Copayment Woes Drive Agenda for Home Care Advocates

There’s another new regulation in the future for home health care that some in the industry are calling doomsday: copayments.

Copayments for home health care, which were eliminated from Medicare several decades ago, have been reintroduced into the health care reform dialogue and could make a full come back, with some proposals placing implementation as early as 2018. That is, unless home care advocates can shift the momentum around copayments in Washington.

The Council of State Homecare Association and the Pennsylvania Homecare Association recently held a public policy summit and “advocacy day on the hill” in Washington D.C. to meet with legislators and lobby against payment cuts and new regulations. The aims of the group were three-fold: prevent the implementation of a home health care copayment, repeal the rebasing cuts from the Centers for Medicare & Medicaid Services and utilize a targeted enforcement approach to combat fraud.


Efforts to combat fraud have come down the pike in more sweeping initiatives, such as the pre-claim review demonstration, which rolled out in Illinois on August 3 and will soon begin in Michigan, Massachusetts, Florida and Texas. With the pre-claim demonstration already underway, home care groups and industry leaders are focusing their lobbying efforts on copayments, which have the potential to greatly impact home health care clients.

Co-Pays? No Way

Industry groups have vehemently opposed to proposals to resurrect copayments, which were eliminated more than 40 years ago. The re-introduction of copayments have been included in President Obama’s budget proposals for the last few years, with potential implementation as early of 2018. The copayment only applies to newly eligible Medicare beneficiaries in the year of implementation.

The proposals call for a $100 copayment per home health episode. Critics of copayments argue that copayments for Medicare beneficiaries did not work years ago, and therefore, they won’t work now. Medicare beneficiaries would circumvent using home health care because of the cost when copays existed.


“Congress eliminated the home health copayment in 1972 for the very reasons it should not be resurrected now,” the National Association for Home Care & Hospice (NAHC) wrote in comments to House Ways and Means Committee back in 2013. “The home health copayment in the 1960s and the 1970s deterred Medicare beneficiaries from accessing home health care and instead created an incentive for more expensive institutional care.”

President Obama’s most recent budget proposal for 2017 aimed to implement home health copayments for new beneficiaries in 2020.

In an election year, political candidates at the state and national levels are taking home care issues to heart, and home care insiders are pushing hard for their causes. With copayments back on the table, home care leaders are utilizing public policy channels to keep any new implementation at bay.

“We met with Medicare, CMS, and MACs locally,” Constance Morrison, president and CEO of Berks Visiting Nurse Association (VNA), Pottstown VNA and Advantage Home Care, said of the advocacy day in July on Capitol Hill. “We were able to probe and educate others about things that are coming down the pike in the industry. We were able to lobby, throw tomatoes. There were 19 states represented, and about 130 people representing home care.”

Berks VNA and Pottstown VNA are Pennsylvania-based registered non-profit home and community based health care services providers that, along with Advantage Home Care, are externally managed by their parent company, Home Health Care Management, Inc. Berks and Pottstown VNA serves nine Pennsylvania counties. Morrison, on behalf of Pennsylvania residents, has taken her aims of expanding access to “top-notch, affordable home health care” to Capitol Hill.

“The home health benefit is such a valuable piece of Medicare altogether,” Morrison said. “It was really clear across the board [at the meeting] that, big or small, we were all on the same page that this is a terrific benefit. We should not make cuts, not add a co-pay because then there will never be services.”

In addition to advocating against future copayments, Morrison continued to lobby for anti-fraud measures that don’t burden the entire home health landscape, as the pre-claim review does by mandating the new regulations on a state-wide basis. It is expected the model will eventually spread to a national level.

“We asked our legislators to support [new ways of targeting fraud] instead of washing us all in the same bathwater,” Morrison told HHCN. “We can do targeted fraud prevention. For the rest of us, the rules must be suitable.”

Lobbying, Throwing Tomatoes

Copayments are just one change to the home health industry stemming from the Affordable Care Act (ACA), which also required rebasing payments for home health agencies and a greater shift toward value-based purchasing. The copayment could potentially provide a financial incentive for Medicare beneficiaries to become more involved in their own care. In other words, a copayment could make care recipients more inclined to follow care directions. However, the price is not set on how much recipients will pay for a home health care episode.

“As part of the ACA, one of the ways to limit or make people responsible for their home care and cut costs is not just have Medicare pay for the 60-day episode,” Morrison said. “Right now, we aren’t sure what [the copayment] will look like, but likely $100 for every 60-day episode.”

However, the expense of copayments could have an opposite effect by deterring Medicare beneficiaries from using the benefit, according to Morrison. For home care recipients who may have to choose which bills to pay, home care will likely come as a last priority.

The group of people who are served through Medicare’s home health benefits are also some of the oldest, sickest and most vulnerable Americans, according to NAHC. About 25 million seniors and people with disabilities lived on income below $22,000 in 2010—200% below the federal poverty level. Medicare beneficiaries also already spend three times as much as the non-Medicare population on health care, about 15% of their total income.

“We know that people who have copays and have to choose between medication or food will choose food,” Morrison said. “If it’s home care versus medication, they will choose medication. It’s not a good topic.” 

Written by Amy Baxter

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