Pilot program could open door to home-based Medicare coverage

Pilot program could open door to home-based Medicare coverage
© Getty Images

(This story previously appeared in The Hill Extra.)


A pilot program to fund home-based assistance for some Medicare Advantage patients could open the door for reimbursement under Medicare, where payment for nonmedical support services is largely off limits.

Sens. Chuck GrassleyChuck GrassleyFormer Sen. Bob Dole dies at 98 Alarm grows over smash-and-grab robberies amid holiday season GOP blocks bill to expand gun background checks after Michigan school shooting MORE (R-Iowa) and Ben CardinBenjamin (Ben) Louis CardinOvernight Defense & National Security — US tries to deter Russian invasion of Ukraine Senate eyes plan B amid defense bill standoff Senators propose sanctions against Iran over alleged plot to kidnap US journalist MORE (D-Md.) are pushing legislation to give the Centers for Medicare and Medicaid Services (CMS) the authority to test potential savings from offering home and community-based care to certain Medicare beneficiaries 65 and older.

That would mirror already successful programs for seniors who also qualify for Medicaid. Although limited in scope, the pilot would be a shift in Medicare coverage policy.

“The goal is to prevent institutionalization by financing services that can make the difference, but services that are not generally considered healthcare,” William Dombi, vice president for law at the National Association for Home Care, whose members include companies and individuals that provide such care, told The Hill Extra.


“Basically, this holistic approach is a recognition that there are multiple factors at play in a person’s health and care that go beyond traditional health services,” he added.

Prevented falls, health deterioration and improved medication adherence reduces nursing home stay costs, and establishing coverage under Medicare could keep more seniors off Medicaid, according to Joe Caldwell, director of long-term services and supports at the National Council on Aging, a nonprofit advocacy group.

“For people who are not on Medicaid, the goal is that if they got a little bit of these services it could keep them at home, improve their health and prevent them from having to spend down all the money to qualify for Medicaid,” Caldwell said.

The demonstration would provide data on state and federal savings for supporting seniors aging in place by helping with their diet, transportation for medical care and providing relief for family caregivers. 

The pilot would be included in five commercial Medicare Advantage plans and cover up to 5,000 beneficiaries, with $3 million in seed money that would not impact the budget.

Grassley cited one estimate that delaying or preventing hospital or nursing home admissions for 5,000 seniors could save about $60 million over four years. 

“I’ve never met anyone who can’t wait to move into a nursing home,” Grassley said.

Caldwell says the private healthcare industry is already headed in this direction, and CMS has looked to expand dually eligible programs for other populations that may benefit from at-home support services. 

Still, the Center for Medicare and Medicaid Innovation hasn’t tested these services within Medicare, claiming it is outside of their scope of authority, according to Cheryl Phillips, a senior vice president at LeadingAge, an association of nonprofit long-term care providers

While Grassley is looking to add names to the bill’s list of sponsors, industry experts say the legislation’s optics, expanding Medicare and upfront costs, could turn off some Republicans.

An even bigger hurdle may be the ongoing debate over ObamaCare repeal and replace legislation. Congress's focus on healthcare may offer other vehicles for this demonstration including the Senate Finance Committee's initiative on chronic care, according to Dombi.

See more exclusive content on policy and regulatory news on our subscription-only service here.