|00 P*

r

,*'

I Medicare and

Home Health

Care

This book explains .

)

The home health benefit and who is eligible.

What is covered by the Original Medicare Plan.

How to find a home health agency.

Where you can get more help.

PUBS

RA

645

.35 M43

1999:Sept.

&*

HEALTH CARE FINANCING ADMINISTRATION

The Federal Medicare Agency
Table of Contents

Page

What is Home Health Care? 1 Who is Eligible for Home Health Care? 1 How Can I Get Care at Home? 1 What Does the Original Medicare Plan Cover? 1 What Doesn't the Original Medicare Plan Cover? 4

What Happens if I Join a Medicare Managed Care Plan? 4

What is a Plan of Care? 4

How Long Can I Keep Getting Home Health Services? 5

How Can Medicaid Help Low Income Beneficiaries? 6

What Can I be Billed For? 6

What Do I Do if Medicare Stops Paying for my Home Health Care? . 7

What Do I Do if Medicare is Not Paying for an Item or Service that

I Feel Should be Paid For? 7

Who Do I Call with Questions? 7

How Do I Find an Approved Home Health Agency? 8

What if I am in a Managed Care Plan? 8

What Questions Do I Ask When I Choose a Home Health Agency? . 9

Where Can I Get Help with My Questions? 10

How Do I Complain About the Quality of My Care? 10

How Do I Find and Report Fraud? 10

Important Telephone Numbers 11

Definition of Important Terms 19

Index 21
Medicare and Home Health Care

The plan of care is described on page 4.

You must meet all four

of these conditions for

Medicare to cover home

health care.

3!vd.

.

What is Home Health Care?

Home Health Care is skilled nursing care and certain

other health care services that you get in your home for

the treatment of an illness or injury. This brochure

explains Medicare's basic home health benefit and

gives you information about where to get more

information and help.

Who is Eligible for Home Health Care?

All Medicare beneficiaries can receive home health

care benefits. This brochure describes home health

care benefits covered by the Original Medicare Plan. If

you are in a Medicare managed care plan, see pages 4,

7, 8, and 10.

How Can I Get Care at Home?

To get Medicare home health care:

1

.

Your doctor must decide that you need medical care

in your home, and make a plan for your care at

home; and

2. You must need at least one of the following:

intermittent (and not full time) skilled nursing care, or physical therapy or speech language pathology

services; and

3. You must be homebound. This means that you are normally unable to leave home. Being homebound

means that leaving home is a major effort. When

you leave home, it must be infrequent, for a short

time, or to get medical care; and

4. The home health agency caring for you must be

approved by the Medicare program.

What Does the Original Medicare Plan Cover?

If you meet all four of the above conditions 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).
Medicare and Home Health Care

Medicare will cover

any of these kinds of

therapy for as long as you are eligible and your

doctor says you need

them.

Home health aide services on a part-time or intermittent basis. A home health aide does not

have a nursing license. The aide provides services

that support any services that the nurse provides.

These services include help with personal care,

such as bathing, using the toilet, or dressing. These

types of services do not need the skills of a licensed

nurse. Medicare does not 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 pathology

services, and occupational therapy for as long as your doctor says you need it. Medicare covers

these types of therapy:

1) Physical therapy, which includes 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 pathology services, which

includes exercise to regain and strengthen

speech skills.

3) Occupational therapy, which helps 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 you have related to your

illness. This might include counseling or help in

finding resources in your community.

Certain medical supplies, like wound dressings,

but not drugs or prescriptions.

Medical equipment. Medicare usually pays 80

percent of the approved amount for certain pieces

of medical equipment, such as a wheelchair or

walker.
Medicare and Home Health Care

The Original Medicare Plan covers these home health care services:

Medicare Services Covered

Part-Time or Intermittent Skilled Nursing Care X

Part-Time or Intermittent Home Health Aide Services X

Physical and Occupational Therapy X

Speech Language Pathology Services X

Medical Social Services X

Medical Supplies (not drugs or biologicals) X

Durable Medical Equipment X*

*The Original Medicare Plan usually pays 80% of the approved amount for certain

pieces of medical equipment. You may have to pay 20% of the approved amount for

durable medical equipment. 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?"
Medicare and Home Health Care

Your plan of care is written just for you. It describes the care you

need, who should give

the care, and any special

equipment and foods that

you might need.

What Doesn't the Original Medicare Plan

Cover?

Medicare does not pay for the following:

24-hour per day care at home.

B Prescription drugs.

Meals delivered to your home.

Homemaker services like shopping, cleaning and

laundry.

Personal care given by home health aides, like

bathing, using the toilet, or help in getting dressed

when this is the only care you need.

What Happens if I Join a Medicare Managed

Care Plan?

Medicare managed care plans 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 managed care plans must cover all Medicare

Part A and Part B health care, including home health

care. Some plans cover extras, like prescription drugs. If

you belong to a Medicare managed care plan, you need

to call your plan's benefit administrator to see what

your plan covers, your appeal rights, and your costs.

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 a home health care nurse to decide:

what kind of services you need,

what type of health care professional should give

these services, and

how often you will need the services.

Your plan may also include things like 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

62 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 receive home

health care as long as you are eligible and your doctor

says you need it.
Medicare and Home Health Care

Intermittent means you

need home health care

for a fairly short period of

time.

Your doctor can increase

the number of hours per

week you receive care.

How Long Can I Keep Getting Home Health

Services?

To start receiving your home health benefit, your doctor must tell Medicare about your plan of care. Medicare pays for 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 paid for only 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

receive skilled nursing or home health aide services.

To decide whether or not you are eligible for home

health care, Medicare defines "intermittent" as:

ffl Skilled nursing care or home health aide services

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).

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 fifteen days. Jane's need for home health care meets the Medicare definition of "intermittent."

Hour and day limits can be increased in special cases when the need for more care is limited and able to be

planned ahead.

Once you are receiving home health care, Medicare uses the following definition of part-time or intermittent to

make decisions about your coverage:

Skilled nursing or home health aide services

combined to total less than 8 hours per day and 28

or fewer hours each week.

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 two 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, which meets Medicare's definition of "parttime or intermittent" home health care.
Medicare and Home Health Care

The home health agency

must tell you how much

of your bill will be paid

by Medicare.

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 Can Medicaid Help Low Income

Beneficiaries?

Medicaid is a joint Federal and State program that

helps with medical costs for some people with low

incomes and limited resources. Medicaid may pay for homemaker, personal care, and

other services that are not paid for by Medicare. To

qualify for Medicaid, you must have very low income

and few savings or other assets. Medicaid has 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. Medicaid coverage differs from state to

state. In all states, Medicaid pays for basic home

health care and medical equipment.

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 for

your State, call 1-800-MEDICARE (1-800-633-4227

TTY: 1-877-486-2048 for speech and hearing impaired).

What Can I Be Billed For?

The home health agency sends bills to Medicare.

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 pay for.

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 should 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.
Medicare and Home Health Care

You are protected when

your home health care

ends.

What Do I Do if Medicare Stops Paying for

my Home Health Care?

Home health agencies must give you a notice that explains why and when they think Medicare will stop

paying for your home health care. If you get this notice

and think 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. You should talk

to your doctor and family about this.

Understand you may have to pay the home health

agency for these services.

Ask the home health agency to send your claim to

Medicare so that Medicare will decide if it will pay.

If Medicare decides to pay, you will get back all of

your payments, except for any coinsurance for durable

medical equipment.

What Do 8 Do if Medicare is Not Paying for an

Item or Service that I Feel 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, or did not pay enough for, an item or service you re- ceived. If you file an appeal, ask your doctor or provider

for any information related to the bill that might help

your case. Your appeal rights are on the back of the

Explanation of Medicare Benefits or Medicare

Summary Notice that is mailed to you from a company

that handles bills for Medicare. The notice will also

tell you why your bill was not paid and what appeal

steps you can take.

Who Do I Call with 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 (see

pages 12 ana 13). If you have questions about home

health care and you are in a Medicare managed care

plan, call your plan. If you are covered by another kind

of supplemental insurance plan, call the plan's member

services office.
Medicare and Home Health Care

Look for agencies that

say they are "Medicare

approved."

How Do I Find an Approved Home Health

Agency?

If your doctor decides you need home health care, you

have the right to choose the home health agency that

gives you needed care and 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 given by a home health

agency that meets Medicare's quality standards and is approved by Medicare. Medicare regularly inspects home

health agencies to make sure that these standards are met.

You can find a Medicare approved home health

agency by:

asking your doctor or hospital discharge planner

using a senior community referral service, or other

community agencies who 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 say they

are Medicare approved.)

When you start getting home care, Medicare approved

home health agencies will ask you a set of questions

about your health to help them give you proper care. The

home health agency is required to keep this information

confidential. You may ask to see this information. The

home health agency will explain these questions to you,

and give you written information about them.

What if I am in a Managed Care Plan?

It is very important to remember: If you belong to a Medicare managed care plan, your choice of home

health agencies is limited to agencies that work with the

managed care plan. Call your managed care plan if you

have questions about the plan's home health care rules.

If you get services from a doctor or a home health care agency that doesn't work with the managed care plan,

neither the plan nor Medicare will pay the bill. If you are not sure if you are in a Medicare managed care plan, you

can call your local Social Security Administration

(SSA) office, or call SSA at 1-800-7724213. If you

would like more information about Medicare managed

care plans, call 1-800-MEDICARE (1-800-6334227).

8
Medicare and Home Health Care

What Questions Do I Ask When I Choose a

Home Health Agency?

Before you choose your home health agency, ask these

important questions:

Is the agency Medicare approved?

How long has the agency been serving the

community?

Does this agency give the services I need?

How are emergencies handled?

Is the agency's staff on duty 24 hours a day, seven

days a week?

What will I be charged for services/supplies?

Will Medicare or Medicaid pay for the items I need?

How are my rights protected?

Can my family and I help decide my plan of care?

Does the agency teach family members about the

type of care being given?

Who makes sure that the home health care plan is being followed? Does the supervisor make regular

visits to the home?

Who can I call if I have questions or complaints?

What happens if a home health agency staff

person does not come when scheduled?

Will the agency be in regular contact with my

doctor?
Medicare and Home Health Care

A counselor in your

State's Health Insurance

Assistance Program can

help answer your questions.

You are important in

fighting Medicare fraud.

Where Can I Get Help with My Questions?

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 Medicare

Supplemental Insurance or Medigap Policy or long'

term care insurance, dealing with payment denials and

appeals, Medicare rights and protections, sending

complaints about your care or treatment, or help you

in choosing a Medicare health plan. You can find the

phone number for your State Health Insurance

Assistance Program on pages 14-18.

The Regional Home Health Intermediary is also able

to help you with questions about the Medicare Home

Health Care benefit in the Original Medicare Plan.

The Regional Home Health Intermediary covers

several states. You can find the phone number on

pages 12-13 under Information Assistance. If you are

in a Medicare managed care plan, call your plan with

questions about the plan rules on home health care. How Do I Complain About the Quality of My

Care?

If you believe that the home health agency is not

giving you good quality care, 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 Peer Review

Organization (PRO) in your state to file a complaint

(see pages 14-18).

How Do I Find and Report Fraud?

Most home health agencies are honest, and use correct billing information. Unfortunately, fraud

occurs in the home health industry. It wastes

Medicare dollars and takes money used to pay claims.

You are important in the fight to prevent fraud, waste

and abuse in the Medicare program.

10
Medicare and Home Health Care

To report Medicare

fraud, call

1-800447-TIPS

(1-800447-8477).

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.

You should look for:

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 do

not need.

Items listed on your Medicare Summary Notice or Explanation of Medicare Benefits that you do not

think you received.

You also should be careful about activities such as: Home health services your doctor did not

authorize. 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

(see pages 12 and 13), or call 1-800-447-TIPS (1-800-

447-8477). Each call is taken seriously.

Important Telephone Numbers

The following pages have telephone numbers that you

can use if you need more information.

Learn more about Medicare by calling the national tollfree number, 1-800-MEDICARE (1-800-633-4227).

You can also look on the internet at www.medicare.gov

to get help with your Medicare questions.

11
Medicare and Home Health Care

Regional Home Health Intermediary (RHHI): Call about home health care,

hospice care, and fraud and abuse.

If you live in: Your Regional Home Health Intermediary is:

Connecticut Assoc. Hospital Svc Of Maine

Maine 1(888)896-4997

Massachusetts

New Hampshire

Rhode Island

Vermont

If you live in: Your Regional Home Health Intermediary is:

Alaska Blue Cross Of California Medicare

American Samoa 1(805)383-2990

Arizona

California

Guam

Hawaii

Idaho

Nevada

Northern Mariana Islands

Oregon

Washington

If you live in: I Your Regional Home Health Intermediary is:

Maryland

Washington D.C.

Medicare Customer Service Center

1(800)444-4606

12
Medicare and Home Health Care

Regional Home Health Intermediary (RHHI): Call about home health care,

hospice care, and fraud and abuse.

If you live in: Your Regional Home Health Intermediary is:

Florida Palmetto Government Benefits

| 1(727)773-9225

If you live in: | Your Regional Home Health Intermediary is:

Alabama New Mexico Palmetto Government Benefits

Arkansas North Carolina I 1(803)788-4660

Georgia Ohio

Illinois Oklahoma

Indiana South Carolina

Kentucky Tennessee

Louisiana Texas

Mississippi

If you live in: Your Regional Home Health Intermediary is:

Michigan

Minnesota

New Jersey

New York

Puerto Rico

Virgin Islands

Wisconsin

United Government Services

1(414)224-4954

If you live in: Your Regional Home Health Intermediary is:

Colorado North Dakota Wellmark/Blue Cross Blue Shield Of Iowa

Delaware South Dakota 1(515)246-0126

Iowa Utah

Kansas Virginia

Missouri West Virginia

Montana Wyoming

Nebraska

13
Medicare and Home Health Care

State

State Health Insurance

Assistance Program (SHIP):

Call about Medicare plan

choices, help with filing an

appeal, and supplemental

insurance policies (Medigap)

Peer Review Organization

(PRO): Call about quality of

care complaints and filing an

appeal or complaint

Alabama 1(800)243-5463

in-state calls only

1(800)760-4550

Alaska 1(800)478-6065

in-state calls only

1(800)878-7170

American

Samoa

1(808)586-7299

Government of

American Samoa

1(800)524-6550

Arizona 1(800)432-4040 1(800)359-9909

Arkansas 1(800)272-5528 1(800)447-8477

California 1(800)434-0222 or

call 800-510-2020

in state only

1(800)841-1602

Colorado 1(800)544-9181

in-state calls only

1(800)727-7086

Connecticut 1(800)994-9422

in-state calls only

1(800)553-7590

Delaware 1(800)336-9500

in-state calls only

1(800)422-8804

in-state calls only

Florida 1(800)963-5337

in-state calls only

1(800)844-0795

Georgia 1(800)669-8387

in-state calls only

1(800)979-7217

Guam 1(808)586-7299 1(800)524-6550

Hawaii 1(808)586-7299 1(800)524-6550

14
Medicare and Home Health Care

State

State Health Insurance

Assistance Program (SHIP):

Call about Medicare plan

choices, help with filing an

appeal, and supplemental

insurance policies (Medigap)

Peer Review Organization

(PRO): Call about quality of

care complaints and filing an

appeal or complaint

Idaho 1(800)247-4422

in-state calls only

1(800)445-6941

Illinois 1(800)548-9034

in-state calls only

1(800)647-8089

Indiana 1(800)452-4800 1(800)288-1499

Iowa 1(800)351-4664 1(800)752-7014

Kansas 1(800)860-5260

in-state calls only

1(800)432-0407

Kentucky 1(502)564-7372 1(800)288-1499

Louisiana 1(800)259-5301

in-state calls only

1(800)433-4958

in-state calls only

Maine 1(800)750-5353 1(800)772-0151

in-state calls only

Maryland 1(800)243-3425

in-state calls only

1(800)492-5811

Massachusetts 1(800)882-2003

in-state calls only

1(800)252-5533

in-state calls only

Michigan 1(800)803-7174 1(877)787-2847

Minnesota 1(800)333-2433 1(877)787-2847

Mississippi 1(800)948-3090 1(800)844-0600

15
Medicare and Home Health Care

State

State Health Insurance

Assistance Program (SHIP):

Call about Medicare plan

choices, help with filing an

appeal, and supplemental

insurance policies (Medigap)

Peer Review Organization

(PRO): Call about quality of

care complaints and filing an

appeal or complaint

Missouri 1(800)390-3330 1(800)347-1016

Montana 1(800)332-2272

in-state calls only

1(800)497-8232

Nebraska 1(800)234-7119 1(800)247-3004

Nevada 1(800)307-4444 1(800)748-6773 or 1(800)748-6944

New Hampshire 1(800)852-3388

in-state calls only

1(800)772-0151

in-state calls only

New Jersey 1(800)792-8820

in-state calls only

1(800)624-4557

in-state calls only

New Mexico 1(800)432-2080

in-state calls only

1(800)279-6824

New York 1(800)333-4114 1(800)331-7767

Appeals

North Carolina 1(800)443-9354

in-state calls only

1(800)722-0468

North Dakota 1(800)247-0560

in-state calls only

1(800)472-2902

in-state calls only

Northern

Mariana Islands

1(808)586-7299

Government of

American Samoa

1(800)524-6550

Ohio 1(800)686-1578

in-state calls only

1(800)589-7337

in-state calls only

1(800)837-0664

out-of-state calls

only

16
Medicare and Home Health Care

State

State Health Insurance

Assistance Program (SHIP):

Call about Medicare plan

choices, help with filing an

appeal, and supplemental

insurance policies (Medigap)

Peer Review Organization

(PRO): Call about quality of

care complaints and filing an

appeal or complaint

Oklahoma 1(800)763-2828

in-state calls only

1(800)522-3414

in-state calls only

Oregon 1(800)722-4134 1(800)344-4354

Pennsylvania 1(800)783-7067 1(800)322-1914

Puerto Rico 1(877)725-4300

in-state calls only

1(800)981-5062

in-state calls only

Rhode Island 1(800)322-2880

in-state calls only

1(800)662-5028

in-state calls only

South Carolina 1(800)868-9095

in-state calls only

1(800)922-3089

in-state calls only

South Dakota 1(800)822-8804 1(800)658-2285

Tennessee 1(800)525-2816 1(800)489-4633

Texas 1(800)252-9240 1(800)725-8315

Utah 1(800)541-7735

in-state calls only

1(800)274-2290

Vermont 1(800)642-5119

in-state calls only

1(802)748-5182

out-of-state calls only

1(800)772-0151

in-state calls only

Virgin Islands 1(340)778-6311

X2338

1(340)778-6470

17
Medicare and Home Health Care

Wyoming

State

State Health Insurance

Assistance Program (SHIP):

Call about Medicare plan

choices, help with filing an

appeal, and supplemental

insurance policies (Medigap)

Peer Review Organization

(PRO): Call about quality of

care complaints and filing an

appeal or complaint

Virginia 1(800)552-3402 1(800)545-3814

in-state calls only

Washington 1(800)397-4422

in-state calls only

1(800)445-6941

Washington

D.C.

1(202)676-3900 1(800)999-3362

West Virginia 1(877)987-4463 1(800)422-8804

in-state calls only

Wisconsin 1(800)242-1060 1(800)362-2320

1(800)497-8232

18
Definition of Important Terms

Approved Amount: The fee Medicare

sets as reasonable for a covered medical

service. It may be less than the actual

amount charged. Approved amount is sometimes called "approved charge."

Durable Medical Equipment: Medical

equipment that is ordered by a doctor for use in the home. These items must be

reusable, such as walkers, wheelchairs, or

hospital beds.

Health Care Financing Administration

(HCFA): The federal agency that runs

the Medicare, Medicaid, and Children's

Health Insurance Program, and works to

make sure that the beneficiaries in these

programs have access to high quality

health care.

Homebound: Normally unable to leave

home. Leaving home takes considerable

and taxing effort. A person may leave

home for medical treatment or short,

infrequent absences for nonmedical

reasons, such as a trip to the barber.

Home Health Agency: An organization

that provides home care services,

including skilled nursing care, physical

therapy, occupational therapy, speech

therapy, and care by home health aides.

Home Health Care: Skilled nursing care and certain other health care that you get

in your home for the treatment of an

illness or injury.

Medicare: A health insurance program

for people 65 years of age or older, certain

younger people with disabilities, and

people with End-Stage Renal Disease

(ESRD), (people with permanent kidney

failure who need dialysis or a transplant).

Medicaid: A joint Federal and State

program that helps with medical costs for

some people with low incomes. Programs

vary from State to State, but most health

care costs are covered if you qualify for

both Medicare and Medicaid.

Medically Necessary: Services or

supplies that:

M are proper and needed for the

diagnosis, or treatment of your

medical condition;

II are provided for the diagnosis, direct

care, and treatment of your medical

condition;

M meet the standards of good medical

practice in the medical community of

your local area; and

ffij are not mainly for the convenience of

you or your doctor.

Out-of-Pocket Costs: Health care costs

that you must pay on your own because

they are not covered by Medicare.

Plan Of Care: A plan written by your

doctor that describes what kind of

services and care you must receive for

your health problem.

19
Definition of Important Terms

Provider: A doctor, hospital, health care

professional, or health care facility.

Regional Home Health Intermediaries:

A private company that contracts with

Medicare to process claims and make

checks of home health care.

of skilled nursing care are: getting

intravenous injections, tube feeding,

oxygen to help you breathe, and changing

sterile dressings on a wound. Any service

that could be safely performed by an

average nonmedical person (or one's self)

without the direct supervision of a

licensed nurse is not covered.

* Skilled Nursing Care: A level of care that must be given or supervised by

licensed nurses and is under the general

direction of a doctor. All of your needs are taken care of with this type of service,

including giving direct services. Examples

State Health Insurance Assistance

Program (SHIP): A State organization

that receives money from the Federal

Government to give free health insurance

counseling and assistance to Medicare

beneficiaries.

*This definition, whole or in part, was used with permission from Walter Feldesman,

Esq., Dictionary ofEldercare Terminology , © 1997.

20
Index

Assignment 6

Durable Medical Equipment 3,19

Eligibility 1

Fraud 10, 11, 12, 13

Home Health Aide 2, 3, 4

Home Health Agency 1, 2, 5, 6, 7, 8, 19

Homebound 1, 19

Intermittent 1,5

Medicaid 6, 9, 19

Medical Equipment 2, 3, 6

Medical Social Services 2

Medicare Managed Care Plan 1, 4, 7, 8, 10

Medicare Supplemental Insurance Policy 10

Occupational Therapy 2, 3

Payment 6, 7

Peer Review Organization 10, 14-18

Physical Therapy 2

Plan of Care 4, 20

Regional Home Health Intermediary 7, 10, 12, 13, 20

Skilled Nursing Care 1, 3, 5, 20

Speech Language Pathology 2, 3

State Health Insurance Assistance Program 7, 10, 14-18, 20

i

' "'1244

"U.S. Government Printing Office: 1999 — 771-635 21
CHS LIBRARY U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES 3 BOTH 0D0110fl4 7

Health Care Financing Administration

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Publication No. HCFA- 10969

September 1999

Starting October 1,2000, Medicare changed the way it pays for home health

care. Medicare now pays your home health agency a set amount of money for

each 60 days that you need care. The payment is based on what kind of health

care an average person in your situation would need. Medicare has paid hospitals

in this way for many years. The information in this booklet is still correct.

nwr~#m

MEDICARE • MEDICAID

Health Care Financing Administration