When Does Medicare Pay for In-Home Care?
We’ve all seen it.
Neighbor A suffers a medical event, spends multiple days in the hospital and gets discharged to home. Medicare pays for a team of professionals to come out and care for Neighbor A in the home, including, for example, a licensed practical nurse, a physical therapist, a speech therapist, and an occupational therapist. Medicare also pays for home health aides who help with daily activities in the home including bathing and dressing.
Neighbor B, on the other hand, is simply getting older and more frail and needs more help with daily activities in the home. His children have jobs and can’t be with him all day. Neighbor B privately pays in full for home health aides to come out each day and help him in the home. Medicare pays for nothing toward the home health aides. Neighbor B’s assets are depleting rapidly. The family fears it might be time for Neighbor B move to an assisted living facility, at its exorbitant cost in independence, emotion, and money. Neighbor B and his family are distraught.
Why does Medicare pay for Neighbor A’s home care but not Neighbor B’s? It seems so unfair.
The Law: When and What Medicare Covers in the Home, and For How Long
When Medicare Covers In-Home Care:
Under the Medicare Act, Medicare covers home health services under both Parts A and B of Medicare when:
1.The services are medically “reasonable and necessary”, which is a specialized definition linked to the service in question. For example, per 42 C.F.R. § 409.42(c)(1)(i): “In the home health setting, management and evaluation of a patient care plan is considered a reasonable and necessary skilled service when underlying conditions or complications are such that only a registered nurse can ensure that essential non-skilled care is achieving its purpose.”; and
2.The following 4 criteria are met:
a.Plan of Care. The physician or authorized provider must: (i) prescribe a plan of care for furnishing the services, and (ii) periodically review that plan of care to continue or discontinue the services. 42 C.F.R. § 409.43.
b.Homebound. The person is confined to home, commonly referred to as “homebound”. This does not mean the individual is unable to ever leave the home. The requirement is generally met if non-medical absences from home are infrequent, and leaving home requires a considerable and taxing effort. This can be shown by the patient needing personal assistance or the help of an assistive device such as a wheelchair or walker. The following should not bar a “homebound” finding: walks around the block, or attendance at an adult day care center, religious services, or a special occasion. 42 C.F.R. § 409.42.
c.Skilled Services Needed on Intermittent Basis.
The person must need care that is defined by Medicare as “skilled” (meaning (i) skilled nursing care, or (ii) physical or speech-language therapy) on an intermittent basis.
These “hooks” of skilled services are first required before occupational therapy and home health aides are available. Skilled nursing, physical therapy, and speech-language pathology services are defined as “qualifying skilled” services for the purpose of establishing eligibility for Medicare home health coverage. A person must initially require and receive one of these skilled services, in order to receive Medicare for “dependent services” (meaning dependent upon a skilled service being in place) which include: (i) home health aide, (ii) medical social worker, (iii) occupational therapy, and (iv) medical supplies.
For example, while occupational therapy is not considered a skilled service to begin Medicare home health coverage, if in addition to occupational therapy the person was receiving skilled nursing, or physical or speech therapy, but those skilled services end, Medicare will continue paying for the occupational therapy. 42 C.F.R. §§ 409.42, 409.44, 409.45.
d. The term “intermittent or part-time” means furnished any number of days per week, so long as they are provided: (i) less than 8 combined hours each day and (ii) 28 or fewer hours each week (or, subject to review on a case-by-case basis based on need, less than 8 hours each day and 35 or fewer hours per week).
e.Medicare-certified home health agency. The services must be furnished by, or under arrangement with, a Medicare-certified home health agency.
42 U.S.C. § 1395f(a)(2)(C) ; 42 C.F.R. §§409.42 et seq.
What Medicare Covers in the Home:
If the qualifying conditions above are satisfied, Medicare covers the following home health services:
1.Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;
2.Physical therapy, speech-language pathology, and occupational therapy;
3.Part-time or intermittent services of a home health aide (personal hands-on care), which include:
42 C.F.R. § 409.45(b)(1)(i)-(v).
4.Medical social services; and
42 C.F.R. §§ 409.42, 409.44, 409.45, Medicare Beneficiary Policy Manual, Ch. 7, § 30.4.
How Long Medicare Covers In-Home Care
As stated in the Issue Brief of the Center for Medicare Advocacy titled” Medicare Home Health Coverage: Reality Conflicts with the Law”, dated April 7, 2021, found at: https://medicareadvocacy.org/issue-brief-medicare-home-health-coverage-reality-conflicts-with-the-law/ :
“Importantly, and contrary to what is often stated, Medicare home health coverage is not just a short-term, acute care benefit. 42 C.F.R. §§ 409.48(a),(b); Medicare Beneficiary Policy Manual, Ch. 7, §§ 40,1.1 and 70.1. There is no duration of time limit for Medicare Home Health Coverage. So long as the law’s qualifying criteria are met, coverage 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 C.F.R. §§ 409.48(a)-(b); Medicare Benefit Policy Manual, Chapter 7, § 70.1.”
The Reality: Misinformation; Evidence of Limited Access
Access to good information is the key to everything. What we do not know about, we do not know to investigate or request.
Misinformation. The Issue Brief from the Centers for Medicare Advocacy (“CMA”) states it hears regularly from people who meet Medicare coverage criteria for home health services, but are denied, or not given the appropriate amount of care. Examples include: patients have been told Medicare will only cover one to five hours per week of home health aide services, or for only one bath per week, or that they aren’t homebound (because they roam outside due to dementia); or that their condition must first decline before therapy can commence or recommence. CMA reports one person being told he could not receive home health aide coverage under Medicare because he was “over income” even though Medicare has no income limit. See the Issue Brief: https://medicareadvocacy.org/issue-brief-medicare-home-health-coverage-reality-conflicts-with-the-law/.
Evidence of Limited Access. CMA reports in its Issue Brief that the full level of home health aide coverage (not only bathing, but also dressing, grooming, feeding, toileting, and other key services to help an individual remain healthy and safe at home):
“[I]s 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 60-day episode of home care declined by 88% from 1998 to 2017, from an average of 13.4 visits per episode to 1.6 visits. AS a percentage of total visits from 1997 to 2017, home health aides declined from 48% of total services to 9%.” See Issue Brief (citations therein).
According to CMA in the Issue Brief, Medicare-certified home health agencies “have all but stopped providing necessary, legally-authorized home health aide services, even when patients are homebound and are receiving the requisite skilled nursing or therapy to trigger coverage.” Indeed, per the Issue Brief, the Centers for Medicare and Medicaid Services (“CMS”), the government agency responsible for monitoring and punishing agencies who do not comply with Medicare law, “does not monitor or rebuke agencies for failure to provide this mandated and necessary care.” See Issue Brief.
Medicare should cover in-home care when, and only when, stringent statutory requirements are met. But once these criteria are satisfied, Medicare should cover home health aides at an amount of hours that makes a real difference for families, not the small amount in terms of type or hours to which misinformation and other external criteria lead.
For more on this topic, see the CMA Issue Brief: https://medicareadvocacy.org/issue-brief-medicare-home-health-coverage-reality-conflicts-with-the-law/.