Medicare and Home Health Care

• Qualifying for Home Health Care
• What's Covered?
• What's Not Covered?
• What is a Plan of Care?
• How Long Will Services Continue?
• What Can You Be Billed For?
• Handling Coverage Disagreements
• How to Find an Approved Agency
• Detecting and Reporting Fraud
• Quality of Care Complaints
• Information and Counseling Services
• Important Telephone Numbers

Qualifying for Home Health Care

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?

• 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?

• 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?

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?

• 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?

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

• 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

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

• 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

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

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.

California Districts
(Call for complaints about Home Health Care)

Source: Health Care Financing Administration, April 1998

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