CMS Allows Medicare Advantage Homemaker Coverage

In April, we learned that CMS was opening Medicare Advantage plans up to include coverage for homemaker services. While this is great for patients, you can expect more traditional Medicare patients transitioning to Medicare Advantage payers during the next enrollment period.

CMS provided the rationale for allowing homemaker services as part of the Medicare Advantage benefit.  According to the memo as released, agencies will be able to seek payment for services through a Medicare Advantage plan as long as the need is for ADLs and IADLs.

Medicare Advantage plans will however, have the final say on which patients qualify.  While Humana may allow the patient to receive these additional services for a particular ADL, United Healthcare may not allow that ADL, but may allow others.  Verification of benefits for each patient is going to become a lot trickier and more detailed once this coverage becomes available.

CMS is opening agencies up to a very new, potentially lucrative revenue stream.  Being a certified agency will allow services to be offered to your patients without the additional expense or coordination of private duty homemakers or aides. For many agencies these new revenue streams are going to be coming at just the perfect time when Medicare thinks about offering pre-claim review which won’t affect Medicare Advantage plans.

Each Medicare Advantage plan will need to include the applicable areas of coverage under the new rule from Medicare.  But according to early information from CMS, a primary health related benefit that is allowed under the new interpretation is quite broad.

  • In-Home Support Services
    Agencies will be allowed to provide services to patients who have a condition which impacts ADLs and IADLs. The purpose of this is to help reduce hospitalizations, more skilled and expensive services and reduce overall dependence on seeking healthcare services from other providers. Agencies who are licensed by Medicare will be all set as Medicare requires that the agency be licensed for personal care services by the state in which it operates.
  • Palliative Care
    Caring for patients who are terminally ill but may not be ready for hospice just yet, will now be covered by Medicare Advantage plans. This allows agencies to expand services to patients who are terminally ill but are not expected to pass away in less than 6 months, the qualification for traditional hospice services under Medicare.
  • Respite Care
    Medicare will allow 2-4 week Respite coverage to a family member who acts as a primary caregiver in order to obtain training or certification in caring for the patient. This service must be intermittent with the goal of providing either a short break for an existing family member or seek additional education and skills to provide the care that is necessary to keep the patient out of the hospital and reduce the risk of additional healthcare issues.

Other services that are going to be included and might be an interesting new revenue stream for agencies to consider to expand their revenue streams.

  • Adult Day Care Services
  • Medically-Approved Non-Opioid Pain Management
  • Stand-Alone Memory Fitness Benefit
  • Home & Bathroom Safety Devices & Modifications
  • Transportation
  • Over-the-Counter Benefits (Medications and healthcare items not covered by Medicare Part A, B or D.)

These new provisions and additional benefits are to be effective on January 1, 2019.  Medicare Advantage plans will begin to notify members of the new coverage this coming fall and during open enrollment. Get ready to be bombarded by all of the new Medicare Advantage TV commercials!