Medicare & Home Health Care 

C E N T E R S f o r M E D I C A R E & M E D I C A I D S E R V I C E S 

This official government booklet tells you: 

■ Who’s eligible 

■ What services are covered 

■ How to find and compare home health agencies 

■ Your Medicare rights 
Paid for by the Department of Health & Human Services. 

The information in this booklet describes the Medicare Program 

at the time this booklet was printed. Visit Medicare.gov, or call 

1-800-MEDICARE (1-800-633-4227) to get the most current 

information. TTY users can call 1-877-486-2048. 

“Medicare & Home Health Care” isn’t a legal document. Official 

Medicare Program legal guidance is contained in the relevant statutes, 

regulations, and rulings. 
3

Table of Contents

Section 1: Medicare Coverage of Home Health Care ������������������������� 5

Who’s eligible? ����������������������������������������������������������������������� 5

How Medicare pays for home health care ��������������������������������������������� 7

What’s covered? ���������������������������������������������������������������������� 7

What isn’t covered? ������������������������������������������������������������������ 10

What you pay ������������������������������������������������������������������������ 10

“Advance Beneficiary Notice of Noncoverage “ (ABN) �������������������������������� 11

Your right to a fast appeal ����������������������������������������������������������� 12

Section 2: Choosing a Home Health Agency ����������������������������������� 15

Finding a Medicare-certified home health agency ����������������������������������� 15

Comparing home health agencies ��������������������������������������������������� 15

Comparing quality ������������������������������������������������������������������ 16

Home Health Agency Checklist ������������������������������������������������������ 17

Special rules for home health care ��������������������������������������������������� 18

Find out more about home health agencies ����������������������������������������� 18

Section 3: Getting Home Health Care ������������������������������������������� 19

Your plan of care �������������������������������������������������������������������� 19

Your rights getting home health care ������������������������������������������������ 20

Where to file a complaint about the quality of your home health care ��������������� 21

Home Health Care Checklist ��������������������������������������������������������� 22

Section 4: Getting the Help You Need ������������������������������������������� 23

Help with questions about home health coverage ����������������������������������� 23

What you need to know about fraud ������������������������������������������������ 24

Definitions ����������������������������������������������������������������������������� 27
4

Home health care 

Many health care treatments that were 

once offered only in a hospital or a doctor’s 

office can now be done in your home. 

Home health care is usually less expensive, 

more convenient, and can be just as 

effective as care you get in a hospital or 

skilled nursing facility. In general, the goal 

of home health care is to provide treatment 

for an illness or injury. Where possible, 

home health care helps you get better, 

regain your independence, and become 

as self-sufficient as possible. Home health 

care may also help you maintain your 

current condition or level of function, or to 

slow decline.

Medicare pays for you to get health care services in your 

home if you meet certain eligibility criteria and if the 

services are considered reasonable and necessary for the 

treatment of your illness or injury. 

This booklet describes the home health care services 

that Medicare covers, and how to get those benefits 

through Medicare. If you get your Medicare benefits 

through a Medicare health plan (not Original Medicare) 

check your plan’s membership materials, and contact 

the plan for details about how the plan provides your 

Medicare-covered home health benefits. 
Words in red

are defined on 

pages 27–28. 

5

Section 1: 

Medicare Coverage of Home Health Care 

Who’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 services 

under a plan of care established and reviewed regularly by a 

doctor. 

2. You need, and a doctor certifies that you need, one or more 

of these: 

■ Intermittent skilled nursing care (other than drawing 

blood)

■ Physical therapy 

■ Speech-language pathology services 

■ Continued occupational therapy 

See pages 8–9 for more details on these services.

3. The home health agency caring for you is approved by 

Medicare (Medicare certified). 

4. You’re homebound, and a doctor certifies that you’re 

homebound. To be homebound means: 

■ You have trouble leaving your home without help (like 

using a cane, wheelchair, walker, or crutches; special 

transportation; or help from another person) because of an 

illness or injury, or leaving your home isn’t recommended 

because of your condition.

■ You’re normally unable to leave your home, but if you do it 

requires a major effort. 

You may leave home for medical treatment or short, 

infrequent absences for non-medical reasons, like an 

occasional trip to the barber, a walk around the block or a 

drive, or attendance at a family reunion, funeral, graduation, 
6 Section 1: Medicare Coverage of Home Health Care 

or other infrequent or unique event. You can still get home 

health care if you attend adult day care or religious services.

5. As part of your certification of eligibility, a doctor, or certain 

health care professionals who work with a doctor (like a nurse 

practitioner), must document that they’ve had a face-to-face 

encounter with you (like an appointment with your primary care 

doctor) within required timeframes and that the encounter was 

related to the reason you need home health care.

If you only need skilled nursing care, but you need more than 

“intermittent” skilled nursing care, you don’t qualify for home 

health services. To determine if you’re eligible for home health care 

based on a medically predictable recurring need for skilled nursing, 

Medicare defines “intermittent” as skilled nursing care that’s needed 

or given either: 

■ Fewer than 7 days each week.

■ Daily for less than 8 hours each day for up to 21 days. Medicare 

may extend the three week limit in exceptional circumstances 

if your doctor can predict when your need for daily skilled 

nursing care will end.

If you’re expected to need full-time skilled nursing care over an 

extended period of time, you wouldn’t usually qualify for home 

health benefits. 
Section 1: Medicare Coverage of Home Health Care 7

How Medicare pays for home health care 

Medicare pays your Medicare-certified home health agency one 

payment for the covered services you get during a 60-day period. This 

60-day period is called an “episode of care.” The payment is based on 

your condition and care needs. 

Getting treatment from a home health agency that’s Medicare certified 

can reduce your out-of-pocket costs. A Medicare certified home health 

agency agrees to: 

■ Be paid by Medicare 

■ Accept only the amount Medicare approves for their services 

Medicare’s home health benefit only pays for services provided by the 

home health agency. Other medical services, like visits to your doctor or 

equipment, are generally still covered by your other Medicare benefits. 

Look in your “Medicare & You” handbook for information on 

how these services are covered under Medicare. To view or print 

this booklet, visit Medicare.gov/publications. You can also call 

1-800-MEDICARE (1-800-633-4227) if you have questions about your 

Medicare 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 for 

the treatment of your illness or injury. Skilled nursing and therapy 

services are covered when a personalized assessment of your clinical 

condition shows that the specialized judgment, knowledge, and skills 

of a nurse or therapist are necessary for the services to be safely and 

effectively provided. 

● Skilled nursing care: Medicare covers skilled nursing care when the 

services you need require the skills of a nurse, are reasonable and 

necessary for the treatment of your illness or injury, and are given 

on a part-time or intermittent basis (visits solely for the purpose of 

getting your blood drawn aren’t covered by Medicare). “Part-time 

or intermittent” means you may be able to get home health aide and 

skilled nursing services (combined) any number of days per week as 

long as the services are provided:
8 Section 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 some 

limited situations)

A registered nurse (RN) or a licensed practical nurse (LPN) can provide 

skilled nursing services. If you get services from an LPN, your care 

will be supervised by an RN. Home health nurses provide direct care 

and teach you and your caregivers about your care. They also manage, 

observe, and evaluate your care. Examples of skilled nursing care 

include: giving IV drugs, certain injections, or tube feedings; changing 

dressings; and teaching about prescription drugs or diabetes care. Any 

service that could be done safely and effectively by a non-medical person 

(or by yourself) without the supervision of a nurse isn’t skilled nursing 

care. 

● Physical therapy, occupational therapy, and speech-language 

pathology services: Your therapy services are considered reasonable 

and necessary in the home setting if: 

1. They’re a specific, safe, and effective treatment for your 

condition 

2. They’re complex such that your condition requires services 

that can only be safely and effectively performed by, or under 

the supervision of, qualified therapists 

3. Your condition requires one of these: 

■ Therapy that’s reasonable and necessary to restore or 

improve functions affected by your illness or injury 

■ A skilled therapist to safely and effectively establish a 

program and/or perform therapy under a maintenance 

program to help you maintain your current condition or to 

prevent your condition from getting worse

4. The amount, frequency, and duration of the services are 

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 injury. Medicare 
Section 1: Medicare Coverage of Home Health Care 9

doesn’t cover home health aide services unless you’re also getting 

skilled care. Skilled care includes:

■ Skilled nursing care

■ Physical therapy

■ Speech-language pathology services

■ Continuing occupational therapy, if you no longer need any of 

the above

“Part-time or intermittent” means you may be able to get home health 

aide and skilled nursing services (combined) any number of days per 

week, 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 some 

limited situations)

● Medical social services: Medicare covers these services when a doctor 

orders them to help you with social and emotional concerns that may 

interfere with your treatment or how quickly you recover. This might 

include counseling or help finding resources in your community. 

However, Medicare doesn’t cover medical social services unless you’re 

also 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 equipment 

must meet certain criteria and be ordered by a doctor. Medicare usually 

pays 80% of the Medicare-approved amount for certain pieces of medical 

equipment, like a wheelchair or walker. If your home health agency 

doesn’t supply durable medical equipment directly, the home health 

agency staff will usually arrange for a home equipment supplier to bring 

the items you need to your home. 

Note: Before your home health care begins, the home health agency 

should tell you how much of your bill Medicare will pay. The agency 

should also tell you if any items or services they give you aren’t covered 

by Medicare, and how much you’ll have to pay for them. This should be 

explained by both talking with you and in writing. 
10 Section 1: Medicare Coverage of Home Health Care 

The home health agency is responsible for meeting all of your medical, 

nursing, rehabilitative, social, and discharge planning needs, as noted in 

your home health plan of care. See page 19 for more information. Home 

health agencies are required to perform a comprehensive assessment of 

each of your care needs when you’re admitted to the home health agency, 

and communicate those needs to the doctor responsible for the plan of 

care. After that, home health agencies are required to routinely assess 

your 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 the 

bathroom when this is the only care you need

Talk to your doctor or the home health agency if you have 

questions about whether certain services are covered. You can 

also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 

1-877-486-2048. 

Note: If you have a Medigap (Medicare Supplement Insurance) policy 

or other health coverage, be sure to tell your doctor or other health care 

provider so your bills get paid correctly. 

What you pay 

You may be billed for these: 

■ Services and supplies that are never paid for by Medicare, like 

routine foot care. 

■ Services and supplies that are usually paid for by Medicare but 

won’t be paid for in this instance, when you’ve agreed to pay for 

them. The home health agency must give you a notice called the 

“Advance Beneficiary Notice of Noncoverage” (ABN) in these 

situations. See the next page. 
Section 1: Medicare Coverage of Home Health Care 11

■ 20% of the Medicare-approved amount for Medicare-covered 

medical equipment, like wheelchairs, walkers, and oxygen 

equipment. 

“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 giving 

you a home health service or supply that Medicare probably won’t 

pay for because of any of these: 

■ The care isn’t medically reasonable and necessary. 

■ The care is only nonskilled, personal care, like help with 

bathing 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 for 

a medical service or supply, the notice should describe the service 

and/or supply, and explain why Medicare probably won’t pay. 

The ABN gives clear directions for getting an official decision from 

Medicare about payment for home health services and supplies and 

for filing an appeal if Medicare won’t pay. 

In general, to get an official decision on payment, you should do 

these: 

■ Keep getting the home health services and/or supplies if you 

think you need them. The home health agency must tell you 

how much they’ll cost. Talk to your doctor and family about 

this decision. 

■ Understand you may have to pay the home health agency for 

these services and/or supplies. 

■ Ask the home health agency to send your claim to Medicare 

so that Medicare will make a decision about payment. You 

have the right to have the home health agency bill Medicare 

for your care. 
12 Section 1: Medicare Coverage of Home Health Care 

If Original Medicare pays for your care, you’ll get back all of your 

payments, except for any applicable coinsurance or deductibles, 

including any coinsurance payments you made for durable medical 

equipment. 

The home health agency must also give you the ABN or a “Home 

Health Change of Care Notice” (HHCCN) when they reduce or stop 

providing home health services or supplies: 

■ For business-related reasons 

■ Because your doctor has changed or hasn’t renewed your orders 

If a home health agency reduces or stops providing certain services or 

supplies, you may have the option to keep getting them. The ABN or 

HHCCN will explain what service or supply is going to be reduced or 

stopped and give you instructions on what you can do if you want to 

keep getting the service or supply. 

Your right to a fast appeal 

When all of your covered home health 

services are ending, you may have the right 

to a fast appeal if you think these services 

are ending too soon. During a fast appeal, an 

independent reviewer called a Beneficiary and 

Family Centered Care Quality Improvement 

Organization (BFCC-QIO) looks at your case and 

decides if you need your home health services to 

continue. 

Your home health agency will give you a written 

notice called the “Notice of Medicare Non-Coverage” (NOMNC) at 

least 2 days before all covered services end. If you don’t get this notice, 

ask for it. Read the notice carefully. It contains important information 

about the termination 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 are 

ending 

■ Any other information required by Medicare 
Section 1: Medicare Coverage of Home Health Care 13

If you ask for a fast appeal, the BFCC-QIO will ask why you 

think coverage of your home health services should continue. 

The BFCC-QIO will also look at your medical information and 

talk to your doctor. The BFCC-QIO will notify you of its decision 

as soon as possible, generally no later than 3 days after the effective 

date of the NOMNC. 

If the BFCC-QIO decides your home health services should 

continue, Medicare may continue to cover your home health care 

services, except for any applicable coinsurance or deductibles. 

If the BFCC-QIO decides that your coverage should end, you’ll 

have to pay for any services you got after the date on the NOMNC 

that says your covered services should end. Your home health 

agency must give you an ABN with an estimate of how much these 

services will cost. 

You may stop getting services on or before the date given on the 

NOMNC and avoid paying for any further services. If you don’t ask 

for a fast appeal and want to continue getting services after the date 

listed on the NOMNC, your home health agency must give you an 

ABN to let you know what you must pay. 
14 Section 1: Medicare Coverage of Home Health Care 

For more information on your right to a fast appeal and other 

Medicare appeal rights, look at your “Medicare & You” handbook 

or visit Medicare.gov/appeals. You can also call 1-800-MEDICARE 

(1-800-633-4227). TTY users can call 1-877-486-2048. 
15

Words in red

are defined on 

pages 27–28. 

Section 2: 

Choosing a Home Health Agency 

Finding a Medicare-certified home health 

agency 

If your doctor decides you need home health care, you may 

choose an agency from the participating Medicare-certified 

home health agencies that serve your area. Home health 

agencies are certified to make sure they meet certain federal 

health and safety requirements. Your choice should be honored 

by your doctor, hospital discharge planner, or other referring 

agency. You have a say in which agency you use, but your 

choices may be limited by agency availability, or by your 

insurance coverage. If you have a Medicare Advantage Plan

(like an HMO or PPO) or other Medicare health plan, it may 

require that you get home health services from agencies they 

contract with. Call your plan for more information. 

Comparing home health agencies

Visit Medicare.gov/homehealthcompare to compare home 

health agencies in your area. You can compare home health 

agencies by the types of services they offer and the quality 

of care they provide. Home Health Compare shows this 

information about home health agencies: 

■ Name, address, and phone number 

■ Services offered, like nursing care, physical therapy, 

occupational therapy, speech-language pathology services, 

medical/social services, and home health aide services 

■ Initial date of Medicare certification

■ Type of ownership (for profit, government, non-profit) 

■ Information about the quality of care they give (quality 

measures) 
16 Section 2: Choosing a Home Health Agency

Comparing quality 

Some home health agencies do a better job of caring for their patients than 

others. Home health agencies give quality care when they give their patients 

care and treatment known to get the best results for each patient’s condition. 

In some cases, the home health agency will help improve the patient’s 

condition. In other situations, it will help maintain a patient’s condition or 

slow their decline. 

Visit Medicare.gov/homehealthcompare to see how well home health agencies 

in your area care for their patients. You can compare agencies based on various 

measures of quality and against state and national averages. 

See below for an example of some of the information you’ll find on Home 

Health Compare. In this example, the score for each measure means the 

percentage of patients the home health agency was able to help regain or 

maintain their health during their episode of care.

Quality measures Percentage 

for XYZ home 

care agency 

State 

average 

National 

average 

Higher percentages are better 

Percentage of patients who 

get better at walking or 

moving around 

71% 76% 82% 

Percentage of patients who 

have less pain when moving 

around 

59% 80% 76% 

How often the home health 

team taught patients (or 

their family caregivers) 

about their drugs

99% 97% 97% 

Lower percentages are better

How often home health 

patients had to be admitted 

to the hospital 

20% 16% 17% 
Section 2: Choosing a Home Health Agency 17

Home Health Agency Checklist 

Use this checklist when choosing a home health agency. 

Name of the home health agency: 

Question Yes No Comments 

1. Medicare certified? 

2. Medicaid certified (if you have both 

Medicare and Medicaid)?

3. Offers the specific health care services 

I need, like skilled nursing services or 

physical therapy?

4. Meets my special needs, like language or 

cultural preferences?

5. Offers the personal care services I need, 

like help bathing, dressing, and using the 

bathroom?

6. Offers the support services I need, or can 

help me arrange for additional services, like 

a meal delivery service, that I may need?

(NOTE: These types of services aren’t 

generally covered by Medicare).

7. Has staff that can give the type and hours 

of care my doctor ordered and start when I 

need them?

8. Is recommended by my hospital discharge 

planner, doctor, or social worker? 

9. Has staff available at night and on weekends 

for emergencies? 

10. Explained what my insurance will cover and 

what I must pay out-of-pocket?

11. Has letters from satisfied patients, family 

members, and doctors that testify to the 

home health agency providing good care? 
18

Special rules for home health care 

In general, most Medicare-certified home health agencies will accept 

all people with Medicare. An agency isn’t required to accept you if 

it can’t meet your medical needs. An agency shouldn’t refuse to take 

you because of your condition, unless the agency would also refuse to 

take other people with the same condition. 

Medicare will only pay for you to get care from one home health 

agency at a time. You may decide to end your relationship with one 

agency and choose another at any time. Contact your doctor to get 

a referral to a new agency. You should tell both the agency you’re 

leaving and the new agency you choose that you’re changing home 

health agencies. 

Find out more about home health agencies 

Your State Survey Agency, the agency that inspects and certifies home 

health agencies for Medicare, also has information about home health 

agencies. Ask them for the state survey report on the home health 

agency of interest to you. Visit Medicare.gov/contacts to get your State 

Survey 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 have 

information on the home health agencies in your area. Visit 

ltcombudsman.org, visit eldercare.gov, or call the eldercare locator at 

1-800-677-1116. 

To find out more about home health agencies, you can do either of 

these: 

■ Ask your doctor, hospital discharge planner, or social worker. 

Or, ask friends or family about their home health care 

experiences. 

■ Use a senior community referral service, or other community 

agencies that help you with your health care. 

Section 2: Choosing a Home Health Agency
19

Words in red

are defined on 

pages 27–28. 

Section 3: 

Getting Home Health Care 

Usually, once your doctor refers you for home health 

services, staff from the home health agency will come to 

your home to talk to you about your needs and ask you 

some questions about your health. The home health agency 

will also talk to your doctor about your care and keep your 

doctor updated about your progress. You need a doctor’s 

order to start and continue care. 

Your plan of care 

Your home health agency will work with you and your doctor 

to develop your plan of care. A plan of care lists what kind of 

services and care you should get for your health condition. 

You have the right to be involved in any decisions about your 

plan of care. Your plan of care includes these: 

■ What services you need 

■ Which health care professionals should give these 

services 

■ Visit schedule 

■ How often you’ll need the services 

■ The medical equipment you need 

■ What results your doctor expects from your treatment 

Your home health agency must give you all of the home care 

listed in your plan of care, including services and medical 

supplies. The agency may do this through its own staff or 

through an arrangement with another agency. The agency 

could also hire nurses, therapists, home health aides, and 

medical social workers to meet your needs. 
20 Section 3: Getting Home Health Care 

Your plan of care (continued) 

Your doctor and home health team review your plan of care as often 

as necessary, but at least once every 60 days. If your health condition 

changes, the home health team should tell your doctor right away. Your 

health care team will review your plan of care and make any necessary 

changes with the approval of your doctor. Your home health team should 

tell you about any changes in your plan of care. If you have a question 

about your care, or if you feel your needs aren’t being met, talk to both 

your doctor and the home health team. 

The home health team will teach you (and your family or friends who 

are helping you) to continue any care you may need, including wound 

care, therapy, and disease management. You should learn to recognize 

problems like infection or shortness of breath, and know what to do or 

whom to contact if they happen. 

Your rights getting home health care 

In general, as a person with Medicare getting home health care from a 

Medicare certified home health agency, you’re guaranteed certain rights, 

including these: 

■ To get a written notice of your rights before your care starts 

■ To have your home and property treated with respect 

■ To be told, in advance, what care you’ll be getting and when your 

plan of care is going to change 

■ To participate in your care planning and treatment 

■ To get written information about your privacy rights and your 

appeal rights 

■ To have your personal information kept private 

■ To get written and verbal information about how much Medicare is 

expected to pay and how much you’ll have to pay for services 

■ To make complaints about your care and have the home health 

agency follow up on them 

■ To know the phone number of the home health hotline in your state 

where you can call with complaints or questions about your care 
Section 3: Getting Home Health Care 21

Visit Medicare.gov to learn more about your rights and protections. 

You can also call 1-800-MEDICARE (1-800-633-4227). TTY users 

can call 1-877-486-2048. 

Where to file a complaint about the quality of 

your home health care 

If you have a complaint about the quality of care you’re getting from 

a home health agency, you should call either of these organizations: 

■ Your state home health hotline. Your home health agency 

should give you this number when you start getting home 

health services. 

■ The Beneficiary and Family Centered Care Quality 

Improvement Organization (BFCC-QIO) in your state. To get 

the phone number for your BFCC-QIO, visit Medicare.gov/

contacts. You can also call 1-800-MEDICARE. 
22 Section 3: Getting Home Health Care 

Home Health Care Checklist 

This checklist can help you (and your family or friends who are helping you) monitor 

your home health care. Use this checklist to help make sure that you’re getting good 

quality home health care. 

When I get my home health care Yes No Comments 

1. The staff is polite and treats me and my 

family with respect. 

2. The staff explains my plan of care to 

me and my family, lets us participate in 

creating the plan, and lets us know ahead 

of time of any changes. 

3. The staff is properly trained and licensed 

to perform the type of health care I need. 

4. The agency explains what to do if I have 

a problem with the staff or the care I’m 

getting. 

5. The agency responds quickly to my 

requests. 

6. The staff checks my physical and 

emotional condition at each visit. 

7. The staff responds quickly to changes in 

my health or behavior. 

8. The staff checks my home and suggests 

changes to meet my special needs and to 

ensure my safety. 

9. The staff has told me what to do if I have 

an emergency. 

10. The agency and its staff protect my 

privacy. 
23

Words in red

are defined on 

pages 27–28. 

Section 4: 

Getting the Help You Need 

Help with questions about home 

health coverage 

If you have questions about your Medicare home 

health care benefits or coverage and you have 

Original Medicare, visit Medicare.gov, or call 

1-800-MEDICARE (1-800-633-4227). TTY users can 

call 1-877-486-2048. If you get your Medicare benefits 

through a Medicare Advantage Plan (Part C) or other 

Medicare health plan, call your plan. 

You may also call the State Health Insurance 

Assistance Program (SHIP). SHIP counselors answer 

questions about Medicare’s home health benefits 

and what Medicare, Medicaid, and other types of 

insurance pay for. 

To get the phone number for your SHIP, visit 

shiptacenter.org or call 1-800-MEDICARE. 
24 Section 4: Getting the Help You Need 

What you need to know about fraud 

In general, most home health agencies are honest and use correct 

billing information. Unfortunately, there may be some who commit 

fraud. Fraud wastes Medicare dollars and takes money that could be 

used to pay claims. You play an important role in the fight to prevent 

Medicare fraud, waste, and abuse. 

Look for these: 

■ Home health visits that your doctor ordered, but that you didn’t 

get. 

■ Visits by home health staff that you didn’t request and that you 

don’t need. 

■ Bills for services and equipment you never got. 

■ Fake signatures (yours or your doctor’s) on medical forms or 

equipment orders. 

■ Pressure to accept items and services that you don’t need or that 

Medicare doesn’t cover. 

■ Items listed on your “Medicare Summary Notice” (MSN) that 

you don’t think you got or used. 

■ 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 and 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 don’t understand something in your plan of care, ask questions. 
Section 4: Getting the Help You Need 25

Reporting fraud

If you suspect fraud, you can: 

■ Contact your home health agency to be sure the bill is correct. 

■ Contact the Office of Inspector General: 

Phone: 1-800-HHS-TIPS (1-800-447-8477) 

Fax: 1-800-223-2164 (no more than 10 pages) 

E-mail: HHSTips@oig.hhs.gov

Mail: Office of the Inspector General 

 HHS TIPS Hotline 

 P.O. Box 23489 

 Washington, DC 20026 

 Please note that it’s current Hotline policy not to 

 respond directly to written communications. 

■ Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 

1-877-486-2048. 

Important: If you’re reporting a possible case of Medicare fraud, 

provide as much identifying information as possible. Include the 

person or company’s name, address, and phone number. Details 

should include the basics of who, what, when, where, why, and how. 
26 Section 4: Getting the Help You Need 

Important phone numbers 

Doctor 

Health insurance company 

Notes 

 
Appeal—An appeal is the action you can take if you disagree 

with a coverage or payment decision made by Medicare, your 

Medicare health plan, or your Medicare Prescription Drug Plan. 

You can appeal if Medicare or your plan denies one of these: 

■ Your request for a health care service, supply, item, or 

prescription drug that you think you should be able to get 

■ Your request for payment for a health care service, supply, 

item, or prescription drug you already got 

■ Your request to change the amount you must pay for a 

health care service, supply, item or prescription drug 

You can also appeal if Medicare or your plan stops providing 

or paying for all or part of a health care service, supply, item, or 

prescription drug you think you still need. 

Durable medical equipment—Certain medical equipment, 

like a walker, wheelchair, or hospital bed, that’s ordered by your 

doctor for use in the home. 

Medicaid—A joint federal and state program that helps 

with medical costs for some people with limited income and 

resources. Medicaid programs vary from state to state, but most 

health care costs are covered if you qualify for both Medicare 

and Medicaid. 

Medicare Advantage Plan (Part C)—A type of Medicare 

health plan offered by a private company that contracts with 

Medicare to provide you with all your Part A and Part B 

benefits. Medicare Advantage Plans include Health Maintenance 

Organizations, Preferred Provider Organizations, Private 

Fee-for-Service Plans, Special Needs Plans, and Medicare 

Medical Savings Account Plans. If you’re enrolled in a Medicare 

27

Definitions 
28 Definitions 

Advantage Plan, most Medicare services are covered through the plan and 

aren’t paid for under Original Medicare. Most Medicare Advantage Plans 

offer prescription drug coverage.

Medicare health plan—Generally, a plan offered by a private company that 

contracts with Medicare to provide Part A and Part B benefits to people with 

Medicare who enroll in the plan. Medicare health plans include all Medicare 

Advantage Plans, Medicare Cost Plans, and Demonstration/Pilot Programs. 

Programs of All-inclusive Care for the Elderly (PACE) organizations are 

special types of Medicare health plans. PACE plans can be offered by public 

or private entities and provide Part D and other benefits in addition to Part A 

and Part B benefits. 

Medigap policy—Medicare Supplement Insurance sold by private insurance 

companies to fill “gaps” in Original Medicare coverage. 

Original Medicare—Original Medicare is a fee-for-service health plan that 

has 2 parts: Part A (Hospital Insurance) and Part B (Medical Insurance). 

After you pay a deductible, Medicare pays its share of the Medicare-approved 

amount, and you pay your share (coinsurance and deductibles). 

State Health Insurance Assistance Program (SHIP)—A state program 

that gets money from the federal government to give free local health 

insurance counseling to people with Medicare.
29

Notice of Availability of Auxiliary Aids & Services 

We’re committed to making our programs, benefits, services, facilities, 

information, and technology accessible in accordance with Sections 504 

and 508 of the Rehabilitation Act of 1973. We’ve taken appropriate steps 

to make sure that people with disabilities, including people who are 

deaf, hard of hearing or blind, or who have low vision or other sensory 

limitations, have an equal opportunity to participate in our services, 

activities, programs, and other benefits. We provide various auxiliary aids 

and services to communicate with people with disabilities, including: 

Relay service — TTY users can call 1-877-486-2048. 

Alternate formats — This product is available in accessible formats, 

including large print, Braille, audio, CD, or as an eBook.

To request a Medicare product in an accessible format, call 

1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. 

To request the Medicare & You handbook in an alternate format, visit 

Medicare.gov/medicare-and-you.

For all other CMS publications: 

1. Call 1-844-ALT-FORM (1-844-258-3676). TTY users can call 

1-844-716-3676. 

2. Send a fax to 1-844-530-3676. 

3. Send an email to AltFormatRequest@cms.hhs.gov.

4. Send a letter to: 

Centers for Medicare & Medicaid Services

Offices of Hearings and Inquiries (OHI) 

7500 Security Boulevard, Room S1-13-25 

Baltimore, MD 21244-1850 

Attn: Customer Accessibility Resource Staff

Note: our request for a CMS publication should include your name, phone 

number, mailing address where we should send the publications, and the 

publication title and product number, if available. Also include the format 

you need, like Braille, large print, audio CD, or a qualified reader.
30

Nondiscrimination Notice 

The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, 

deny benefits to, or otherwise discriminate against any person on the 

basis of race, color, national origin, disability, sex, or age. If you think 

you’ve been discriminated against or treated unfairly for any of these 

reasons, you can file a complaint with the Department of Health and 

Human Services, Office for Civil Rights by: 

■ Calling 1-800-368-1019. TTY users can call 1-800-537-7697. 

■ Visiting hhs.gov/ocr/civilrights/complaints. 

■ Writing: 

Office for Civil Rights 

U.S. Department of Health and Human Services 

200 Independence Avenue, SW 

Room 509F, HHH Building 

Washington, D.C. 20201 

This booklet is available in Spanish. To get your copy, 

call 1-800-MEDICARE (1-800-633-4227). TTY users 

can call 1-877-486-2048.

Esta publicación está disponible en Español. Para 

obtener una copia, llame al 1-800-MEDICARE 

(1-800-633-4227). Los usuarios de TTY pueden llamar 

al 1-877-486-2048.

U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

7500 Security Blvd. 

Baltimore, MD 21244-1850

Official Business 

Penalty for Private Use, $300 

CMS Product No. 10969 

Revised October 2017