Shrinking Medicare Home Health Coverage: It’s Time to Act

62 million older Americans and people with disabilities rely on Medicare to finance their health care. For this large segment of the population, when Medicare coverage is unavailable or denied, access to health care is also often denied.

Especially since the COVID pandemic, commentators and policymakers reiterate the need and preference for home-based, rather than institutional, health care. Medicare can be a valuable resource to pay for home health care for people who meet the legal qualifying criteria. The Medicare benefit includes home health aide services, defined as hands-on personal care, that allows people to live safely at home. The law authorizing Medicare coverage for home health care and home health aides has not been changed or circumscribed in years. However, payment models and implementation have changed over time, and the ability to obtain Medicare-covered home health and home health aide care, has greatly declined. This is true even when individuals meet the law’s threshold homebound and skilled care requirements – and qualify for Medicare coverage.

Sadly, and incorrectly, Medicare beneficiaries are often told the only aide care they can get is a bath, only a few times a week, for a short period of time. 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.

In fact, Medicare law authorizes up to 28 to 35 hours a week of home health aide and nursing services combined. 42 USC 1395x(m)(1)-(4). Medicare is also available for home health aides if the individual receives physical therapy, speech language pathology therapy, and sometimes, occupational therapy. While personal hands-on care does include bathing under the law, 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). (See also, Medicare Benefits Policy Manual, Chapter 7, §§50.1 and 50.2.)

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 2021 MedPAC reported that home health aide visits per 60-day episode of home care declined by 90% from 1998 to 2019, from an average of 13.4 visits per episode to 1.3 visits.  As a percent of total visits from 1997 to 2019, home health aides declined from 48% of total services to 6%. (March 2021 MedPAC Report to Congress, page 245 and March 2019 MedPAC Report to Congress, p. 234.)

The real, personal, impact of this reduced access to home health aides was 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).[1] The article includes stark 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 home care through Medicare, it is likely that far more qualify than are able to access 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.” A May 2019 Johns Hopkins Bloomberg Study also found that people with limitations in activities of daily living (ADLs) experience significant harm when they cannot access adequate help with ADLs at home.[2]

In fact, the problem is two-fold:

1. The Medicare home health benefit is being unfairly and inaccurately articulated and administered. 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 implemented in 2019 allowing private Medicare Advantage (MA) plans to provide personal care services for their enrollees without a homebound or skilled care requirement. (CMS Calendar Year 2019 Final Call Letter, Health Related Supplemental Benefits, p. 207-208.) 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 for people to join private limited-network MA plans.

Conclusion

Congress should address the lack of access to Medicare-covered home health and home health aide care.

1. Congressional hearings or other public 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 necessary 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. Such a benefit will keep many people out of institutions and help them remain safely at home.

Most people want to remain home when they need longer-term services and supports. In most instances, as we’ve learned from the pandemic, it’s also better for the community’s public health for people to stay out of institutions – if they can do so safely and with a quality of life.  It’s time to make sure people who rely on Medicare to access care can obtain the home and community-based services they need.

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[1] See also, Kaiser Health News, “Home Care Agencies Often Wrongly Deny Medicare to Chronically Ill,” Susan Jaffe (1/18/2018), https://khn.org/news/home-care-agencies-often-wrongly-deny-medicare-help-to-the-chronically-ill/.
[2] https://www.eurekalert.org/pub_releases/2019-05/jhub-msh_1052819.php