medical care.

When you’re in the middle of a caregiving crisis, this distinction feels unfair. However, understanding the difference between Skilled Home Health and Non-Medical Home Care is the first step toward getting the right support in place.

1. Skilled Home Health (The Medicare World)

Medicare Part A and Part B are designed to help you recover from a medical event.

- What it covers: Registered nurses, physical therapists, occupational therapists, or speech-language pathologists

- Caregiving:

• Part-time or intermittent home health aide care (typically this is skilled nursing care or therapy, e.g., IV Infusion therapies, Wound Care, etc).
• Short term stays in Nursing Homes typically as a medically necessary stay after a hospital visit.

- The Reality: Once your parent is "stabilized" or stops improving, Medicare coverage stops.

For more information, visit Medicare.gov.

2. Non-Medical / Custodial Care (The Medicaid World)

This is the daily help that keeps an aging adult safe and independent at home. It includes help with Activities of Daily Living (ADLs):

• Bathing and dressing.
• Meal preparation and feeding.
• Medication reminders.
• Companionship and supervision.

- The Reality: Medicare does not pay for this. Because this is long-term, ongoing support, the responsibility falls to Medicaid. Funding for Medicaid is jointly funded by the federal government and state governments -- which means that each state disperses the funding to best fit their state's population and priorities.

- In Ohio: We have several critical long-term care waivers and services that fill the gap Medicare leaves behind, including PASSPORT, MyCare Ohio, the Ohio Home Care Waiver, and Structured Family Caregiving (SFC).  

3. Can You Have Both? (The "Dual-Eligible" Advantage)

If your parent is 65+ and meets Medicaid-income requirements, they may qualify for both Medicare and Medicaid. This is often called being "dually eligible."

• Medicare acts as the primary payer for medical appointments, hospital visits, and skilled nursing.
• Medicaid acts as the secondary payer, potentially covering the "custodial" home care that keeps your loved one safe at home.
• In Ohio: This is combined into one plan called MyCare. Through MyCare, your parent can receive services for both long-term care and critical care seamlessly. Furthermore, Personal Care, Homemaking and Structured Family Caregiving are all offered through all four of Ohio’s MyCare plans, making it a powerful resource for families looking to work together.

How to Navigate Your Next Steps in Ohio

Don't wait until a second crisis happens to figure out your funding path. Here is how to move forward:

1. Assess the "Level of Care": Does your parent need a nurse (medical) or a companion (non-medical)? Often, they need a combination of both.
2. Contact your local Area Agency on Aging (AAA): They can perform an assessment to see if your loved one qualifies for a Medicaid waiver.
3. Explore Structured Family Caregiving (SFC): If you are already the primary caregiver for your parent, you may be eligible to receive training and payment through an Ohio agency, leveraging the very waiver programs that Medicare cannot touch.

Need help understanding if you qualify?

Navigating the alphabet soup of PASSPORT, MyCare, and SFC can feel like a full-time job. We specialize in helping Ohio families decode these programs so they can focus on what matters: their loved ones.