- 6th Annual National Voices of Medicare Summit Welcomes Congressman John Lewis as the 2019 Sen. Jay Rockefeller Lecturer – Register Now
- Home Health Aide Coverage Continues to Shrink: Attention Must Be Paid
- Case Spotlight: A Medicare Beneficiary in Need of Home Health Aides
- Cathy Hurwit Joins Center for Medicare Advocacy Advisory Board
- The Administration for Community Living (ACL) Releases Annual Minority Aging Statistics
2019 Sen. Jay Rockefeller Lecturer, Rep. John Lewis.
Health Care is a Human Right:
Medicare’s Role in Making it a Reality
(Past, Present, Future)
Support the Center for Medicare Advocacy! Join us for our 6th annual National Voices of Medicare Summit and Senator Jay Rockefeller Lecture. This year’s program will connect leading experts and advocates to discuss access to health care as a human right, the challenges and successes of Medicare, and where we can go moving forward.
Congressman John Lewis
will deliver this year’s
Sen. Jay Rockefeller Lecture
Rep. Lewis will then be joined by Sen. Rockefeller and others for a panel discussion.
May 9, 2019 8:30 AM – 3:30 PM, EDT
Kaiser Family Foundation
1330 G. Street, NW Washington, DC
Early-Bird Registration, through March 15, 2019: $200.00
Individual registration thereafter: $225.00
You won’t want to miss this Incredible day!
Space is limited. Register now.
Sponsorship and advertising opportunities are also available via the registration page or by contacting Scott Perkins, Development Director, at email@example.com or (202) 293-5760.
As in prior years, the Center has reserved a block of rooms at the Washington Marriott at Metro Center, just a few minutes walk from the venue. These rooms will only be held through April 18, 2019, so reserve yours now at https://aws.passkey.com/e/49829939.
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As we have reported in the past, the ability to get Medicare-covered home health aide care has greatly declined in recent years. This is true even when individuals meet the law’s homebound and skilled care requirements – and thus qualify for coverage. Sadly, and incorrectly, Medicare beneficiaries are often told the only aide care they can get is a bath, and only a few times a week. Sometimes they are told Medicare simply does not cover home health aides. The Center has even heard of an individual being told he could not receive home health aide care because he was “over income” – although Medicare has no such income limit (see case study in separate article below).
In fact, Medicare law authorizes up to 28 to 35 hours a week of home health aide (personal hands-on care) and nursing services combined. 42 USC 1395(m)(1)-(4). While personal hands-on care does include bathing, it also includes dressing, grooming, feeding, toileting, and other key services to help an individual remain healthy and safe at home. 42 CFR 409.45(b)(1)(i)-(v).
This level of home health aide personal care used to be available. The Center helped many clients remain at home because these services were in place, but now such care is 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.)
The real, personal, impact of this reduced access to home health aides has recently been made clear in a Kaiser Health News article, (Judith Graham, Seniors Aging In Place Turn To Devices And Helpers, But Unmet Needs Are Common, 2/14/2019). The article includes striking findings about the unmet needs of vulnerable Americans struggling to live at home with little or no help. For example:
- “About 25 million Americans who are aging in place rely on help from other people and devices such as canes, raised toilets or shower seats to perform essential daily activities, according to a new study documenting how older adults adapt to their changing physical abilities.”
- “Nearly 60 percent of seniors with seriously compromised mobility reported staying inside their homes or apartments instead of getting out of the house. Twenty-five percent said they often remained in bed. Of older adults who had significant difficulty putting on a shirt or pulling on undergarments or pants, 20 percent went without getting dressed. Of those who required assistance with toileting issues, 27.9 percent had an accident or soiled themselves.”
- “60 percent of the seniors surveyed used at least one device, most commonly for bathing, toileting and moving around. (Twenty percent used two or more devices and 13 percent also received some kind of personal assistance.)
- Five percent had difficulty with daily tasks but didn’t have help and hadn’t made other adjustments yet.”
While it isn’t clear how many of these individuals should be receiving needed help through Medicare, it is likely that far more qualify than are accessing the benefit, since the surveyed population was 65 or older and infirm. Indeed, the author states “The problem, experts note, is that Medicare doesn’t pay for most of these non-medical services, with exceptions.”
In fact, the problem is two-fold:
1.Even the government’s information on Medicare.gov includes “personal care” in the list of what Medicare does not pay for. (https:/www.medicare.gov/coverage/home-health-services
- Medicare-certified home health agencies have all but stopped providing necessary, legally authorized home health aide personal care,
- even when patients are homebound and receiving the requisite nursing or therapy to trigger coverage.he Medicare home health benefit is being unfairly and inaccurately articulated and administered.
2. Instead of correcting this harmful misapplication of Medicare coverage for all beneficiaries, CMS issued a new policy in 2018 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 ironic and unjust given the restrictive interpretation of the Medicare home health benefit in general, and the obliteration of home health aide coverage in particular.
While it remains to be seen how much this stand-alone 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.
Congress should address this inequity as soon as possible.
- Hearings or other action should be taken to ensure CMS and Medicare-certified home health agencies are interpreting and administering the current home health benefit as provided by law. Individuals who are homebound, receiving skilled care, and in need of home health aide/personal hands-on care should be able to receive the full array of care authorized by law.
- Further, all Medicare beneficiaries, not just those enrolled in Medicare Advantage plans, should be able to receive Medicare coverage for necessary home health aide care even if they are not homebound or require skilled nursing or therapy.
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Mrs. B contacted the Center for Medicare Advocacy seeking assistance with Medicare home health coverage. She lives with her husband who has advanced Parkinson’s disease. He receives physical therapy and speech language pathology through a Medicare-certified home health agency, but the agency told Mr. and Mrs. B they are “over Medicare’s income limit for a home health aide,” so they are paying the agency privately for a home health aide, 24 hours a week. Although Mrs. B is past full retirement age, and would like to retire, she works to support the private payments for her husband’s home health aide. The aide helps Mr. B get in and out of bed, does his grooming, helps him to eat and take medications, and takes him to the porch where he can enjoy the sunshine. The aide also sweeps the floor of his room and takes him to the doctor.
Analysis and Guidance from the Center for Medicare Advocacy
- B is homebound and receives Medicare-covered skilled therapy. Under the law, this makes him eligible for necessary personal hands-on care from a home health aide for up to 28 hours a week (35 hours a week if specifically documented by his doctor). There are no income limits in Medicare – everyone who receives Medicare is eligible for the same benefit coverage. The B’s should not have to pay privately for a home health aide for Mr. B’s personal hands-on care for up to the hours coverable under the law.
- Federal Regulations define the kinds of personal hands-on care from a home health aide that are coverable by Medicare (42 CFR 409.45(b)(1)(i)-(v); see definitions, below). The services include getting Mr. B in and out of bed, grooming, assistance with eating and taking medications, and helping to get to another area of the house. While sweeping the floor of his room is not directly hands-on personal care, Medicare allows for such services “incident” to personal care. When Mr. B moves barefoot from his bed to the bathroom, crossing a clean floor is important and, therefore, sweeping his bedroom floor, which takes little time, can be included as part of the home health aide services. On the other hand, driving Mr. B to his doctor is not a coverable service, since Medicare-covered aide services are limited to hands-on care performed in the home. Mr. B will need to make private arrangements for the transportation.
- The Bs should contact Mr. B’s doctor to make sure the services provided by a home health aide have been ordered by the physician and are included in Mr. B’s Plan of Care. The physician can be very specific about the reason for the services and the best time of day to provide the care. Realistically, however, the Bs may need to be flexible in order to work with the agency regarding the hours of the day when the aide is available.
- All home health services must be organized through a single Medicare-certified home health agency. However, if that agency cannot provide all the required services, it can make “arrangements” for the services it cannot provide with another agency. All Medicare payments must go to the original agency which must share them with the other agency as appropriate. In practice, when home health agencies decline to provide home health aide services, they usually will not arrange with another agency to provide them. If Mr. B’s current agency cannot (or will not) provide Medicare-covered home health aide care, and if the Bs are not attached to that particular agency (because of Mr. B’s physical therapist and speech language pathologist, for example), they might want to seek services from another Medicare-certified home health agency that serves their zip code. They can find information on other available agencies by inserting their zip code at: https://www.medicare.gov/homehealthcompare/search.html
- The official Medicare publication describing home health services may be helpful to support a conversation with a home health agency, home health aides are referenced on pages 8 and 9: https://www.medicare.gov/Pubs/pdf/10969-Medicare-and-Home-Health-Care.pdf.
- There is also a great deal of information about Medicare home health coverage on the Center for Medicare Advocacy’s website, MedicareAdvocacy.org.
A. The Medicare Act includes personal hands-on care provided by home health aides as a Medicare covered service for individuals who are homebound and need and receive skilled nursing or therapy: 42 USC §1395x(m)(1)-(4)
B. Federal Regulations: 42 CFR §409.45(b), defines Home Health Aide Services as follows:
Home health aide services. To be covered, home health aide services must meet each of the following requirements:
(1) The reason for the visits by the home health aide must be to provide hands-on personal care to the beneficiary or services that are needed to maintain the beneficiary‘s health or to facilitate treatment of the beneficiary‘s illness or injury. The physician’s order must indicate the frequency of the home health aide services required by the beneficiary. These services may include but are not limited to:
(i) Personal care services such as bathing, dressing, grooming, caring for hair, nail and oral hygiene that are needed to facilitate treatment or to prevent deterioration of the beneficiary‘s health, changing the bed linens of an incontinent beneficiary, shaving, deodorant application, skin care with lotions and/or powder, foot care, ear care, feeding, assistance with elimination (including enemas unless the skills of a licensed nurse are required due to the beneficiary‘s condition, routine catheter care, and routine colostomy care), assistance with ambulation, changing position in bed, and assistance with transfers.
(ii) Simple dressing changes that do not require the skills of a licensed nurse.
(iii) Assistance with medications that are ordinarily self-administered and that do not require the skills of a licensed nurse to be provided safely and effectively.
(iv) Assistance with activities that are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed, such as routine maintenance exercises and repetitive practice of functional communication skills to support speech-language pathology services.
(v) Routine care of prosthetic and orthotic devices.
(2) The services to be provided by the home health aide must be –
(i) Ordered by a physician in the plan of care; and
(ii) Provided by the home health aide on a part-time or intermittent basis.
(3) The services provided by the home health aide must be reasonable and necessary. To be considered reasonable and necessary, the services must –
(i) Meet the requirement for home health aide services in paragraph (b)(1) of this section;
(ii) Be of a type the beneficiary cannot perform for himself or herself; and
(iii) Be of a type that there is no able or willing caregiver to provide, or, if there is a potential caregiver, the beneficiary is unwilling to use the services of that individual.
(4) The home health aide also may perform services incidental to a visit that was for the provision of care as described in paragraphs (b)(3)(i) through (iii) of this section. For example, these incidental services may include changing bed linens, personal laundry, or preparing a light meal.
C. Medicare Benefit Policy Manual, Chapter 7, Section 40 – Covered Services Under a Qualifying Home Health Plan of Care (Rev. 1, 10-01-03) A3-3118, HHA-205, Authorizes Medicare Coverage of Home Health Aide, as follows:
Section 1861(m) of the Act governs the Medicare home health services that may be provided to eligible beneficiaries by or under arrangements made by a participating home health agency (HHA). Section 1861(m) describes home health services as…
…The term “part-time or intermittent” for purposes of coverage under §1861(m) of the Act means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). See §50.7.
For any home health services to be covered by Medicare, the patient must meet the qualifying criteria as specified in §30, including having a need for skilled nursing care on an intermittent basis, physical therapy, speech-language pathology services, or a continuing need for occupational therapy as defined in this section.
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The Center for Medicare Advocacy is pleased to announce that Cathy Hurwit has joined our Advisory Board. Ms. Hurwit recently retired as Chief of Staff to Representative Jan Schakowsky (D-IL), where she also had responsibility for universal health care, senior and labor issues. Prior to joining Rep. Schakowsky’s staff in January 1999, she was a legislative affairs specialist at the American Federation of State, County and Municipal Employees (AFSCME).
Ms. Hurwit served as legislative director of Citizen Action for twelve years. With her particular focus on health care, Ms. Hurwit was the founder of the Campaign for Health Security and served as its chair from 1991 to 1998. She also co-chaired the health care task force of Jobs with Justice and served on its executive committee. She provided technical assistance on single-payer and state implementation issues to President Clinton’s Health Care Task Force. Ms. Hurwit served as energy policy director for Representative Toby Moffett (1976-1979), adviser to the House Government Operations Committee’s Subcommittee on Environment, Energy and Natural Resources (1979-1982), and legislative director for Representative Ed Markey (1987-1989).
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The Administration for Community Living (ACL) recently released their annual summary of minority aging statistics, the 2017 Minority Aging Statistical Profiles and Profile of Older Americans. The summaries provide statistics on older adults within the African American, American Indian and Alaska Native, Asian American, and Hispanic American populations. The summaries are compiled primarily with data from the U.S. Census Bureau, and include data regarding income and poverty, self-rated health status, chronic conditions, disability status, health insurance, and participation in Older Americans Act (OAA) programs.
The data reveal that the population of older Americans is becoming more racially and ethnically diverse, which is attributed to greater longevity among minority populations. Racial and ethnic minority populations have increased from 19% of the older adult population in 2006 to 23% in 2016, and the percentage is expected to rise to 28% by 2030.
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