Let’s start with the premise that there are no stupid questions. Just like with elementary school, the question you have is probably the same one that someone else has too. And never is that more true than when we get into the world of Medicare, Medicaid and Social Security. These big systems all interact, overlap and pose a challenge to navigate, not to mention can send the smartest, most competent person down a rabbit hole of what we call bureaucratic fatigue — the sinking, agonizing and quick-sandy feeling of being up to your eyeballs in paperwork, hold times and red tape. But, as one of my students calmly informed the class tonight, we need to be more hopeful, like his generation was. Maybe that comes with clear answers — let’s give this a shot:
Question #1: Sometimes I just need someone to come and be with (insert name) for a few hours so I can have a break. Doesn’t Medicare pay for that?
Think of Medicare as your health insurance. The industry-speak for staying with someone for a few hours and making sure they are okay is usually called “supervisory care”. This is not covered by Medicare. In fact, the only time Medicare sends someone to your home is if you have a skilled need as in you need help with something that only someone with a medical license can provide. For example, a doctor could write an order to say you need a nurse to come to your home and help you take care of a wound or that you need the support of a hospice team. A physical therapist could come to help you learn balance exercises and, along with an occupational therapist, give you ideas of how to stay safe in your home. These skilled services are through your Medicare home health benefit.
What you can do in this scenario is talk with a professional care manager or social worker and see what your options are for respite care — respite means “to take a period of rest” and it’s important.
Question #2: My mom only receives Social Security — what is she eligible for?
The amount you receive in Social Security benefits is different for everyone because — with a few exceptions — it depends on how much you paid into it over your lifetime and how old you are when you decide to start taking benefits. Interestingly, the benefit is also graduated meaning that someone who made minimum wage their whole career will receive a benefit payout of around 60% of what they paid in but someone like Bill Gates will only receive 26%. Social Security is considered social insurance and is the primary mechanism to reducing poverty among older adults.
To determine what someone is eligible for and maximize your opportunities for receiving those benefits, it’s a good idea to know exactly how much a person receives when you talk to an aging service professional.
Question #3: I can do almost everything myself but what about Medicaid paying for someone to come help me with laundry and making meals?
States often have what are called “waiver programs” through Medicaid which literally means the state waives the income requirements for qualifying. These are administered under Medicaid Home & Community-Based Services (HCBS) and have different names in each state. The cool part about these programs is they can provide care in your home but you must need help with three ADLs or Activities of Daily Living. Some of the less intensive ADLs to think about include having someone standing by to make sure you’re safe when you take a shower, help managing or taking your medications, or help getting dressed. Laundry and meal prep are not enough to be eligible for Medicaid HCBS.
Question #4: I have about $48,000 in savings but only get $2400 from Social Security every month — can Medicaid come help me in my home?
To be eligible for a Medicaid Home & Community-Based Services (HCBS) waiver program which includes help in the home, you have to qualify both functionally (see Question #3) as well as financially. To qualify financially, the general rule of thumb is that, as an individual, you must have less than $2000 in resources (your checking/savings accounts, etc.) and you must make less than 300% of the maximum federal Supplemental Security Income (SSI) amount. In 2023, this is $2742 per month. There are ways to put the excess income into a Medicaid Qualifying Trust and protect your assets but you definitely want to do your homework with a professional before going this route. Generally you will need to “spend-down” your resources until you meet the financial eligibility criteria.
Question #5: Can Medicare have someone pick me up after outpatient surgery and spend four hours afterward with me to make sure I’m okay?
Many outpatient procedures require that someone drive you home and be with you for a few hours in case you have any negative side effects or reactions, or sometimes because you might be at greater risk for falling. Procedures could include cataract surgery, colonoscopies, endoscopies and even some orthopedic surgeries. While some of us may have friends who would pay to see us on painkillers — as in the time my mom heard all about my experience with cannabis and who knows what else — Medicare does not have the same sense of humor. Medicare does not pay for transportation to or from outpatient surgery and definitely will not cover that (again) supervisory care. If you want to go to rehab after an outpatient procedure, it’s likely going to be out-of-pocket. And just a reminder, Medicare requires that you spend three midnights as an admitted patient in a hospital before Part A will pay for a rehabilitation in a skilled nursing facility.
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Most conversations I have about Medicare, Medicaid and Social Security sound like alphabet soup. If you haven’t lived in the world of HCBS Medicaid where ADLs mean everything…or applied for SSDI through the SSA…or tried to figure out Parts A, B, C and D of Medicare, then it makes sense to be overwhelmed by options that seem to range from A to Z. One fear in these situations is that we’ll make more work for ourselves or search for something that doesn’t exist and waste time when answers are of the essence. The best thing to do is talk with someone who can listen to your situation, triage your options so that you can prioritize where to start, and, most of all, reassure you that there are no stupid questions.