Home Health Aide Coverage Continues to Shrink: Attention Must Be Paid

As we have reported in the past, the ability to get Medicare-covered home health aide care has greatly declined in recent years. This is true even when individuals meet the law’s homebound and skilled care requirements – and thus qualify for coverage. Sadly, and incorrectly, Medicare beneficiaries are often told the only aide care they can get is a bath, and only a few times a week. Sometimes they are told Medicare simply does not cover home health aides. The Center has even heard of an individual being told he could not receive home health aide care because he was “over income” – although Medicare has no such income limit (see case study in separate article below).
In fact, Medicare law authorizes up to 28 to 35 hours a week of home health aide (personal hands-on care) and nursing services combined. 42 USC 1395(m)(1)-(4). While personal hands-on care does include bathing, it also includes dressing, grooming, feeding, toileting, and other key services to help an individual remain healthy and safe at home. 42 CFR 409.45(b)(1)(i)-(v).
This level of home health aide personal care used to be available. The Center helped many clients remain at home because these services were in place, but now such care is almost never obtainable. Statistics demonstrate this point. In 2018 MedPAC reported that home health aide visits per 60-day episode of home care declined by 87% from 1998 to 2016, from an average of 13.4 visits per episode to 1.8 visits. As a percent of total visits from 1997 to 2016, home health aides declined from 48% of total services to 10%. (MedPAC Report to Congress, p. 246, March 2018.)
The real, personal, impact of this reduced access to home health aides has recently been made clear in a Kaiser Health News article, (Judith Graham, Seniors Aging In Place Turn To Devices And Helpers, But Unmet Needs Are Common, 2/14/2019). The article includes striking findings about the unmet needs of vulnerable Americans struggling to live at home with little or no help. For example:

• “About 25 million 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.”
• “Nearly 60 percent of seniors with seriously compromised mobility reported staying inside their homes or apartments instead of getting out of the house. Twenty-five percent said they often 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.”
• “60 percent of the seniors surveyed used at least one device, most commonly for bathing, toileting and moving around. (Twenty percent used two or more devices and 13 percent also received some kind of personal assistance.)
• Five percent had difficulty with daily tasks but didn’t have help and hadn’t made other adjustments yet.”

While it isn’t clear how many of these individuals should be receiving needed help through Medicare, it is likely that far more qualify than are accessing the benefit, since the surveyed population was 65 or older and infirm. Indeed, the author states “The problem, experts note, is that Medicare doesn’t pay for most of these non-medical services, with exceptions.”
In fact, the problem is two-fold:

1. The Medicare home health benefit is being unfairly and inaccurately articulated and administered.
• Even the government’s information on Medicare.gov includes “personal care” in the list of what Medicare does not pay for. (https:/www.medicare.gov/coverage/home-health-services)
• Medicare-certified home health agencies have all but stopped providing necessary, legally authorized home health aide personal care, even when patients are homebound and receiving the requisite nursing or therapy to trigger coverage.

2. Instead of correcting this harmful misapplication of Medicare coverage for all beneficiaries, CMS issued a new policy in 2018 allowing private Medicare Advantage (MA) plans to provide personal care services for their enrollees without a homebound or skilled care requirement. (CMS Memo, Reinterpretation of “Primarily Health Related” for Supplemental Benefits, April 27, 2018.) This is ironic and unjust given the restrictive interpretation of the Medicare home health benefit in general, and the obliteration of home health aide coverage in particular.

While it remains to be seen how much this stand-alone MA personal care benefit will actually be offered and provided, it continues the trend of discriminating against the majority of beneficiaries, who are enrolled in traditional Medicare. It also adds to the myriad enticements from CMS for people to join private MA plans.
Conclusion
Congress should address this inequity as soon as possible.

1. Hearings or other action should be taken to ensure CMS and Medicare-certified home health agencies are interpreting and administering the current home health benefit as provided by law. Individuals who are homebound, receiving skilled care, and in need of home health aide/personal hands-on care should be able to receive the full array of care authorized by law.
2. Further, all Medicare beneficiaries, not just those enrolled in Medicare Advantage plans, should be able to receive Medicare coverage for necessary home health aide care even if they are not homebound or require skilled nursing or therapy.