Medicare Advantage: A Powerful Tool for Aging in Place (Just in Time for Open Enrollment!)

As families plan for aging in place, maintaining independence at home rather than moving to a nursing home or assisted living facility is key. Medicare plays a pivotal role in either facilitating or frustrating aging in place plans. Original Medicare (Parts A and B) offers limited support for home-based care, but Medicare Advantage (MA) plans (Part C), offered by private insurers, significantly enhance options for home care, telehealth, and post-hospital recovery. These plans not only cover everything Original Medicare does but also provide supplemental benefits tailored to aging in place, often improving health outcomes and reducing costs. With Open Enrollment (October 15–December 7) approaching, understanding MA’s advantages is critical for  families committed to staying home.

Why Medicare Advantage for Aging in Place?

Aging in place involves services like home care (e.g., help with bathing, meal prep), short-term disability support (e.g., recovery from surgery), and long-term care (e.g., chronic condition management). Original Medicare covers short-term skilled home health care (nursing, therapy) if you’re homebound and a doctor certifies medical necessity, but it excludes ongoing custodial care, short-term disability income, and most non-skilled home care. Moreover, original Medicare incentivized institutional care by paying for institutional rehabilitation for a period of time following a three-day hospitalization. MA plans bridge these gaps with flexible, home-focused benefits, often reducing out-of-pocket costs and supporting independence.

Recent data underscores MA’s impact: studies show MA enrollees have lower hospital readmission rates compared to Original Medicare (even with shorter periods necessary for rehabilitation), thanks to enhanced care coordination and home-based services. For aging-in-place families, this translates to fewer disruptions and better recovery at home.

Key Medicare Advantage Benefits Over Original Medicare

Here’s how MA plans enhance aging-in-place elements, with specific advantages in telehealth, hospital-at-home programs, in-home physical/occupational therapy (PT/OT), and transitions from hospital to long-term care, plus other post-hospitalization perks:

●Home Care (e.g., aides, meal prep):

• Original Medicare Coverage (2025): Limited to skilled care (nursing, therapy) if homebound; no custodial care (e.g., bathing). 

• MA Advantages: MA plans can pay for help that isn’t strictly medical, unlike Original Medicare. This includes: aides (someone to assist with daily tasks like bathing or dressing), for about 20–40 hours per month (e.g., a few hours a week); meal delivery services that bring prepared meals to your home, helping if cooking is hard; and, home modifications like grab bars in the bathroom to make your home safer and easier to navigate.  These are typically limited to in-network providers (out of network may not be covered or might cost you) and prior authorization is often required. 

• Potential Cost Savings & Health Outcomes: Potentially saves $200–$500/month on meals or $4,000–$6,000/month on aides; reduces nursing home risk (average cost: $100,000+/year).

●Short-Term Disability (e.g., post-surgery): 

• Original Medicare Coverage (2025):  Up to 100 days skilled nursing/home health; 20% coinsurance after day 20 ($204/day in 2024) possibly covered by supplemental insurance.

• Medicare Advantage Advantages: Lower copays, durable equipment (walkers), temporary aides. Expenses typically counts toward out-of-pocket max ($3,000–$8,000/year).

• Potential Cost Savings & Health Outcomes: Caps costs vs. Original Medicare's unlimited coinsurance; 10–15% fewer ER visits due to better recovery support.

●Long-Term Care (e.g., chronic conditions): 

• Original Medicare Coverage (2025):  No custodial care; limited chronic management.

• MA Advantages:  Partial non-skilled care like bathing, dressing, or eating, which don’t require a nurse or doctor (unlike "skilled" care like wound treatment). Medicare Advantage (MA) plans may cover some of these non-skilled services for a limited number of hours (e.g., 20–40 hours per month) to help you stay at home. Original Medicare doesn’t cover this kind of help at all unless you’re homebound and need skilled care too.  Chronic Special Needs Plans (C-SNPs) are special types of MA plans designed for people with ongoing health conditions like diabetes, heart failure, or lung disease (COPD). These plans often include extra benefits like devices or services that check your health at home (e.g., blood sugar monitors or telehealth check-ins with a nurse). This helps you manage your condition without frequent hospital visits.  Pair with Medicaid/insurance for full coverage.

• Potential Cost Savings & Health Outcomes:  Offsets 10–20% costs ($100–$300/month); C-SNPs cut hospitalizations by 10–15%.

●Telehealth: 

• Original Medicare Coverage (2025):  Covers office visits, mental health via video/audio; home-based until Sept. 30, 2025, then rural-only for non-mental health. 20% coinsurance.
• MA Advantages:  With MA plans, you can use telehealth (like video or phone calls with doctors) from your home at any time, regardless of where you live (urban or rural); original Medicare, however, may limit home-based telehealth after September 30, 2025, to rural areas for most non-mental health services, requiring you to visit a clinic or hospital for telehealth in urban areas. MA plans often allow telehealth visits using just a phone call (no video needed), which is great if you don’t have a smartphone or reliable internet. Original Medicare covers audio-only for mental health and some services through September 2025, but MA plans may extend this option for more types of visits (like routine check-ups) even after that date. 

MA plans also cover a wider range of telehealth services than Original Medicare. Beyond standard doctor visits or mental health sessions, MA might include quick check-ins with nurses, medication reviews, or chronic condition management (e.g., diabetes monitoring). MA plans may cover telehealth for routine check-ins, follow-ups after hospitalization, chronic disease management (e.g., COPD or diabetes), and even physical/occupational therapy (PT/OT) guidance. Original Medicare sticks to a narrower list, like office visits and mental health. For example, an MA plan might let a nurse call to check your blood pressure readings, reducing the need for in-person visits.

These extra services help keep you healthy at home without frequent in-person visits.

• Potential Cost Savings & Health Outcomes:  Improves access (43% fewer missed follow-ups); vital for rural Ohioans post-Sept. 2025.  MA plans often have $0–$20 copays for telehealth, compared to Original Medicare’s 20% coinsurance (e.g., $50 for a $250 specialist visit). Some plans waive copays entirely for telehealth to encourage use. Telehealth counseling, often expanded in MA, improves post-hospital recovery by addressing depression, common in 20% of elderly post-discharge.

●Hospital at Home: 

• Original Medicare Coverage (2025):  No dedicated program; skilled home health only if homebound.

• MA Advantages: Covers acute care at home (IV meds, monitoring) as inpatient alternative. 

• Potential Cost Savings & Health Outcomes: Reduces readmissions by 20–30% in pilots; lowers infection risk vs. hospitals.

●In-Home Physical/Occupational Therapy (PT/OT): 

• Original Medicare Coverage (2025):  Covers if medically necessary (no cap, $2,410 threshold); 20% coinsurance.  Medicare will pay for in-home PT (to improve movement, strength, or balance) or OT (to help with daily tasks like dressing or cooking) only if a doctor says it’s needed for your health. For example, you might need PT after a hip replacement to regain mobility or OT after a stroke to relearn daily activities. For in-home coverage under Part A (home health benefit), you must be homebound (hard to leave home without help) and need skilled care (like therapy from a licensed professional). A doctor must certify this. If you’re not homebound, Part B may cover PT/OT as outpatient services, even at home, as long as it’s medically necessary.  

In 2025, Medicare starts paying closer attention once your PT or OT costs hit $2,410 per year (this applies to PT and speech therapy combined, or OT separately). After this threshold, providers must add a special code (KX modifier) to your claims to confirm the therapy is still needed. Medicare usually keeps paying if justified, but it’s a checkpoint to ensure necessity.

You pay 20% of the cost for each PT/OT session, and Medicare covers the other 80%. For example, if a session costs $100, you pay $20 out of pocket. This applies after you meet the Part B deductible ($257 in 2025). If you’re getting in-home care under Part A’s home health benefit (and you’re homebound), there’s no coinsurance for those services. 

• Medicare Advantage Advantages: Lower copays ($20–$50), extended sessions, non-homebound access. MA plans often reduce the 20% coinsurance to a fixed copay (e.g., $20–$50 per session) or waive it entirely, saving you money compared to Original Medicare’s uncapped 20%.  Some MA plans cover in-home PT/OT even if you’re not strictly homebound, making it easier to get therapy at home for aging in place. MA plans may also include virtual PT/OT (via telehealth) or home safety modifications (like ramps) to complement therapy, boosting recovery compared to Original Medicare.

• Potential Cost Savings & Health Outcomes: Unlike Original Medicare, MA plans have an annual out-of-pocket maximum ($3,000–$8,000 in 2025), so your PT/OT costs won’t spiral indefinitely. MA’s coordinated care (e.g., therapy paired with nurse check-ins) reduces hospital readmissions, as therapy continuity prevents setbacks like falls (5–8% of readmissions).

●Hospital-to-LTC Transition (MMI): 

• Original Medicare Coverage (2025): Medicare only pays for skilled care if it’s helping you get better or maintain your abilities. If your doctor decides you’ve reached a point where more care won’t improve your condition (called “maximum medical improvement”), Medicare stops covering it. For example, if you’re recovering from a stroke but can’t make more progress with therapy, Medicare will say the skilled care isn’t needed anymore, even if you still need help or assistance, even if needed on a daily basis throughout the day. Skilled care means specialized care from trained professionals, like nurses giving injections or physical therapists helping you regain strength after surgery. It’s different from everyday help (like bathing or cooking), which can be provided by non-professionals like family, and for which Medicare doesn’t cover.  

If you’re in a skilled nursing facility (like a rehab center after a hospital stay), Medicare Part A covers up to 100 days per “benefit period” (a specific time frame tied to your condition). But this coverage stops earlier if your condition isn’t improving. For the first 20 days, Medicare pays 100%; for days 21–100, you pay a daily copay (about $204 in 2024). If you hit 100 days or stop improving before that, Medicare stops paying, and you’d need to cover the full cost (often $300–$500/day) or find other help, like Medicaid.

• Medicare Advantage Advantages:  Flexible prior authorization, extended SNF days, care managers for transitions.  MA plans offer advantages over Original Medicare for managing care, particularly when moving from a hospital to a skilled nursing facility (SNF) or home. It’s about making transitions smoother and potentially extending coverage for certain services.

Prior authorization is when your MA plan needs to approve certain services (like therapy or nursing home stays) before they’re covered. Unlike Original Medicare, which has strict rules about when care is “medically necessary,” MA plans can be more flexible in approving these services. For example, they might okay extra therapy sessions or specialized care if it helps you stay out of the hospital, even if Original Medicare would deny it. Extra days can give you more time to recover without paying huge out-of-pocket costs (SNFs can cost $300–$500/day without coverage). This supports aging in place by helping you return home stronger.

MA plans often assign a care manager (like a nurse or social worker) to guide you through transitions in care, like when moving from a hospital to an SNF, home, or another care setting. They help coordinate things like therapy schedules, medication plans, or follow-up doctor visits. They also make sure everyone (doctors, therapists, family) is on the same page.  These managers reduce confusion and mistakes (like wrong medications), making your move from hospital to home smoother and safer. This can prevent you from going back to the hospital.

• Potential Cost Savings & Health Outcomes:  Flexible Prior Authorization  means you might get extra PT/OT at home to avoid a nursing home,  reducing reliance on institutional care.  MA care managers reduce hospital readmissions by significantly by ensuring proper medication and follow-up care (e.g., >15% fewer heart failure readmissions with MA coordination).  By way of illustration, a care manager might arrange telehealth check-ins or home PT to keep you stable after leaving an SNF, cutting risks like medication errors (reducing hospital readmissions).

●Utilization of Technology: Remote Patient Monitoring (RPM) and More: 

• RPM Defined: RPM uses devices like blood pressure cuffs, glucose monitors, or wearable heart rate trackers that send data to your doctor from home. MA plans, particularly Chronic Special Needs Plans (C-SNPs), often cover these for conditions like diabetes, heart failure, or COPD.

• Original Medicare Coverage (2025): Limited RPM coverage (only specific codes like 99453–99457 for chronic conditions).

• Medicare Advantage Advantages:   Unlike Original Medicare, which has limited RPM coverage, MA plans may include RPM as a supplemental benefit, covering device costs or monitoring services. For example, a 2025 Humana MA plan in Ohio offered free glucose monitors and monthly nurse check-ins for diabetic patients.

• Potential Cost Savings & Health Outcomes: RPM significantly reduces ER visits  by catching issues early (e.g., high blood sugar spikes). A 2024 study showed MA’s RPM programs improved blood pressure control in 60% of hypertensive patients within 6 months.  For example, If you have heart failure, an MA plan might provide a scale to monitor weight daily (fluid retention is a red flag). Data goes to your doctor, who can adjust meds via telehealth, preventing hospital trips.

• Other Technologies: 

• Smart Home Devices: Some MA plans cover or subsidize devices like motion-sensor lights or fall detection systems (e.g., integrated with Alexa or Apple Watch) as part of home safety benefits. These reduce fall risks, a leading cause of readmissions (5–8% of elderly cases).

• Health Apps and Portals: MA plans often provide apps for scheduling telehealth, tracking vitals, or accessing care coordinators. For instance, UnitedHealthcare’s 2025 MA plans include a portal for real-time medication reminders, boosting adherence significantly.

• Virtual PT/OT: Some MA plans offer virtual physical or occupational therapy sessions, guiding exercises via video to maintain mobility after in-person sessions end. This is rare in Original Medicare.

MA plans don’t cover all non-skilled care needs, especially if you need help 24/7. To fill this gap, you can combine MA with Medicaid (a state program for low-income people), private long-term care insurance, or spend-down of your personal assets and property. For example, Ohio’s PASSPORT program (through Medicaid) can cover more in-home aide hours if you qualify (income under $2,901/month in 2025). Private insurance can also help pay for ongoing care costs that MA doesn’t fully cover.

Moreover, some plans present challenges that only a Medicare Specialist would know.  It is imperative that, in addition to conducting your own investigation, you consult with a Specialist who can guide you based on "inside" information that might be unavailable to you, or at least hard to access and assess.

In short,  MA plans can give you some help with daily tasks and tools to monitor chronic illnesses at home, but they too are limited. To get full support for staying at home long-term, you’ll likely need to add Medicaid, private insurance, or asset spend-down to cover the rest.  If you select the latter, your assets will last longer, leaving a greater chance that assets will pass to heirs rather than being consumed by long=term care expenses. 

Additional MA Benefits for Post-Hospital Recovery

When Original Medicare’s benefits cease (e.g., after 100 skilled nursing days or when PT/OT no longer shows “progress”), MA plans offer unique supports to maintain health and prevent setbacks:

• Care Coordination: Dedicated managers ensure medication reconciliation and follow-ups, reducing readmissions by 8–20%. For example, a 2025 study by Providence VNA Home Health showed medication reconciliation cut 30-day hospitalizations from 12% to 9% for heart failure patients.

• Supplemental Benefits: Meal delivery, transportation, or flex cards ($50–$300/year for OTC items) support nutrition and mobility, reducing malnutrition-related readmissions.

• Behavioral Health: Expanded telehealth counseling addresses post-hospital depression, improving physical recovery by 10–15%.

• Out-of-Pocket Caps: MA caps annual costs ($3,000–$8,000), unlike Original Medicare’s unlimited costs, ensuring affordability for ongoing care.

Ohio Context: Why MA Matters Now

Recent Ohio developments, like the September 2, 2025, Ohio Supreme Court ruling previously discussed on this blog, (State ex rel. LeadingAge Ohio v. Ohio Dept. of Medicaid), highlight Medicaid funding shortfalls for nursing homes ($527 million in 2024-2025), threatening care quality for 66,000 residents. MA’s home-based benefits offer a buffer, reducing reliance on facilities and aligning with programs like Ohio’s PASSPORT waiver, which supports in-home aides for those with income under $2,901/month.

Steps to Leverage MA for Aging in Place

Assess Needs: Consult a doctor or geriatric care manager to outline required services (e.g., PT/OT, home mods).

Compare Plans: Use Medicare.gov’s Plan Finder to identify plans with telehealth, in-home care, or C-SNPs. Prioritize low out-of-pocket maximums and strong Ohio networks.

Speak with a Specialist: A Medicare specialist is a must, not only to access your needs and goals, but to advise regarding which plans are best, and which specific plan is best for you and your circumstances.  

Enroll Strategically: Switch during Open Enrollment (October 15–December 7). Check for Special Needs Plans for chronic conditions.

Maximize Benefits: Request prior authorization early; combine with Veterans benefits, Area Agencies on Aging, or long-term care insurance. Track annual allowances.

Plan for Gaps: Budget for premiums ($0–$200/month) and copays; use trusts (e.g., $154,140 Community Spouse Resource Allowance in 2025) or Medicaid planning to cover full custodial care.

Monitor Health: Use MA’s telehealth and care coordination to prevent setbacks, leveraging data like 43% fewer missed follow-ups.

A Call to Action

Medicare Advantage plans empower Ohio families to age in place with dignity, offering cost savings, flexible care, and better health outcomes, like  fewer readmissions and !improved recovery. Amid uncertainties like Ohio’s Medicaid disputes, MA’s home-focused benefits are a lifeline. Don’t wait!  For tailored strategies, consult an elder law attorney or your State Health Insurance Assistance Program (SHIP). Secure your aging-in-place plan now to avoid facility costs and thrive at home.

Trump Administration deploys Medicaid Scorecard

In June, the Trump administration embarked on a basic change to Medicaid that for the first time evaluates states based on the health of millions of Americans and the services they use through the vast public insurance program for the poor.  Centers for Medicare and Medicaid Services CMS), deployed a “scorecard” that compiles and publicizes data from states for both Medicaid and the Children’s Health Insurance Program (CHIP), a companion for youngsters in working-class families.

This first scorecard includes state-by-state information showing that, on average, just over half the women on Medicaid are getting care while they are pregnant and after giving birth. Only three in five babies get checkups during their first 15 months, and less than half of children and teenagers have preventive dental visits.These and other measures show wide variations among states, though the initial version does not explicitly rank them. The scorecard also makes public for the first time measures of governments’ performance, such as how long both state and federal health officials take when states request “waivers” to deviate from Medicaid’s ordinary rules.

The Trump administration did not initially attach any consequences to how states make out, and indeed has declined to "rank" states.  That could change over the next few years as CMS refines and adds to the scorecard and members of Congress assess what it shows.  

The Trump Administration, through Seema Verma, head of CMS, explained that the scorecard is intended to initiate a conversation about health outcomes.  Medicaid pays for roughly half the nation’s births, but there is no data or discussion how or why states vary in birth outcomes.

The scorecard is part of a fundamental recalibration of the power relationship in Medicaid between the federal government and states. Since the program was created in 1965 as part of Lyndon Johnson’s War on Poverty, both have shared responsibility for paying for and defining the eligibility and benefits.  Medicaid now covers more than 67 million individuals, while CHIP covers nearly 6.5 million.

In the Trump era, federal health officials have been eager to give states more flexibility over Medicaid’s rules and benefits. Most significantly, the administration told states this year that it will allow them to require people to work or participate in other forms of “community engagement” to qualify for the program.

Such flexibility must be accompanied by heightened federal efforts to keep tabs on how well each state’s Medicaid program is functioning. Verma has said that “With all the flexibility must come accountability. We must be honest with ourselves and honest with our stakeholders . . . about how well we are doing.”

The scorecard’s initial information is based on states that voluntarily report a series of measures about the health of their Medicaid and CHIP enrollees. It shows, for instance, that the percentage of adults on Medicaid with high blood pressure under control as of 2016 varied from 26 percent in Louisiana to 72 percent in Rhode Island. The percentage of children ages 3 to 6 on Medicaid and CHIP who were getting adequate doctors’ care varied from 48 percent in Alaska and Idaho to 86 percent in Massachusetts.

Verma did not specify what additional information will be in later scorecards, but she said federal officials might be interested in how many people on Medicaid are working or volunteering, regardless of whether a state has imposed work requirements in its program.

Aging in Place Frustrated By Morass of Regulations- Federal Court Orders State to Give Senior Opportunity to Return Home

It is rare that a single case admits the existence of the morass of laws and regulations frustrating "Aging in Place" as a discreet planning objective.  It is rarer still that a judge carefully outlines just how these laws and regulations frustrate a patient's simple desire to "return home."  We find both in the opinion of the Hon. Jane Maghus-Stinson, Chief Judge United States District Court Southern District of Indiana, in the case Vaughn v. Wernert (S.D. Indiana, June 1, 2018).

Karen Vaughn, a woman living with quadriplegia in her own apartment for some 4o years, was held against her will in a care facility following a hospitalization for a temporary illness. The temporary illness did not alter dramatically her functional or cognitive capability. She wanted to go home. The state refused to let her "return home," arguing that it could no longer find a home care agency that could provide the level of services Ms. Vaughn needed following a tracheotomy in 2012.  The Court introduced the case as follows:

This case is before the Court because Karen Vaughn, a woman living with quadriplegia, has been institutionalized in hospitals and nursing homes for nearly two years, and she wants to go home. She desires and is eligible to receive home-based care, and she seeks to require Defendants, various entities of the Indiana Family and Social Services Administration, to provide that care. She raises claims under the Americans with Disabilities Act, the Rehabilitation Act, and the Medicaid Act, arguing that Defendants have failed to provide her with the medical assistance for which she qualifies, thereby institutionalizing her against her will. Ms. Vaughn seeks injunctive relief, requiring Defendants to take whatever measures are necessary and required by law to provide her with community-based care in the setting of her home (emphasis added).

The  case permitted  Judge Maghus-Stinson to revisit the Supreme Court's landmark 1999 decision in Olmstead v. L.C., 527 U.S. 581 (1999), in which the the U.S. Supreme Court ruled that states can violate Title II of the Americans With Disabilities Act of 1990 (ADA) if they provide only institutional care for the disabled when the disabled could be appropriately served in a home or community-based setting. While the Olmstead decision involved two women with developmental disabilities and mental illness who were residents of a psychiatric hospital, it has been interpreted to extend beyond those specific circumstances. The decision is seen to apply to people with physical as well as mental disabilities, to those in nursing homes, and to those living in the community and at risk of institutionalization. As a result, Olmstead has generated considerable discussion regarding the provision of long-term care services, not only for people with disabilities who currently need services, but also for the growing numbers of aging baby boomers who might need care in the coming decades. The Medicaid program is also seen to be governed by Olmstead, which program permits states to make many of their own decisions, within broad federal guidelines, about whom and what long-term care services to cover, and in what settings.

In Vaughn, ruling on cross motions for summary judgment, the court rejected the state's arguments that home or community based care was unavailable to Ms. Vaughn.  The court ruled that these were only unavailable to Ms. Vaughn because of the complexity in reimbursement rates, not because of the availability of appropriate care providers.  Judge Jane Magnus-Stinson observed,  in ruling in favor of Ms. Vaughn, that:

"...the undisputed medical evidence establishes that at or near the time of the filing of this Complaint, Ms. Vaughn’s physicians believed that she could and should be cared for at home—both because home healthcare is medically safer and socially preferable for her, and because Ms. Vaughn desires to be at home... That support has continued throughout the pendency of this litigation, through at least April of 2018 when Dr. Trambaugh was deposed. Based on the evidence before this Court, it concludes as a matter of law that Ms. Vaughn has established that treatment professionals have determined that the treatment she requests—home healthcare—is appropriate."

The court traced, and criticized, the almost indecipherably complex nature of Medicaid waiver programs that fund portions of home care:

Defendants' [the State] own administrative choices—namely, the restrictions they have imposed on Ms. Vaughn’s home healthcare provision pursuant to their Medicaid Policy Manual—have resulted in their inability to find a caregiver, or combination of caregivers, who can provide Ms. Vaughn’s care in a home-based setting. It may be the case that other factors, such as the nursing shortage or inadequate reimbursement rates, contribute to or exacerbate the difficulty in finding a provider. But, at a minimum, Ms. Vaughn has established that Defendants' administrative choices, in addition to their denials of her reasonable accommodation requests, have resulted in her remaining institutionalized.

The court explained:

"[The state's] efforts to locate a home healthcare provider were expressly limited by two factors: the reimbursement rate offered by Defendants to home healthcare providers, and the "Medicaid Policy Manual" requirements that certain tasks be performed by skilled medical professionals. But, as Defendants discovered in attempting to locate care providers for Ms. Vaughn, no skilled medical provider will provide the care at the reimbursement rates authorized by the State. Significantly, however, both Ms. Vaughn and her health care providers disagree with the Manual's requirement that a skilled level of care is necessary for some of the tasks associated with Ms. Vaughn's care. Ms. Vaughn has requested relief from the Manual's skilled care requirements. Defendants have offered no source of authority aside from the Medicaid Policy Manual itself as to why it cannot accommodate Ms. Vaughn's request for some skill-level service modifications (emphasis added).

Discussing the State's designations of services as either skilled, or non-skilled, the Court's frustration is obvious:

"...some of these services can be performed by either skilled or non-skilled

caregivers, as deemed appropriate in an individual's plan of care. Some of these overlapping services include active and passive exercise (which is, interestingly, only listed as skilled care on the corresponding respiratory disorders chart), stimulation, and vital signs. In yet another chart, regarding "Gastrointestinal Disorders," vital signs are listed as only skilled care services, and exercise is listed as only a non-skilled care service. In the "Central Nervous System Disorders" chart, "positioning" is listed as only a non-skilled care service,  but on the "Musculoskeletal Disorders" chart, "position changes" are listed as only a skilled care service. [citations and footnotes ommitted]. 

The Court simply cannot make heads or tails of these designations, and Defendants have offered no explanation whatsoever as to the basis for their categorizations in the first place, or the inconsistencies among them in the second. Defendants have also offered no explanation as to how those distinctions might be "necessary for the provision of the service." As Steimel explained, Defendants "cannot avoid the integration mandate by binding [their] hands in [their] own red tape." Steimel, 823 F.3d at 916.

Judge Maghus-Stinson recognized that the court could not simply order Ms. Vaughn's "return home" as an appropriate remedy under the law.  Instead she set a "remedy hearing" to explore all proposals, while  urging the parties to meet prior to that hearing in hopes of finding a mutually agreeable plan.  One hopes that the State will remove the impediments in the path to Ms. Vaughn's return home. 

GAO Report Warns that Assisted Living Quality Oversight Lacking: "National Scandal"

According to the Long Term Care Community Coalition (LTCCC) and the Center for Medicare Advocacy (CMA), "assisted living is viewed by seniors and their families as a desirable option for residential care when an individual wishes to avoid the institutional environment characteristic of a typical nursing home. While the assisted living industry has grown rapidly to meet this demand, little is known about the quality and safety provided to residents in these facilities." 

A newly released Report by the Government Accountability Office (GAO) warns that the Centers for Medicare & Medicaid Services (CMS) ability to oversee and regulate the quality of care provided to Medicaid beneficiaries in assisted living communities is severely compromised.  McKnights Senior Living reports that some federal lawmakers and consumer advocates are already pushing for changes in assisted living because of the report’s findings.

The GAO, at the request of a bipartisan group of  Senators, surveyed all state Medicaid agencies (including Washington, DC) for the report, titled “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed.” The Senators sought “to understand federal and state spending and oversight of care, but as the title suggests, the GAO was unable to respond effectively to the Senators' request because facts were difficult to ascertain. 

State Medicaid agencies in 48 states that covered assisted living services reported spending more than $10 billion (federal and state) on assisted living services in 2014. These 48 states reported covering these services for more than 330,000 beneficiaries through more than 130 different programs. Most programs were operated under Medicaid waivers that allow states to target certain populations, limit enrollment, or restrict services to certain geographic areas.

With respect to oversight of their largest assisted living programs, state Medicaid agencies reported varied approaches to overseeing beneficiary health and welfare, particularly in how they monitored critical incidents involving beneficiaries receiving assisted living services. Although state Medicaid agencies are required to protect beneficiary health and welfare and operate systems to monitor for critical incidents—cases of potential or actual harm to beneficiaries such as abuse, neglect, or exploitation, the GAO found a lack of required monitoring and reporting:

• Twenty-six state Medicaid agencies could not report to GAO the number of critical incidents that occurred in assisted living facilities, citing reasons including the inability to track incidents by provider type (9 states), lack of a system to collect critical incidents (9 states), and lack of a system that could identify Medicaid beneficiaries (5 states).
• State Medicaid agencies varied in what types of critical incidents they monitored. All states identified physical, emotional, or sexual abuse as a critical incident. A number of states did not identify other incidents that may indicate potential harm or neglect such as medication errors (7 states) and unexplained death (3 states).
• State Medicaid agencies varied in whether they made information on critical incidents and other key information available to the public. Thirty-four states made critical incident information available to the public by phone, website, or in person, while another 14 states did not have such information available at all.

The report Highlights summarized:

Oversight of state monitoring of assisted living services by... CMS, an agency within the Department of Health and Human Services (HHS), is limited by gaps in state reporting. States are required to annually report to CMS information on deficiencies affecting beneficiary health and welfare for the most common program used to provide assisted living services. However, states have latitude in what they consider a deficiency. States also must describe their systems for monitoring critical incidents, but CMS does not require states to annually report data from their systems. Under federal internal control standards, agencies should have processes to identify information needed to achieve objectives and address risk. Without clear guidance on reportable deficiencies and no requirement to report critical incidents, CMS may be unaware of problems. For example, CMS found, after an in-depth review in one selected state seeking to renew its program, that the state lacked an effective system for assuring beneficiary health and welfare, including reporting insufficient information on the number of unexpected or suspicious beneficiary deaths. The state had not reported any deficiencies in annual reports submitted to CMS in 5 prior years (emphasis added).

The GAO recommended that CMS provide guidance and clarify requirements for states regarding their monitoring and reporting of deficiencies in assisted living communities. Additionally, the GAO recommended that CMS establish standard Medicaid reporting requirements that all states could use to annually report information on critical incidents. Finally, GAO recommended that CMS ensure that all states submit annual reports for Home and Community Based Services (HCBS) waivers on time as required.

HHS agreed with two of the three recommendations, according to the report, but “did not explicitly agree or disagree with [GAO's] third recommendation to require all states to report information on critical incidents to CMS annually.”

“The oversight of the assisted living industry at the state level has failed to protect residents,” the LTCCC and the CMA said in a joint press release.

“This report verifies reports from families over the years indicating that, too often, the “promise” of assisted living is unfulfilled for seniors,” said Richard Mollot, executive director of LTCCC, "Medicare beneficiaries deserve good care and dignity no matter where they access care and services.” 

“State oversight has failed assisted living residents and the taxpayers who help pay for their care,” said Toby S. Edelman, Senior Policy Attorney, CMA; “This national scandal cannot be swept under the rug any longer.”

LTCCC and CMA said their “near-term recommendations” for the federal government include that state and federal websites similar to Nursing Home Compare be developed for assisted living communities, with validated information on staffing, inspection results, complaints and critical incidents. The two organizations also recommend that the federal government “take immediate steps to protect assisted living residents by enacting sensible standards to ensure safety and dignity.”

Assisted Living and other community based care programs must be well administered, and  able to produce and demonstrate positive health outcomes for seniors before they will be reliable Aging in Place strategies.

Assisted Living Medicaid Waiver Recipients Entitled to Retroactive Benefits Even in Ohio

In another setback for the State of Ohio Department of Medicaid, a federal district court has ruled that  applicants for an assisted living Medicaid waiver program in Ohio are entitled to retroactive benefits. Price v. Medicaid Director, Office of Medical Assistance (U.S. Dist. Ct., S.D. Ohio, W.Div., No. 1:13-cv-74, Sept. 1, 2015).

Assisted living residents Betty Hilleger and Geraldine A. Saunders applied for a Medicaid assisted living waiver from the state of Ohio to pay for home health care. The state found them eligible for benefits, but it denied them retroactive benefits because the state provides only prospective coverage from the date the applicant is enrolled in the waiver program.

Ms. Hilleger and Ms. Saunders filed a class action lawsuit against the state, arguing that Ohio is violating federal law by providing only prospective assisted living waiver benefits. Federal law specifically requires that retroactive benefits be provided during the three months before the application if the applicant was eligible for benefits during that time. The state argued that eligibility for assisted living waiver benefits is prospective only, because it requires, among other things, a face-to-face assessment of the applicant.  Because these specific Ohio rules mean that an individual applicant cannot be eligible for benefits prior to the face-to-face assessment, individuals cannot be enrolled retroactively in the waiver program.

The United States District Court, Southern District of Ohio, agreed that Ohio is violating federal law and granted summary judgment to Ms. Hilleger and Ms. Saunders certifying the class action.  The Court held that the clear language of federal Medicaid law requires the state to provide retroactive benefits. According to the court, "there is nothing about a face-to-face assessment or the use of the assessment tool that prevents a retrospective determination of eligibility."  In other words,  state rules cannot be used in a manner to deny the applicant what federal law plainly permits.