The Promise and Failure of Medicare Home Health Coverage
The Center for Medicare Advocacy has been hearing from people who meet Medicare coverage criteria but are unable to access Medicare-covered home health care, or the appropriate amount of care. These problems have been escalating in 2016. Care provided often falls short of care that is covered under the law and ordered by the physician. There are no practical solutions to obtain care or protections to prevent discharge from care. Many who are unable to access care are unable to stay at home.
In particular, people living with long-term and debilitating conditions find themselves facing significant access problems. For example, patients have been told the following:
- Medicare will only cover one to five hours per week of home health aide services, or only one bath per week;
- They aren’t homebound (because they roam outside due to dementia);
- They must first decline before therapy can commence (or recommence).
Consequently, these individuals and their families are struggling with too little care, or no care at all.
The Center has been contacted about Medicare beneficiaries from all over the country who are struggling to obtain sufficient home health care to stay at home. Here is one example that typifies what we hear from beneficiaries:
- My dad is in the end stages of Parkinson’s disease and has qualified for home health aide care for 2 hours per week through Medicare. We were shocked to learn that Medicare only covers a few hours per week and would like to see changes to allow more coverage for individuals living with a long term, progressive terminal disease. (Emphasis added.)
– T.J., Montana (See Attachment A for further beneficiary stories.)
Here is one example that typifies what beneficiaries hear from home health agencies (in an email from a home health agency to a patient who made an inquiry about coverage):
- “Medicare typically covers only short term rehabilitative care for therapies and nursing as well as a home health aide a few times a week during these rehabilitative episodes to provide bathing help.”
In order to try to help all individuals in need of home care, those who may improve and those who will never get better, and to learn about the breadth and depth of access problems, an advocate for people living with ALS and Staff from the Center surveyed 160 home health agencies in seven states throughout the country. We recognize this is not a scientific effort, but the results are nonetheless telling. Here’s what we learned:
- A care manager for people with ALS called 42 of the 48 home health agencies listed on Home Health Compare in her area. Only 3 of the 42 home health agencies would consider evaluating the individual for care. None would consider providing more than 3 hours of home health aide per week with a doctor’s order for 20-28 home health aide hours/week.
- Center staff contacted 118 home health agencies in six states, and also Medicare Advantage plans and 1(800)MEDICARE to inquire what care is available for someone who qualifies for home health coverage. The 1(800)MEDICARE staff made it clear that Medicare can cover up to 35 hours combined of home health aides and nursing combined per week. The Medicare Advantage plan representatives contacted also recognized this by referring to their Summary of Benefits which include up to 35 hours of combine home health aide and nursing as (theoretically) available. Home health industry leaders report more limited coverage from MA plans than from traditional Medicare. (Attachment B)
Of the total 118 home health agencies contacted, 74 were willing to discuss their services. Of these 74 agencies, 70 said they were able to provide one hour of physical therapy and two hours of nursing a week. Only 6 agencies (8%) were able to offer up to 20 hours of home health aide a week. 39 agencies (52%) were able to offer up to three visits of a home health aide a week. Many indicated home care patients could expect an aide to bathe them only once per week. Some suggested that they would send an OT to provide personal care services rather than a home health aide. The vast majority said Medicare was not available for the care requested. Further, most reported that care would be available only for a total of 30-60 days. (See Attachment B for details of the survey.)
Home health access problems have ebbed and flowed over the years, depending on the reigning payment mechanisms, systemic pressures, and misinformation about Medicare home health coverage. Regrettably, it appears these problems are increasing, especially for those with long term, chronic, and debilitating conditions and, if current and proposed policies and practices continue, they will only get worse.
Accordingly, it is important to know what Medicare home health coverage should be under the law. The threshold criteria are as follows (See Attachment C for more details and citations):
- A physician has signed or will sign a care plan, certifying that the services are medically necessary; the physician must also certify that there has been a face-to-face encounter with the patient within 90 days prior to the start of care, or within 30 days after the start of care.
- The patient is homebound. This criterion is generally met if non-medical absences from home are infrequent and leaving home requires a considerable and taxing effort, which may be shown by the patient needing personal assistance, or the help of a wheelchair or crutches, etc. Occasional “walks around the block” are allowable. Attendance at an adult day care center or religious services is not an automatic bar to meeting the homebound requirement.
- The patient needs skilled nursing care on an intermittent basis (less than 7 days per week but at least once every 60 days) or skilled physical therapy, speech therapy, or continuing occupational therapy.
- Daily skilled nursing care is available for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional daily skilled nursing is finite and predictable).
- The care must be provided by, or under arrangements with, a Medicare-certified provider.
If the triggering conditions above are met, the beneficiary is eligible for Medicare coverage for home health services. Home health benefits can continue with no duration of time limit so long as these coverage criteria are met. Coverable home health services include:
- Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;
- Physical, occupational, or speech therapy;
- Medical social services;
- Part-time or intermittent services of a home health aide, and;
- Durable medical equipment (DME) and medical supplies