The Centers for Medicare and Medicaid Services (CMS) may expandit’s benefits to home health and other personal care services which may not be included in MA plans, but which can be included and may redefine the reimbursement landscape.

The expansion refers to certain benefits which are initially not part of the original Medicare, yet are primarily health-related. The development further encompasses other services provided that the additional inclusions are aimed at curing, preventing or diminishing the impact of an injury or illness.

Moreover, CMS believes that items and services that prevent, cure and diminish the impact of health conditions are proven to reduce the use of emergency and health care services. In a survey conducted by the American College of Emergency Physicians (ACEP), it was found out that nine out 10 emergency room doctors are not fully prepared to handle major disasters or mass tragedies. Should personal home services be covered by the development, there will be lesser number of patients who will crowd emergency rooms and hospitals.

Beneficiaries may now be able to enjoy unconventional assistance like grocery delivery and ride-hailing amenities which are known to minimize the effect of their current health issues. Moreover, home health care can be maximized to employ the skilled nursing staff at home which will be less expensive yet as effective as the intervention received by patients in hospitals and other types of nursing facilities.

“Primarily Health Related” Defined

In line with the expansion, CMS provides a new interpretation of what can be considered as “primarily health-related”. Below are few examples of what can fall under the new CMS definition:

  • Items or services that are used to diagnose, prevent or treat illness and injury, act to enhance the psychological/functional impact of injuries, compensate for physical impairments and reduce utilization of emergency and healthcare facilities.
  • Items and services should address the enrollee’s healthcare needs, be medically appropriate and should have been recommended by a provider
  • Items and services that compensate for physical impairments include cleaning, cooking and transportation.
  • Items and services that reduce healthcare services use are intensive home-based support and adult day care.

The Next Big Step for Medicare Advantage Insurance Providers

The CMS expansion will not only be beneficial to enrollees but will also be an advantage to providers. In less than a year before its implementation, providers can start preparing their data and analysis showing how an item or service can reduce the cost and impact to a patient’s condition. The provision of home care services should reflect how it can dramatically minimize the utilization of healthcare facilities. Providers can also remain watchful for other announcements to be made by CMS for them to reconcile certain aspects of the program that may or may not be contradictory to the new definitions and coverage.

Since all MA plans should have compliance programs in place, providers can best organize extensive research and study that could help them explore the ins and outs of personal care services. By doing so, providers can effectively respond to payor initiative and maintain an established compliance program once the expansion takes effect in 2019.

Steve Shain video discussing this news (2nd half)