Many seniors who qualify for home-based care under Medicare aren’t receiving it. Why?

One of the greatest gaps in Medicare coverage is that it does not help to pay for home-based care unless such care is requested by a physician as medically necessary. Medicaid will cover such long-term custodial care for people with little to no income or assets. But Medicaid covers fewer than one in five of the roughly 55 million people on Medicare, leaving the rest to fend for themselves or, for a small group of mostly better-off folks, purchase private long-term care insurance.

Now, it appears that even Medicare’s limited home-based coverage benefits for those with medical needs are also not possible for many people. The nonprofit Center for Medicare Advocacy says it been researching the availability of Medicare-covered home-based care in response to a worrisome and growing volume of complaints from Medicare enrollees that they are being denied home-based care even though they are qualified to receive it and it is covered by Medicare.

Like nearly everything about Medicare, this is a complex topic. But it appears that Medicare is not keen to encourage use of allowable home care benefits. Home care providers don’t much like this benefit either. They don’t make much money on it, and under new Medicare rules, they can actually lose money providing such care.

Let’s begin with the benefit itself. According to the Center for Medicare Advocacy, Medicare will pay for up to 35 hours a week of home-based care — provided by nursing and home health aids — to people who are housebound and for whom such care is prescribed as medically necessary by their doctor or another authorized caregiver. The home health benefit also includes physical, occupational or speech-language therapy.

READ MORE: Does Medicare pay for a home health care provider?

Skilled nursing care is covered on an “intermittent” and “part-time” basis and also for home-based medical social services and for home health aides, who are allowed to perform certain personal services that stem from the patient’s underlying medical needs, but which are not the same as custodial care, which is not covered by Medicare.

These last two coverage categories, while part of Medicare’s benefits, merit only a footnote on the Medicare website. And when Medicare updated its home health care brochure last March, it was full of errors about the nature of available coverage, according to Center for Medicare Advocacy associate director Kathleen Holt.

Holt says the allowable benefits are thus broader than people realize. However, she adds, it looks like it doesn’t matter what’s actually covered, because home health agencies routinely decline to provide even the skimpier services that Medicare publicizes to Medicare enrollees who request them.

Significantly, Medicare will only pay insurance claims to home health agencies who are registered and approved by Medicare. Ostensibly to help consumers, it has developed an extensive quality rating system, so consumers can find the most qualified agency. However, there apparently is no requirement that an agency actually provide home health services when Medicare enrollees request them.

The reasons why these agencies turn away business, Holt claims, stem partly from Medicare’s increasing emphasis on paying for health care that actually helps patients get better. This is an admirable goal, but what it means is that home health agencies are rewarded for treating patients who are likely to get better.

Supporting care that cures people, while understandable, is not a requirement Medicare insists on for covering most health care. Therapy that maintains a person’s ability to function, or even that slows the pace of decline, is a perfectly good goal for treatment and one that many older Americans and their families embrace.

However, Medicare and Congress have supported the shift from fee-for-service health care to fee-for-results care. In this situation, home health agencies face a carrot-and-stick financial incentive system based on measurable patient improvement. That’s all fine and dandy, but what this means is that agencies are effectively discouraged from treating people with long-term chronic conditions who may be qualified for services, but are unlikely to get better.  (Click to Continue)

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Many seniors who qualify for home-based care under Medicare aren’t receiving it. Why?