Below is an at-length article on Medicare Home Care in NY. We also encourage you to download our “7 Quick Points” on Medicare Home Care:
Important Note: The information provided herein is for general informational purposes and does not constitute legal advice or counsel. The information provided herein is not comprehensive and is also subject to change.
Medicare is the most common health insurance covering the elderly and disabled. Many people might therefore assume that Medicare would provide sufficient coverage for assistance with activities of daily living (“ADLs” such as bathing, dressing, eating, and toileting) – one of the most common needs of the people it is designed to serve. Unfortunately, this is far from the case. Nevertheless, some home care assistance is sometimes available to consumers with Medicare.
Here, we provide an outline of the circumstances under which Medicare may cover home care, the types of home care it may cover, a comparison of Original Medicare to Managed Medicare (Medicare Advantage plans) with regards to home care coverage, common Medicare home care provider types, and how to obtain Medicare home care. In closing, we will examine some ideas regarding how legislation could expand Medicare to include the provision of more coverage for assistance with ADLs.
A note before we begin:
Medicare is a Federal program that is available throughout the United States, and much of what is presented in this article will be relevant wherever you live in the USA. However, we operate exclusively in New York State and the information and observations we are imparting is based on our experience here in New York. The information and observations presented herein should therefore be consumed keeping this in mind.
When Medicare May Cover Home Care
Types of Home Care Medicare May Cover
Original Medicare VS Medicare Advantage
Common Medicare Home Care Provider Types
How to Obtain Medicare Home Care
Ideas for Expanding Medicare Coverage for Home Care
Traditionally, Medicare will only cover home care if a consumer is “homebound” and there is a determined skilled need such as nursing, physical therapy, or occupational therapy. Assistance with activities of daily living (“ADLs”) such as dressing, ambulating, eating, and toileting are traditionally not considered sufficient to warrant home care being covered by Medicare.
Some Medicare Advantage plans are now beginning to offer coverage for home care for consumers that require assistance with ADLs, but do not require skilled care. Please see below in the section Original Medicare VS Medicare Advantage to learn more.
Medicare may cover “skilled” home care services such as part-time or “intermittent” skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medical social services, and injectible osteoporosis drugs for women. Additionally, Medicare may cover part-time or intermittent home health aide services that is provided in conjunction with “skilled” services. A home health aide can assist with ADLs, complementing the skilled services. Notably, Original Medicare will not cover “custodial or personal care (like bathing, dressing, or using the bathroom), when this is the only care you need”. Source
Coverage for “custodial or personal care” by Medicare Advantage plans will be discussed in the next section.
To properly understand the differences between Original Medicare and Medicare Advantage plans when it comes to home care, it is important to first understand the difference between the two coverage options themselves:
People may receive their Medicare in two different forms, Original Medicare or via a Medicare Advantage plan.
The Difference Between Original Medicare and Medicare Advantage
For people who receive coverage under Original Medicare, the Federal government is their health insurance. To illustrate, providers must send bills for services rendered to a government sponsored entity that administers Medicare benefits in order to receive payment. For people who elect to receive coverage through a Medicare Advantage plan, the Federal government pays a monthly fee to a third-party health plan which is responsible for administering their benefits. These plans function much like traditional HMOs or PPOs, and providers must go through these plans to receive payment.
The Difference Between Original Medicare and Medicare Advantage When it Comes to Home Care
The first important difference to note is that people with Original Medicare will usually be able to access care from almost any “home health care” provider (see Common Medicare Home Care Provider Types below). Conversely, people enrolled in Medicare Advantage plans may find that some providers do not accept their coverage. Additionally, we generally find that people with Original Medicare will receive more care services than those enrolled in Medicare Advantage plans. Disclaimer: This is a practical observation and each person’s situation may vary.
As of 2019, Medicare Advantage plans are “allowed” (not required) to offer non-skilled home care among their supplemental services – making assistance for just ADLs available to some consumers. While we feel this is a step in the right direction, we are not very optimistic about the amount of help that will be available through the plans that opt-in to providing this benefit. The reason for this boils down to money. The average Medicare Advantage plan receives roughly $800-$1,200/month per member. This is far from enough money to provide significant, non-medical home care services at scale. Here is a candid interview with a home care executive regarding this relatively new available benefit.
The most common type of Medicare Home Care provider are Certified Home Health Agencies (“CHHAs” [chah]). CHHAs are agencies that provide skilled services such as nursing, physical therapy, and occupational therapy, usually to homebound patients recently discharged from a hospital or rehabilitation center. Additionally, they will also often provide home health aides to complement these skilled services. In New York, CHHAs do not employ home attendants directly, rather they contract with non-medical home care providers known as Licensed Home Care Services Agencies (“LHCSAs”) to provide them. To learn more, see Certified Home Health Agencies.
Strictly “non-medical” home care agencies cannot bill Original Medicare. However, if a Medicare Advantage plan elects to offer strictly non-skilled home care as a benefit, a non-Medical home care agency may be able to bill them if they fit their approved network provider criteria and are appropriately credentialed with the plan.
Most often, Medicare consumers receive home care from CHHAs. To obtain care, a doctor must fill out paperwork to validate the need for home health care. CHHAs then send a nurse to evaluate the patient and determine the services they require. Medicare consumers in the community who needs “home health care” can contact a local CHHA, which will likely be happy to assist them with obtaining the required paperwork so they can access care.
If someone is in a hospital or rehabilitation center (skilled nursing facility) and will need home health care upon their return home, a discharge planner (often a Social Worker) at the facility will usually help with arranging these services. If you or a loved one are in this position, be sure to speak with the discharge planner about home health care arrangements upon the return home.
Many have begun to recognize the tremendous need for long-term care coverage for all Americans. According to longtermcare.acl.gov, “Someone turning age 65 today has almost a 70% chance of needing some type of long-term care services and supports in their remaining years”. Shouldn’t Medicare, the insurance designed to cover this population, provide adequate coverage for these needs?
In an article authored by Harvard instructor Madhuri Reddy together with Nathan Stall and Paula Rochon from the University of Toronto, they recommend that “the Centers for Medicare and Medicaid Services (CMS) could expand the definition of “home health” to include “personal care””. Medicare already covers “home health” and they are recommending utilizing this redefinition as an actionable step towards improving the coverage available to Medicare consumers. This would certainly help and is a change we would applaud. Ultimately, however, we feel that more should be done.
The nature of the needs that warrant “home health care” are fundamentally different than “personal care”. “Home health care” needs tend to be short-term, and approved services and reimbursement structures for “home health care” are designed with this in mind. When people need “personal care” (i.e. assistance with ADLs), the needs are often long-term. For this challenge, we believe that a solution tailored especially to address these needs is in order – something more similar to the long-term care coverage that many states offer within their Medicaid programs.
Get Help Obtaining Medicare Home Care
To receive assistance obtaining Medicare home care, please call us at (718) 838-3838.