What Is Home Health Care?
Home health care includes skilled nursing care, as well as other skilled care services, like physical and occupational therapy, speechlanguage therapy, and medical social services. These services are given by a variety of skilled health care professionals at home.
The home health staff provides and helps coordinate the care and/or therapy your doctor orders. Along with the doctor, home health staff create a plan of care, which is a written plan for your care. It tells what services you will get to reach and keep your best physical, mental, and social well-being. The home health staff keeps your doctor up-to-date on how you are doing and updates your plan of care as needed, as authorized by your doctor. More information about plans of care can be found on pages 19 and 20.
The need for home health care has grown for many reasons. Medical science and technology have improved. Many treatments that could once be done only in a hospital can now be done at home. Also, home health care is usually less expensive and can often be just as effective as care in a hospital or skilled nursing facility. And just as important, most patients and their families prefer to stay at home rather than be in a hospital or a nursing home.
While you get home health care, home health staff teach you (and those who help you) to continue any care you may need, including medication, wound care, therapy, and managing stress. Since most home health care is intermittent and part-time, patients (and their informal caregivers) should learn how to identify and care for possible problems, like confusion or shortness of breath.
The goal of short-term home health care is to provide treatment for an illness or injury. It helps you get better, regain your independence, and become as self-sufficient as possible. The goal of long-term home health care (for chronically ill or disabled people) is to maintain your highest level of ability or health, and help you learn to live with your illness or disability.
How do I find a Medicare-approved home health agency?
You can find a Medicare-approved home health agency by
• looking at “Home Health Compare” at www.medicare.gov on the web. Home Health Compare provides the
• name and office address of the agency,
• agency phone number,
• services offered by the agency (i.e. Nursing Care, Physical Therapy, Occupational Therapy, Speech Language Pathology, Medical/Social Services, and Home Health Aide),
• agency’s initial date of Medicare certification,
• type of ownership (For Profit, Government, Non-Profit), and
• quality measures (see page 6).
• asking your doctor, hospital discharge planner, or social worker. Or, ask friends or family about their home health care experiences.
• using a senior community referral service, or other community agencies that help you with your health care.
• looking in your telephone directory in the Yellow Pages under “home care” or “home health care.” (Look for home health care agencies that are Medicare-approved.)
Note: A home health agency has the right to refuse to accept any individual patient if it is unable to meet the patient’s needs.
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. Your choice should be honored by your doctor, hospital discharge planner, or other referring agency. Although you have a say in which agency you use, your choices may be limited by agency availability, or by Medicare’s rules. See below for Medicare’s requirements for home health agencies.
Some hospitals have their own home health agency. You don’t have to choose the hospital’s agency. You may choose any Medicare-certified agency that you feel will meet your medical needs. If you are in a Medicare health plan, you may have to use a home health agency that works with the plan. See page 16 for more information about Medicare health plans.
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. Medicare regularly inspects home health agencies to make sure that these standards are met.
Your home health agency must provide you with all the home care identified in your plan of care (see page 19–20), including staff services and medical supplies. The agency may do this through its own staff, through an arrangement with another agency, or by hiring someone else to meet your needs. This includes nurses, therapists, home health aides, and medical social service counselors.
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. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious services. A need for adult day care doesn’t keep you from getting home health care for other medical conditions, and
• the home health agency caring for you must be approved by the Medicare program (Medicare-certified).
HCPCS Codes* Required Clinical Information
Home Health Care
T1002
T1003
Initial and Subsequent Requests
Must include services requested, number of visits and weekly frequency, diagnosis codes, CPT
codes, start date of care
Indicate the number of hours per visit for skilled nursing and home health aide services
Initial Episode
Physician order and completed 485 Plan of Care for period being requested
Current Skilled Nurse Assessment and or initial visit summary
Subsequent Episodes
Current 485 (may be unsigned) or 485 draft
Signed 485 from the previous episode; this must be signed by physician
Note: The 485 is required; if unable to provide at this time, then submit the 60-day Skilled Nurse
Summary to include the following:
Nursing summary needs to be current and related to all stated diagnoses
PT, OT, ST, SW evaluations and notes if applicable
Home Health Aide duties
Vital Signs ranges, 02 saturations, glucose levels, PT/INR levels, HCT/HGB if receiving B12
injections
Medication changes, wound care with wound measurements, edema with description, weight
gain/weight loss
Member’s functional mobility
Caregiver must be identified
o Does caregiver participate in care of the member?
o Who lives with the member? Name and relationship
o Who administers medications?
Recent inpatient or ER visits with dates and diagnosis
Discharge plan
What home health services does Medicare cover?
If you meet all four of the conditions above for home health care, Medicare will cover
• skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
• home health aide services on a part-time or intermittent basis. A home health aide doesn’t have a nursing license. The aide provides services that give additional support to the nurse. These services include help with personal care such as bathing, using the toilet, or dressing. These types of services don’t need the skills of a licensed nurse. Medicare doesn’t cover home health aide services unless you are also getting skilled care such as nursing care or other therapy.
The home health aide services must be part of the home care for your illness or injury.
• physical therapy, speech-language therapy, and occupational therapy for as long as your doctor says you need it.
1) Physical therapy: including exercise to regain movement and strength to a body area, and training on how to use special equipment or do daily activities, like how to get in and out of a wheelchair or bathtub.
2) Speech-language therapy (pathology services): including exercise to regain and strengthen speech skills.
3) Occupational therapy: to help you become able to do usual daily activities by yourself. You might learn new ways to eat, put on clothes, comb your hair, and new ways to do other usual daily activities. You may continue to receive occupational therapy even if you no longer need other skilled care.
• medical social services to help you with social and emotional concerns related to your illness. This might include counseling or help in finding resources in your community.
• certain medical supplies like wound dressings, but not prescription drugs or biologicals.
• medical equipment such as a wheelchair or walker.
What doesn’t Medicare cover for home health care?
Medicare doesn’t pay for
• 24-hour a day care at home,
• prescription drugs,
• meals delivered to your home,
• homemaker services like shopping, cleaning, and laundry, and
• 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 “intermittent” basis. This means there are limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services. Therapy services do not have to be part-time or intermittent.
To decide whether or not you are eligible for home health care, Medicare defines “intermittent” as skilled nursing care that is needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less) with some exceptions in special circumstances.
For 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 at 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 home health care meets the Medicare definition of “intermittent.”
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. Once you are getting home health care, Medicare defines part-time or intermittent as skilled nursing or home health aide services combined to total less than 8 hours per day and 28 or fewer hours each week. This definition helps Medicare make decisions about your coverage.
For 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.
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.
If a home health agency denies, cuts back, or stops your care, because it believes that Medicare won’t pay for home health care services that a doctor has ordered for you, the agency must give you a Home Health Advance Beneficiary Notice (HHABN). The HHABN should
• explain why the agency thinks that Medicare won’t pay for the services,
• explain that you may have to pay for the services if Medicare doesn’t pay for them, and
• give clear directions for getting an official decision from Medicare and for appealing that decision if payment is denied.
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 if I am in a Medicare health plan?
Medicare health plans, such as a Medicare Managed Care Plan or a Medicare Private Fee-for-Service Plan, are health care choices in some areas of the country. In most plans, you can only go to doctors, specialists, or hospitals on the plan’s list. Medicare health plans must cover all Medicare Part A and Part B health care including home health care.
If you belong to a Medicare health plan, you may only be able to choose a home health agency that works with the health care plan. Call your Medicare health plan if you have questions about the plan’s home health care rules, coverage, appeal rights, and your costs. If you get services from a doctor or a home health agency that
doesn’t work with the Medicare health plan, neither the plan nor Medicare will pay the bill. If you are not sure if you are in a Medicare health plan, you can call your local Social Security Administration (SSA) office, or call SSA at 1-800-772-1213 to find the answer.
If you would like more information about Medicare health plans, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 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. To qualify, generally you must have a low income and few savings or other assets. Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid
may pay for homemaker, personal care, and other services that aren’t paid for by Medicare. States have programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain people who are entitled to Medicare and have a low income.
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 should call 1-877-486-2048.
What is a plan of care?
A plan of care describes what kind of services and care you must get for your health problem. Your doctor will work with home health staff to decide
• what kind of services you need,
• what type of health care professional should give these services,
• how often you will need the services,
• the kind of home medical equipment you need,
• what kind of special foods you need, and
• what your doctor expects from your treatment.
Your doctor and home health agency staff review your plan of care as often as necessary, but at least once every 60 days. If your health problems change, your plan of care will be reviewed and may change. Home health agency staff must tell your doctor right away if your health changes. You will continue to get home health care as long as you are eligible.
Only your doctor can change your plan of care. Your home health agency can’t change your plan of care without getting your doctor’s approval. You must be told of any changes in your plan of care. If you have a question about your care, you should call your doctor.
If your agency changes your plan of care without your doctor’s approval, you have the right to appeal. Your appeal rights are on the back of the Medicare Summary Notice that is mailed to you from the company that handles bills for Medicare. The notice will also tell you how you can appeal.
If you feel your medical needs aren’t being met, you should talk to both your doctor and the home health agency.
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. Your home health agency should give you this number when you start getting home health services. 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 should call 1-877-486-2048.
You also should be careful about activities such as
• home health services your doctor didn’t order. The doctor who approves home health services for you should know you, and should be involved in your care. If your plan of care changes, make sure that your doctor was involved in making those changes.
• 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 they need your number for their records.
To report any suspected home health care fraud, call the Regional Home Health Intermediary for your state, or call 1-800-447-TIPS (1-800-447-8477). Each call is taken seriously.
You also should be careful about activities such as
• home health services your doctor didn’t order. The doctor who approves home health services for you should know you, and should be involved in your care. If your plan of care changes, make sure that your doctor was involved in making those changes.
• 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 they need your number for their records.
