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How to Choose a Home Care Agency
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
for Home Health Care
What is a Plan
Will Services Continue?
What Can You
Be Billed For?
How to Find an
of Care Complaints
and Counseling Services
Qualifying for Home Health Care
To qualify for Medicare home health coverage, you must meet all four
of the following conditions:
- Your doctor must determine that you need medical care in your home
and prepare a plan for your care at home.
- The care you need must include intermittent (not full time) skilled
nursing care, or physical therapy or speech language pathology services.
- 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.
- The home health agency serving you must be approved by the Medicare
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
- 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
- Speech language pathology as often and for as long as it is
medically necessary and reasonable. This type of therapy includes exercises to restore
- 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
- 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
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
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
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
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
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
||Home Health Complaint Hotline
||(813) 796-8292 x 5501
||See Table Listed Below
||1-303-894-7499 ext. 356
||(207) 822-7000 ext. 7303
|The Federated States of Micronesia
||Office of Health Services, Ponape, E.C.I.
||(813) 796-8292 ext. 5501
Twin Falls 800-488-5731
(Call for complaints about Home Health Care)
|Los Angeles County
Source: Health Care Financing
Administration, April 1998