Medicare Advantage & Home Care:
The Reality Gap
Does Medicare Advantage really cover 35 hours per week of home care? CMS billing data and the MedPAC 2025 Report to Congress tell a very different story. Here's what Southeast Michigan families actually need to know.
The Short Answer
Medicare Advantage does not cover "classic home care" — the daily companionship, personal care, meal preparation, and supervision that most families need. MA covers skilled home health (short-term nursing and therapy visits ordered by a doctor), which is an entirely different service. The widely-cited "35 hours per week" claim conflates a 1988 Medicare Part A legal standard with Medicare Advantage supplemental benefits, which typically provide only 4–20 hours per year. For ongoing home care in Michigan, families must rely on private pay ($29–$37/hr for personal care), MI Choice Medicaid Waiver, VA benefits, or long-term care insurance.
THE CLAIM
The "35 Hours Per Week" — What's True and What's Not
| Claim | Reality |
|---|---|
| "MA provides 35 hrs/wk of home care" | False as stated. The 35-hour figure comes from a 1988 federal court ruling (Duggan v. Bowen) establishing Medicare Part A home health aide services could include 28–35 hours/week — but only as part of a skilled home health episode, physician-ordered, with a qualifying clinical need. This is Medicare Part A/B, not an MA supplemental benefit. |
| "MA supplemental benefits cover home care" | Partially true, but extremely limited. Some MA plans offer in-home support as a supplemental benefit (SSBCI), but actual hours provided are typically 4–20 hours per year (not per week). |
| "PT/OT/RN visits are subtracted from the 35 hours" | True. In a skilled home health episode, all disciplines (RN, PT, OT, HHA) share the same per-episode payment (~$2,000/30 days). Adding HHA hours doesn't increase the payment, so agencies avoid it. |
THE EVIDENCE
CMS Billing Data: The Hard Numbers
Data from CMS Medicare Post-Acute Care Utilization and MedPAC June 2025 Report to Congress
90%
Decline in home health aide visits
From 1998 to 2019 (Center for Medicare Advocacy)
−$3,000
Net loss per episode with aide hours
Agency receives $2,000 but delivers $5,000–$6,000 in care
| Metric | Data |
|---|---|
| Episode payment (2024) | ~$2,000 for a 30-day skilled home health episode |
| Cost to add HHA aide services | $3,000–$4,000 for 30 days of aide visits (~4 hrs/day) |
| Total rebate spending (2025) | $86 billion ($2,530/enrollee) — MedPAC June 2025 |
| In-home support tracking | Not separately tracked by CMS. Lumped with pest control, meals, and transportation. |
"You can't expect a home health agency to get paid $2,000 to deliver $5,000 to $6,000 worth of care. As an existing care provider, they would last a nanosecond if they started doing that."
MICHIGAN PLANS
What Michigan MA Plans Actually Provide
| Plan | Listed Benefit | What It Actually Means |
|---|---|---|
| HAP Senior Plus | $0 copay "home health aide" | Standard skilled home health only — intermittent visits, no personal care hours |
| Blue Cross Complete (D-SNP) | "In-home support" via flex card | Flex card for approved services; actual aide hours often 10–20 hrs/year |
| UnitedHealthcare MA | "Personal home care aide" | When available, typically 4–8 hours/month — not 35 hours/week |
| Meridian Complete (D-SNP) | SSBCI "in-home support" | Targeted to chronically ill; hour allotment not publicly disclosed |
| Humana (PPO) | "In-home support" in select plans | Varies significantly; most plans offer zero non-skilled home care hours |
Plan details reflect 2026 plan year. Benefits may change annually — verify with your plan directly.
EXPECTATIONS vs. REALITY
What Families Expect vs. What They Get
What families expect
"My MA plan covers home care"
What actually happens
MA covers skilled home health visits (RN, PT, OT) — not ongoing personal care or companionship.
What families expect
"I'll get 35 hours/week of aide help"
What actually happens
The 35-hour standard exists in law but is financially impossible for agencies to deliver under current reimbursement (~$2,000/episode).
What families expect
"My plan's supplemental benefit covers an aide"
What actually happens
Most supplemental benefits provide 4–20 hours per YEAR in flex card credits — not weekly aide service.
What families expect
"A home health agency will send someone daily"
What actually happens
Home health agencies send clinicians for intermittent visits (1–5x/week, 30–60 min each). They don't staff daily personal care shifts.
What families expect
"Medicare Advantage is cheaper than private pay"
What actually happens
For skilled medical visits, yes. For "classic home care" (companion/personal care), MA provides essentially nothing — families must private-pay.
KEY DISTINCTION
Home Health vs. Home Care — They're Not the Same
This confusion is at the heart of the Medicare Advantage problem. Here's how the two services actually differ.
Home Health (Skilled)
- Medical — nursing, PT, OT, speech therapy
- Short-term — typically 30–60 day episodes
- Physician-ordered — requires doctor's referral
- Intermittent visits — 1–5x/week, 30–60 min each
- Covered by Medicare
Home Care (Non-Medical)
- Non-medical — companionship, personal care, meals
- Long-term — ongoing, months to years
- Family-initiated — no doctor's order needed
- Scheduled shifts — 4–12 hours per day, your schedule
- Not covered by Medicare — private pay, waiver, or VA
REAL OPTIONS
How Michigan Families Actually Pay for Home Care
Since Medicare Advantage won't cover it, here are the reliable funding sources for ongoing non-medical home care.
Private Pay (Agency)
$29–$37/hr (personal care)
Most common. No eligibility requirements. Choose your hours and schedule.
MI Choice Medicaid Waiver
Covered (if eligible)
Must be nursing-home eligible AND meet Medicaid income/asset limits. Waitlists possible.
VA Aid & Attendance
Up to $2,795/mo
For veterans or surviving spouses who need assistance with daily activities. Rates vary by status ($1,515–$2,795/mo); adjusted annually with COLA.
Long-Term Care Insurance
Policy-dependent
Must have been purchased before needing care. Check daily benefit limits and elimination period.
PACE Program
$0 for dual-eligible
All-inclusive care for seniors 55+ who are nursing-home eligible. Must use PACE physicians.
Medicaid Home Help
Covered (limited)
Limited hours, strict eligibility. Self-directed option available in Michigan.
Not sure which funding option fits your situation?
CONGRESSIONAL REPORT
What MedPAC Told Congress in June 2025
MedPAC's June 2025 analysis revealed that Medicare Advantage supplemental benefits are largely opaque — even to the federal government:
- •$86 billion in rebate spending ($2,530/enrollee) with $39 billion allocated to non-Medicare services ($100/member/month)
- •In-home support is not separately tracked. CMS lumps it with pest control, meals, and transportation — there is no line item for personal care aide hours.
- •Encounter data for home health services are incomplete. Plans don't reliably submit records for supplemental benefits.
- •MedPAC's conclusion: "Little is known about how often enrollees use the benefits and plans' spending for the benefits."
Even Congress's own advisory body cannot determine how much personal care is actually delivered under MA supplemental benefits. The data simply doesn't exist.
The Bottom Line
If you need "classic home care" — a caregiver in the home for 4–8 hours per day providing companionship, personal care. Meal prep. And supervision — Medicare Advantage will not pay for this. Don't let misleading claims delay getting your loved one the care they need.
FAQ
Medicare Advantage & Home Care FAQ
Common questions about what Medicare Advantage actually covers for home care in Michigan