CMA Alert | April 22, 2021 - Center for Medicare Advocacy

Shrinking Medicare Home Health Coverage: It’s Time to Act
Nurse Aide Training Bill Could Diminish Quality of Care for Nursing Home
Personal Care Attendants: Troubling New Class of Worker in Florida Long-Term Care Facilities
New Oral Health Resources
Oscar Nominated Documentary Goes Undercover in Chilean Nursing Home
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Shrinking Medicare Home Health Coverage: It’s Time to Act

62 million older Americans and people with disabilities rely on Medicare to finance their health care. For this large segment of the population, when Medicare coverage is unavailable or denied, access to health care is also often denied.

Especially since the COVID pandemic, commentators and policymakers reiterate the need and preference for home-based, rather than institutional, health care. Medicare can be a valuable resource to pay for home health care for people who meet the legal qualifying criteria. The Medicare benefit includes home health aide services, defined as hands-on personal care, that allows people to live safely at home. The law authorizing Medicare coverage for home health care and home health aides has not been changed or circumscribed in years. However, payment models and implementation have changed over time, and the ability to obtain Medicare-covered home health and home health aide care, has greatly declined. This is true even when individuals meet the law’s threshold homebound and skilled care requirements – and qualify for Medicare coverage.

Sadly, and incorrectly, Medicare beneficiaries are often told the only aide care they can get is a bath, only a few times a week, for a short period of time. Sometimes they are told Medicare simply does not cover home health aides. The Center has even heard of an individual being told he could not receive home health aide care because he was “over income” – although Medicare has no such income limit.

In fact, Medicare law authorizes up to 28 to 35 hours a week of home health aide and nursing services combined. 42 USC 1395x(m)(1)-(4). Medicare is also available for home health aides if the individual receives physical therapy, speech language pathology therapy, and sometimes, occupational therapy. While personal hands-on care does include bathing under the law, it also includes dressing, grooming, feeding, toileting, and other key services to help an individual remain healthy and safe at home. 42 CFR 409.45(b)(1)(i)-(v). (See also, Medicare Benefits Policy Manual, Chapter 7, §§50.1 and 50.2.)

This level of home health aide personal care used to be available. The Center helped many clients remain at home because these services were in place, but now such care is almost never obtainable. Statistics demonstrate this point. In 2021 MedPAC reported that home health aide visits per 60-day episode of home care declined by 90% from 1998 to 2019, from an average of 13.4 visits per episode to 1.3 visits. As a percent of total visits from 1997 to 2019, home health aides declined from 48% of total services to 6%. (March 2021 MedPAC Report to Congress, page 245 and March 2019 MedPAC Report to Congress, p. 234.)

The real, personal, impact of this reduced access to home health aides was made clear in a Kaiser Health News article, (Judith Graham, Seniors Aging In Place Turn To Devices And Helpers, But Unmet Needs Are Common, 2/14/2019).[1] The article includes stark findings about the unmet needs of vulnerable Americans struggling to live at home with little or no help. For example:

“About 25 million Americans who are aging in place rely on help from other people and devices such as canes, raised toilets or shower seats to perform essential daily activities, according to a new study documenting how older adults adapt to their changing physical abilities.”
“Nearly 60 percent of seniors with seriously compromised mobility reported staying inside their homes or apartments instead of getting out of the house. Twenty-five percent said they often remained in bed. Of older adults who had significant difficulty putting on a shirt or pulling on undergarments or pants, 20 percent went without getting dressed. Of those who required assistance with toileting issues, 27.9 percent had an accident or soiled themselves.”
“60 percent of the seniors surveyed used at least one device, most commonly for bathing, toileting and moving around. (Twenty percent used two or more devices and 13 percent also received some kind of personal assistance.)
Five percent had difficulty with daily tasks but didn’t have help and hadn’t made other adjustments yet.”

While it isn’t clear how many of these individuals should be receiving needed home care through Medicare, it is likely that far more qualify than are able to access the benefit, since the surveyed population was 65 or older and infirm. Indeed, the author states “The problem, experts note, is that Medicare doesn’t pay for most of these non-medical services, with exceptions.” A May 2019 Johns Hopkins Bloomberg Study also found that people with limitations in activities of daily living (ADLs) experience significant harm when they cannot access adequate help with ADLs at home.[2]

In fact, the problem is two-fold:

The Medicare home health benefit is being unfairly and inaccurately articulated and administered. Medicare-certified home health agencies have all but stopped providing necessary, legally authorized home health aide personal care, even when patients are homebound and receiving the requisite nursing or therapy to trigger coverage.
Instead of correcting this harmful misapplication of Medicare coverage for all beneficiaries, CMS issued a new policy implemented in 2019 allowing private Medicare Advantage (MA) plans to provide personal care services for their enrollees without a homebound or skilled care requirement. (CMS Calendar Year 2019 Final Call Letter, Health Related Supplemental Benefits, p. 207-208.) This is ironic and unjust given the restrictive interpretation of the Medicare home health benefit in general, and the obliteration of home health aide coverage in particular.

While it remains to be seen how much this stand-alone MA personal care benefit will actually be offered and provided, it continues the trend of discriminating against the majority of beneficiaries, who are enrolled in traditional Medicare. It also adds to the myriad enticements for people to join private limited-network MA plans.

Conclusion

Congress should address the lack of access to Medicare-covered home health and home health aide care.

Congressional hearings or other public action should be taken to ensure CMS and Medicare-certified home health agencies are interpreting and administering the current home health benefit as provided by law. Individuals who are homebound, receiving skilled care, and in need of home health aide/personal hands-on care should be able to receive the full array of necessary care authorized by law.
Further, all Medicare beneficiaries, not just those enrolled in Medicare Advantage plans, should be able to receive Medicare coverage for necessary home health aide care even if they are not homebound or require skilled nursing or therapy. Such a benefit will keep many people out of institutions and help them remain safely at home.

Most people want to remain home when they need longer-term services and supports. In most instances, as we’ve learned from the pandemic, it’s also better for the community’s public health for people to stay out of institutions – if they can do so safely and with a quality of life. It’s time to make sure people who rely on Medicare to access care can obtain the home and community-based services they need.

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[1] See also, Kaiser Health News, “Home Care Agencies Often Wrongly Deny Medicare to Chronically Ill,” Susan Jaffe (1/18/2018), https://khn.org/news/home-care-agencies-often-wrongly-deny-medicare-help-to-the-chronically-ill/.
[2] https://www.eurekalert.org/pub_releases/2019-05/jhub-msh_1052819.php

Nurse Aide Training Bill Could Diminish Quality of Care for Nursing Home Residents

The Nurses CARE Act of 2021, currently pending in Congress, reflects misguided public policy. The aim of the bipartisan bill is to address staffing shortages in long-term care facilities that have been felt most acutely during the coronavirus pandemic. The proposed means for accomplishing this worthwhile goal, however, will inevitably diminish the quality of care nursing home residents receive.

Current federal law requires that within four months of working at a nursing home, new nurse aides complete a minimum of 75 hours of training, including 16 hours of clinical training under the direct supervision of a registered or licensed practical nurse.[1] Due to the public health emergency (PHE) that emerged with COVID-19, the Centers for Medicare & Medicaid Services (CMS) temporarily waived these training requirements in order to combat staffing shortages.[2] The American Health Care Association (AHCA), the for-profit nursing home association, promptly developed a free eight-hour training program for a new category of direct care worker that AHCA called Temporary Nurse Aides (TNAs).[3] Many states used the AHCA program to approve temporary workers during the pandemic.[4]

The Nurses CARE Act, sponsored by Representatives Fred Keller (R-PA) and Susan Wild (D-PA), would allow a TNA, supported with only eight-hours of online training, to be considered qualified as a nurse aide in nursing homes if the individual has clocked 80 hours of work in a facility. Furthermore, in a guidance memo issued on April 8, 2021, CMS is potentially paving the way for training requirements to be scaled down permanently. While confirming that nurse aide training requirements will be reinstated when the waiver is lifted, CMS recommends that states “consider allowing some of the time worked by the nurse aides during the PHE to count toward the 75-hour training requirement.”[5] The Center for Medicare Advocacy has been reporting on this issue throughout the pandemic (find past Alerts here and here).

Why These Changes Matter

The Nurses CARE Act essentially formalizes a work-around for federal nurse aide training requirements. If passed, it would partially roll back essential progress that was made over three decades ago in the Nursing Home Reform Act of 1987, which established standards of care fundamentally important to securing the safety of our nation’s older adults. It is also potentially unfair to those working as nurse aides and could even exacerbate the staffing shortage issue.

Adults in the United States are living longer with more complex health care needs. Now, more than ever, nurse aides need more training – not less – to equip them with the skills they need to effectively navigate the challenges of caring for a frail, vulnerable population. Staff shortages in nursing homes were an issue before the pandemic, largely due to poor pay and poor training mixed with physically and psychologically demanding work. The answer lies in fixing these root issues, such as increasing wages, not adding to them by lowering the training bar. The Nurses CARE Act will not help nurse aides in the long run, and it will certainly not help our nation’s nursing home residents receive the quality care they desperately need.

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[1] Requirements for approval of a nurse aide training and competency evaluation program, 42 CFR § 483.152.
[2] CMS, “Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19” (Mar. 28, 2020), https://www.cms.gov/files/document/covid-long-term-care-facilities.pdf.
[3] AHCA, Temporary Nurse Aide Training & Competency Checklist, https://educate.ahcancal.org/products/temporary-nurse-aide.
[4] The Center for Medicare Advocacy issued an Alert, https://medicareadvocacy.org/whos-providing-care-to-nursing-home-residents/, and a Report, “Who’s Providing Care for Nursing Home Residents? Nurse Aide Training Requirements during the Coronavirus Pandemic” (Jul. 29, 2020), https://medicareadvocacy.org/wp-content/uploads/2020/07/Report-Nurse-Aide-Training.pdf, about states’ authorization of temporary nurse aides.
[5] CMS, “Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issues in response to COVID-19” Centers for Clinical Standards and Quality/Quality, Safety & Oversight Group (April 8, 2021).

Personal Care Attendants: Troubling New Class of Worker in Florida Long-Term Care Facilities

As lawmakers look for ways to resolve the staffing shortages in long-term care facilities, the solutions of lowering the bar on training and qualifications are troubling and potentially dangerous to the vulnerable residents who live in these facilities.

This week, the Florida House has tentatively approved a new type of worker in long-term care – the Personal Care Attendants (PCAs). They have been described as essentially “paid interns” that are tasked with some duties that certified nursing assistants (CNAs) have performed with activities of daily living. The Florida Agency for Health Care Association approved the use of PCAs by emergency order to fill the staffing needs during the pandemic. Now, state lawmakers want to ensure PCAs remain in the facilities permanently. PCAs currently must take an 8-hour “Preservice Course” which involves 5-hours in the classroom and 3-hours of a “simulation/competency check-off” administered by the Florida Health Care Association (FHCA), an advocacy association for long-term care providers.

COVID-19 has ravaged our nation’s nursing homes. Residents have witnessed a high death toll within the places they call home, faced extreme social isolation, and have even seen neglect and abuse. Continually reducing the training that staff are required to have directly diminishes the quality of care those residents receive.

New Oral Health Resources

The ADA Health Policy Institute (HPI) recently developed an infographic series on racial disparities in oral health:

Oscar Nominated Documentary Goes Undercover in Chilean Nursing Home

The Academy Awards are this Sunday, April 25th. Nominated for best documentary is The Mole Agent – a moving Chilean film that gives us a rare glimpse of life in a nursing home from a resident’s perspective. The documentary follows an 83-year-old man (“Sergio”) who was hired by a private investigator to go undercover in a nursing home to find potential abuse or neglect. What unfolds is a tender story about ageism, loneliness, and preservation of identity. Social isolation and loneliness were issues in long-term care before the pandemic, which has only amplified this public health concern. The Mole Agent illustrates how even a simple phone call to a loved one can make a meaningful difference.

May Webinars | Register Now

May 5, 2021, 2:00 – 3:15 PM EDT

Geography is not Destiny: Mitigating Harm in SNFs During and After COVID 19

Sponsored by California Health Advocates Senior Medicare Patrol, this presentation will include a discussion of the Center’s recent research into nursing home successes and failures during the COVID pandemic, and what can be done to improve care going forward, as well as updates on residents rights, and fraud awareness and prevention.

Presenters include:

Micki Nozaki, SMP Project Director with California health Advocates
Toby S. Edelman, Center for Medicare Advocacy Senior Policy Attorney
Cinnamon St. John, Center for Medicare Advocacy Chiplin Medicare & Health Policy Fellow

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May 19, 2021, 2:00 – 3:00 PM EDT

Voices of Medicare: Updates from the Field

This presentation will examine real stories of current Medicare Issues told by our advocates, including:

Home Health Access Issues – Associate Director Kathy Holt
Medicare Advantage – Senior Attorney Mary Ashkar
Medicare Appeals – Attorney Paul Grabowski
Low-Income Beneficiary Issues– Policy Attorney Kata Kertesz
Oral Health – Senior Attorney Wey-Wey Kwok

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