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Original Fee-For-Service Medicare: How To Maximize Use

Home Health Care

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To qualify for Medicare Home Health benefits, your doctor must certify your eligibility for the benefit. Then a nurse from the home health agency will visit you to assess your needs.

You will then start receiving home health services based on the assessment from the home health agency. The assessment will not only determine which home health services you will receive, it will also assign a number of hours each week you are authorized to receive the services within the Medicare cap of 8 hours per day and 35 hours per week.

Don't expect to receive the maximum hours of services. The maximum is almost never awarded. Rather, based on what they determine your needs to be, you will likely receive a few hours per week of nursing care, usually to supervise medications and check your progress. You will probably also receive a few hours of home health aide services and some other services.

Services available through Medicare's Home Health Benefit include:

Skilled Services. Skilled services must be reasonable and necessary and so inherently complex that a skilled nurse or therapist must perform or supervise them in order to be safe and effective. If a home health aide or other person could perform the service, it is not considered skilled.

Skilled Nursing. The skilled care of a registered nurse must be reasonable and necessary to the diagnosis and treatment of your illness or injury. Examples of such services include:

  • Administration of medications
  • Tube feedings, catheter changes and wound care
  • Teaching and training activities
  • Observation and assessment of a patient's condition
  • Management and evaluation of a patient's care plan

Skilled Therapy. Physical, speech and occupational therapy services are covered up to the limits described in Medicare -- Schedule of Benefits. To receive coverage for occupational therapy, you must need it initially in conjunction with physical or speech therapy.

Home Health Aide Services. Aide services include personal care such as bathing, feeding, dressing and toileting.

Medicare does not cover housekeeping services, such as cleaning and cooking.

Medical Social Services. Social services help patients and families deal with the logistics and emotional issues related to the illness.

Medical Supplies. The home health agency will provide whatever supplies (other than medications) that are required to perform their duties. For example, if an I.V. drip is needed, the agency will supply the pole, the bottle, the tube, and, if needed, the regulator. It will not supply the medication to go into the drip. Durable medical equipment is covered at 80% of the Medicare Approved Amount. (See Obtaining Durable Medical Equipment.)

To assure you receive all the home care benefits you need and for which you are eligible:

  • Make a list of what you believe you may need. For example:
  • What care do you need?
  • How frequently do you need care?
  • How long do you need care each time?
  • Do you need a Registered Nurse to provide care, and if so, for how many hours and for how many days a week?
  • Do you need a Home Health Aide to help with housekeeping?
  • Remember, don't expect to receive all the care you ask for. Still, it is worthwhile spending some time thinking about what you believe you need and why.
  • Review the list with your doctor. Work with him or her to develop the final list of what services (including the frequency and duration) the doctor will put in letter certifying your eligibility for benefits.
  • When the person from the home health agency comes to assess your needs:
  • Advocate for yourself by clearly listing all the needs you and your doctor have come up with. This is frequently somewhat of a bargaining situation so it won't hurt to ask for more than you expect in the hope of "compromising" and settling for what you do need. If you're not up to the discussion, have a friend or family member with you at the interview to raise the issues and do the negotiation.
  • Confirm with the assessment nurse that you are a Medicare patient and their services will be paid by Medicare.
  • Know what is authorized for your care and how many hours are supposed to be provided so you can monitor your care to make sure you receive everything that is authorized. If you're not up to it, ask a family member or friend to take on the responsibility of doing the monitoring for you.
  • Read the paperwork you are provided during the assessment. Included in it will be the procedures for making grievances and complaints about the care.
  • Generally, you first raise the issue with the nurse providing your care.
  • Next, contact the administrator of the home health agency. The more specific you are with examples and specific dates and times, the more weight your complaint will have.
  • Involve your doctor if you have trouble getting the issues resolved.
  • If your doctor can't resolve the situation, contact the numbers provided in Medicare -- Making Contact.
  • If you continue to be unable to resolve your problems with the agency, you have the right to change and receive your care from another Medicare Certified Home Health Agency.
If You Need Home Health Care, But The Home Health Agency Doesn't Believe Medicare Will Pay For It

If a Home Health Agency does not believe that Medicare will cover your Home Health Services -- or that your care will be terminated -- you must be notified before services are delivered. You must then either agree to postpone start of the services or to pay for services while Medicare is reviewing your case.

The notice an agency must give is known as a Home Health Agency Beneficiary Notice (HHABN).

  • An HHABN must identify the specific home health services that are being denied, reduced, or terminated.
  • The notice must be hand-delivered where possible.
  • The notice must state why the agency expects Medicare to deny care. Possible reasons:
    • The care is "not medically necessary and reasonable."
    • The care is custodial in nature.
    • You, the beneficiary, is not really homebound.
    • You, the beneficiary, does not require part-time or intermittent services.
  • The notice must contain a "return page" on which you can indicate either that you agree to the termination, reduction, or denial of care, or that you wish to pay for the services at issue and have the home health agency submit a demand bill for an initial Medicare decision.
  • The Home Health Agency must provide you assistance in understanding the HHABN.

The Home Health Agency must implement your choice of either to terminate services or pay for the continuation of services while the demand bill is being processed by Medicare.


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