Dec. 19, 2023
One of the biggest areas of confusion about Medicare is whether, and when, it covers home care.
Partly, that depends on the distinction between “home care” and “home health care.”
But it’s also about the difference between what Medicare is allowed to cover and the ways home health care agencies and medical practices actually work.
“There’s a growing disconnect between what is coverable under the law versus what’s available for practical purposes,” says David Lipschutz, associate director of the Center for Medicare Advocacy.
If you’re scratching your head, you’re in good company.
“There is a lot of confusion” regarding Medicare’s coverage of home health care and home care, says Lisa Harootunian, a co-author of the Bipartisan Policy Center’s report, “Optimizing the Medicare Home Health Benefit to Improve Outcomes and Reduce Disparities.”
Here’s a guide to help clear up the confusion and to find home health care through Medicare:
What is home health care vs. home care?
First off, the difference between home health care (which Medicare will often cover if you meet certain requirements) and home care (which it often won’t).
Home health care, by Medicare’s definition, includes skilled services given in your home for an illness or an injury—things like wound care, intravenous therapy and injections, often after a hospitalization.
By contrast, home care is assistance to live safely at home. It often includes non-medical help with what are called activities of daily living such as dressing, bathing and toileting.
Just remember: Medicare generally does not pay for long-term care.
Who qualifies for Medicare’s home health care coverage?
To be eligible for “reasonable and necessary” home health care coverage under Medicare Part A (returning home after hospitalization or a stay in a skilled nursing facility) and Part B (no prior hospital stay required), you must meet certain requirements:
The care must be medically necessary. That means it must be ordered by a doctor or health care provider after a face-to-face assessment certifying you need home health services. The doctor and home health team need to review and recertify the care plan at least once every 60 days.
The care must be either skilled nursing, physical therapy, speech-language pathology or continued occupational therapy services as well as medical social services, durable medical equipment (like a walker) and medical supplies. Medicare defines medical social services as care ordered by a doctor or health provider to help you with social and emotional concerns that may interfere with your treatment or how quickly you recover.
If you’re receiving skilled nursing or therapy after an illness, injury or surgery, you may qualify for Medicare reimbursement for short-term help withbathing, dressing and grooming — known as custodial care, says Harootunian.
The care must be part-time or intermittent. Translation: less than eight hours a day or generally under 28 hours a week. (Medicare permits care up to 35 hours a week on a case-by-case basis.)
If you need round-the-clock care, most of that won’t be covered.
You must be homebound. But that may not mean what you think it does.
“It doesn't mean the person can never leave the home or is bedbound,” says Harootunian. “There are exceptions that allow an individual to attend something that's infrequent and relatively short duration. They can go for a walk around the block, they can drive or attend a family occasion, they're allowed to go receive health care treatment, they're allowed to attend religious activities.”
The care must be provided by a Medicare-certified home health agency. There are roughly 11,000 of these across the United States. But since the number of home health agencies has been falling since 2013 and there’s a home health aide shortage, finding the care is getting harder.
“Efforts to bolster the direct care workforce are really a key part to ensuring these services are accessible,” says Harootunian.
Home health aide visits per 60-day episode of home care declined by 90% from 1998 to 2019, from an average of about 13 visits per episode to just one, according to MedPAC (the Medicare Payment Advisory Commission).
If you meet all of Medicare’s home health care tests, you’ll pay nothing for covered services, with one exception: You’ll owe 20% of the cost of durable medical equipment under Part B, plus the Part B deductible ($226 in 2023, rising to $240 in 2024).
Medicare home care rules and the reality
Those are the rules. Now, for the reality.
These days, many Medicare beneficiaries are being turned down for home health care coverage by agencies, doctors and other medical professionals.
Says Lipschutz: “Because of patterns and practices and entrenched misunderstandings, despite what the law says, home health care is actually only available through Medicare in a much more truncated fashion.”
He believes Medicare’s home health care benefit is shifting to only being available for short-term needs, such as rehab at home after a knee replacement.
Harootunian says the way Medicare’s home health benefit is being interpreted “makes for very inconsistent determinations and sometimes inappropriate determinations, which results in beneficiaries not getting the care they need.”
Medicare coverage for home health aides has declined enormously, says Howard Bedlin, vice president at the National Council on Aging. “That means people don’t get the kinds of help with activities of daily living that they might assume,” he notes.
Bedlin speaks from personal experience. When his father needed home health care, the only service the home health aide provided through Medicare was a shower once or twice a week.
At a September 2023 Senate Finance Committee hearing, Center for Medicare Advocacy Executive Director Judith Stein said her nonprofit has received calls from beneficiaries and families across the U.S. saying they were denied Medicare coverage for incorrect reasons.
“Often, a home health agency will say, ‘We can send out an aide to give you one bath a week for one hour,’” says Lipschutz.
Not only is that far less than what’s permitted, after the maximum 28-35 hours a week period of care expires, it can be extended by the doctor.
“Medicare law allows for Medicare coverage in the home indefinitely,” says Lipschutz.
Some people have been instructed they can’t get home health care coverage because Medicare requires the care will improve their health. Actually, Stein told Congress, a 2013 settlement recognized that Medicare covers home health nursing and therapy services that will maintain a person’s health.
She testified that the level of hands-on care and nursing services allowed by law under Medicare “is almost never obtainable.”
Changing Medicare’s payment system
One reason coverage has been restricted in recent years: a major change in Medicare’s payment system.
In 2020, Medicare adopted what’s known as the Payment-Driven Groupings Model (PDGM) for home health care. It provides higher payments to providers in the first 30 days of care, leading some to deny or limit services after that.
PDGM “created more challenges for individuals with complex needs who might need multiple visits to receive the level of service that would benefit them,” says Harootunian.
As the authors of the Health Affairs article, “Reset Medicare’s Home Health Benefit,” wrote: “Medicare’s payment systems, quality measures and audit systems have led to misunderstandings as to what is actually covered and financial services that can limit the services provided.”
Lipschutz says many home health care providers now “are risk-averse; they don’t think things are going to get paid by Medicare” so they refuse to order the care. “It’s incredibly frustrating for beneficiaries,” he adds.
Medicare is changing its reimbursement rules again with what’s called the Home Health Value-Based Purchasing Model, tying payment to “quality performance.”
So far, the Centers for Medicare and Medicaid Services reports, home health care access and usage hasn’t changed as a result. But, it said, the new model has led to declines in professional care, communication and discussion of care with Medicare beneficiaries.
“We’ll see how this home health value-based purchasing model is going to influence access and service delivery going forward,” says Harootunian.
Home health care: Original Medicare vs. Medicare Advantage
The rules for qualifying for home health care coverage are the same whether you have Original Medicare or a Medicare Advantage plan with a private health insurer.
Some Medicare Advantage plans, however, offer additional home health care and home care coverage. So, if you have Medicare Advantage, ask your plan what it will pay for.
Lately, however, some Medicare Advantage plans have scaled back their supplemental home health care coverage. That’s partly due to the plans’ prior authorization and utilization management mechanisms, Harvard Medical School professor David Grabowski recently told Congress.
“In our experience, people have even more difficulty obtaining home health care through Medicare Advantage plans than in traditional Medicare,” says Lipschutz.
A 2021 Avalere Health report found that Medicare Advantage beneficiaries get 19% less home health care than people with Original Medicare.
Finding and getting home health care
If you want help receiving home health care through Medicare, here are a few resources:
The Centers for Medicare & Medicaid Services free online guide, “Medicare & Home Health Care.” It explains who’s eligible for home health care, which services are covered, how to find and compare home health agencies and your Medicare rights.
The Medicare.gov site’s free tool that lets you find certified home health agencies in your area. It then lets you compare them by showing you Medicare’s star ratings for quality of care and ratings from patient surveys. You’ll need to call agencies to see which types of care they’re currently able to provide, and how much they offer.
Your State Health Insurance Assistance Program, also known as SHIP. Here, experts can provide free explanations about home health care and other Medicare topics. “They’re a great source of information,” says Bedlin.
The U.S. government’s Eldercare Locator site. Ithas a list of questions to ask when looking for a home health care agency as well as a directory of Area Agencies on Aging (AAA). Your local AAA can tell you more about home care agencies nearby.
Your doctor. The Center for Medicare Advocacy recommends working with your physician to set out a plan of care. The doctor’s plan can then help you get a home health care agency to accept the plan and provide the care Medicare will pay for.
Your hospital discharge planner. If you’ll be needing home health care after a hospital stay, ask the medical center’s discharge planner for information about local Medicare-certified home health care agencies, says Bedlin.
When you’re denied home health care
If you are denied Medicare coverage for home health care but believe you qualify for it, you can file an appeal.
You do that through Medicare itself if you have Original Medicare or with your Medicare Advantage plan if you have one.
The future of Medicare’s home health coverage
Whether more Medicare beneficiaries will be able to get coverage for home health care depends on how serious the government becomes ensuring its rules are followed by home health agencies and health providers.
“We often say that in order to properly implement the home health benefit, we need an absolute culture change from top to bottom — with the Medicare agency, all of its contractors, its auditors, providers and prescribing physicians knowing the true scope of Medicare coverage,” says Lipschutz.
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