Pillar 07 of The Fain Standard

Private pay and private insurance only

No Medicaid, no Medicare. A firm brand rule, not a market limitation.

Why this is a pillar

FAINS serves private pay families and families with private long-term care insurance policies exclusively. We do not participate in Medicaid or Medicare. This is not because those payer sources are lesser. It is because our operating model, with weekly transparent invoicing, RN supervision on every case, and chemistry-matched staffing, cannot be delivered inside the reimbursement ceiling those programs set. Families needing Medicaid or Medicare services deserve a fit-for-purpose provider and we refer them to one.

Extended principle: why the payer-source discipline is a fit judgment, not a market judgment

The private pay and private insurance only pillar is the pillar that most often generates the question "why not." I want to answer that question directly, because the reason is worth understanding and because families deserve a plain answer rather than a corporate deflection.

FAINS serves private pay families and families with private long-term care insurance policies exclusively. We do not participate in Medicaid, including the New Jersey Managed Long Term Services and Supports program, and we do not participate in Medicare, including the Medicare Advantage home health benefit. This is not because those payer sources are lesser or because the families who rely on them are lesser. Both are legitimate payer categories serving families with real needs.

The reason is operational. The reimbursement rates that Medicaid and Medicare pay for home care services are set by regulation and are calibrated to a specific operating model. That model is not the FAINS operating model. Medicaid and Medicare home care programs generally assume higher caregiver-to-supervisor ratios, less frequent RN oversight, standardized care plans rather than customized ones, and a billing overhead that spreads administrative cost across a large volume of shorter visits. Agencies that operate under those payer sources have organized themselves to be delivery-efficient at those rates, and many of them do genuinely good work inside that structure.

The FAINS structure is different. A Registered Nurse Supervisor on every case, monthly live license verification, a human matcher who reads the plan of care before pulling candidates, four-hour minimum shifts that fund unbundled RN case supervision, weekly transparent invoicing with no coordination fees. Those commitments cost more per hour of care delivered than the Medicaid or Medicare reimbursement ceilings will support. If FAINS accepted those payer sources, we would either have to under-deliver on the operating pillars (which I refuse), cost-shift onto private pay clients to subsidize the reimbursed cases (which is dishonest), or run at a loss on the reimbursed cases (which is unsustainable and eventually catches up as a service degradation). None of the three is acceptable.

The pillar exists to protect the operating model. It is a firm brand rule, published on the front of the site, so families evaluating FAINS know before they call. It is not a bait-and-switch discovered on the intake conversation. And it is paired with a commitment to honest, specific referrals when Medicaid or Medicare is the right fit for a family, because the alternative (accepting the intake and then quietly disappointing the family) is worse for everyone.

Three composite case examples

The Union County referral to MLTSS. A daughter in Union County called FAINS on behalf of her mother, who was on Medicaid and eligible for the NJ Managed Long Term Services and Supports program. The daughter had heard about FAINS from a discharge planner and did not know the payer restriction. On the intake call, I confirmed the mother's Medicaid MLTSS eligibility, explained that FAINS is a private pay and private insurance agency, and named two MLTSS-participating home care agencies in her county whose reputations we know from operator networks. I gave her the direct number for the NJ Aging and Disability Resource Connection and a warm-referral option if she wanted me to contact one of the named agencies on her behalf. The call took twenty minutes. The daughter thanked me for the specificity of the referral and told me it was the first time an agency had turned her away by pointing her to a better fit rather than by hanging up.

The Morris County long-term care insurance case. A family in Morris County had a father with a long-term care insurance policy issued in the early 2000s, when policies were more generous than what is available today. The policy covered up to 60 hours per week of private duty home care with a $200 per day cap. The FAINS billing coordinator identified the carrier at intake, confirmed the carrier permitted assignment of benefits with the required documentation, and configured the weekly invoice format with the care summary and RN Supervisor signature the carrier required. The carrier paid directly on a 30-day cycle. The family paid a small share of the weekly invoice out of pocket for the hours above the daily cap and for the mileage line. Over the two-year arc of the case, the direct-pay setup saved the family the administrative burden of reimbursement submission on 100 weekly invoices.

The Somerset County private pay case with a Veterans benefit. A widow in Somerset County was eligible for the VA Aid and Attendance benefit as a surviving spouse. The benefit paid a monthly cash amount that covered a meaningful portion of her private duty budget. FAINS accepted her private pay funding, drawn from a combination of her Aid and Attendance benefit and personal savings, the same way we would accept any private pay funding. The RN Supervisor helped her think through the shift structure that maximized coverage during her highest-need hours, four hours in the afternoon rather than a longer, thinner schedule, and the pillar of a four-hour minimum aligned with the benefit budget in a way that worked without either being stretched.

How a family verifies this pillar is real

The payer-source discipline is easy to verify because it is stated plainly and consistently across every surface.

Confirm the payer-source policy on the intake call before providing any personal information. The person on the FAINS side should confirm the private pay and private insurance only policy without prompting. If your primary payer source is Medicaid or Medicare, you should hear that FAINS is not the fit and receive specific referrals within the first ten minutes of the call.

Ask for the referral list in writing if the fit is not right. The referral to a specific MLTSS-participating provider or a specific Medicare-certified home health agency should be nameable. The referral is not a corporate courtesy; it is part of the pillar commitment.

Read the service agreement for the payer-source language. The agreement states plainly that services are billed on a private pay or private long-term care insurance basis. If you signed the agreement believing Medicaid or Medicare would be billed, the agreement wins in legal effect and the discrepancy should be raised before signing.

Confirm the long-term care insurance direct-pay path with the carrier before assuming direct pay is available. The billing coordinator does this at intake, but a family who wants an independent verification can call the carrier and ask whether the policy permits assignment of benefits for a NJ Health Care Service Firm.

Notice the invoice format if long-term care insurance is being used. The invoice format for a long-term care insurance case is different from the format for a straight private pay case; it includes the additional documentation the carrier requires. If the invoice format has not changed to match the payer setup, the payer configuration has not been done and the reimbursement path will stall.

How this pillar interacts with the other six

The private pay and private insurance only pillar is what funds the operating structure of the other six. The RN Supervisor's bundled case management, the monthly license verification pipeline, the four-hour minimum shift that anchors caregiver scheduling and pay, the weekly transparent invoicing that eliminates coordination fees, the human matcher and zero-cost first-week swap, and the 24-hour cancellation window with a real on-call structure all depend on a revenue model that supports them. Pillar 7 is what makes Pillars 1 through 6 operationally sustainable.

The framework close

This is Pillar 7 of The Fain Standard. It is the pillar most likely to send a family to another provider, and I would rather that happen at the top of the intake call than three weeks into a case we could not deliver at the standard we published. The referral is the pillar working. The acceptance of a case that fits is also the pillar working. Both outcomes are the pillar doing its job.

Common questions

Why does FAINS not accept Medicaid or Medicare?

The FAINS operating model, with a Registered Nurse Supervisor on every case, monthly license verification, a human matcher, and weekly transparent invoicing, cannot be delivered inside the reimbursement ceiling those programs set. It is not a judgment on the payer sources. It is a fit judgment on our operating model. Families needing Medicaid or Medicare services deserve a fit-for-purpose provider and we refer them to one.

Which long-term care insurance carriers does FAINS work with?

FAINS works with any private long-term care insurance carrier whose policy permits payment for private duty home care under a Health Care Service Firm. We have processed reimbursement packages for most major carriers. Some carriers permit direct pay under assignment of benefits; some require the family to pay and submit for reimbursement. The billing coordinator identifies your carrier's process at intake and configures the invoice format accordingly.

Where do I go if I need Medicaid home care in New Jersey?

New Jersey Medicaid home care runs primarily through the Managed Long Term Services and Supports (MLTSS) program, administered by the state's Medicaid managed care organizations. The starting point is a call to the NJ Aging and Disability Resource Connection at 877-222-3737, or a call to the Office of Community Choice Options in the county where the person lives. FAINS keeps a current referral list at intake and can name a specific MLTSS-participating provider in your county.

What about Medicare Advantage plans that offer home care benefits?

Medicare Advantage home care benefits, when they exist, are typically for short-term post-acute care under a physician's order and are delivered by Medicare-certified home health agencies, not by Health Care Service Firms. FAINS is a Health Care Service Firm, not a Medicare-certified home health agency, and cannot bill Medicare directly. If a family is eligible for a Medicare Advantage home health benefit, that benefit should be used first and FAINS can supplement, on a private pay or long-term care insurance basis, for the hours beyond what Medicare covers.

Can I use a Veterans benefit to pay for FAINS?

The Veterans Aid and Attendance benefit, when the veteran or surviving spouse qualifies, is a monthly cash benefit paid directly to the veteran and can be used at the veteran's discretion for private duty home care. FAINS accepts payment funded by Aid and Attendance the same way we accept private pay. We do not bill the VA directly.

Is there a payment assistance option if the family cannot afford full private rates?

FAINS does not offer sliding-scale or subsidized rates. Our published rates are the rates. If the private pay budget is insufficient for the level of care needed, the RN Supervisor can help the family think through the coverage window strategically (for example, four hours a day of professional care rather than eight hours a day, with family covering the remaining hours) and can name lower-cost service models as referrals when appropriate.

Does the private pay commitment affect who my caregiver is?

Yes, indirectly. Private pay funding is what allows FAINS to compensate caregivers at a rate that attracts and retains license-verified, chemistry-matched caregivers who choose private duty over other employment options. The caregivers on the FAINS roster are on the roster in part because our payer-source discipline funds the wage and working-condition commitments we make to them.