What Home Care Services Are Covered By Medicare

Medicare dwelling health coverage tin be an important resource for Medicare beneficiaries who need wellness care at home. When properly implemented, the Medicare dwelling health benefit provides coverage for a constellation of skilled and nonskilled services, all of which add together to the wellness, safety, and quality of life of beneficiaries and their families. Under the law, Medicare coverage is available for people with astute and/or chronic atmospheric condition, and for services to amend, or maintain, or wearisome decline of the private'southward condition. Farther, coverage is bachelor even if the services are expected to continue over a long period of time.^[1]

Unfortunately, nonetheless, people who legally qualify for Medicare coverage ofttimes have dandy difficulty obtaining and affording necessary home intendance. In that location are legal standards that ascertain who can obtain coverage, and what services are available. However, the criteria are oft narrowly construed and misrepresented by providers and policy-makers, resulting in inappropriate barriers to Medicare coverage for necessary intendance. This is increasingly true for home health aide services – the very kind of personal intendance services vulnerable people oft need to remain safely at abode.

A. The Law: What Home Intendance Is Covered Nether the Medicare Human activity? ^[two]

Home health access problems accept ebbed and flowed over the years, depending on the reigning payment model, systemic pressures, and misinformation almost Medicare abode wellness coverage. Regrettably, these problems are increasing and, if current and proposed policies and practices continue, they will only become worse. Accordingly, information technology is important to know what Medicare home wellness coverage should exist under the law, especially for people with longer-term, chronic, and debilitating conditions.

1. Medicare Habitation Health Qualifying Criteria

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

A physician or other authorized practitioner has established a plan of intendance for furnishing the services that is periodically reviewed as required;
The individual is confined to home (commonly referred to as "homebound"). This criterion is generally met if non-medical absences from home are infrequent, and leaving domicile requires a considerable and taxing effort, which may exist shown by the patient needing personal assistance or the help of an assistive device, such every bit a wheelchair or walker.. (Occasional "walks effectually the block" are allowable. Attendance at an adult mean solar day care center, religious services, or a special occasion is not a bar to coming together the homebound requirement.);
The individual needs skilled nursing care on an intermittent basis, or concrete therapy or spoken communication-language pathology (or, in the instance of an individual who has been furnished home health services based on such a need, but no longer requires skilled nursing care or physical or speech therapy, the private continues to need occupational therapy); and
Such services are furnished by, or under arrangement with, a Medicare-certified home wellness agency.^[4]

2. Medicare-Covered Domicile Health Services

If the qualifying atmospheric condition described higher up are satisfied, Medicare coverage is bachelor for an array of home health services. Abode health services that can be covered by Medicare include:^[5]

Part-time or intermittent nursing care provided past or nether the supervision of a registered professional nurse;
Physical therapy, speech-language pathology, and occupational therapy;
Part-time or intermittent services of a home wellness aide;
Medical social services; and
Medical supplies.

Every bit described to a higher place, skilled nursing, physical therapy, and speech-linguistic communication pathology services are defined equally "qualifying skilled services" for the purpose of establishing eligibility for Medicare dwelling wellness coverage.^[6] A patient must initially require and receive one of these skilled services in society to receive Medicare for other covered home wellness services.^[7] Home health aide, medical social worker, and occupational therapy services^[8] are defined as "dependent services," (dependent upon a skilled service being in place) equally are certain medical supplies.^[ix] While occupational therapy is not considered a skilled service to begin Medicare home wellness coverage, if the individual was receiving skilled nursing, physical or speech communication therapy, merely those services end, coverage can continue if occupational therapy continues.^[x]

The term "role-time or intermittent" ways skilled nursing and home health aide services furnished any number of days per calendar week equally long as they are provided less than 8 combined hours each day and 28 or fewer hours each week (or, subject to review on a case-by-example basis equally to the demand for care, less than eight hours each twenty-four hour period and 35 or fewer hours per week).[11]

M3. Medicare Home Health Coverage Tin can be Long Term

Importantly, and contrary to what is oftentimes stated, Medicare home health coverage is not but a short-term, acute care benefit.^[12]

There is No Elapsing of Time Limit for Medicare Home Health Coverage

So long as the constabulary'south qualifying criteria are met, coverage tin can continue 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 Transmission, Affiliate seven, §70.1)

B. The Reality: Access to Medicare Coverage and Habitation Care is Limited

The Center for Medicare Advancement hears regularly from people who meet Medicare coverage criteria simply are unable to access Medicare-covered home health care, or the advisable corporeality of care.

In particular, people living with longer-term and debilitating weather detect themselves facing significant admission problems. For case, patients have been told Medicare volition only embrace one to five hours per calendar week of dwelling house health aide services, or for just one bathroom per calendar week, or that they aren't homebound (considering they roam exterior due to dementia), or that their condition must beginning pass up before therapy can commence (or recommence). Consequently, these individuals and their families struggle with too lilliputian care, or no intendance at all.

As reported in Health Diplomacy 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 burden, and 30 percentage said that they were a minor brunt… When asked about getting help in recent years, 60 percent said that family unit members and friends helped a lot, 25 pct said that they helped a trivial, and 14 percentage said that they provided no assist. Family unit members and friends experienced considerable strain as a outcome of providing help, including financial problems, lowered income, and lost or inverse jobs or reduced hours. Xx-nine percent of respondents said that there was a time when they did not get outside aid because of price.

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

The Heart for Medicare Advancement has been contacted by Medicare beneficiaries and their families from all over the state who are trying to obtain sufficient home health care to help amend or maintain their status and remain safely at home. Here is one example that typifies what we hear:

My dad is in the cease stages of Parkinson'southward disease and has qualified for home health aide treat 2 hours per week through Medicare. He should have 24/7 intendance, nonetheless, the financial brunt for paying for home health intendance is too much for us – and the average family. Nosotros were shocked to hear from domicile health agencies that Medicare only covers a few hours per week. Nosotros would similar to see changes to allow more than coverage for individuals living with a long term, progressive, concluding disease.

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

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

Help with personal easily-on care is key to the well-being of patients, every bit well equally their families and caregivers. Unfortunately, access to Medicare coverage for such intendance has declined. This is true even when individuals have an order and run into the constabulary's homebound and skilled intendance requirements – and thus authorize for coverage. Unfortunately, Medicare beneficiaries are often misinformed. They are told they tin can just get home health aides a few times a calendar week, for a short time, and/or but for a bath. Sometimes they are told Medicare simply does not cover abode health aides. The Heart for Medicare Advocacy has even heard of an individual being told he could non receive dwelling house wellness adjutant coverage because he was "over income" – although Medicare has no income limit.

As noted above, under the constabulary Medicare authorizes upwards to 28 to 35 hours a week of abode health adjutant (personal easily-on care) and nursing services combined.^[15] While personal hands-on intendance does include bathing, information technology also includes dressing, grooming, feeding, toileting, and other primal services to assistance an individual remain healthy and safe at abode.^[16] In the past, this level of abode health adjutant coverage was really available. Indeed, the Center for Medicare Advocacy has helped many clients remain at dwelling because 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 Advisory Commission (MedPAC) reported that home health aide visits per lx-solar day episode of dwelling care declined past 88% from 1998 to 2017, from an average of thirteen.iv visits per episode to one.half dozen visits. As a percent of total visits from 1997 to 2017, home health aides declined from 48% of total services to nine%.^[17]

The real, personal impact of this reduced admission to habitation health aides was highlighted in a 2019 Kaiser Wellness News article.^[eighteen] The commodity includes stark findings nearly the unmet needs of vulnerable Americans struggling to live at abode with little or no help. For example:

"Near 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 irresolute physical abilities."
"Well-nigh 60 percent of seniors with seriously compromised mobility reported staying within their homes or apartments instead of getting out of the house. Xx-five percentage said they often remained in bed. Of older adults who had significant difficulty putting on a shirt or pulling on undergarments or pants, xx per centum went without getting dressed. Of those who required assist with toileting problems, 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. (Xx pct used 2 or more devices and xiii percent also received personal assistance.)" and
Five percent had difficulty with daily tasks only didn't have assist and hadn't made other adjustments yet."

The Medicare home wellness benefit is misunderstood, inaccurately articulated, and narrowly implemented. Medicare-certified dwelling wellness agencies have all merely stopped providing necessary, legally-authorized dwelling wellness 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 non monitor or rebuke agencies for failure to provide this mandated and necessary care.

As Dr. Archbald-Pannone notes,

"As a geriatrician, every week I see patients who are fortunate enough to have family unit who are able to provide medical care and back up. Notwithstanding, I too see more than patients who practise not have family unit available to provide full care, are in drastic demand of more home intendance back up, just cannot beget the price tag … Without in-home care, nosotros're leaving our family unit members lone and at hazard. … We may not be available to stay dwelling house with them, but Medicare should support trained care aides who can be."[19]

When Medicare doesn't encompass in-home care, patients and families often must become without. Those who can afford to, pay out-of-pocket, from savings, or with credit cards. Others, who are, or become, poor (frequently due to wellness care costs) look to their land's low-income Medicaid programme for help. Thus, costs are regularly shifted to people in need and, for those who are dually eligible for Medicaid every bit well every bit Medicare, to state Medicaid programs. The needs and costs of caring for people who are dually eligible are substantial:

In 2018, there were 12.2 million individuals simultaneously enrolled in Medicare and Medicaid. These dually eligible individuals feel high rates of chronic illness, with many having long-term care needs and social risk factors. Forty-ane percent of dually eligible individuals take at least i mental wellness diagnosis, 49 percent receive long-term care services and supports (LTSS), and 60 percent accept multiple chronic conditions. Eighteen percent of dually eligible individuals report that they take "poor" health status, compared to half-dozen percentage of other Medicare beneficiaries.^[twenty]

In summary, equally the authors in the Nov 2019 Health Affairs commodity concluded:^{^[21]}

"Medicare insurance is broadly pop, but seriously ill beneficiaries who most need fiscal protection study widespread problems affording care and fiscal instability."

The harm to Medicare beneficiaries and their families would be greatly reduced if dwelling house health adjutant coverage was provided as intended by police force. As it is, access to assistance with personal intendance and activities of daily living is minimal. ^[22]

D. Impact of Caregivers on Admission to Medicare Home Health Coverage

Medicare does not cover or assistance to pay for family caregivers, merely the fact that caregivers are – or are not – available, willing, or able to serve as caregivers oft interferes with a casher's power to obtain Medicare-covered in-dwelling house intendance. On the one hand, beneficiaries and their families may be told that a dwelling house health agency will not provide care because it is not condom for the individual to remain at home without a caregiver available. On the other paw, when a family caregiver is available, patients may be told that, as a result, Medicare will not encompass in-dwelling care since that caregiver should provide the care.

CMS Benefit Policy Transmission, Affiliate 7

20.2 – Impact 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: 05-11-15) Where the Medicare criteria for coverage of dwelling wellness services are met, patients are entitled past constabulary to coverage of reasonable and necessary abode health services. Therefore, a patient is entitled to have the costs of reasonable and necessary services reimbursed by Medicare without regard to whether at that place is someone available to furnish the services. However, where a family member or other person is or volition be providing services that adequately see the patient's needs, it would not exist reasonable and necessary for HHA personnel to furnish such services. Ordinarily information technology can be presumed that at that place 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 by the HHA, or unless the HHA has first-hand knowledge to the contrary.

EXAMPLE ane: A patient who lives with an adult daughter and otherwise qualifies for Medicare coverage of home health services, requires the assistance of a home health aide for bathing and assistance with an practise program to improve endurance. The daughter is unwilling to bathe her elderly male parent and assist him with the exercise program. Home health aide services would be reasonable and necessary. …

Instance 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 unit members sleep. The care provided past the nurse, as respite to the family members, does non require the skills of a licensed nurse (as defined in §40.ane) and therefore has no impact on the casher's eligibility for Medicare payment of habitation health services even though another third political party insurer may pay for that nursing intendance.

In fact, neither of these is true. Medicare coverage is not dependent on whether there is or is not a family caregiver – or other caregiver – available. Medicare beneficiaries are eligible for Medicare-covered habitation care regardless of whether they practice or practice not have family unit or other caregivers in identify.

As federal regulations land, amidst other requirements, services must "[b]due east of a type that at that place is no able or willing caregiver to provide, or, if there is a potential caregiver, the beneficiary is unwilling to use 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 by Medicare without regard to whether in that location is someone bachelor to furnish the services. The CMS Policy Manual states, "ordinarily it tin be presumed that in that location is no able and willing person at home to provide services rendered by the habitation wellness aide or other home health personnel." (Emphasis added.)^[24]

E. Medicare's Home Health Payment Arrangement Influences Access to Care

On January 1, 2020, CMS implemented a new Medicare payment system for domicile health services called the "Patient Driven Groupings Model" (PDGM). PDGM inverse abode health agencies' fiscal incentives and disincentives to admit or proceed intendance for Medicare beneficiaries.^[25] Unfortunately, the fiscal motivations are oft harmful to vulnerable beneficiaries, particularly those with chronic conditions 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 most significant components of PDGM consider admission source and timing, non patient needs.

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

The new Medicare payment system and shift in fiscal incentives have reduced access to necessary care.[27] Abode Wellness Care 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 nether the home health benefit…" ^[28] Reductions in skilled therapy do non but harm the individual who needs that care; they can likewise end admission to home health aides, because aide coverage is dependent on the individual also receiving skilled therapy or nursing.

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

Abode health services tin continue every bit long as individuals meet the Medicare coverage criteria; and Medicare home health coverage and service rules have not changed;
Beneficiaries can receive abode health services to improve their condition, and to maintain their current condition, or to dull or prevent further decline.²⁹

"… [East]ligibility criteria and coverage for Medicare dwelling house health services remain unchanged. … as long equally the individual meets the criteria for dwelling house wellness services equally described in the regulations at 42 CFR 409.42, the private can receive Medicare dwelling health services, including therapy services. … Citing to the Jimmo v. Sebelius Settlement Agreement, the MLN too states "in that location is no comeback standard under the Medicare home health do good and therapy services tin can exist provided for restorative or maintenance purposes." (Emphasis added.)

Conclusion

All too oft, older adults and people with disabilities are unfairly denied access to necessary, Medicare-covered home health care. As a event, they and their families endure. 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 authorize for nether the law.

[i] 42 C.F.R §408.48(a)-(b); MBP Manual, Ch. 7, §§401.1 and 70.1. Meet, Jimmo v. Sebelius, No. 11-cv-17 (D.Vt.), filed Jan 18, 2011; Settlement 2013; Corrective Action Plan 2017. Come across, https://medicareadvocacy.org/medicare-info/improvement-standard/. Run into, https://www.cms.gov/Center/Special-Topic/Jimmo-Center.
[2] For a fuller word of Medicare home health coverage, see, Chiplin Jr., Alfred, Stein, Judith, Medicare Handbook, Chapter iv, Domicile Wellness Coverage, (Wolters Kluwer, 2020; updated annually).
[3] 42 U.S.C. §1395f(a)(2)(C); 42 C.F.R. §§409.42 et seq.
[4] 42 The statesC. §1395x(m).
[5] 42 UsC. §1395x(m)(ane)–(four).
[6] 42 C.F.R. §409.42.
[7] 42 C.F.R. §409.44.
[eight] Occupational therapy services can exist either a qualifying service or a dependent service. Occupational therapy services that are not qualifying services under 42 C.F.R. §409.44(c) can be 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 Casher Policy Manual, Ch. vii, §30.four.
[xi] 42 U.Southward.C. § 1361(g).
[12] 42 C.F.R §§409.48(a)-(b); Medicare Beneficiary Policy Transmission, Ch. 7, §§40,1.1 and 70.1.
[thirteen] Health Affairs, "Financial Hardships of Medicare Beneficiaries With Serious Disease" by Kyle, Blendon, et al, Vol. 38, No. 11, pp. 1801-1806 (November 2019). Note: The authors define "serious affliction" as individuals "reported having a serious disease or condition that, over the past three years, had required ii or more hospital stays and visits to three or more physicians." p. 1802.
[14] The Hill, "Family Caregivers Demand Support, Medicare Should Embrace In-Home Aides" by Laurie Archbald-Pannone, MD (Nov 15, 2019), available at: https://thehill.com/opinion/healthcare/470677-family-caregivers-need-support-medicare-should-cover-in-home-care-aides.
[xv] 42 U.S.C. §1395x(m)(1)-(4). Annotation, receipt of skilled therapy can also trigger coverage for dwelling health aides.
[16] 42 CFR §409.45(b)(1)(i)-(v). Meet besides, Medicare Benefits Policy Manual, Chapter 7, §§50.1 and 50.ii.
[17] Medicare Payment Informational Commission (MedPAC), "Written report to Congress: Medicare Payment Policy" (March 2019), Ch. 9, pp. 234-235, available 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 Identify Turn To Devices And Helpers, But Unmet Needs Are Common" by Judith Graham (February 14, 2019), available at: https://khn.org/news/seniors-crumbling-in-place-turn-to-devices-and-helpers-but-unmet-needs-are-common/. See also, Kaiser Health News, "Dwelling house Intendance Agencies Oft Wrongly Deny Medicare to Chronically Ill," Susan Jaffe (1/18/2018), https://khn.org/news/home-care-agencies-ofttimes-wrongly-deny-medicare-help-to-the-chronically-ill/.
[nineteen] The Colina, "Family Caregivers Need Back up, Medicare Should Embrace In-Home Aides" by Laurie Archbald-Pannone, MD (Nov xv, 2019), bachelor at: https://thehill.com/stance/healthcare/470677-family-caregivers-need-support-medicare-should-embrace-in-habitation-care-aides.
[20] Centers for Medicare & Medicaid Services (CMS), Medicare-Medicaid Coordination Office, Fact Sheet: "People Dually Eligible for Medicare and Medicaid" (March 2020), available at: https://world wide web.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf.
[21] Health Diplomacy, "Financial Hardships of Medicare Beneficiaries With Serious Illness" by Kyle, Blendon, et al, Vol. 38, No. 11, pp. 1801-1806 (November 2019).
[22] See also, Johns Hopkins Academy Bloomberg School of Public Health study that also finds people with limitations in activities of daily living (ADLs) experience pregnant harm when they cannot access adequate help with ADLs at dwelling. "Medicare Spending and the Adequacy of Back up with Daily Activities in Community-Living Older Adults with Disability" past Jennifer 50. 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 Advancement of Science (AAAS) EurekAlert website at: https://www.eurekalert.org/pub_releases/2019-05/jhub-msh_1052819.php.
[23] 42 C.F.R. §409.45(b)(2)(iii).
[24] CMS, Medicare Benefit Policy Manual, Ch. 7, Sec. 20.2, "Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Wellness Services"(updated April 22, 2015).
[25] See, Eye for Medicare Advocacy "Dwelling house Health Do Guide: Medicare Abode Wellness Coverage and Care Is Jeopardized By the New Payment Model – The Center for Medicare Advocacy May Be Able to Help" (Jan. 7, 2020) available at: https://medicareadvocacy.org/abode-health-practice-guide/; besides see, due east.1000., Center for Medicare Advocacy Weekly Alarm "Medicare Coverage of Home Health Intendance Has Not Changed Under the New Payment System (PDGM)" (February. twenty, 2020), available at: https://medicareadvocacy.org/medicare-coverage-of-home-health-care-has-non-changed-under-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-Assessment-Instruments/HomeHealthQualityInits; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/HHVBP.
The Medicare payment construction creates incentives for home health agencies to provide care for beneficiaries with shorter-term, post-acute care weather condition. Further, 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;
* Dwelling Health Quality Reporting Program (HHQRP);
* Habitation Wellness Value Based Purchasing (HHVBP) Models;
* Part of Inspector Full general, Medicare Contractor, and other audits of Home Health Agencies pointing to and so-chosen "overutilization".
[28] Domicile Health Care News, "CMS Watching Home Health Providers Closely Amidst Shifting Therapy Strategies" past Robert Holly, (Feb. 12, 2020), available at: https://homehealthcarenews.com/2020/02/cms-watching-home-health-providers-closely-among-shifting-therapy-strategies/.
[29] CMS, MLN Matters article "The Role of Therapy under the Domicile Health Patient-Driven Groupings Model (PDGM)", Number: SE20005 (Feb. 10, 2020), available at: https://www.cms.gov/files/certificate/se20005.pdf.