Helping families navigate the landscape of home care in Florida.
By Jonathan Marsh, Certified Alzheimer’s Educator
This guide is dedicated to my Grandmother Leola and Cousin Risa.
I watched as my grandmother went from living independently
to needing my cousin to provide full-time care.
These two strong women and role models in my life struggled
with their changing roles and bravely overcame many challenges.
It is from them that my passion for caretaking
and commitment to providing the best care possible was inspired.
May they both Rest in Peace.
If you are reading this guide, you probably have a current need for home care for yourself or a loved one, or you are planning for the future. Those who can benefit from home care include:
When searching for home care, it’s important that you find the best care for you or your loved one. In Florida, that search can be overwhelming, given all the available options.
This guide helps families navigate the landscape of home care in Florida. Let us help you better understand each option.
When searching for home care, you may find that a lot of the terminology can be confusing. You may hear terms such as private duty home care, in-home care, senior home care, senior care, elder care, elderly care, Alzheimer’s care, dementia care, Parkinson’s care, non-medical home care, respite care, and many others. Some of these terms specifically describe home care; others are broader terms that apply to a wide variety of care and in various settings.
Home care
The “Hands-Off” category of home care includes homemaker and companion services. These services are sometimes referred to as assistance with instrumental ADLs (Activities of Daily Living) or the complex skills that are required to live independently. Examples of these services are:
Personal care services are part of the “Hands-On” category. These services are commonly referred to as assistance with basic ADLs and include:
Figure 1
Figure 2 shows an easy way to distinguish between home care and home health care. Though they are different in terms of the services offered, both types of care have a significant impact on the client’s long-term quality of life.
Figure 2
Home care is about maintaining a person’s independence and quality of life in their home or wherever they reside at the current time. In other words, home care services can be rendered in-home or in other locations such as independent and assisted living communities, skilled nursing/rehab facilities, or hospitals. These services are performed by caregivers, commonly referred to as homemakers, companions, and home health aides. A good term for this type of care is supportive care, where services such as companionship, meal preparation, light housekeeping, bathing, assistance with taking
As noted earlier, some examples of individuals that may require home care are as follows:
Home care often will vary in terms of duration. When compared to home health care, the length of time that care is provided is not as rigid or fixed. Home care may remain in place for the duration of time the client requires care, for a duration of time to allow adequate relief for a family caregiver, for the duration of time the client is healthy enough to remain at home, etc.
In contrast, home health care is skilled care administered by medical professionals such as registered nurses, physical therapists, and occupational therapists. Examples of services provided by a home health care provider are:
This type of care generally requires a doctor’s order and can be paid for by Medicare and other insurance providers. A general rule: When you see verbiage in a health insurance policy that states that home health care is covered, the insurance policy is referring to this type of care (“skilled care”). There are very few exceptions to this rule.
Examples of someone who would need home health care are a person who had an injury related to a recent fall or an individual who recently had surgery. In these situations, a doctor may order both physical therapy and occupational therapy to be administered in the home.
Home health care is for finite short-term care and will focus on very specific tasks, largely because of the way Medicare and other insurances work.
When selecting a home care provider, you must think about the level of care you or your loved one needs, cost, and how much liability you are willing to take on related to the person who will provide the care. For example, would you prefer to hire a provider that will handle all HR (Human Resources) responsibilities, payroll, supervision, and scheduling of the people taking care of you or your loved one? Or would you rather handle some or all those functions on your own? In addition, would you rather allow an organization to handle all legal responsibilities? Or would you prefer to handle those on your own? This section will help to guide you in this area.
Cost comparison considerations are discussed in more detail at the end of this section.
Comparison of Home Care Providers
Figure 3
When you first begin your search for care, home care providers may appear to all be the same. However, state regulations specify the different levels of service they may offer. Florida’s Agency for Health Care Administration (AHCA) requires that a license or registration number be documented on all marketing materials for the provider, including website, business cards, brochures, and other marketing or printed materials. This makes it easy for you, the client, to clearly identify the type of provider. Here’s how those numbers differ based on the type of provider:
To find out more about the difference between the types of providers listed above, see “Florida Home Care Provider Types At A Glance”.
Whether a provider hires employees or contractors, there are legal ramifications for both the provider and the employee or contractor. The Internal Revenue Service (IRS) and the Department of Labor (DOL) differentiate between employees and contractors using a number of factors. These factors limit the nature of the relationship a provider may have with contractors as well as the degree of control the provider has over them.
For home care clients, the factors identified by the IRS and DOL set the stage for significant differences when working with providers that hire employees versus those that hire contractors. The burden that the client is willing to assume in areas such as supervision and scheduling, payroll and tax liability, insurance, and training will impact the decision on the type of provider selected.
Employees
A home care agency generally hires all W-2 employees. A homemaker and companion services provider generally does as well. When hiring employees, these providers generally have robust screening processes, handle all supervision and scheduling, handle payroll and tax withholdings, have insurance, and provide training. More information is provided later in this section.
Contractors
For a registry, ALL direct care personnel
Independent caregivers are contractors. Therefore, all responsibilities such as recruitment, screening, supervision, scheduling, processing payroll, paying taxes for caregivers, and acquiring insurance coverage to pay for medical bills and disability (if the caregiver is injured in the home) are the responsibility of the client. This can all be a significant burden, as the home care client now must handle all aspects of running a business.
A home care agency can provide homemaker and companion care as well as personal care.
A homemaker and companion services provider is limited to
A registry, through their contractors, can provide homemaker and companion care as well as personal care. The registry will refer you to a contractor who has the correct qualifications depending on the level of care that is required.
An independent caregiver’s qualifications may vary. The client must verify the qualifications or the capability of the caregiver. Independent caregivers often provide care without any formal qualifications or training and with limited to no experience. According to AHCA, “hands-on care” (also known as “personal care”) can only be performed by individuals with the required certification or professional license, such as home health aides and certified nursing assistants. An individual is not entitled to perform these services without the required qualifications.
When hiring employees, both the home care agency and homemaker and companion services providers perform background screening, check references, and verify previous employment. Additional screening measures may also take place and are reviewed, such as drug screening, motor vehicle history reports, and auto insurance verification.
With registries, screening is limited and will vary. In Florida, registries are required to ensure a valid background screening and to verify qualifications of the contractor (for example, home health aide training or a CNA license). Check with the registry to understand their screening process.
For independent caregivers, all screening is done by the client. The cost, both in time and money, is the responsibility of the client.
Important: At a minimum, and as required by law, home care agencies, homemaker and companion services providers, and registries are all required to verify background screening results processed by the Background Screening Unit at the Florida AHCA. The background screening is a state and national fingerprint-based criminal history check used by the Background Screening Unit to decide on eligibility or ineligibility to provide services to children, the elderly, and disabled individuals. Background screening results are available to providers licensed or registered through AHCA in what is called the “Care Provider Background Screening Clearinghouse” or more commonly known as the “AHCA Clearinghouse”.
Given the nature of caregiving in the home, home care providers are at risk of injury. According to the Occupational Safety and Health Administration (OSHA), home care providers “have little control over their work environment which may contain a number of safety and health hazards. These hazards include bloodborne pathogens and biological hazards, latex sensitivity, ergonomic hazards from patient lifting, violence, hostile animals and unhygienic and dangerous conditions. In addition, if their daily work schedule requires them to provide care for multiple patients, they face hazards on the road as they drive from home to home.” “The most common injuries to home healthcare workers are sprains, strains, and other musculoskeletal injuries related to lifting and moving patients.”
You must consider what would happen if a caregiver is injured while working in your home and who would be responsible for any type of medical bills. In most cases, your homeowner’s insurance policy will not cover employees working in the home, especially non-legal employees (i.e., those with no taxes being withheld). This puts you at risk if you have taken the position of an employer with services provided through a registry or an independent caregiver.
Home care agencies have insurance for property damage and
Homemaker and companion services providers are not required by the state to carry liability insurance. However, they likely have workers’ compensation coverage. Check with the homemaker and companion services provider to understand what insurance coverages they have in place.
Important: Employers in Florida engaged in non-construction work with four or more employees are required to have workers’ compensation coverage.
With registries,
Independent caregivers generally do not have their own insurance coverage.
A home care agency will verify state-required training or
With a homemaker and companion services provider, training may be limited. There are generally no set training standards required by the state. Check with the individual service provider for more information on the training they provide.
Examples of training that a provider may verify or conduct as part of their own training curriculum are:
These types of training help employees become better prepared to meet the challenges encountered in home care.
A registry will verify required training and qualifications for licensing prior to referring to a client, but the relationship with the registry stops there in terms of training. Ongoing training is not provided by a registry.
With independent caregivers, there may or may not have been any prior training. Any training during their employment will be the responsibility of the caregiver or the client.
Home care agencies and homemaker and companion services providers will ensure a certain standard is met on the job, often above and beyond what the state requires. With home care agencies and homemaker and companion services providers, ongoing supervision of caregivers by agency personnel is in place to ensure the quality of work and adherence to agency policies. However, an important distinction is that the home care agency, by law, has at least one registered nurse on staff to assist with supervision. A homemaker and companion services provider is not required to have a registered nurse on staff.
Registries, by
Important: When working with contractors, the client essentially becomes the employer and is subject to all federal and state workplace laws.
With a home care agency as well as a homemaker and companion services provider, all scheduling is handled by the administrative staff. If the scheduled caregiver is for some reason unavailable, a qualified substitute caregiver will be sent.
With a registry, there is limited to no involvement in scheduling. More specifically, registries, by law, cannot dictate schedules or methods to contractors. Typically, the scheduling is coordinated by the client, as the relationship the client has with the registry is minimal after the referral of the independent contractor is completed.
All scheduling is the responsibility of the client when working with an independent contractor.
When working with contractors, whether it be through a registry or directly with an independent caregiver, consider what you will need to do if the caregiver cannot make a shift. In some cases, you may know of the caregiver’s absence well in advance of the shift. However, in other cases (e.g., sickness, personal emergency) the inability to make a shift is communicated by the caregiver at the last minute. Will a family member or friend be available to provide care during the caregiver’s absence? Will this have an impact on the family member’s employment or ability to attend other activities?
Home care agency or homemaker and companion services provider employees are disciplined by administrative staff if they are not meeting the required standards of work. If the employee is not meeting expectations, another caregiver can be sent in their place. If necessary, terminations are handled by the provider.
Contractor caregivers are disciplined by the client, whether through a registry or hired directly. The client also must handle terminations or ask the caregiver to not return, which can be a difficult conversation. If the caregiver has been provided by a registry, the client will need to work with them again to have another qualified caregiver referred. If the client has hired an independent contractor, the client will need to invest additional time and perhaps financial resources to recruit and interview more caregivers. This may result in a gap in the delivery of care.
Give some thought to how comfortable you are with disciplining employees involved in home care before choosing a provider.
All payroll processing and payment of taxes are handled by home care agencies. This includes federal and state taxes, Social Security, Medicare, and unemployment. Typically, the same is true for homemaker and companion services providers.
By law, registries cannot pay taxes for contractors. Some registries require the family to pay the caregiver directly which also makes the client responsible for paying withholding taxes. Some registries will process payroll, requiring the contractor to ensure that all taxes are paid. When taxes are not paid by the employer, the situation can open the door to confusion on the part of the contractor regarding how much is owed and when and who is responsible. This situation has the potential to embroil the family in a dispute over the matter.
When employing an independent contractor, the client is the employer and is legally responsible for paying taxes in a timely and accurate manner. Most home care clients do not know or understand all details involved with payroll. However, that does not decrease their liability or responsibility.
An important consideration with homemaker and companion services providers is continuity of care. Even though the needs of you or your family member may be limited to homemaker and companion services at this time, the needs generally progress in the future. For instance, your loved one may have early onset Alzheimer’s disease that later advances and will require additional care. In this situation, if personal care is required in the future, you will have to find a new provider.
In general, you should expect that a home care agency that provides multiple services such as HR, scheduling, training, payroll, and insurance would be priced higher for caregiving services than a caregiver referred through a registry or an independent caregiver. If you select a caregiver through a registry or if you select an independent caregiver, there should be significant cost savings given the burden you will assume related to HR, scheduling, liability, and other factors.
TIP: Do some research by calling several providers in the area. In general, the pricing should be
Ensure all aspects identified in this section are considered when you compare costs:
The following table summarizes at a high level the differences between home care provider types in Florida. If you have difficulty viewing the table online, be sure to download a free copy of the guide at the top of this web page. Or you can download a
Click the 'Download' button below to download a high-resolution pdf file of the "Florida Home Care Provider Types At A Glance" table.
When selecting a home care provider, it is important to understand the implications of your decision. Use the cheat sheet below to help guide you through the process. The chart allows you to compare three different home care providers.
Click the 'Download' button below to download a high-resolution pdf file of the "Questions to Ask When Selecting a Home Care Provider" cheat sheet.
In general, the industry standard is to price the cost of care for home care at an hourly rate.
Genworth 2015 Cost of Care Survey for Florida
When considering home care in the State of Florida, the best report available is the Genworth 2015 Cost of Care Survey for Florida. In that report, you will find ranges and averages for the cost of home care, assisted living, and independent living. This will give you a good idea of hourly pricing for home care in Florida in general or for a specific region in Florida. In some areas of Florida, care will be more expensive compared to other areas of the state. It’s important to look at the costs specific to where you live. Also, be aware that pricing has increased since the report was originally published. When we contacted Genworth, 2015 was the last year their organization published a cost of care report for the State of Florida.
This report can be found by entering the URL below or by entering the words “Genworth 2015 Cost of Care Survey Florida” in a search engine such as Google or Bing.
https://www.genworth.com/dam/Americas/US/PDFs/Consumer/corporate/cost-of-care/118928FL_040115_gnw.pdf
Genworth Long-Term Care Cost – Online Tool
Genworth also has an online tool to estimate the cost of care. This online tool uses more current data than the report referenced above and will help you look at ranges of pricing across the United States, across a specific state, or for a specific region. It gives a monthly cost, based on the assumption of 44 hours of care per week on a regular basis. Unfortunately, however, the tool does not give pricing on an hourly basis.
This online tool can be found by entering the URL below or by entering the words “Genworth Long-Term Care Cost” in a search engine such as Google or Bing.
https://www.genworth.com/about-us/industry-expertise/cost-of-care.html
There are multiple sources to pay for home care. Home care providers will differ in terms of what sources of payment they can or will accept. Payment sources for home care can be categorized into two broad categories: 1) private pay and 2) federal, state, and county programs.
To help you understand what Medicare will pay for, the terms “skilled care” and “unskilled care” are reiterated in this section for purposes of clarity and to avoid confusion of terminology.
It is a common misconception that Medicare will pay for ALL home care (unskilled care) needs. However, home care (unskilled care) may only be paid for by Medicare if home health care (skilled care) is currently being received.
In general, Medicare will pay for services in the home when a doctor certifies that home health care (skilled care) is required. The payment for services is done by lump sum to a Medicare-certified home health home agency for covered services in a 60-day period. This period is known as the “episode of care”. The lump sum must cover all services (both skilled and unskilled) rendered during the episode of care. Therefore, even though some home care (unskilled care) may be included as part of those services being received, those unskilled services may be limited (if at all) as they reduce the portion of the lump sum that can be used to cover the home health services (skilled care). If a portion of the lump sum is used for home care (unskilled care) to assist with ADLs such as bathing, feeding, transferring, etc., these home care visits will be intermittent and for short durations.
For more information on Medicare and what services are covered in the home, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). A great resource is their official government booklet ‘Medicare & Home Health Care’, which explains eligibility and what is and is not covered. That booklet is found at the following URL:
https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf
Many home care clients opt to pay for home care using their savings. Savings may be in the form of cash on hand, bank accounts, retirement accounts, etc.
Some individuals have planned for long-term care expenses with a long-term care (LTC) insurance policy. LTC insurance policies allow for coverage of the unpredictable cost of long-term care in the future. LTC insurance policies may have been purchased individually or provided through an employer or other organization or program. Premiums are paid over time. An individual that has an LTC plan will qualify for benefits generally when they need help with two to three ADLs. Be aware of what is called an elimination period during which the individual may have to pay for a certain amount of days or hours of care before benefits are received from the LTC insurance policy.
Additional options that can be considered from a private-pay perspective are reverse mortgages, home equity lines of credit, life insurance policy conversions, or loans designed specifically for home care. Before proceeding with these options, you may wish to seek the guidance of a financial advisor.
Check with your county government to see if they offer services to assist in the home. The program name may be something along the lines of “Aging Services,” “Elder Services,” etc. There may be qualifications for these programs such as income level, age, and how dire the need is. In addition, some programs may require a copay based on a sliding fee scale.
Navigating the U.S. Department of Veteran Affairs (VA) Pension benefits and Medicaid Long-Term Care benefits can be very confusing and complex. We recommend seeking guidance from VA-accredited professionals (attorney, agent, or veteran service organization) and/or an expert in Medicaid benefits in the state of Florida. If an individual is eligible for both VA pension benefits and Medicaid long-term care benefits, receiving benefits through one program may result in the denial of benefits or a penalty from the other program.
For more information on VA benefits, call the VA toll-free at (800) 827-1000, visit their website at www.va.gov, or visit a VA regional office.
VA Aid and Attendance Pension Benefit
The VA has an Aid and Attendance Pension Benefit for veterans and surviving spouses with non-service related disabilities that require regular assistance with their ADLs. There are four eligibility requirements: a) the veteran must have served at least 90 consecutive days of active duty service with one day during a period of war, b) the veteran must have non-service-related medical conditions that require assistance with ADLs, c) asset limitations based on a sliding scale based on age, and d) medical expense to income ratio. Contact the VA for further information.
VA Health Care System Enrollees
A veteran enrolled in the VA health care system may be eligible for home and community-based service benefits, including home care. Contact the VA for further information.
Individuals who are eligible for Medicaid may have options to receive home care. Typically, this care is provided through the Statewide Medicaid Managed Care program (SMMC) or through Home and Community-Based Services (HCBS) Waiver Programs.
To learn more about Medicaid in Florida, visit the Agency for Health Care Administration’s website at the following URL: ahca.myflorida.com/Medicaid or enter the words “Florida Agency for Health Care Administration Medicaid” in a search engine.
Statewide Medicaid Managed Care
SMMC is the program where most Medicaid recipients receive their Medicaid services. Home care services are offered as a part of this program. Visit www.flmedicaidmanagedcare.com or call 1-877-711-3662 to talk to a choice counselor.
Home and Community-Based Services (HCBS) Waiver Programs
Several HCBS programs exist in Florida, such as Adult Cystic Fibrosis Waiver (ACF), Developmental Disabilities Individual Budgeting (
Learn more: https://ahca.myflorida.com/Medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/index.shtml or enter the words “Florida Agency for Health Care Administration Waivers” in your search engine.
Hopefully, this guide has given you some helpful information to better understand your home care options. Take your time to find the right home care provider for you, your family, or other loved ones in your life. Finding the right provider can make all the difference in their life—and yours.
Jonathan Marsh is an impassioned, compassionate professional with a vision of service and community. He now stands at the forefront of a company that is changing the very course of home care services.
After graduating from Florida State University, Jonathan built a career spanning 16 years. During those years, he consulted with some of the most recognizable Fortune 500 companies but also began to take stock of his personal journey. While his work had been deemed a success by industry standards, it left him feeling empty and often at odds with his own values and personal goals.
It was during this period of re-evaluation that Jonathan began to consider his best destiny. He reflected on the life of his grandmother, a strong and formative influence in his life. He remembers that during her life of 97 years, there were times when she needed regular care in her home but had no family or resources locally to provide that. Jonathan witnessed firsthand the sheer devastation that this can bring upon families in this situation. This realization, along with some deep consideration, extensive conversation and encouragement from friends inspired Jonathan to consider a new direction.
In January of 2015, with the formation of Home Helpers of Bradenton, Jonathan embarked on a lifelong dream of fulfilling his best destiny. With the formation of his home care agency, Jonathan now provides a resource to give compassionate,
Jonathan is a Certified Alzheimer’s Educator and holds a degree from Florida State University, College of Business. He has traveled extensively and enjoys sports and healthy living. His greatest desire is to give back to the community through helping others while creating jobs and providing exceptional service.
ACH: Automated Clearing House
ADL(s): Activities of Daily Living
AHCA: Agency for Health Care Administration
Basic ADLs: Eating, bathing, dressing, toileting, transferring (walking) and continence
Client: Person receiving care and/or Family Member
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DOL: Department of Labor
HCBS: Home and Community-Based Services
HCS: Homemaker and Companion Services
HHA: Home Health Agency
HR: Human Resources
Independent Contractor: A self-employed contractor or business owner as opposed to one of your employees. Also known as a 1099 contractor.
Instrumental ADLs: Activities requiring complex skills to live independently such as meal preparation, housekeeping, and laundry.
IRS: Internal Revenue Service
LPN: Licensed Practical Nurse
LTC: Long-Term Care
NR: Nurse Registry
OSHA: Occupational Safety and Health Administration
RN: Registered Nurse
SMMC: Statewide Medicaid Managed Care
VA: U.S. Department of Veteran Affairs
W-2 Employee: Payroll taxes are deducted by an employer and paid to the government.
