Does Medicare Take All Of Your Money Before They Will Pay For Home Health Care

Medicare dwelling wellness coverage can exist an important resource for Medicare beneficiaries who demand health care at domicile. When properly implemented, the Medicare home wellness benefit provides coverage for a constellation of skilled and nonskilled services, all of which add to the health, rubber, and quality of life of beneficiaries and their families. Nether the law, Medicare coverage is available for people with acute and/or chronic conditions, and for services to improve, or maintain, or slow decline of the individual's condition. Further, coverage is available even if the services are expected to continue over a long menstruation of fourth dimension.^[1]

Unfortunately, however, people who legally qualify for Medicare coverage frequently have great difficulty obtaining and affording necessary home care. There are legal standards that define who tin obtain coverage, and what services are bachelor. However, the criteria are often narrowly construed and misrepresented past providers and policy-makers, resulting in inappropriate barriers to Medicare coverage for necessary care. This is increasingly true for home health aide services – the very kind of personal care services vulnerable people frequently need to remain safely at home.

A. The Law: What Home Care Is Covered Nether the Medicare Act? ^[2]

Home health access problems have ebbed and flowed over the years, depending on the reigning payment model, systemic pressures, and misinformation about Medicare home health coverage. Regrettably, these problems are increasing and, if current and proposed policies and practices continue, they will only go worse. Appropriately, it is important to know what Medicare abode wellness coverage should exist under the police force, especially for people with longer-term, chronic, and debilitating weather.

1. Medicare Home Wellness Qualifying Criteria

Medicare covers dwelling health services under both Parts A and B when the services are medically "reasonable and necessary," and when:^[iii]

A doc or other authorized practitioner has established a programme of care for furnishing the services that is periodically reviewed as required;
The individual is confined to home (commonly referred to every bit "homebound"). This criterion is generally met if non-medical absences from domicile are infrequent, and leaving dwelling house requires a considerable and taxing endeavor, which may be shown by the patient needing personal assistance or the aid of an assistive device, such as a wheelchair or walker.. (Occasional "walks effectually the block" are allowable. Attendance at an adult 24-hour interval care center, religious services, or a special occasion is not a bar to meeting the homebound requirement.);
The individual needs skilled nursing care on an intermittent basis, or physical therapy or speech-language pathology (or, in the example of an private who has been furnished home wellness services based on such a demand, only no longer requires skilled nursing care or physical or speech therapy, the individual continues to need occupational therapy); and
Such services are furnished by, or under arrangement with, a Medicare-certified home wellness bureau.^[4]

two. Medicare-Covered Dwelling house Health Services

If the qualifying conditions described above are satisfied, Medicare coverage is bachelor for an array of domicile health services. Home health services that tin can be covered by Medicare include:^[5]

Part-fourth dimension or intermittent nursing care provided by or under the supervision of a registered professional nurse;
Physical therapy, spoken communication-language pathology, and occupational therapy;
Office-time or intermittent services of a home health adjutant;
Medical social services; and
Medical supplies.

As described higher up, skilled nursing, concrete therapy, and oral communication-language pathology services are defined equally "qualifying skilled services" for the purpose of establishing eligibility for Medicare habitation health coverage.^[6] A patient must initially require and receive one of these skilled services in order to receive Medicare for other covered home health services.^[7] Home wellness adjutant, medical social worker, and occupational therapy services^[viii] are defined every bit "dependent services," (dependent upon a skilled service being in identify) equally are certain medical supplies.^[nine] While occupational therapy is not considered a skilled service to brainstorm Medicare domicile wellness coverage, if the individual was receiving skilled nursing, physical or oral communication therapy, merely those services end, coverage tin can go along if occupational therapy continues.^[10]

The term "part-time or intermittent" means skilled nursing and dwelling house health aide services furnished any number of days per calendar week equally long every bit they are provided less than 8 combined hours each twenty-four hours and 28 or fewer hours each week (or, subject to review on a instance-by-case basis every bit to the need for intendance, less than 8 hours each day and 35 or fewer hours per week).[eleven]

M3. Medicare Home Wellness Coverage Can be Long Term

Importantly, and contrary to what is often stated, Medicare home health coverage is non just a short-term, astute care benefit.^[12]

There is No Duration of Time Limit for Medicare Domicile Health Coverage

So long every bit the law'due south qualifying criteria are met, coverage can proceed for an unlimited number of visits. "to the extent that all coverage requirements specified in this subpart are met, payment may be made on behalf of eligible beneficiaries … for an unlimited number of covered visits."

(42 CFR §§409.48(a)-(b); Medicare Benefit Policy Manual, Chapter 7, §70.i)

B. The Reality: Admission to Medicare Coverage and Dwelling house Care is Limited

The Center for Medicare Advancement hears regularly from people who meet Medicare coverage criteria but are unable to admission Medicare-covered home health care, or the appropriate amount of care.

In detail, people living with longer-term and debilitating conditions notice themselves facing meaning access problems. For case, patients have been told Medicare will only cover one to five hours per week of domicile health aide services, or for just i bath per week, or that they aren't homebound (because they roam outside due to dementia), or that their condition must first reject earlier therapy can commence (or recommence). Consequently, these individuals and their families struggle with too little care, or no care at all.

As reported in Health Affairs in Nov 2019: ^[13]

When asked how much costs had burdened their family, 25 percent of the seriously sick said that costs were a major brunt, and 30 pct said that they were a minor brunt… When asked about getting help in recent years, 60 percent said that family members and friends helped a lot, 25 percent said that they helped a little, and fourteen percent said that they provided no help. Family members and friends experienced considerable strain as a consequence of providing help, including fiscal problems, lowered income, and lost or changed jobs or reduced hours. Twenty-nine percent of respondents said that there was a time when they did not get outside help because of cost.

As reported in Health Affairs in November 2019: ^[13]

The Middle for Medicare Advocacy has been contacted by Medicare beneficiaries and their families from all over the country who are trying to obtain sufficient home wellness intendance to help improve or maintain their condition and remain safely at home. Here is i example that typifies what we hear:

My dad is in the end stages of Parkinson's illness and has qualified for home health aide treat 2 hours per week through Medicare. He should accept 24/7 care, however, the financial burden for paying for home health care is too much for united states – and the boilerplate family. Nosotros were shocked to hear from abode health agencies that Medicare only covers a few hours per calendar week. We would like to see changes to let more coverage for individuals living with a long term, progressive, final disease.

As geriatrician Dr. Laurie Archbald-Pannone states, "While family caregivers truly do selflessly requite of themselves in the care of others, they need more than than our recognition of their work. They demand the Medicare system to provide appropriate resources for the care of their family members."^[14] (Emphasis added.)

C. Access to Medicare-Covered Home Wellness Aides is Shrinking

Assistance with personal hands-on care is key to the well-being of patients, equally well as their families and caregivers. Unfortunately, access to Medicare coverage for such care has declined. This is truthful even when individuals have an order and run across the police force'southward homebound and skilled intendance requirements – and thus qualify for coverage. Unfortunately, Medicare beneficiaries are often misinformed. They are told they can only become home health aides a few times a calendar week, for a short time, and/or only for a bathroom. Sometimes they are told Medicare simply does not encompass domicile wellness aides. The Center for Medicare Advocacy has fifty-fifty heard of an individual being told he could not receive home health adjutant coverage because he was "over income" – although Medicare has no income limit.

As noted to a higher place, under the law Medicare authorizes up to 28 to 35 hours a week of home wellness aide (personal hands-on care) and nursing services combined.^[15] While personal hands-on care does include bathing, it besides includes dressing, grooming, feeding, toileting, and other cardinal services to help an individual remain healthy and safe at habitation.^[16] In the past, this level of domicile health aide coverage was actually available. Indeed, the Middle for Medicare Advocacy has helped many clients remain at habitation considering these services were in identify.

Currently, however, this level of coverage and care is almost never obtainable. Data demonstrate this dramatic change in coverage. In 2019 the Medicare Payment Informational Commission (MedPAC) reported that dwelling house health aide visits per 60-twenty-four hour period episode of home care declined by 88% from 1998 to 2017, from an average of thirteen.4 visits per episode to i.6 visits. As a percent of total visits from 1997 to 2017, dwelling health aides declined from 48% of total services to ix%.^[17]

The real, personal impact of this reduced admission to habitation health aides was highlighted in a 2019 Kaiser Health News commodity.^[xviii] The commodity includes stark findings about the unmet needs of vulnerable Americans struggling to live at home with little or no aid. For example:

"Near 25 meg Americans who are aging in place rely on help from other people and devices such as canes, raised toilets or shower seats to perform essential daily activities, according to a new study documenting how older adults adapt to their changing physical abilities."
"Well-nigh threescore per centum of seniors with seriously compromised mobility reported staying within their homes or apartments instead of getting out of the business firm. Twenty-five percent said they ofttimes remained in bed. Of older adults who had significant difficulty putting on a shirt or pulling on undergarments or pants, 20 percent went without getting dressed. Of those who required assistance with toileting issues, 27.9 percent had an accident or soiled themselves."
"threescore percent of the seniors surveyed used at to the lowest degree one device, almost commonly for bathing, toileting and moving around. (Twenty percent used ii or more devices and xiii per centum also received personal help.)" and
Five percent had difficulty with daily tasks simply didn't have help and hadn't made other adjustments even so."

The Medicare dwelling house health benefit is misunderstood, inaccurately articulated, and narrowly implemented. Medicare-certified habitation health agencies have all simply stopped providing necessary, legally-authorized home health adjutant services, even when patients are homebound and are receiving the requisite skilled nursing or therapy to trigger coverage. The Centers for Medicare & Medicaid Services (CMS) does not monitor or rebuke agencies for failure to provide this mandated and necessary care.

As Dr. Archbald-Pannone notes,

"As a geriatrician, every week I meet patients who are fortunate enough to have family unit who are able to provide medical care and back up. Notwithstanding, I also see more patients who do not accept family available to provide total care, are in desperate need of more home care support, just cannot beget the toll tag … Without in-home care, we're leaving our family unit members lone and at risk. … We may not exist available to stay abode with them, but Medicare should back up trained intendance aides who tin can be."[19]

When Medicare doesn't cover in-home intendance, patients and families often must go without. Those who can afford to, pay out-of-pocket, from savings, or with credit cards. Others, who are, or become, poor (often due to health care costs) expect to their country'southward depression-income Medicaid program for aid. Thus, costs are regularly shifted to people in demand and, for those who are dually eligible for Medicaid likewise as Medicare, to state Medicaid programs. The needs and costs of caring for people who are dually eligible are substantial:

In 2018, in that location were 12.2 1000000 individuals simultaneously enrolled in Medicare and Medicaid. These dually eligible individuals feel high rates of chronic affliction, with many having long-term care needs and social adventure factors. Twoscore-ane percent of dually eligible individuals have at to the lowest degree i mental wellness diagnosis, 49 percentage receive long-term care services and supports (LTSS), and lx pct have multiple chronic conditions. Eighteen percent of dually eligible individuals report that they have "poor" health status, compared to six per centum of other Medicare beneficiaries.^[20]

In summary, as the authors in the November 2019 Health Diplomacy article concluded:^{^[21]}

"Medicare insurance is broadly popular, simply seriously ill beneficiaries who most need financial protection report widespread problems affording care and financial instability."

The damage to Medicare beneficiaries and their families would be greatly reduced if home wellness adjutant coverage was provided as intended by law. As information technology is, admission to aid with personal care and activities of daily living is minimal. ^[22]

D. Impact of Caregivers on Access to Medicare Home Wellness Coverage

Medicare does not cover or help to pay for family caregivers, but the fact that caregivers are – or are not – available, willing, or able to serve as caregivers frequently interferes with a beneficiary'southward power to obtain Medicare-covered in-domicile intendance. On the one mitt, beneficiaries and their families may exist told that a home health agency will not provide care because it is not safety for the individual to remain at dwelling house without a caregiver available. On the other hand, when a family unit caregiver is available, patients may exist told that, as a issue, Medicare will not embrace in-home intendance since that caregiver should provide the care.

CMS Do good Policy Manual, Chapter 7

20.2 – Affect of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services (Rev. 208, Issued: 04-22-15, Effective: 01-01-xv, Implementation: 05-xi-xv) Where the Medicare criteria for coverage of home health services are met, patients are entitled by law to coverage of reasonable and necessary home health services. Therefore, a patient is entitled to have the costs of reasonable and necessary services reimbursed by Medicare without regard to whether there is someone bachelor to furnish the services. Even so, where a family member or other person is or will be providing services that adequately meet the patient'southward needs, it would non be reasonable and necessary for HHA personnel to furnish such services. Ordinarily information technology can be presumed that there is no able and willing person in the home to provide the services being rendered by the HHA unless the patient or family indicates otherwise and objects to the provision of the services past the HHA, or unless the HHA has get-go-paw knowledge to the contrary.

EXAMPLE 1: A patient who lives with an adult daughter and otherwise qualifies for Medicare coverage of habitation health services, requires the assistance of a habitation health adjutant for bathing and assistance with an practise program to amend endurance. The girl is unwilling to bathe her elderly father and assist him with the practice program. Domicile health aide services would be reasonable and necessary. …

EXAMPLE 3: A patient who needs skilled nursing care on an intermittent basis also hires a licensed applied (vocational) nurse to provide dark assistance while family members slumber. The intendance provided by the nurse, as respite to the family members, does not require the skills of a licensed nurse (every bit defined in §40.ane) and therefore has no impact on the beneficiary's eligibility for Medicare payment of home health services fifty-fifty though another third political party insurer may pay for that nursing care.

In fact, neither of these is true. Medicare coverage is non dependent on whether there is or is non a family caregiver – or other caregiver – available. Medicare beneficiaries are eligible for Medicare-covered home care regardless of whether they do or do non have family or other caregivers in identify.

Every bit federal regulations country, amidst other requirements, services must "[b]e of a type that in that location is no able or willing caregiver to provide, or, if at that place is a potential caregiver, the casher is unwilling to employ the services of that individual."^[23] Indeed, CMS's ain Medicare Policy Manual confirms that beneficiaries are entitled to take the costs of reasonable and necessary services reimbursed past Medicare without regard to whether there is someone available to furnish the services. The CMS Policy Manual states, "usually it can be presumed that at that place is no able and willing person at home to provide services rendered by the home wellness aide or other home wellness personnel." (Accent added.)^[24]

Due east. Medicare's Home Health Payment System Influences Access to Care

On January 1, 2020, CMS implemented a new Medicare payment system for home health services called the "Patient Driven Groupings Model" (PDGM). PDGM changed dwelling house health agencies' financial incentives and disincentives to admit or continue intendance for Medicare beneficiaries.^[25] Unfortunately, the financial motivations are oftentimes harmful to vulnerable beneficiaries, particularly those with chronic atmospheric condition and longer-term health intendance needs. Although CMS has stated that "PGDM relies more heavily on clinical characteristics,"[26] such as functional levels and co-morbidities, the well-nigh significant components of PDGM consider admission source and timing, not patient needs.

PDGM'south financial incentives include higher rates for the first 30 days of abode care. Payments are also college for beneficiaries who are admitted later an inpatient institutional stay (hospitals and skilled nursing facilities), and lower for those admitted from the community. (The "customs" category includes hospital outpatients, including hospitalized patients in "Observation Status," too every bit patients who outset intendance from home, without a prior hospital or SNF stay.) The new payment model as well reduced the billing menses from lx days to 30 days, encouraging shorter periods of intendance. Additionally, PDGM lowered the fiscal incentive to provide physical, occupational or spoken language language pathology therapy by removing therapy service utilization payment thresholds.

The new Medicare payment arrangement and shift in fiscal incentives have reduced access to necessary care.[27] Home Health Intendance News reports that "[s]tories of widespread layoffs of PTs, OTs and SLPs persist — and now new reports of agencies incorrectly telling their patients that Medicare no longer covers therapy under the habitation health do good…" ^[28] Reductions in skilled therapy do non but harm the individual who needs that care; they can as well end admission to dwelling house wellness aides, because adjutant coverage is dependent on the individual besides receiving skilled therapy or nursing.

In response to misinformation and service changes in lite of PDGM, CMS released a special edition Medicare Learning Network (MLN) Matters article on Feb 10, 2020.^[29] The MLN made clear that, while the reimbursement system had changed, Medicare coverage law and rules had not:

Home health services can continue every bit long as individuals run across the Medicare coverage criteria; and Medicare domicile health coverage and service rules have not changed;
Beneficiaries tin can receive home health services to ameliorate their status, and to maintain their electric current status, or to ho-hum or prevent further decline.²⁹

"… [E]ligibility criteria and coverage for Medicare abode wellness services remain unchanged. … as long every bit the individual meets the criteria for abode health services as described in the regulations at 42 CFR 409.42, the individual can receive Medicare habitation health services, including therapy services. … Citing to the Jimmo five. Sebelius Settlement Agreement, the MLN also states "there is no improvement standard under the Medicare home wellness benefit and therapy services can be provided for restorative or maintenance purposes." (Emphasis added.)

Determination

All besides oftentimes, older adults and people with disabilities are unfairly denied access to necessary, Medicare-covered home health care. As a outcome, they and their families suffer. The Center for Medicare Advocacy urges CMS and its contractors to ensure that Medicare beneficiaries obtain the Medicare home health coverage and necessary services they qualify for under the law.

[ane] 42 C.F.R §408.48(a)-(b); MBP Manual, Ch. 7, §§401.1 and 70.one. See, Jimmo five. Sebelius, No. xi-cv-17 (D.Vt.), filed Jan xviii, 2011; Settlement 2013; Corrective Action Plan 2017. Come across, https://medicareadvocacy.org/medicare-info/comeback-standard/. Meet, https://www.cms.gov/Middle/Special-Topic/Jimmo-Centre.
[ii] For a fuller discussion of Medicare home health coverage, see, Chiplin Jr., Alfred, Stein, Judith, Medicare Handbook, Affiliate 4, Abode Health Coverage, (Wolters Kluwer, 2020; updated annually).
[3] 42 United statesC. §1395f(a)(2)(C); 42 C.F.R. §§409.42 et seq.
[4] 42 U.S.C. §1395x(m).
[five] 42 U.S.C. §1395x(thousand)(i)–(4).
[vi] 42 C.F.R. §409.42.
[7] 42 C.F.R. §409.44.
[viii] Occupational therapy services can be either a qualifying service or a dependent service. Occupational therapy services that are not qualifying services nether 42 C.F.R. §409.44(c) can exist covered as dependent services if the requirements of reasonableness and necessity are met. 42 C.F.R. §409.45.
[9] 42 C.F.R. §409.45.
[10] 42 C.F.R. §409.42(c)(4); Medicare Beneficiary Policy Manual, Ch. 7, §30.4.
[11] 42 U.S.C. § 1361(m).
[12] 42 C.F.R §§409.48(a)-(b); Medicare Beneficiary Policy Manual, Ch. 7, §§40,one.1 and 70.one.
[xiii] Wellness Affairs, "Financial Hardships of Medicare Beneficiaries With Serious Disease" by Kyle, Blendon, et al, Vol. 38, No. eleven, pp. 1801-1806 (November 2019). Annotation: The authors define "serious illness" equally individuals "reported having a serious affliction or condition that, over the past three years, had required 2 or more hospital stays and visits to three or more than physicians." p. 1802.
[14] The Colina, "Family Caregivers Need Support, Medicare Should Embrace In-Home Aides" by Laurie Archbald-Pannone, Md (November 15, 2019), available at: https://thehill.com/stance/healthcare/470677-family-caregivers-need-support-medicare-should-cover-in-home-care-aides.
[15] 42 U.Due south.C. §1395x(m)(1)-(4). Note, receipt of skilled therapy can also trigger coverage for home health aides.
[sixteen] 42 CFR §409.45(b)(1)(i)-(5). See also, Medicare Benefits Policy Manual, Chapter 7, §§50.i and l.2.
[17] Medicare Payment Advisory Committee (MedPAC), "Report to Congress: Medicare Payment Policy" (March 2019), Ch. 9, pp. 234-235, bachelor at: http://world wide web.medpac.gov/docs/default-source/reports/mar19_medpac_ch9_sec_rev.pdf?sfvrsn=0.
[18] Kaiser Health News, "Seniors Crumbling In Place Plow To Devices And Helpers, But Unmet Needs Are Mutual" by Judith Graham (Feb fourteen, 2019), bachelor at: https://khn.org/news/seniors-aging-in-place-turn-to-devices-and-helpers-simply-unmet-needs-are-common/. Encounter also, Kaiser Wellness News, "Home Care Agencies Often Wrongly Deny Medicare to Chronically Ill," Susan Jaffe (1/18/2018), https://khn.org/news/home-intendance-agencies-oft-wrongly-deny-medicare-help-to-the-chronically-ill/.
[19] The Colina, "Family Caregivers Need Support, Medicare Should Cover In-Home Aides" by Laurie Archbald-Pannone, MD (Nov 15, 2019), available at: https://thehill.com/opinion/healthcare/470677-family unit-caregivers-need-support-medicare-should-encompass-in-habitation-intendance-aides.
[twenty] Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Part, Fact Sheet: "People Dually Eligible for Medicare and Medicaid" (March 2020), available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Role/Downloads/MMCO_Factsheet.pdf.
[21] Health Affairs, "Financial Hardships of Medicare Beneficiaries With Serious Disease" past Kyle, Blendon, et al, Vol. 38, No. eleven, pp. 1801-1806 (November 2019).
[22] See besides, Johns Hopkins University Bloomberg School of Public Health study that also finds people with limitations in activities of daily living (ADLs) experience significant impairment when they cannot access acceptable help with ADLs at dwelling house. "Medicare Spending and the Adequacy of Support with Daily Activities in Community-Living Older Adults with Inability" by Jennifer L. Wolff, Lauren H. Nicholas, Amber Willink, John Mulcahy, Karen Davis and Judith D. Kasper, Commonwealth Fund and National Institutes on Aging (May 2019), as reported by American Association for the Advocacy of Science (AAAS) EurekAlert website at: https://world wide web.eurekalert.org/pub_releases/2019-05/jhub-msh_1052819.php.
[23] 42 C.F.R. §409.45(b)(ii)(three).
[24] CMS, Medicare Benefit Policy Manual, Ch. 7, Sec. 20.2, "Affect of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Domicile Health Services"(updated April 22, 2015).
[25] See, Center for Medicare Advocacy "Abode Health Exercise Guide: Medicare Home Health Coverage and Care Is Jeopardized By the New Payment Model – The Center for Medicare Advocacy May Be Able to Assistance" (Jan. 7, 2020) available at: https://medicareadvocacy.org/dwelling house-health-exercise-guide/; also see, e.g., Center for Medicare Advocacy Weekly Alert "Medicare Coverage of Home Health Care Has Non Inverse Under the New Payment System (PDGM)" (February. 20, 2020), available at: https://medicareadvocacy.org/medicare-coverage-of-abode-health-care-has-non-changed-nether-the-new-payment-system-pdgm/.
[26] https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.
[27] https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Cess-Instruments/HomeHealthQualityInits; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/HHVBP.
The Medicare payment structure creates incentives for domicile health agencies to provide treat beneficiaries with shorter-term, post-acute care conditions. Farther, CMS policies and practices create barriers to Medicare-covered home intendance for people with longer-term and chronic conditions.
These barriers and incentives include:
* Inaccurate and/or incomplete training for entities that make Medicare coverage determinations;
* Domicile Wellness Quality Reporting Program (HHQRP);
* Home Wellness Value Based Purchasing (HHVBP) Models;
* Role of Inspector General, Medicare Contractor, and other audits of Dwelling house Health Agencies pointing to so-chosen "overutilization".
[28] Home Health Intendance News, "CMS Watching Home Health Providers Closely Amongst Shifting Therapy Strategies" by Robert Holly, (Feb. 12, 2020), available at: https://homehealthcarenews.com/2020/02/cms-watching-home-health-providers-closely-amidst-shifting-therapy-strategies/.
[29] CMS, MLN Matters article "The Office of Therapy nether the Dwelling Health Patient-Driven Groupings Model (PDGM)", Number: SE20005 (Feb. x, 2020), available at: https://world wide web.cms.gov/files/certificate/se20005.pdf.