Home Health Aide Coverage Continues to Shrink in Traditional Medicare While CMS Enhances it in Medicare Advantage

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For years the Center for Medicare Advocacy and other stakeholders have advocated for Medicare coverage for home health aides without the current prerequisites that the individual be homebound and require skilled nursing or therapy. Unfortunately, the ability to get Medicare-covered home health aide care has greatly declined in recent years, even when individuals meet the homebound and skilled care requirements. Indeed, people are often told the most they can get is just a bath a few times a week.

Medicare law authorizes up to 35 hours a week of personal hands-on care and nursing services combined. Personal hands-on care does include bathing, but is also includes dressing, grooming feeding, toileting, and other key services to help an individual remain healthy and safe at home. This care used to be available. The Center helped many clients remain at home because these services were in place, but it is now 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.) 

Instead of correcting this harmful misapplication of Medicare coverage for all beneficiaries, CMS recently issued a new policy 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 particularly ironic and unjust as advocates continue to challenge the limited interpretation of the Medicare home health benefit, particularly the reduction in home health aide coverage. While it remains to be seen how much this special 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.

The new Congress should address this inequity as soon as possible. In general, legislation is needed that adds equivalent benefits in traditional Medicare to all those included in private Medicare Advantage. In particular, Congress should authorize Medicare coverage for home health aides to provide hands-on personal care without a homebound or skilled care requirement – the same benefit criteria now allowed for MA enrollees.

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