What is Home Health Care? Choosing a Home Health Agency Medicare Coverage of Home Health Care How can Medicaid help people with low incomes? Your Home Health Care Where Can I Get Help with My Questions? The text from the Medicare site The link to the Medicare site (PDF version) WHAT IS HOME HEALTH CARE? Home Health Care allows you to have skilled care service providers, such as nurses or therapists, in your own home. Short-term home health care provides treatment for an illness or injury, helping you regain your independence and become as self-sufficient as possible. Long-term home health care, for chronically ill or disabled people, helps you maintain your highest level of ability or health and to learn to live with your illness or disability. CHOOSING A HOME HEALTH AGENCY How do I find a Medicare-approved home health agency? Compare our services to other near-by agencies. Ask a doctor, hospital or social worker, or friends and family. When you ask, make sure the agencies are Medicare-approved. Use a senior community eferral service or other community agencies Look in your phone book under "home health" or "home health care&.quot; Do I have a choice in which home health agency I use? If your doctor decides you need home health care, you have the right to choose a home health agency to give you the care and services you need. However, your choices may be limited by agency availability, or by Medicare’s rules. It is important to remember that Medicare only pays for home health services that are given by a home health agency that meets Medicare's standards and is approved (certified) by Medicare. When you start getting home care, staff from the Medicare-approved home health agency will ask you some questions about your health to help them give you proper care. The home health agency is required to keep your information confidential. An agency is not required to accept a patient if it can't meet the patient's medical needs. An agency can't refuse to take a specific patient because of the patient's condition unless they also refuse to take others with the same condition. What if I want to change home health agencies? Medicare will only pay for your to get care for one home health agency at a time. You may choose to end your relationship with one agency and chose another at any time. MEDICARE COVERAGE OF HOME HEALTH CARE Who is eligible to get Medicare-covered home health care? If you have Medicare, you can get home health care benefits if you meet all the following conditions: Your doctor must decide that you need medical care at home, and make a plan for your care at home. You must need at least one of the following: intermittent skilled nursing care, or physical therapy or speech-language therapy, or continue to need occupational therapy. You must be homebound, or normally unable to leave home unassisted. The home health agency caring for you must be Medicare-certified. What home health service does Medicare cover? Skilled nursing care on a part-time or intermittent basis. Home health aide service on a part-time or intermittent basis. The aide doesn't have a nursing licence and provides additional support for the nurse. Medicare doesn't cover home health aide services unless you are also getting skilled care such as nursing or other therapy. Physical therapy, speech-language therapy, and occupational therapy for as long as your doctor says you need it. Medical social services to help you with social and emotional concerns relating to your illness, including counseling or help in finding resources. Certain medical supplies, but not prescription drugs or biologicals. Medical equipment such as a wheelchair or a walker. What doesn't Medicare cover for home health care? 24 hour a day care at home Prescription drugs Meals delivered to your home Homemaker services like shopping, cleaning and laundry Personal care like bathing, using the toilet or help in getting dressed given by home health aides when this is the only care you need. How long can I get home health services? Medicare covers your home health services for as long as you are eligible and your doctor says you need these services. However, the skilled nursing care and home health aide services are only covered on a part-time or "intermittant" basis. Hour and day limits can be increased by your doctor in special cases when the need for more care is limited and can be planned ahead. Example: Jane's doctor says that she needs a nurse to visit her every day for the next 15 days to care for a wound. The total time that the nurse will be a Jane's house will be less than an hour each day, and Jane only needs the nurse to come for 15 days. Jane's need for nome health care meets the Medicare definition of "intermittant." Example: Fred has been getting home health care for 3 weeks. Fred's condition is improved, but his doctor would like Fred to continue to get home health care. Fred's doctor says that he needs a nurse to come in 3 days a week for 2 hours each day (a total of 6 hours) and a home health aide to come in 5 days a week for 3 hours each day (a total of 15 hours). This means that Fred is getting a total of 21 hours of home care per week. This meets Medicare's definition of "part-time or intermittent" home health care. What does the riginal Medicare Plan pay for and what can I be billed for? The Original Medicare Plan pays the full approved amount (cost) of all covered home health visits. The home health agency sends bills to Medicare. Before your care begins, the home health agency must tell you how much of your bill Medicare will pay. The agency must also tell you if any items or services they give you are not covered by Medicare, and how much you will have to pay for them. This must be explained both by talking with you and in writing. You may be charged for: medical services and supplies that Medicare doesn’t pay for 20 percent of the approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment Note: If you are in the Original Medicare Plan, ask your supplier "Do you accept assignment?" Assignment could save you money. Call 1-800-MEDICARE (1-800-633-4227) and ask for a copy of "Does your doctor or supplier accept 'assignment'?" How does the Original Medicare Plan pay for my home health care? Medicare pays your home health agency a set amount of money for each 60 days that you need care. (This 60-day period is called an "episode of care.") The payment is based on what kind of health care an average person in your situation would need. What do I do if the Original Medicare Plan stops paying for my home health care? A home health agency must give you a HHABN that explains why and when it expects Medicare will stop paying for your home health care. If you get this notice and your doctor believes you still need home health care and that Medicare should keep paying, you can ask Medicare for an official decision. To get an official decision you must: keep getting home health care if you think you need it. Ask how much it will cost. Talk to your doctor and family about this decision. understand you may have to pay the home health agency for these services. ask the home health agency in writing to send your claim to Medicare so that Medicare will decide if it will pay. If the Original Medicare Plan decides to pay, you will get back all of your payments, except for any coinsurance for durable medical equipment and any other costs for things that Medicare doesn’t cover. What do I do if the Original Medicare Plan is not paying for an item or service that I think should be paid for? If you are in the Original Medicare Plan, you can file an appeal if you think Medicare should have paid for a item or service. Your appeal rights are on the back of the Medicare Summary Notice that is mailed to you and will also tell you why your bill wasn’t paid and what appeal steps you can take. What if I am in a Medicare health plan? If you belong to a Medicare health plan, such as a Medicare Managed Care Plan or a Medicare Private Fee-for-Service Plan, you may only be able to choose a home health agency that works with the health care plan. If you would like more information about Medicare health plans, call 1-800-MEDICARE (1-800-633-4227), TTY users: 1-877-486-2048. Or, look at your copy of the Medicare & You handbook mailed to all people with Medicare each fall. HOW CAN MEDICAID HELP PEOPLE WITH LOW INCOMES? State programs, like Medicaid may help with medical costs for some people with low incomes and limited resources. Medicaid coverage differs from state to state. To qualify, generally you must have a low income and few savings or other assets. For more information about what Medicaid covers for home health care in your state, call your State medical assistance office. If you need the telephone number in your State, call 1-800-MEDICARE (1-800-633-4227), TTY users: 1-877-486-2048. YOUR HOME HEALTH CARE Does a doctor oversee my home health care services? Your doctor will oversee your home health care by deciding you need care at home, developing your plan of care (see below), and communicating with the home health agency about your progress. What is a plan of care? A plan of care descibes what kind of services you must get for your health problem. Your doctor will work with home health staff to decide the kind and frequency of services and special food you need and what type of health care professionals should provide these services, the kinds of medical equipment you will need, and what the doctor expects from your treatment. This plan will be reviewed as needed but at least every 60 days. If your health changes the doctor will be notied immediately by the staff, but only a doctor can change your plan of care. You must be notified of any changes in your plan. Home Health Care Checklist Use this checklist to help monitor your home health care. What can I do if I have a complaint about the quality of my home health care? If you believe that the home health agency is not giving you good quality care or you have a complaint about your home health agency, you should call your state home health hotline number which you should have from your home health agency. Or, you can call the Quality Improvement Organization (QIO) in your state to file a complaint. You can get local telephone numbers for the organizations that can help you on the "Helpful Contacts" section of the www.medicare.gov website or call 1-800-MEDICARE (1-800-633-4227), TTY users: 1-877-486-2048. How do I find and report fraud? Most home health agencies are honest and use correct billing information. Unfortunately, fraud sometimes occurs. To report Medicare fraud, call 1-800-447-TIPS (1-800-447-8477). Things to look for: Home health visits that your doctor orders that you never get Home Health Services your doctor didn't order Visits by home health staff that are not needed Bills for services and equipment you never get Faking your signature or your doctor’s signature Pressure to accept items and services that you don’t need Items listed on your Medicare Summary Notice that you don’t think you received. 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 your Medicare or medicaid number to people who tell you a service is free but that they need your number for their records. The best way to protect your home health benefit is to know what Medicare covers and to know what your doctor has planned for you. If you do not understand something in your plan of care, ask questions. WHERE CAN I GET HELP WITH MY QUESTIONS? If you have questions about your Medicare home health care and you are in the Original Medicare Plan, call your Regional Home Health Intermediary. If you have questions about home health care and you are in another Medicare health plan, call your plan. If you are covered by another kind of health insurance, call the plan’s member services office. Every State, territory, plus Puerto Rico, the Virgin Islands, and the District of Columbia, has a State Health Insurance Assistance Program with counselors who will give you free health insurance information and help. The counselors should be able to answer your questions about home health care and what Medicare, Medicaid, and other types of insurance pay for. In addition, these counselors will help you with Medicare payment questions; questions on buying a Medigap (Medicare Supplement Insurance) policy, or long-term care insurance; dealing with payment denials and appeals; Medicare rights and protections; complaints about your care or treatment; or choosing a Medicare health plan. WORDS TO KNOW