State Budget Initiative Advances Private-Pay Model of Home Care

Most home care is covered by Medicare and Medicaid – each being government payors with their own income, age, and/or service-level eligibility rules.

While this structure helps lower-income or elderly New Yorkers get home care, it nevertheless leaves many others without access to coverage that can improve their health, lower their utilization of other services, and help them age in place. This is especially so for New Yorkers who can’t afford to pay privately yet are ineligible for Medicaid.

A new state budget provision will provide additional funds to fill this gap, working toward a new model of private-pay support. HCA President Al Cardillo joined administration officials, legislative leaders and stakeholders on a press release from the Governor’s office earlier this month praising the new state budget program, thanks to support from the Legislature.

It includes $15 million in recurring funds for counties that report unmet needs such as personal care, home delivered meals, case management, home modifications and more. It also authorizes the New York State Office For the Aging (NYSOFA) to develop a private-pay market to serve individuals at income levels that would otherwise make them ineligible for Medicaid.

“HCA applauds Governor Cuomo and [NYSOFA] Director [Greg] Olsen on these innovative new supports for home and community services,” Mr. Cardillo says in the press release. “This creative new investment helps older adults’ access to services; taps the HCA home care agencies to provide the expanded services; and takes steps toward a vision of new and needed ways to privately finance long term care in adjunct to Medicaid.”

This effort reveals why it is so important for the state to examine other ways of extending into non-governmental home care coverage.

Along these lines, HCA thanks the Legislature for sponsoring measures that would similarly close a gap in services by modernizing the commercial insurance law for home care. One such bill, sponsored in the Assembly by Insurance Committee Chair Kevin A. Cahill (A.408), would better reflect the current role of home care as a covered service; we urge the Senate to adopt a companion measure this session for advancement in both houses.

The current 40-year-old insurance law was developed at a time when nursing homes were the predominant setting for long term care. It was also a time when hospital payment structures and incentives did not drive the current trend of earlier discharges, where medically complex cases can now be cared for at home. In that time, the home care system has responded to hospital reforms and the demand for non-institutional care options with an infrastructure of cost-effective, increasingly sophisticated in-home alternatives to meet systemic care transitions needs. However, this role for home care has largely been cultivated through government payors, not under commercial insurance.

This bill’s modernization of the law would delineate the conditions of home care coverage consistent with today’s state-of-the-art health and medical care practices. It would support the operation of the entire health care system, synchronize coverage to the newest models and innovations of care, promote cost-savings and efficiency, and, most importantly, benefit covered individuals. It would also preserve and enhance the original statute’s intent of utilizing home care to prevent avoidable hospitalizations, emergency room use and other higher-cost medical services use.