This book explains . . .

• How to find and compare 

home health agencies.

• The Medicare home health 

benefit and who is eligible.

• What is covered by the 

Original Medicare Plan.

• Where you can get more 

help with questions.

Medicare and

Home Health Care
Welcome

Medicare and Home Health Care is designed to help people find and

compare home health agencies. It can help you and your family

choose the agency that is best for you. It includes important

information about eligibility for Medicare coverage of home health

care; what Medicare does and doesn’t cover; quality of care; and

resources for more information.

Medicare and Home Health Care is prepared by the Centers for

Medicare & Medicaid Services (CMS). CMS and States oversee the

quality of care provided by home health agencies. State and Federal

Government agencies certify home health agencies.

Medicare and Home Health Care is not a legal document. 

The official Medicare program provisions are contained in the

relevant laws, regulations, and rulings.
1 - What is Home Health Care? . . . . . . . . . . . . . . . . . . . . . . . .3

2 - Choosing a Home Health Agency

How do I find a Medicare-approved home health agency? . . . .5

Information About Home Health Quality Measures . . . . . . . .6

Home Health Agency Checklist . . . . . . . . . . . . . . . . . . . . . . .7

Do I have a choice in which home health agency I use? . . . .8–9

What if I want to change home health agencies? . . . . . . . . . . .9

3 - Medicare Coverage of Home Health Care

Who is eligible to get Medicare-covered home health care? . . . .11

What home health services does Medicare cover? . . . . . . . .11–12

What doesn’t Medicare cover for home health care? . . . . . . . . .12

How long can I get home health services? . . . . . . . . . . . . .13–14

What does the Original Medicare Plan pay for and 

what can I be billed for? . . . . . . . . . . . . . . . . . . . . . . . . . .14

How does the Original Medicare Plan pay for my 

home health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

What do I do if the Original Medicare Plan stops paying 

for my home health care? . . . . . . . . . . . . . . . . . . . . . . . .15

What do I do if the Original Medicare Plan is not paying 

for an item or service that I think should be paid for? . . . .16

What if I am in a Medicare health plan? . . . . . . . . . . . . . . . . .16

4 - How can Medicaid help people with low incomes? . . . . .17

5 - Your Home Health Care

Does a doctor oversee my home health care services? . . . . . . .19

What is a plan of care? . . . . . . . . . . . . . . . . . . . . . . . . . .19–20

Home Health Care Checklist . . . . . . . . . . . . . . . . . . . . . . . .21

What can I do if I have a complaint about the quality of my 

home health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

How do I find and report fraud? . . . . . . . . . . . . . . . . . . .22–23

6 - Where Can I Get Help with My Questions? . . . . . . . . . .25

7 - Words to Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26–27

Where words in blue are defined

8 - Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

1

Table of Contents
2

Home health services are given

by a variety of skilled health

care professionals at home.
3

Words in

blue are

defined on

pages 26-27.

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.

1 - What Is Home Health Care?
4

Look at “Home Health Compare”

on www.medicare.gov for

information about home health

agencies in your area.
5

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.

2 - Choosing a Home Health Agency
6

2 - Choosing a Home Health Agency

Words in

blue are

defined on

pages 26-27.

Information About Home Health Quality Measures

Quality care means doing the right thing, at the right time, in the

right way, for the right person, and having the best possible results.

Home health agencies are certified to make sure they meet certain

Federal health and safety requirements. To find out how home health

agencies compare in quality, look at www.medicare.gov on the web.

Select “Home Health Compare.” 

These quality measures give you information about how well home

health agencies provide care for their patients. The measures provide

information about patients’ physical and mental health, and whether

their ability to perform basic daily activities is maintained or

improved. This quality information helps you compare and ask

questions of home health agencies. 

Home Health Quality Measures are currently available for home

health agencies in Florida, Massachusetts, Missouri, New Mexico,

Oregon, South Carolina, West Virginia, and Wisconsin. The

measures will be available for agencies in all states in late fall of 2003.

The quality measures available include

• four measures related to improvement in getting around, 

• four measures related to activities of daily living, 

• two measures related to patient medical emergencies, and

• one measure related to improvement in mental health.

You can also get information about home health agencies from state

survey reports, and, in some cases, your local long-term care

ombudsman. You can find local ombudsmen at

www.ltcombudsman.org or by calling the Eldercare Locator at

1-800-677-1116. 
7

2 - Choosing a Home Health Agency

Home Health Agency Checklist

Use this checklist to help you compare and choose a home health agency. 

Name and Location of Home Health Agency: ______________________________

______________________________

______________________________

The Agency: Yes No Comments 

1. Is Medicare-certified.

2. Is Medicaid-certified.

3. Offers the specific health care services I need 

(like nursing or physical therapy).

4. Meets my special needs 

(like language or cultural preference).

5. Offers the personal care services I need (like help 

bathing, dressing, and using the bathroom).

6. Offers the support services I need (like help 

with laundry, cooking, shopping, or housekeeping), 

or can help me arrange for additional services, 

such as Meals on Wheels, that I may need.

7. Has staff available to provide the type and 

hours of care my doctor ordered, and can 

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. Does background checks on all staff.

12. Has letters from satisfied patients, family members, 

and doctors that testify to the home health agency

staff providing good care. 
8

2 - Choosing a Home Health Agency

Words in

blue are

defined on

pages 26-27.

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. 
9

2 - Choosing a Home Health Agency

When you start getting home care, staff from the Medicare-approved

home health agency will ask you some questions about your health

to help them give you proper care. The home health agency is

required to keep your information confidential. You may ask to see

this information. The home health agency will explain these

questions to you, and give you written information about your right

to privacy.

Most Medicare-certified home health agencies will accept all

Medicare patients. An agency is not required to accept a patient if it

can’t meet the patient’s medical needs. An agency can’t refuse to take

a specific patient because of the patient’s condition, unless the

agency also refuses to take other people with the same condition.

What if I want to change home health agencies? 

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

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

agency and choose another at any time. You must tell both the

agency you are leaving and the new agency you choose that you are

changing home health agencies.
10

Home health aide services

are covered if you are also

getting Medicare-covered

skilled care.
11

3 - Medicare Coverage of Home Health Care

Words in

blue are

defined on

pages 26-27.

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).

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. 
12

3 - Medicare Coverage of Home Health Care

Words in

blue are

defined on

pages 26-27.

• 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.
13

3 - Medicare Coverage of Home Health Care

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.
Words in

blue are

defined on

pages 26-27.

14

3 - Medicare Coverage of Home Health Care

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. 

People with Medicare are either in the Original Medicare Plan or are

enrolled in another Medicare health plan such as a Medicare

Managed Care Plan or a Medicare Private Fee-for-Service Plan.

What does the Original Medicare Plan pay for and what

can I be billed for? 

The Original Medicare Plan pays the full approved amount (cost) of

all covered home health visits. The home health agency sends bills to

Medicare. Before your care begins, the home health agency must tell

you how much of your bill Medicare will pay. The agency must also

tell you if any items or services they give you are not covered by

Medicare, and how much you will have to pay for them. This must

be explained both by talking with you and in writing. 

You may be charged for

• medical services and supplies that Medicare doesn’t pay for, such as

prescription drugs, and

• 20 percent of the approved amount for Medicare-covered medical

equipment such as wheelchairs, walkers, and oxygen equipment. If

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

the home health agency staff will arrange for a home equipment

supplier to bring the items you need to your home. 

Note: If you are in the Original Medicare Plan, ask your supplier

“Do you accept assignment?” Assignment could save you money.

Call 1-800-MEDICARE (1-800-633-4227) and ask for a copy of

“Does your doctor or supplier accept ‘assignment’?”
15

3 - Medicare Coverage of 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.
16

3 - Medicare Coverage of Home Health Care

Words in

blue are

defined on

pages 26-27.

What do I do if the Original Medicare Plan is not paying

for an item or service that I think should be paid for? 

If you are in the Original Medicare Plan, you can file an appeal if

you think Medicare should have paid for, or did not pay enough for,

an item or service you received. 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 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 wasn’t

paid and what appeal steps you can take. 

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.
17

4 - 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.
18

Your plan of care includes

the kind of services you

need, and what type of

health care professionals

should give these services.
19

5 - Your Home Health Care

Words in

blue are

defined on

pages 26-27.

Does a doctor oversee my home health care services? 

Your doctor will oversee your home health care by

• deciding you need care at home, 

• developing your plan of care (see below), and

• communicating with the home health agency about your

progress. 

What is a plan of care?

A plan of care 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. 
20

5 - Your Home Health Care

Words in

blue are

defined on

pages 26-27.

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.
21

5 - Your Home Health Care

Home Health Care Checklist

This checklist can help you and your family monitor your home health care. Use this

checklist to help ensure that you are 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 members, with respect.

2. The staff explains my plan of care to me and 

my family, lets us participate in creating the 

plan of care, and lets us know ahead of time 

of any changes. 

3. The staff are 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 am getting.

5. The agency responds quickly to my requests.

6. The staff checks my physical and emotional 

status at each visit.

7. The staff respond quickly to changes in my 

health or behavior. 

8. My home is checked and suggestions are 

made to meet my special needs and to ensure 

my safety.

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

an emergency.

10. My privacy is protected.
22

5 - Your Home Health Care

Words in

blue are

defined on

pages 26-27.

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.

How do I find and report fraud? 

Most home health agencies are honest and use correct billing

information. Unfortunately, fraud sometimes 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.

To report Medicare fraud, call 1-800-447-TIPS (1-800-447-8477).

You should look for

• home health visits that your doctor orders that you never get,

• visits by home health staff that are not needed,

• bills for services and equipment you never get,

• faking your signature or your doctor’s signature,

• pressure to accept items and services that you don’t need, and

• items listed on your Medicare Summary Notice that you don’t

think you received. 

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. 
23

5 - Your Home Health Care

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 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.
24

You can get local telephone

numbers for the organizations

that can help you on the

“Helpful Contacts” section of

the www.medicare.gov website.
25

Words in

blue are

defined on

pages 26-27.

6 - Where Can I Get Help with My Questions? 

If you have questions about your Medicare home health care and

you are in the Original Medicare Plan, call your Regional Home

Health Intermediary. If you have questions about home health care

and you are in another Medicare health plan, call your plan. If you

are covered by another kind of health insurance, call the plan’s

member services office. 

Every State, territory, plus Puerto Rico, the Virgin Islands, and the

District of Columbia, has a State Health Insurance Assistance

Program with counselors who will give you free health insurance

information and help. 

The counselors should be able to answer your questions about home

health care and what Medicare, Medicaid, and other types of

insurance pay for. In addition, these counselors will help you with

Medicare payment questions; questions on buying a Medigap

(Medicare Supplement Insurance) policy, or long-term care

insurance; dealing with payment denials and appeals; Medicare rights

and protections; complaints about your care or treatment; or

choosing a Medicare health plan. 

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.
26

Home Health Agency

An organization that gives home care

services, like skilled nursing care,

physical therapy, occupational therapy,

speech therapy, and care by home 

health aides.

Long-Term Care Ombudsman

An independent advocate (supporter) for

nursing home and assisted living facility

residents who works to solve problems

between residents and nursing homes or

assisted living facilities.

Medicare

The federal health insurance program

for: people 65 years of age or older,

certain younger people with disabilities,

and people with End-Stage Renal

Disease (permanent kidney failure with

dialysis or a transplant, sometimes 

called ESRD).

Medicare Managed Care Plan

These 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. Plans must

cover all Medicare Part A and Part B

health care. Some plans cover extras, like

prescription drugs. Your costs may be

lower than in the Original Medicare Plan.

Appeal

An appeal is a special kind of complaint

you make if you disagree with a decision to

deny a request for health care services, or

payment for services you already received.

You may also make a complaint if you

disagree with a decision to stop services

that you are receiving. For example, you

may ask for an appeal if Medicare doesn’t

pay for an item or service you think you

should be able to get. There is a specific

process that your Medicare health plan or

the Original Medicare Plan must use when

you ask for an appeal.

Approved Amount

The fee Medicare sets for a covered

medical service. This is the amount a

doctor or supplier is paid by you and

Medicare for a service or supply. It may

be less than the actual amount charged

by a doctor or supplier. The approved

amount is sometimes called the

“Approved Charge.”

Assignment

In the Original Medicare Plan, this

means a doctor agrees to accept

Medicare's fee as full payment. If you are

in the Original Medicare Plan, it can save

you money if your doctor accepts

assignment. You still pay your share of

the cost of the doctor's visit.

Durable Medical Equipment (DME)

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. DME is

paid for either under Medicare Part A or

Part B for home health services.

7 - Words to Know
Quality Improvement Organization

Groups of practicing doctors and other

health care experts. They are paid by the

Federal Government to check and

improve the care given to Medicare

patients. They must review your

complaints about the quality of care given

by: inpatient hospitals, hospital outpatient

departments, hospital emergency rooms,

skilled nursing facilities, home health

agencies, Private Fee-for-Service plans,

and ambulatory surgical centers.

Regional Home Health Intermediary

A private company that contracts with

Medicare to pay home health bills and

check on the quality of home health care.

Skilled Nursing Care

A level of care that includes services that

can only be performed safely and

correctly by a licensed nurse (either a

registered nurse or a licensed practical

nurse).

Speech-Language Therapy

Treatment to regain and strengthen

speech skills.

State Health Insurance Assistance

Program (SHIP)

A state program that gets money from

the Federal Government to give free

health insurance counseling and

assistance to people with Medicare.

27

7 - Words to Know

Medicare Private Fee-for-Service Plan

A private insurance plan that accepts

people with Medicare. You may go to any

Medicare-approved doctor or hospital

that accepts the plan’s payment. The

insurance plan, rather than the Medicare

program, decides how much it will pay

for the services you get. You may pay

more for Medicare-covered benefits or

you may have extra benefits the Original

Medicare Plan does not cover.

Occupational Therapy

Services given to help you return to

usual activities (such as bathing,

preparing meals, housekeeping) 

after illness.

Original Medicare Plan

A pay-per-visit health plan that lets you

go to any doctor, hospital, or other

health care provider who accepts

Medicare. You must pay the deductible.

Medicare pays its share of the Medicareapproved amount, and you pay your

share (coinsurance). The Original

Medicare Plan has two parts: Part A

(hospital insurance) and Part B 

(medical insurance).

Physical Therapy

Treatment of injury and disease by

mechanical means, such as heat, light,

exercise, and massage.

Provider

A doctor, hospital, health care

professional, or health care facility.
Appeal . . . . . . . . . . . . . . . . . . . . . . . . .15, 16, 20, 25, 26

Approved Amount . . . . . . . . . . . . . . . . . . . . . . . . .14, 26

Assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14, 26

Durable Medical Equipment . . . . . . . . . . . . . . . . .15, 26

Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Home Health Advance Beneficiary Notice (HHABN) . .15

Home Health Aide . . . . . . . . . . . . . . . . . . . .8, 11–13, 26

Home Health Agency . . . . . . . . .6, 14, 15, 19, 20, 22, 26

Homebound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17, 25

Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Medical Social Services . . . . . . . . . . . . . . . . . . . . . . . .12

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . .8, 12, 24, 26

Medicare Health Plan . . . . . . . . . . . . . . . . . . . .8, 16, 26

Medigap (Medicare Supplement Insurance) Policy . . . .29

Occupational Therapy . . . . . . . . . . . . . . . . .3, 11, 12, 27

Official Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Original Medicare Plan . . . . . . . . . . . . . . .14, 16, 25, 27

Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14–16

Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . .3, 12, 27

Plan of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19, 20

Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . .12, 14

Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6, 8, 21

Quality Improvement Organization . . . . . . . . . . . .22, 27

Regional Home Health Intermediary . . . . . . . . . . .23, 27

Skilled Nursing Care . . . . . . . . . . . . . . . . . .3, 11, 13, 27

Speech-Language Therapy . . . . . . . . . . . . . .3, 11, 12, 27

State Health Insurance Assistance Program . . . . . . .25, 27

28

8 - Index

To get this booklet in English or Spanish, call 1-800-MEDICARE (1-800-633-4227).

TTY users should call 1-877-486-2048. 

Para obtener este folleto español, llame gratis al 1-800-MEDICARE (1-800-633-4227).

TTY 1-877-486-2048 para personas con impedimentos auditivos o del lenguaje oral.

U.S. Department of

Health and Human Services

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Official Business

Penalty for Private Use, $300

Publication No. CMS-10969

April 2003