Eligibility Requirements for Non-Skilled In-Home Care Services in Medicare Advantage Plans

November 21, 2019

The Centers for Medicare & Medicaid Services (CMS) in its final rule issued last year expanded how it defines the “primarily health-related” benefits that insurers can include Medicare Advantage (MA) plans. Beginning in 2019, insurers could opt to include non-skilled in-home care and companion care services (approved by the CMS) in MA plans in addition to providing the benefits traditional Medicare offers. “Medicare Advantage beneficiaries will have more supplemental benefits making it easier for them to lead healthier, more independent lives,” said CMS Administrator Seema Verma when the final rule was initially announced. 

According to the CMS, under the new definition, the agency allows payment for non-skilled supplemental benefits under these circumstances:

  • to compensate for physical impairments,
  • diminish the impact of injuries or health conditions, and/or 
  • reduce avoidable emergency room utilization. 

The goal is to keep patients healthier longer so as to forestall expensive acute-care hospitalization.

While a physician’s order or prescription is not necessary, the new benefits must be “medically appropriate” and recommended by a licensed health care provider, according to the CMS. Covered services under non-skilled care are those offered by a caregiver, which typically include assisting with daily tasks and activities, including dressing, eating, bathing, and other personal care needs; providing rides to medical appointments; and ensuring the patient takes his or her medication. 

When the rule was first announced last year, it was lauded by health care insurers, and seen as a boon to Medicare beneficiaries with MA plans putting more focus on the prevention of avoidable injuries or exacerbation of existing health conditions. The expanded benefits could potentially help as many as 35% (19 million) of Medicare beneficiaries currently enrolled in MA plans. 

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Sources: Home Health Care, Kaiser Health News