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Judith Stein. Credit: Senate Finance Committee

Life Health > Health Insurance > Medicare Planning

Medicare Can Cover a Lot More Home Care: Witness to Senate Panel

By Allison Bell

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What You Need to Know

  • Medicare spending on home health services was about the same in 2021 as in 1997.
  • Judith Stein said Medicare managers give the impression that the home health benefit is a short-term benefit.
  • She argued that the Medicare home health care benefit has no duration limit.

A Medicare patient advocate stunned members of a Senate panel Tuesday by declaring that Medicare has the legal authority to cover large amounts of home care for patients, for extended periods.

Judith Stein, executive director of the Center for Medicare Advocacy in Willimantic, Connecticut, testified at a Senate Finance health subcommittee hearing that the Centers for Medicare and Medicaid Services discourages home care agencies from providing services over long periods by misleading the public and using an incentive system that favors short-term use of the services.

But, it’s “a myth that this is a short-term, acute care benefit,” Stein said. “CMS says it all the time. We have corrected myriad handbooks and pamphlets that come from CMS to indicate that this is a short-term benefit, when it’s not. That myth really needs to be dispelled.”

Sen. Catherine Cortez Masto, D-Nev., asked Stein whether it was really true that, if Medicare was implementing home care coverage benefits correctly, her own mother’s first cousin might be able to avoid selling his home to raise $56,000 to pay to enter an assisted living facility.

“Yes,” Stein said. “It’s definitely part of the challenge.”

What It Means

An experienced Medicare attorney told senators this week that Medicare can pay for enough home care to keep many older people out of assisted living facilities.

When Cortez Masto asked whether the other hearing witnesses or anyone else in the hearing room disagreed with Stein, no one said anything.

The Background

Congress tried to keep Medicare from crowding out private long-term care insurance programs by limiting it to covering acute health care.

Stein argued that changes Congress made in 1980 and 1997 eliminated home health visit caps and made it clear that Medicare enrollees could get extensive coverage for necessary home care visits.’

“Federal regulation and Medicare policy reiterate that there is no duration of time to the Medicare home care benefit,” Stein said.

The Reality

“Unfortunately, Stein said, “the center hears regularly from people who meet Medicare coverage criteria but are unable to access Medicare-covered home care or the appropriate amount of care.”

Getting access to home health aides to provide help with activities such as bathing can be especially challenging, even though federal law authorizes Medicare coverage of 28 to 35 hours a week of home health aide services.

Stein said Medicare creates disincentives for long-term home care benefits use by:

  • Paying more for the first 30 days of services than for services after 30 days.
  • Paying more for home health services for patients who come from a hospital or institution.
  • Using a quality measurement system that rewards only improvement in conditions, not success at efforts to maintain people’s health or slow deterioration.

“We need auditing that looks at underutilization, not just so-called ‘over-utilization,’” Stein added.

The Home Care Supply

David Grabowski, a Harvard Medical School professor, testified that he believes that Medicare provides generous payments for home health care in most of the country, and that the program should aim any extra payments meant to increase the supply of home care services at rural areas, where services may be more difficult to find.

Other witnesses noticed that Medicare may give an inaccurate picture of patients’ access to home care services by showing that the patients have adequate access if they live in the service area of at least two home care agencies, even if the agencies are overloaded and are not accepting new patients.

William Dombi, president of the National Association of Home Care & Hospice, said in testimony at the hearing and in written testimony that trends in the amount of home care covered by Medicare show that the home health services benefit is in trouble.

In 2021, Medicare paid for an average of 25.4 visits for just 3 million enrollees, down from an average of 74 visits for 3.6 million enrollees in 1997, Dombi said.

Medicare spending on home health services increased to just $16.9 billion in 2021, from $16.7 billion in 1997, as Medicare spending on skilled nursing facilities increased to $27.2 billion, from $11.2 billion.

“The evidence is mounting that patients in need of home health services are dealing with major barriers to access to care today, some of which may reach a point where they are insurmountable,” Dombi said.

Judith Stein. Credit: Senate Finance

Allison Bell

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