A group of Democratic senators has unveiled a policy framework to establish a home care benefit within Medicare and expand Medicaid home- and community-based services, a “major policy shift” that was welcomed by home-based care organizations.

The lawmakers’ framework, released on Wednesday, could improve access to care, increase efficiency, and create a more stable payment source for providers – but questions remain about what the framework’s details would entail.

“Adding a meaningful home care benefit to Medicare would be a major policy shift,” Jason Lee, CEO of the Home Care Association of America (the HCAOA), told Home Health Care News in an email. “For providers, it could create a more consistent pathway to serve Medicare beneficiaries who need help with activities of daily living and other non-medical supports that allow them to remain safely at home. … Coverage [for these services is] limited, and families often have to pay privately, rely on unpaid family caregivers or spend down into Medicaid. A Medicare home care benefit could help close that gap, but the details will matter.”

Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) and 16 other Senate Democrats outlined their proposal to Senate colleagues in a letter. The letter’s three goals are to make home care affordable and accessible, improve the quality of care in nursing homes and use incentives to strengthen the long-term care workforce. 

“America is failing people who are aging and those with disabilities, who should have every opportunity to live at home and thrive in their communities,” the senators wrote. “Democrats want to ensure American families have affordable, high-quality care in the setting they choose and quality jobs and living wages for direct care workers. Families that rely on nursing homes should have the peace of mind that their loved ones will receive quality care, and incentives should reward safe staffing. We want to ensure the Senate is prepared to act on these issues when Democrats have another opportunity to enact the bold, meaningful change the American people demand and deserve.”

Senators wrote that they would expand access to home care, build on innovative volunteer models that mobilize community members to care for one another, ensure that home care is a dependable and integrated part of the health care system and guarantee middle-income families access to care without depleting their savings.

The policymakers also shared a flash sheet describing President Donald Trump’s “attack” on home care. The document claimed that Trump slashed Medicaid and therefore harmed access to home care, reduced protections on nursing home care and worsened the long-term care workforce crisis, among other points. 

The potential benefits and the necessary steps of Medicare home care

While home-based care associations highlighted that the lawmakers’ framework could provide advantages to both beneficiaries and providers, the lack of clarity on the specifics of the plan means experts could only hazard their best guesses about what the proposal could mean for the home-based care industry.

“Right now, the Senators are looking for input on how to make that vision a reality, so thinking about specifics around what it would look like for specific providers to bill Medicare from an operational or logistical perspective is premature,” Mollie Gurian, vice president of policy and government affairs at LeadingAge, told HHCN in an email.

Home care providers would benefit from the expansion of services as well as the predictable, uniform coverage policies across the country that Medicare would offer, Damon Terzaghi, the vice president of Medicaid and home care policy at the National Alliance for Care at Home (the Alliance), told HHCN in an email.

“Additionally, this would be a great advancement for beneficiaries who currently have to divest themselves of assets in order to access long-term services in the community,” Terzaghi said. “Adding home care to Medicare would provide options that allow middle-class families to access needed care without impoverishing themselves – which is sorely needed in our country.”

As many providers offer a range of home-based care services, a home care Medicare benefit could lead to more comprehensive, coordinated care, increased system efficiency and improved service delivery, Terzaghi said.

The guarantee of home care services under Medicare could allow home care agencies to expand access and have a more stable payment source, Lee said.

Experts cautioned that lawmakers would need to implement a thoughtful plan to execute their framework.

From Gurian’s perspective, it would be critical to ensure beneficiaries have access to a range of HCBS supports. These could include home care, personal care, care management, transportation and adult day services.

The Medicare home care benefit would have to be designed to reflect the real cost of delivering care, Lee said.

“That means adequate reimbursement, reasonable administrative requirements, clear eligibility rules, and recognition of the workforce challenges providers are already facing,” Lee said. “A benefit that is underfunded or overly burdensome would not solve the access problem families are experiencing.”

Terzaghi added that the existing Medicare home health benefit – which he said is “woefully underutilized” – must be re-fortified through payment, eligibility and coverage modernization efforts.

Implications for expanding HCBS

Senators proposed that the Finance Committee staff develop policies to invest in Medicaid HCBS, but did not provide specifics on what these policies would entail.

Senators did write that these policies would “expand access to home care so families in need are not limited by waiting lists, astronomical out-of-pocket costs or arbitrary poverty thresholds that force families to hand over their hard-earned assets, like their family home, to qualify for services.”

While clear details on exactly how lawmakers will propose expanding Medicaid HCBS are lacking, such an expansion would likely resemble the recently reintroduced HCBS Access Act, according to Terzaghi. If the proposals holistically address challenges, including waiting lists for care, strict coverage limitations and low reimbursement rates, an expansion could increase HCBS access and allow more individuals to receive services in their communities, Terzaghi added.

If an HCBS expansion were combined with the addition of home care to Medicare, beneficiaries and providers could experience significant benefits, Gurian said.

“What an expansion of Medicaid HCBS looks like remains to be seen, but for example, if Medicaid HCBS becomes a mandatory part of the Medicaid program, there might be more opportunity for providers to expand their offerings since more beneficiaries would be eligible for access,” Gurian said. “Taken in tandem with a guarantee for Medicare beneficiaries, the potential to provide care across the spectrum of coverage is big, assuming appropriate reimbursement.”

Gurian, Lee and Terzaghi all specified that their organizations were eager to work with lawmakers on the proposal.