This Official Government Booklet Tells You - Medicare
CENTERS for MEDICARE & MEDICAID SERVICESMedicare & Home Health CareThis official government booklet tells you: Who’s eligibleWhat services are coveredHow to find and compare home health agenciesYour Medicare rights
The information in this booklet describes the Medicare Program at thetime this booklet was printed. Changes may occur after printing. VisitMedicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get themost current information. TTY users can call 1-877-486-2048.“Medicare & Home Health Care” isn’t a legal document. OfficialMedicare Program legal guidance is contained in the relevant statutes,regulations, and rulings.
3Table of ContentsSection 1: Medicare Coverage of Home Health Care 5Who’s eligible? 5How Medicare pays for home health care 7What’s covered? 7What isn’t covered? 10What you pay 10“Advance Beneficiary Notice of Noncoverage “ (ABN) 11Your right to a fast appeal 12Section 2: Choosing a Home Health Agency 15Finding a Medicare-certified home health agency 15Home Health Agency Checklist 16Special rules for home health care 17Find out more about home health agencies 17Section 3: Getting Home Health Care 19Your plan of care 19Your rights getting home health care 20Where to file a complaint about the quality of your home health care 21Home Health Care Checklist 22Section 4: Getting the Help You Need 23Help with questions about home health coverage 23What you need to know about fraud 24Definitions 27
4Home health careMany health care treatments that wereonce offered only in a hospital or a doctor’soffice can now be done in your home.Home health care is usually less expensive,more convenient, and can be just aseffective as care you get in a hospital orskilled nursing facility. In general, the goalof home health care is to provide treatmentfor an illness or injury. Where possible,home health care helps you get better,regain your independence, and becomeas self-sufficient as possible. Home healthcare may also help you maintain yourcurrent condition or level of function, or toslow decline.Medicare pays for you to get health care services in yourhome if you meet certain eligibility criteria and if theservices are considered reasonable and necessary for thetreatment of your illness or injury.This booklet describes the home health care servicesthat Medicare covers, and how to get those benefitsthrough Medicare. If you get your Medicare benefitsthrough a Medicare health plan (not Original Medicare)check your plan’s membership materials, and contactthe plan for details about how the plan provides yourMedicare-covered home health benefits.
5Section 1:Medicare Coverage of Home Health CareWho’s eligible?If you have Medicare, you can use your home health benefits if:1. You’re under the care of a doctor, and you’re getting servicesunder a plan of care established and reviewed regularly by adoctor.2. You need, and a doctor certifies that you need, one or moreof these: Intermittent skilled nursing care (other than drawingblood) Physical therapy Speech-language pathology services Continued occupational therapySee pages 8–9 for more details on these services.3. The home health agency caring for you is approved byMedicare (Medicare-certified).4. You’re homebound, and a doctor certifies that you’rehomebound. To be homebound means: You have trouble leaving your home without help (likeusing a cane, wheelchair, walker, or crutches; specialtransportation; or help from another person) because of anillness or injury, or leaving your home isn’t recommendedbecause of your condition. You’re normally unable to leave your home, but if you do itrequires a major effort.Words in redare defined onpages 27–28.You may leave home for medical treatment or short,infrequent absences for non-medical reasons, like anoccasional trip to the barber, a walk around the block or adrive, or attendance at a family reunion, funeral, graduation,
6Section 1: Medicare Coverage of Home Health Careor other infrequent or unique event. You can still get home healthcare if you attend adult day care or religious services.5. As part of your certification of eligibility, a doctor, or certainhealth care professionals who work with a doctor (like a nursepractitioner), must document that they’ve had a face-to-faceencounter with you (like an appointment with your primary caredoctor) within required timeframes and that the encounter wasrelated to the reason you need home health care.If you need more than “intermittent” skilled nursing care, you don’tqualify for home health services. To determine if you’re eligible forhome health care, Medicare defines “intermittent” as skilled nursingcare that’s needed: Fewer than 7 days each week. Daily for less than 8 hours each day for up to 21 days. Insome cases, Medicare may extend the three week limit if yourdoctor can predict when your need for daily skilled nursingcare will end.If you’re expected to need full-time skilled nursing care over anextended period of time, you wouldn’t usually qualify for homehealth benefits.
Section 1: Medicare Coverage of Home Health Care7How Medicare pays for home health careMedicare pays your Medicare-certified home health agency onepayment for the covered services you get during a 30-day period ofcare. You can have more than one 30-day period of care. Payment foreach 30-day period is based on your condition and care needs.Getting treatment from a home health agency that’s Medicare-certifiedcan reduce your out-of-pocket costs. A Medicare-certified home healthagency agrees to: Be paid by Medicare Accept only the amount Medicare approves for their servicesMedicare’s home health benefit only pays for services provided by thehome health agency. Other medical services, like visits to your doctor orequipment, are generally still covered by your other Medicare benefits.Look in your “Medicare & You” handbook for information onhow these services are covered under Medicare. To view or printthis booklet, visit Medicare.gov/publications. You can also call1-800-MEDICARE (1-800-633-4227) if you have questions about yourMedicare benefits. TTY users can call 1-877-486-2048.What’s covered?If you’re eligible for Medicare-covered home health care (see page 5),Medicare covers these services if they’re reasonable and necessary forthe treatment of your illness or injury. “Skilled nursing and therapyservices are covered when your doctor determines that the care youneed requires the specialized judgment, knowledge, and skills of anurse or therapist to be safely and effectively provided. Skilled nursing care: Medicare covers skilled nursing care when theservices you need require the skills of a nurse, are reasonable andnecessary for the treatment of your illness or injury, and are givenon a part-time or intermittent basis (visits only to draw your bloodaren’t covered by Medicare). “Part-time or intermittent” means youmay be able to get home health aide and skilled nursing services(combined) any number of days per week as long as the services areprovided:
8Section 1: Medicare Coverage of Home Health Care Fewer than 8 hours each day 28 or fewer hours each week (or up to 35 hours a week in somelimited situations)A registered nurse (RN) or a licensed practical nurse (LPN) can provideskilled nursing services. If you get services from an LPN, your carewill be supervised by an RN. Home health nurses provide direct careand teach you and your caregivers about your care. They also manage,observe, and evaluate your care. Examples of skilled nursing careinclude: giving IV drugs, certain injections, or tube feedings; changingdressings; and teaching about prescription drugs or diabetes care. Anyservice that could be done safely and effectively by a non-medical person(or by yourself) without the supervision of a nurse isn’t skilled nursingcare. Physical therapy, occupational therapy, and speech-languagepathology services: Your therapy services are considered reasonableand necessary in the home setting if:1. They’re a specific, safe, and effective treatment for yourcondition2. They’re complex such that your condition requires servicesthat can only be safely and effectively performed by, or underthe supervision of, qualified therapists3. Your condition requires one of these: Therapy that’s reasonable and necessary to restore orimprove functions affected by your illness or injury A skilled therapist or therapist assistant to safely andeffectively perform therapy under a maintenance programto help you maintain your current condition or to preventyour condition from getting worse4. The amount, frequency, and duration of the services arereasonable Home health aide services: Medicare will pay for part-time orintermittent home health aide services (like personal care), if neededto maintain your health or treat your illness or injury. Medicare
Section 1: Medicare Coverage of Home Health Care9doesn’t cover home health aide services unless you’re also gettingskilled care. Skilled care includes: Skilled nursing care Physical therapy Speech-language pathology services Continuing occupational therapy, if you no longer need any ofthe above“Part-time or intermittent” means you may be able to get home healthaide and skilled nursing services (combined) any number of days perweek, as long as the services are provided: Fewer than 8 hours each day 28 or fewer hours each week (or up to 35 hours a week in somelimited situations) Medical social services: Medicare covers these services when a doctororders them to help you with social and emotional concerns that mayinterfere with your treatment or how quickly you recover. This mightinclude counseling or help finding resources in your community.However, Medicare doesn’t cover medical social services unless you’realso getting skilled care as mentioned above.Medical supplies: Medicare covers supplies, like wound dressings,when your doctor orders them as part of your care.Medicare pays separately for durable medical equipment. The equipmentmust meet certain criteria and be ordered by a doctor. Medicare usuallypays 80% of the Medicare-approved amount for certain pieces of medicalequipment, like a wheelchair or walker. If your home health agencydoesn’t supply durable medical equipment directly, the home healthagency staff will usually arrange for a home equipment supplier to bringthe items you need to your home.Note: Before your home health care begins, the home health agencyshould tell you how much of your bill Medicare will pay. The agencyshould also tell you if any items or services they give you aren’t coveredby Medicare, and how much you’ll have to pay for them. This should beexplained by both talking with you and in writing.
10Section 1: Medicare Coverage of Home Health CareThe home health agency is responsible for meeting all of your medical,nursing, rehabilitative, social, and discharge planning needs, as noted inyour home health plan of care. See page 19 for more information. Homehealth agencies are required to perform a comprehensive assessment ofeach of your care needs when you’re admitted to the home health agency,and communicate those needs to the doctor responsible for the plan ofcare. After that, home health agencies are required to routinely assessyour needs.What isn’t covered?Here are some examples of what Medicare doesn’t pay for: 24-hour-a-day care at home Meals delivered to your home Homemaker services, like shopping, cleaning, and laundry Custodial or personal care like bathing, dressing, and using thebathroom when this is the only care you needTalk to your doctor or the home health agency if you havequestions about whether certain services are covered. You canalso call 1-800-MEDICARE (1-800-633-4227). TTY users can call1-877-486-2048.Note: If you have a Medigap (Medicare Supplement Insurance) policyor other health coverage, be sure to tell your doctor or other health careprovider so your bills get paid correctly.What you payYou may be billed for: Services and supplies that are never paid for by Medicare, likeroutine foot care. Services and supplies that are usually paid for by Medicare butwon’t be paid for in this instance, when you’ve agreed to pay forthem. The home health agency must give you a notice called the“Advance Beneficiary Notice of Noncoverage” (ABN) in thesesituations. See the next page.
Section 1: Medicare Coverage of Home Health Care 20% of the Medicare-approved amount for Medicare-coveredmedical equipment, like wheelchairs, walkers, and oxygenequipment.“Advance Beneficiary Notice of Noncoverage “(ABN)The home health agency must give you a written notice called an“Advance Beneficiary Notice of Noncoverage” (ABN) before givingyou a home health service or supply that Medicare probably won’tpay for because of any of these: The care isn’t medically reasonable and necessary. The care is only nonskilled, personal care, like help withbathing or dressing. You aren’t homebound. You don’t need skilled care on an intermittent basis.When you get an ABN because Medicare isn’t expected to pay fora medical service or supply, the notice should describe the serviceand/or supply, and explain why Medicare probably won’t pay.The ABN gives clear directions for getting an official decision fromMedicare about payment for home health services and supplies andfor filing an appeal if Medicare won’t pay.In general, to get an official decision on payment, you should dothese: Keep getting the home health services and/or supplies if youthink you need them. The home health agency must tell youhow much they’ll cost. Talk to your doctor and family aboutthis decision. Understand you may have to pay the home health agency forthese services and/or supplies. Ask the home health agency to send your claim to Medicareso that Medicare will make a decision about payment. Youhave the right to have the home health agency bill Medicarefor your care.11
12Section 1: Medicare Coverage of Home Health CareIf Original Medicare pays for your care, you’ll get back all of yourpayments, except for any applicable coinsurance or deductibles,including any coinsurance payments you made for durable medicalequipment.The home health agency must also give you a “Home Health Changeof Care Notice” (HHCCN) before any reduction or stoppage to homehealth services or supplies that will result in a change to your plan ofcare.Examples: The home health agency makes a business decision to reduceor stop giving you some or all of your home health services orsupplies. Your doctor has changed or hasn’t renewed your orders.Your right to a fast appealWhen all of your covered home healthservices are ending, you may have the rightto a fast appeal if you think these servicesare ending too soon. During a fast appeal, anindependent reviewer called a Beneficiary andFamily Centered Care Quality ImprovementOrganization (BFCC-QIO) looks at your case anddecides if you need your home health services tocontinue.Your home health agency will give you a written notice called the“Notice of Medicare Non-Coverage” (NOMNC) at least 2 daysbefore all covered services end. If you don’t get this notice, ask for it.Read the notice carefully. It contains important information about thetermination of services, including: The date all your covered services will end How to ask for a fast appeal Your right to get a detailed notice about why your services areending Any other information required by Medicare
Section 1: Medicare Coverage of Home Health CareIf you ask for a fast appeal, the BFCC-QIO will ask why youthink coverage of your home health services should continue.The BFCC-QIO will also look at your medical information andtalk to your doctor. The BFCC-QIO will notify you of its decisionas soon as possible, generally no later than 3 days after the effectivedate of the NOMNC.If the BFCC-QIO decides your home health services shouldcontinue, Medicare may continue to cover your home health careservices, except for any applicable coinsurance or deductibles.If the BFCC-QIO decides that your coverage should end, you’llhave to pay for any services you got after the date on the NOMNCthat says when your covered services should end. Your home healthagency must give you an ABN with an estimate of how much theseservices will cost.You may stop getting services on or before the date given on theNOMNC and avoid paying for any further services. If you don’t askfor a fast appeal and want to continue getting services after the datelisted on the NOMNC, your home health agency must give you anABN to let you know what you must pay.13
14Section 1: Medicare Coverage of Home Health CareFor more information on your right to a fast appeal and otherMedicare appeal rights, look at your “Medicare & You” handbookor visit Medicare.gov/appeals. You can also call 1-800-MEDICARE(1-800-633-4227). TTY users can call 1-877-486-2048.
15Section 2:Choosing a Home Health AgencyFinding a Medicare-certified home healthagencyIf your doctor decides you need home health care, you maychoose an agency from the participating Medicare-certifiedhome health agencies that serve your area. Home healthagencies are certified to make sure they meet certain federalhealth and safety requirements. Your choice should be honoredby your doctor, hospital discharge planner, or other referringagency. You have a say in which agency you use, but yourchoices may be limited by agency availability, or by yourinsurance coverage. If you have a Medicare Advantage Plan(like an HMO or PPO) or other Medicare health plan, it mayrequire that you get home health services from agencies theycontract with. Call your plan for more information.Words in redare defined onpages 27–28.
16Section 2: Choosing a Home Health AgencyHome Health Agency ChecklistUse this checklist when choosing a home health agency.Name of the home health agency:Question1. Medicare-certified?2. Medicaid-certified (if you have bothMedicare and Medicaid)?3. Offers the specific health care servicesI need, like skilled nursing services orphysical therapy?4. Meets my special needs, like language orcultural preferences?5. Offers the personal care services I need,like help bathing, dressing, and using thebathroom?6. Offers the support services I need, or canhelp me arrange for additional services, likea meal delivery service, that I may need?(NOTE: These types of services aren’tgenerally covered by Medicare).7. Has staff that can give the type and hoursof care my doctor ordered and start when Ineed them?8. Is recommended by my hospital dischargeplanner, doctor, or social worker?9. Has staff available at night and on weekendsfor emergencies?10. Explained what my insurance will cover andwhat I must pay out-of-pocket?11. Has letters from satisfied patients, familymembers, and doctors that testify to thehome health agency providing good care?YesNoComments
Section 2: Choosing a Home Health Agency17Special rules for home health careIn general, most Medicare-certified home health agencies will accept allpeople with Medicare. An agency isn’t required to accept you if it can’tmeet your medical needs. An agency shouldn’t refuse to take you becauseof your condition, unless the agency would also refuse to take otherpeople with the same condition.Medicare will only pay for you to get care from one home health agencyat a time. You may decide to end your relationship with one agency andchoose another at any time. Contact your doctor to get a referral to anew agency. You should tell both the agency you’re leaving and the newagency you choose that you’re changing home health agencies.Find out more about home health agenciesYour State Survey Agency, the agency that inspects and certifies homehealth agencies for Medicare, also has information about home healthagencies. Ask them for the state survey report on the home healthagency of interest to you. Visit Medicare.gov/contacts to get your StateSurvey Agency’s phone number. You can also call 1-800-MEDICARE(1-800-633-4227). TTY users can call 1-877-486-2048.In some cases, your local long-term care ombudsman may haveinformation on the home health agencies in your area. Visitltcombudsman.org, visit eldercare.gov, or call the eldercare locator at1-800-677-1116.To find out more about home health agencies, you can: Ask your doctor, hospital discharge planner, or social worker. Ask friends or family about their home health care experiences. Use a senior community referral service, or other communityagencies that help you with your health care.
18Section 2: Choosing a Home Health Agency
19Section 3:Getting Home Health CareUsually, once your doctor refers you for home healthservices, staff from the home health agency will come toyour home to talk to you about your needs and ask yousome questions about your health. The home health agencywill also talk to your doctor about your care and keep yourdoctor updated about your progress. You need a doctor’sorder to start and continue care.Your plan of careYour home health agency will work with you and your doctorto develop your plan of care. A plan of care lists what kind ofservices and care you should get for your health condition.You have the right to be involved in any decisions about yourplan of care. Your plan of care include: What services you need Which health care professionals should give theseservices How often you’ll need the services Visit schedule The medical equipment you need What results your doctor expects from your treatmentWords in redare defined onpages 27–28.Your home health agency must give you all of the home carelisted in your plan of care, including services and medicalsupplies. The agency may do this through its own staff orthrough an arrangement with another agency. The agencycould also hire nurses, therapists, home health aides, andmedical social workers to meet your needs.
20Section 3: Getting Home Health CareYour plan of care (continued)Your doctor and home health team review your plan of care as oftenas necessary, but at least once every 60 days. If your health conditionchanges, the home health team should tell your doctor right away. Yourhealth care team will review your plan of care and make any necessarychanges with the approval of your doctor. Your home heath team will: Review your plan of care and make any necessary changes withyour doctor Tell you about any changes in your plan of care. If you have aquestion about your care, or if you feel your needs aren’t being met,talk to both your doctor and the home health team. Teach you (and your family or friends who are helping you) tocontinue any care you may need, including wound care, therapy,and disease management. You should learn to recognize problemslike infection or shortness of breath, and know what to do or whomto contact if they happen.Your rights getting home health careIn general, as a person with Medicare getting home health care from aMedicare-certified home health agency, you have the rights to: Get a written notice of your rights before your care starts Have your home and property treated with respect Be told, in advance, what care you’ll be getting and when your planof care is going to change Participate in your care planning and treatment Get written information about your privacy rights and your appealrights Have your personal information kept private Get written and verbal information about how much Medicare isexpected to pay and how much you’ll have to pay for services Make complaints about your care and have the home health agencyfollow up on them Know the phone number of the home health hotline in your statewhere you can call with complaints or questions about your care
Section 3: Getting Home Health CareVisit Medicare.gov to learn more about your rights and protections.You can also call 1-800-MEDICARE (1-800-633-4227). TTY userscan call 1-877-486-2048.Where to file a complaint about the quality ofyour home health careIf you have a complaint about the quality of care you’re getting froma home health agency, you should call either of these organizations: Your state home health hotline. Your home health agencyshould give you this number when you start getting homehealth services. The Beneficiary and Family Centered Care QualityImprovement Organization (BFCC-QIO) in your state. To getthe phone number for your BFCC-QIO, visit Medicare.gov/contacts. You can also call 1-800-MEDICARE.21
22Section 3: Getting Home Health CareHome Health Care ChecklistThis checklist can help you (and your family or friends who are helping you) monitoryour home health care. Use this checklist to help make sure that you’re getting goodquality home health care.When I get my home health care1. The staff is polite and treats me and myfamily with respect.2. The staff explains my plan of care tome and my family, lets us participate increating the plan, and lets us know aheadof time of any changes.3. The staff is properly trained and licensedto perform the type of health care I need.4. The agency explains what to do if I havea problem with the staff or the care I’mgetting.5. The agency responds quickly to myrequests.6. The staff checks my physical andemotional condition at each visit.7. The staff responds quickly to changes inmy health or behavior.8. The staff checks my home and suggestschanges to meet my special needs and toensure my safety.9. The staff has told me what to do if I havean emergency.10. The agency and its staff protect myprivacy.YesNoComments
23Section 4:Getting the Help You NeedHelp with questions about homehealth coverageIf you have questions about your Medicare homehealth care benefits or coverage and you haveOriginal Medicare, visit Medicare.gov, or call1-800-MEDICARE (1-800-633-4227). TTY users cancall 1-877-486-2048. If you get your Medicare benefitsthrough a Medicare Advantage Plan (Part C) or otherMedicare health plan, call your plan.You may also call the State Health InsuranceAssistance Program (SHIP). SHIP counselors answerquestions about Medicare’s home health benefitsand what Medicare, Medicaid, and other types ofinsurance pay for.To get the phone number for your SHIP, visitshiptacenter.org or call 1-800-MEDICARE.Words in redare defined onpages 27–28.
24Section 4: Getting the Help You NeedWhat you need to know about fraudIn general, most home health agencies are honest and use correctbilling information. Unfortunately, there may be some who commitfraud. Fraud wastes Medicare dollars and takes away money thatcould be used to pay claims. You play an important role in the fight toprevent Medicare fraud, waste, and abuse.Look for these: Home health visits that your doctor ordered, but that you didn’tget. Visits by home health staff that you didn’t request and that youdon’t need. Bills for services and equipment you never got. Fake signatures (yours or your doctor’s) on medical forms orequipment orders. Pressure to accept items and services that you don’t need or thatMedicare doesn’t cover. Items listed on your “Medicare Summary Notice” (MSN) thatyou don’t think you got or used. Home health services your doctor didn’t order. The doctor whoapproves home health services for you should know you, andshould be involved in your care. If your plan of care changesmake sure that your doctor was involved in making thosechanges. A home health agency that offers you free goods or services inexchange for your Medicare number. Treat your Medicare cardlike a credit card or cash. Never give your Medicare or Medicaidnumber to people who tell you a service is free and they needyour number for their records.The best way to protect your home health benefit is to know whatMedicare covers and to know what your doctor has planned for you.If you don’t understand something in your plan of care, ask questions.
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to help you maintain your current condition or to prevent your condition from getting worse 4.e amount, frequency, and duration of the services are Th reasonable Home health aide services: Medicare will pay for part-time or intermittent home health aide services (like personal care), if needed to maintain your health or treat your illness or .
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U.S. GOVERNMENT OFFICIAL EDITION NOTICE Use of ISBN This is the Official U.S. Government edition of this publication and is herein identified to certify its authenticity. Use of the ISBN 978-0-16-095053-7 is for U.S. Government Publishing Office Official Editions only. The Superintendent of Documents of the U.S. Government Publishing Office .
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