Understanding Home Health Care Access After Recent Medicare Payment Changes

A new article from Kaiser Health News (KHN), “What To Do If Your Home Health Care Agency Ditches You,” shines a light on confusion regarding recent changes to Medicare home health payments and beneficiary access to those services.

Under Medicare, home health care includes a wide range of health and social services delivered in the home to treat illness or injury. Covered services include intermittent skilled nursing care, therapy, and care provided by a home health aide.

To qualify for services under Part B, individuals must meet certain eligibility requirements including being homebound and in need of skilled care. To receive coverage under Part A, individuals must also have spent at least three consecutive days as a hospital inpatient or had a Medicare-covered skilled nursing facility (SNF) stay. In such instances, Part A will cover the first 100 days of home health care.

The article shares the experience of Medicare beneficiaries Craig Holly and his wife, Effie Costas-Holly. Effie has advanced multiple sclerosis and was receiving a relatively minimal amount of home health care. The agency abruptly ended her services last month and told Craig this was due to Medicare’s new home health payment system.

While CMS did adopt a new payment structure on January 1, known as the Patient-Driven Groupings Model (PDGM), the underlying benefit and coverage rules were not affected. All that changed is how Original Medicare pays home health agencies.

Under the old system, Medicare’s home health rates reflected the amount of therapy delivered, so that more visits meant higher payments. Under the PDGM, therapy isn’t explicitly factored into the reimbursements. Instead, payments are based on several factors that result in agencies being paid higher rates for serving beneficiaries who require complex nursing care and lower rates for providing care to people with long-term chronic conditions.

Such financial incentives would seem to put those who need lower amounts of care at risk. In response to this concern, CMS said that it does “not expect home health agencies to under-supply care or services; reduce the number of visits in response to payment; or inappropriately discharge a patient receiving Medicare home health services as these would be violations of [Medicare] conditions of participation.”

However, reports suggest that is indeed happening. Further, the article notes that “therapists, home health agencies and association leaders say that patients across the country are being told they no longer qualify for certain services…or that services have to be cut back or discontinued.”

Craig and Effie were, fortunately, able to have her services restored. Since home health agency confusion appears to be widespread, the KHN article outlines steps people can take if they find themselves in a similar situation. The recommendations include getting as much information from the agency as possible, enlisting the assistance of the physician who ordered the home health care services, and reaching out to 1-800-Medicare and consumer advocates for help.

If you are experiencing a coverage disruption or have questions, counselors at Medicare Rights’ National Helpline are available Monday through Friday at 800-333-4114. Medicare Rights is concerned about the impacts of the new home health payment system on beneficiary access and will continue to monitor its implementation.

Read the article, “What To Do If Your Home Health Care Agency Ditches You.”

Read more about Medicare’s Home Health benefit.