Medicare and Home Health Care

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Home Health Care is skilled medical care and other health care services that you receive in your home for the treatment of an illness or injury. This article explains Medicare's basic home health benefits and provides you with additional sources of information and help.

Table of Contents

Qualifying for Home Health Care

To qualify for Medicare home health coverage, you must meet all four of the following conditions:

  1. Your doctor must determine that you need medical care in your home and prepare a plan for your care at home.
  2. The care you need must include intermittent (not full time) skilled nursing care, or physical therapy or speech language pathology services.
  3. You must be homebound. This means you normally are unable to leave your home. If you do leave your home, it is with considerable and taxing effort. Absences from home must be infrequent, or of short duration, or to get medical care. You can still be considered homebound if you occasionally go to the barber or beauty shop or for a walk around the block or a short drive.
  4. The home health agency serving you must be approved by the Medicare program.

What's Covered?

If you meet all four of the conditions to qualify for home health care, Medicare will pay for:

  • Skilled nursing care either on an intermittent or part-time basis. Skilled nursing includes services and care that can only be performed safely and effectively by a licensed nurse.
  • Home health aide services either on an intermittent or part-time basis. Home health aide services include assistance with personal care such as bathing, using the toilet, or dressing. These types of services do not require the skills of a licensed nurse.
  • Physical therapy as often and for as long as it is medically necessary and reasonable. Physical therapy includes exercise to restore movement and strength to an injured arm or leg, and training in getting into and out of a wheelchair or bathtub.
  • Speech language pathology as often and for as long as it is medically necessary and reasonable. This type of therapy includes exercises to restore speech.
  • Occupational therapy as often and for as long as it is medically necessary and reasonable, even if you no longer need other skilled care. Occupational therapy helps you to achieve independence in daily living by learning new techniques for eating, dressing and performing other routine tasks.
  • Medical social services to assess the social and emotional factors related to your illness, counseling based on this assessment, and searches for available community resources.
  • Medical supplies like wound dressings.
  • Medical equipment. Medicare pays 80 percent of the approved ammount. An example of medical equipment would be a wheel chair or walker.

What's Not Covered?

Medicare does not cover the following:

  • 24-hour care at home.
  • Self-administered prescription drugs.
  • Meals delivered to the home.
  • Homemaker services such as shopping, cleaning and laundry.
  • Personal care provided by home health aides, such as bathing, toileting, or providing help in getting dressed when this is the only care you need. Medicare classifies this as "custodial care" because it could be provided safely and reasonably by people without professional skills and training. Medicare does not pay for "custodial care" unless you are also getting skilled care such as nursing or therapy and the custodial care is related to the treatment of your illness or injury.

What is a Plan of Care?

A plan of care directs what type of services and treatment you receive. Your doctor will work with a home health care nurse and then will decide:

  • what kind of services you need
  • what type of health care professional should provide your services
  • how often you will need the services
  • the kind of home medical equipment you will need
  • the kind of food you may need and
  • the results your doctor expects from the therapy.

The home health agency staff provide care according to your authorized plan of care. Your doctor and home health agency personnel review your plan of care at least every 62 days or more often if the severity of your condition requires.

Home health agency professional staff are required to notify your doctor promptly of any changes that suggest a need to modify your plan of care.

How Long Will Services Continue?

Medicare pays for covered home health services for as long as they are considered medically reasonable and necessary. However, skilled nursing care and home health aide services are covered on a part time or intermittent basis. Basically, this means there are limits on the number of hours and days of care you can receive in any week for certain types of services.

For purposes of qualifying for home health benefits, Medicare defines "intermittent" as:

  • Skilled nursing care that is needed or provided on fewer than seven days each week or less than eight hours each day over a period of 21days (or less).
  • Extensions can be made in exceptional circumstances when the need for additional care is finite and predictable.

For purposes of coverage, Medicare defines part-time/intermittent care as:

  • Skilled nursing or home health aides services that are provided (combined) for any number of days per week so long as they are furnished less than 8 hours per day and 28 or fewer hours each week.
  • The weekly maximum number of hours of care can be increased from 28 to 35 if Medicare determines that your condition requires additional care.

What Can You Be Billed For?

The home health agency submits claims to Medicare for payment. Medicare pays the full approved cost of all covered home health visits. You may be charged for:

  • Medical services and supplies that Medicare does not cover.
  • 20 percent coinsurance for Medicare covered medical equipment such as wheelchairs, walkers and oxygen equipment. If the home health agency doesn't supply medical equipment directly, they will arrange for a home equipment supplier to provide you with the items you need.

Before your care begins, the home health agency must tell you how much of your bill Medicare or other Federal programs should pay. The agency must also tell you if any items or services they provide are not covered by Medicare and how much you will have to pay for them. This must be explained orally and in writing.

If you are eligible for Medicaid it might be possible to get services in addition to those covered by Medicare. Medicaid coverage differs from State to State, but in all States it covers basic home health care and medical equipment. In addition, Medicaid programs everywhere cover homemaker, personal care, and other services that are not covered by Medicare.

To be eligible for Medicaid, you must have very low income and few savings or other assets. For more information about whether you might be eligible and about what Medicaid covers in your State, contact your State Medicaid Agency.

Handling Coverage Disagreements

If your home health agency believes that Medicare will not cover certain services and will not pay your bill, and you think they are wrong:

  • Ask the home health agency to file a claim on your behalf with Medicare and to get an official decision. This is called a "Notice of Medicare Claim Determination". Medicare will send you its official decision.
  • If you disagree with Medicare's "determination", you may appeal the decision by following the instructions on the Notice. Your State health insurance counseling program can assist you in filing an appeal. The phone number for the counseling program in your State is listed at the end of this article under General Information.

How to Find an Approved Agency

You have the right to choose the home health agency from which you get services. Your choice should be honored by your doctor, hospital discharge planner or other referring agency.

It is important to remember that Medicare only pays for home health services that are provided by a home health agency that meets Medicare's quality standards. Medicare inspects home health agencies every year to assure these standards are meet.

You can find a Medicare approved Home Health agency by: asking your doctor or hospital discharge planner, a senior community referral service, or other community agencies involved with your health care. You can also refer to the telephone directory Yellow Pages under "home care" or "home health care". Look for home health care agencies that indicate they are Medicare certified.

Before you select an agency, ask these important questions:

-- Is the agency approved for participation in the Medicare program?
-- How long has the agency been serving the community?
-- Does it provide the services I need?
-- What arrangements are made for emergencies?
-- Are the agency's caregivers available 24 hours a day, seven days a week?
-- Will I be charged for any services/supplies?
-- Would these services/supplies be covered under the home health benefit, if the home health agency included the services on the bill to Medicare?
-- What role will my family and I have in creating the plan of care?
-- Does the agency educate family members on the type of care being provided?
-- Who supervises the home health care plan?
-- Does the supervisor make regular visits to the home?
-- Whom can I call with questions or complaints?
-- What happens if a care provider does not come when scheduled?
-- Will the agency be in regular contact with my doctor?

Also ask the home health agencies for names of former clients. Contact the clients and ask if they were pleased with the care provided and whether they would use the agency again.

It is very important to remember: if you belong to a managed care plan, your choice of home health agencies is limited to agencies that are affiliated with the managed care plan. If you get services from a doctor or a home health care agency that isn't affiliated with the managed care plan, neither the plan nor Medicare will pay the bill.

Detecting and Reporting Fraud

Unfortunately, fraud exists in the home health industry. Even on a small scale, it wastes Medicare dollars and reduces the funds available to pay legitimate claims. It can also endanger the quality of your care.

Be alert for:

  • Unnecessary visits by home health staff
  • Billing for services and equipment you never get
  • Forgery of a patient's or doctor's signature
  • Pressure to accept unneeded items and services

You also should be alert to questionable activities such as:

  • Home health agencies whose doctor authorizes home health services your doctor did not authorize. The doctor who authorizes home health services should know you and be involved in assessing the care you receive. Your doctor may be the best judge of whether or not you need specific home health care services.
  • A home health agency that offers you free goods or services in exchange for your Medicare number. Treat your Medicare card like a credit card or cash. NEVER give out your Medicare number to people you don't know.

The phone number to report any suspected home health care fraud for your state can be found at the end of this page.

Quality of Care Complaints

In evaluating the quality of care provided by an agency, consider the following questions:

  • Were you able to call a supervisor if you had a question about your service or the staff?
  • Did the staff plan your home care services with you?
  • Did the agency provide the services needed and promised?

If the answer is "no" to one or more of these questions and you believe that the agency is not providing quality care, you should call the home health hotline phone number for your state to register a complaint. Those numbers are found at the end of this article. You can also get a copy of your home health agency's most recent inspection report from the State office. The report is known as a "survey report."

Information and Counseling Services

Every State, plus Puerto Rico, the Virgin Islands, and the District of Columbia, has a health insurance counseling program that provides free information and assistance. The program is operated either by your State Office on Aging or by your State Insurance Department.

The counselors should be able to answer your questions about Medicare's Home Health benefit. The phone number for the counseling program for your State is listed at the end of this article under General Information.

Important Telephone Numbers

To register a complaint about the quality of home health care services received, to report possible Medicare fraud, or to get answers to general questions about home health and other Medicare benefits, call the number(s) listed below for your State. Calls made to the toll free numbers should be free when made within the respective State.

STATE Home Health Complaint Hotline Fraud Hotline General Information
Alabama 1-800-356-9596 (813) 796-8292 x 5501 1-334-242-5743
Alaska 1-907-563-0037   1-907-269-3666
Arizona 1-800-221-9668   1-602-542-6588
Arkansas 1-800-223-0340 (803) 788-5414 1-501-371-2785
California See Table Listed Below   1-916-323-6525
Colorado 1-800-842-8826 (515) 245-7880 1-303-894-7499 ext. 356
Connecticuit 1-800-828-9796 (207) 822-7000 ext. 7303 1-860-424-5245
Delaware 1-800-942-7373 (215) 228-7354 1-302-739-6266
District of Columbia 1-202-727-7873 (215) 228-7354 1-202-676-3900
The Federated States of Micronesia -- -- Office of Health Services, Ponape, E.C.I. 96941
Florida 1-888-419-3456 (813) 796-8292 ext. 5501 1-850-414-2060
Georgia 1-800-326-0291 (813) 796-8292
ext. 5510
Guam -- -- 1-671-475-0262/3
Hawaii 1-800-762-5949 (800) 593-2006 1-808-586-7299
Idaho 1-800-345-1453   Boise 800-247-4422
Pocatello 800-488-5764
Twin Falls 800-488-5731
Lewiston 800-448-5725
Illinois 1-800-252-4343 (312) 938-6266 1-217-785-3021
Indiana 1-800-227-6334 (312) 938-6266 1-317-233-3475
Iowa 1-800-383-4920 (515) 245-7880 1-515-281-6867
Kansas 1-800-842-0078 (515) 245-7880 1-316-337-6010
Kentucky 1-800-635-6290 (800) 635-6290 1-502-564-7372
Louisiana 1-800-327-3419 (803) 788-5411 1-504-342-5301
Maine 1-800-621-8222 (207) 822-7000
ext. 7303
Maryland 1-800-284-4510 (215) 228-7354 1-410-767-1074
Massachusetts 1-800-462-5540 (207) 822-7000
ext. 7303
Michigan 1-800-882-6006 (414) 224-4954 1-800-803-7174
Minnesota 1-800-369-7994 (414) 224-4954 1-612-333-2433
Mississippi 1-800-227-7308 (813) 796-8292
ext. 5510
Missouri 1-800-877-6485 (515) 245-7880 1-573-893-7900
Montana 1-800-762-4618 (515) 245-7880 1-406-444-7781
Nebraska 1-800-245-5832 (515) 245-7880 1-402-471-2201
Nevada 1-800-225-3414   1-702-486-4602
New Hampshire 1-800-621-6232 (207) 822-7000
ext. 7303
New Jersey 1-800-792-9770 (414) 224-4954 1-609-588-3139
New Mexico 1-800-752-8649 (803) 788-5414 1-505-827-7640
New York 1-800-628-5972 (414) 224-4954 1-800-333-4114
City Area
North Carolina 1-800-624-3004 (803) 788-3414 1-919-733-0111
North Dakota 1-800-545-8256 (515) 245-7880 1-800-247-0560
Ohio 1-800-342-0553 (312) 938-6266 1-614-644-3399
Oklahoma 1-800-234-7258 (803) 788-5414 1-405-521-6628
Oregon 1-800-542-5186   1-503-947-7984
Pennsylvania 1-800-222-0989 (215) 228-7354 1-717-783-8975
Puerto Rico 1-800-961-8666 (414) 224-4954 1-787-721-8590
Rhode Island 1-800-228-2716 (207) 822-7000
ext. 7303
South Carolina 1-800-922-6735 (803) 788-5414 1-803-253-6177
South Dakota 1-800-592-1861 (515) 245-7880 1-605-773-3656
Tennessee 1-800-541-7367 (803) 788-5414 1-800-525-3439
Texas 1-800-228-1570 (803) 788-5414 1-512-424-6840
Utah 1-800-999-7339 (515) 245-7880 1-801-538-3910
Vermont 1-800-564-1612 (702) 822-7000
ext. 7303
Virginia 1-800-955-1819 (215) 228-7354 1-804-662-9333
Virgin Islands -- (414) 224-4954 1-809-778-6311
ext. 2338
Washington 1-800-633-6828   1-800-397-4422
West Virginia 1-800-442-2888 (215) 228-7354 1-304-558-3317
Wisconsin 1-800-642-6552 (414) 224-4954 1-608-267-3201
Wyoming 1-800-548-1367 (515) 245-7880 1-307-856-6880

California Districts
(Call for complaints about Home Health Care)

DISTRICT Phone Number
Berkeley 1-800-554-0352
Chico 1-800-554-0350
Daly City 1-800-554-0350
Fresno 1-800-554-0351
Los Angeles County 1-800-228-1019
Orange County 1-800-228-5234
Riverside 1-888-354-9203
Sacramento 1-800-554-0354
San Bernardino 1-800-344-2896
San Diego 1-800-824-0613
San Jose 1-800-554-0348
Santa Rosa 1-800-554-0349
Ventura 1-888-354-9203

Source: Health Care Financing Administration, April 1998


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