Medicare and 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 is the official U.S. government booklet 

about Medicare home health care benefits 

for people with Original Medicare. This 

booklet has important information about 

the following: 

■ Who is eligible 

■ What services are covered 

■ How to find and compare home health agencies 

■ Your Medicare rights 
The information in this booklet was correct when it was printed. 

Changes may occur after printing. Call 1-800-MEDICARE 

(1-800-633-4227), or visit www.medicare.gov to get the most current 

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

“Medicare and 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

Introduction �������������������������������������������������������� 4

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

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

Eligibility is also based on the amount of services you need ������������ 6

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

What Medicare covers ����������������������������������������������� 8

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

What you have to pay ��������������������������������������������� 10

Home Health Advance Beneficiary Notice �������������������������� 11

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

General Medicare appeal rights ������������������������������������ 14

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 as a person with Medicare ������������������������������ 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

Extra Help paying for Medicare Prescription Drug Coverage (Part D) � � 23

State Pharmacy Assistance Programs (SPAPs) ����������������������� 24

Medicaid ��������������������������������������������������������� 24

Medicare Savings Programs (Help with Medicare costs) �������������� 25

For more information ��������������������������������������������� 25

Help with questions about home health coverage ������������������ 26

What you need to know about fraud ������������������������������� 27

Definitions ��������������������������������������������������������� 29

Index ���������������������������������������������������������������� 31
4

Introduction 

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 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. Home health care helps you get 

better, regain your independence, and 

become as self-sufficient as possible. 

Medicare pays for you to get certain 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 is known as 

the Medicare home health benefit. 

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 29–30. 

5

Section 1: 

Medicare Coverage of Home Health Care 

Who’s eligible? 

If you have Medicare, you can use your home health benefits if 

you meet all the following conditions: 

1. You must be under the care of a doctor, and you must 

be getting services under a plan of care established and 

reviewed regularly by a doctor. 

2. You must need, and a doctor must certify that you need, 

one or more of the following. 

■ Intermittent skilled nursing care 

■ Physical therapy 

■ Speech-language pathology services 

■ Continued occupational therapy 

See page 8 for more detail on these services.

3. The home health agency caring for you must be approved 

by Medicare (Medicare-certified). 

4. You must be homebound, and a doctor must certify that 

you’re homebound. To be homebound means the following:

■ Leaving your home isn’t recommended because of your 

condition. 

■ Your condition keeps you from leaving home without 

help (such as using a wheelchair or walker, needing 

special transportation, or getting help from another 

person). 

■ Leaving home takes a considerable and taxing effort. 

A person may leave home for medical treatment or short, 

infrequent absences for non-medical reasons, such as 

attending religious services. You can still get home health 

care if you attend adult day care, but you would get the 

home care services in your home. 
6 Section 1: Medicare Coverage of Home Health Care 

Eligibility is also based on the amount of services 

you need 

If you meet the conditions above, Medicare pays for your covered 

home health services for as long as you’re eligible and your doctor 

certifies you need them. If you need more than part-time or 

“intermittent” skilled nursing care, you aren’t eligible for the home 

health benefit. 

To decide whether you’re eligible for home health care, Medicare 

defines part-time or “intermittent” as skilled nursing care that’s 

needed or given on fewer than 7 days each week or less than 8 hours 

each day over a period of 21 days (or less) with some exceptions in 

special circumstances. 

Hour and day limits may be extended in exceptional circumstances 

when your doctor can predict when your need for care will end. 
Section 1: Medicare Coverage of Home Health Care 7

How Medicare pays for home health care 

In Original Medicare, Medicare pays your Medicare-certified home 

health agency one payment for 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 Medicarecertified can reduce your out-of-pocket costs. A Medicare-certified 

home health agency agrees to the following conditions: 

■ To be paid by Medicare 

■ To 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, such as visits 

to your doctor, are generally still covered by your other Medicare 

benefits. Look in your copy of the “Medicare & You” handbook, 

mailed to each Medicare household every fall, for information 

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

print this booklet, visit http://go.usa.gov/iDJ. You can also call 

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

your Medicare benefits. TTY users should call 1-877-486-2048. 
8 Section 1: Medicare Coverage of Home Health Care 

What Medicare covers 

If you’re eligible for Medicare-covered home health care (see page 5), 

Medicare covers the following services if they’re reasonable and 

necessary for the treatment of your illness or injury: 

■ Skilled nursing care. Skilled nursing services are covered when 

they’re given on a part-time or intermittent basis. In order for skilled 

nursing care to be covered by the Medicare home health benefit, your 

care must be necessary and ordered by your doctor for your specific 

condition. You must not need full time nursing care and you must be 

homebound. See page 5. 

Skilled nursing services are given by either a registered nurse (RN) or 

a licensed practical nurse (LPN). If you get services from a LPN, your 

care will be supervised by a 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, shots, or tube feedings; changing 

dressings; and teaching about prescription drugs or diabetes care. 

Any service that could be done safely by a non-medical person (or by 

yourself) without the supervision of a nurse, isn’t skilled nursing care. 

Home health aide services may be covered when given on a part-time 

or intermittent basis if needed as support services for skilled nursing 

care. Home health aide services must be part of the care for your 

illness or injury. Medicare doesn’t cover home health aide services 

unless you’re also getting skilled care such as nursing care or other 

physical therapy, occupational therapy, or speech-language pathology 

services from the home health agency. 

■ Physical therapy, occupational therapy, and speech-language 

pathology services. Medicare uses the following criteria to assess 

whether these therapy services are reasonable and necessary in the 

home setting: 

1. The therapy services must be a specific, safe, and effective 

treatment for your condition. 

2. The therapy services must be complex or your condition 

must require services that can safely and effectively be 

performed only by qualified therapists. 
Section 1: Medicare Coverage of Home Health Care 9

3. One of the three following conditions must exist: 

■ It’s expected that your condition will improve in a reasonable 

and generally-predictable period of time. 

■ Your condition requires a skilled therapist to safely and 

effectively establish a maintenance program. 

■ Your condition requires a skilled therapist to safely and 

effectively perform maintenance therapy. 

4. The amount, frequency, and duration of the services must be 

reasonable. 

■ Medical social services. These services are covered when given under the 

direction of a doctor to help you with social and emotional concerns related 

to your illness. This might include counseling or help finding resources in 

your community. 

■ Medical supplies. Supplies, like wound dressings, are covered when they 

are ordered as part of your care. 

Durable medical equipment, when ordered by a doctor, is paid separately by 

Medicare. This equipment must meet certain criteria to be covered. Medicare 

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

medical equipment, such as 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 will have to pay for them. This should be explained by both 

talking with you and in writing. 

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

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

your home health plan of care. See page 19. This includes skilled therapy 

services for a condition that may not be the primary reason for getting 

home health services. 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. 
10 Section 1: Medicare Coverage of Home Health Care 

What isn’t covered? 

Below 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 when this 

is the only care you need, and when these services aren’t related to 

your plan of care. See page 19. 

■ Personal care given by home health aides 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 should call 

1-877-486-2048. 

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

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

health care provider so your bills get paid correctly.

What you have to pay 

You may be billed for the following: 

■ Medical services and supplies that Medicare doesn’t pay for when you 

agree to pay out of pocket for them. The home health agency should 

give you a notice called the Home Health Advance Beneficiary 

Notice (HHABN) before giving you services and supplies that 

Medicare doesn’t cover. See page 11. 

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

medical equipment such as wheelchairs, walkers, and oxygen 

equipment. 
Section 1: Medicare Coverage of Home Health Care 11

Home Health Advance Beneficiary Notice 

The home health agency should give you a written notice called 

a Home Health Advance Beneficiary Notice (HHABN) in the 

following situations: 

■ The home health agency reduces or stops providing you with 

some home health services or supplies for business-related 

reasons while continuing other home health services. 

■ The home health agency reduces or stops providing home health 

services or supplies because your doctor has changed your orders. 

■ The home health agency plans to give you a home health service 

or supply that Medicare probably won’t pay for. 

If a home health agency reduces or stops providing certain services 

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

HHABN 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. 

When you get an HHABN 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 HHABN 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. 
12 Section 1: Medicare Coverage of Home Health Care 

Home Health Advance Beneficiary Notice 

(continued) 

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

following: 

■ 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 will 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 agency bill Medicare for your care. 

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

payments, except for any applicable coinsurance or deductibles, 

including any coinsurance payments you made for durable medical 

equipment. 

Your right to a fast appeal 

When all 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 Quality 

Improvement Organization (QIO) looks at your case and decides if 

you need home health services to continue. The QIO is a group of 

practicing doctors and other health care experts paid by the Federal 

government to check and improve the care given to Medicare patients. 
Section 1: Medicare Coverage of Home Health Care 13

Your home health agency will give you a written notice called the 

Notice of Medicare Provider Non-Coverage 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 the following information: 

■ 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 

If you ask for a fast appeal, the Quality Improvement Organization 

(QIO) will ask for your opinion about why you believe coverage of 

your home health services should continue. The QIO will also look 

at your medical information and talk to your doctor. The QIO will 

notify you of its decision as soon as possible, generally no later than 

2 days after the effective date of the Notice of Medicare Provider 

Non-Coverage. 

If the 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 QIO decides that your coverage should end, you will have to 

pay for any services you got after the date on the Notice of Medicare 

Provider Non-Coverage that says your covered services should 

end. You won’t be responsible for paying for any covered services 

provided before that date. 

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

Notice of Medicare Provider Non-Coverage and avoid paying for 

any further services. Before giving you services that Medicare may 

not pay for, your home health agency should give you a Home 

Health Advance Beneficiary Notice (HHABN) with an estimate of 

how much these services will cost. 
14 Section 1: Medicare Coverage of Home Health Care 

General Medicare appeal rights 

After Medicare makes a decision on a claim, you have the right to a 

fair, efficient, and timely process for appealing health care payment 

decisions or initial determinations on items or services you got. 

You may appeal if either of the following is true: 

■ A service or item you got isn’t covered, and you think it should be. 

■ A service or item is denied, and you think it should be paid. 

The company that handles claims for Medicare will send you a list of 

your claims, called The Medicare Summary Notice (MSN), every 3 

months. This notice tells you if your claim is approved or denied. If 

the claim is denied, the reason for the denial will be included on the 

notice. The notice will also include information about how to file an 

appeal. Review this notice carefully, and follow the instructions to file 

an appeal. 

You can file an appeal if you disagree with Medicare’s decision on 

payment or coverage for the items or services you got. If you appeal, 

ask your doctor, health care provider, or supplier for any information 

that might help your case. You should keep a copy of everything you 

send to Medicare as part of your appeal. 

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

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

or “Your Medicare Rights and Protections” booklet. To view or 

print this booklet, visit http://go.usa.gov/low. You can also call 

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

1-877-486-2048. 
15

Words in red

are defined on 

pages 29–30. 

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. (Medicare Advantage Plans or other 

Medicare health plans may require that you get home health 

services from agencies they contract with.) 

Comparing home health agencies

Use Medicare’s “Home Health Compare” web tool by visiting 

www.medicare.gov/HHCompare 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 provides the following 

information about home health agencies: 

■ Name, address, and telephone number 

■ Services offered (such as 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 provided (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. Use Home Health Compare 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. 

Here’s an example of the information you’ll find on Home Health 

Compare: 

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 

get better at getting in and 

out of bed 

74% 72% 72% 

Percentage of patients who 

have less pain when moving 

around 

59% 80% 76% 

Percentage of patients whose 

wounds improved or healed 

after an operation 

77% 76% 80% 
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, 

such as Meals on Wheels, that I may 

need?

7. Has staff that can provide 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.Does background checks on all staff? 

12.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 Medicare patients. An agency isn’t required to accept a patient if 

it can’t meet the patient’s medical needs. An agency shouldn’t refuse 

to take a specific Medicare patient because of the patient’s condition, 

unless the agency would also refuse to take other patients 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. Call 1-800-MEDICARE (1-800-633-4227) to 

get your State Survey Agency’s telephone number. TTY users should 

call 1-877-486-2048. You can also visit www.medicare.gov. 

In some cases, your local long-term care ombudsman may have 

information on the home health agencies in your area. Visit 

www.ltcombudsman.org. You can also call the Eldercare Locator at 

1-800-677-1116, or visit www.eldercare.gov. 

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

following: 

■ 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. 

■ Look in your telephone directory in the Yellow Pages under “home 

care” or “home health care.”

Section 2: Choosing a Home Health Agency
19

Words in red

are defined on 

pages 29–30. 

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. Doctor’s orders are needed to 

start 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 problem. 

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

Your plan of care includes the following: 

■ What services you need 

■ Which health care professionals should give these services 

■ How often you will need the services 

■ The medical equipment you need 

■ What results your doctor expects from your treatment 

Your home health agency must provide you with all 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; or by 

hiring nurses, therapists, home health aides, and medical 

social service counselors 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 problems 

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

plan of care will be reviewed and may change. Your home health team 

should only change your plan of care with your doctor’s approval. Your 

home health team should also 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 as a person with Medicare 

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

a Medicare-certified home health agency, you’re guaranteed certain 

rights, including the following: 

■ 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 will 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 will have to pay for any services 

that you will be getting 

■ 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

Read more about these rights and protections in the following 

publications: 

■ “Your Medicare Rights and Protections”—Visit 

http://go.usa.gov/low.

■ “Medicare & You” handbook—Visit http://go.usa.gov/iDJ. 

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

should 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 the following 

organizations: 

■ Your state home health hotline. Your home health agency should 

give you this number when you start getting home health services. 

■ The Quality Improvement Organization (QIO) in your state. 

The QIO is a group of practicing doctors and other health care 

experts paid by the Federal government to check and improve 

the care given to Medicare patients. To get the telephone 

number for your QIO, visit www.medicare.gov. 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 ensure 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 of care, 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 29–30. 

Section 4: 

Getting the Help You Need 

Extra Help paying for Medicare Prescription 

Drug Coverage (Part D) 

You may qualify for Extra Help, also called the low-income 

subsidy (LIS), from Medicare to pay prescription drug costs 

if your yearly income and resources are below the following 

limits in 2010: 

■ Single person—Income less than $16,245 and resources less 

than $12,510 

■ Married person living with a spouse—Income less than 

$21,855 and resources less than $25,010 

These amounts may change in 2011. You may qualify even if 

you have a higher income (like if you still work, or if you live 

in Alaska or Hawaii, or have dependents living with you). 

Resources include money in a checking or savings account, 

stocks, and bonds. Resources don’t include your home, car, 

household items, burial plot, up to $1,500 for burial expenses 

(per person), or life insurance policies. For more information, 

call Social Security at 1-800-772-1213, or visit 

www.socialsecurity.gov. TTY users should call 

1-800-325-0778. All information you share is confidential. 
24 Section 4: Getting the Help You Need 

State Pharmacy Assistance Programs (SPAPs) 

Many states have State Pharmacy Assistance Programs (SPAPs) that 

help certain people pay for prescription drugs based on financial 

need, age, or medical condition. Each SPAP makes its own rules 

about how to provide drug coverage to its members. Depending on 

your state, the SPAP will help you in different ways. To find out about 

the SPAP in your state, call your State Health Insurance Assistance 

Program (SHIP). To get their number, visit www.medicare.gov or 

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

1-877-486-2048. 

Medicaid 

Medicaid is a joint Federal and state program that helps pay medical 

costs if you have limited income and resources and meet other 

requirements. Some people qualify for both Medicare and Medicaid 

(these people are called “dual eligibles”). 

■ If you have Medicare and full Medicaid coverage, most of your health 

care costs are covered. 

■ Medicaid programs vary by state. They may also be called by different 

names, like “Medical Assistance” or “Medi-Cal.” 

■ People with Medicaid may get coverage for services that Medicare 

doesn’t fully cover, such as nursing home and home health care. 

■ Each state has different Medicaid income and resource limits and 

other eligibility requirements. 

■ In some states, you may need to apply for Medicare to be eligible for 

Medicaid. 

■ Call your State Medical Assistance (Medicaid) office for more 

information and to see if you qualify. Call 1-800-MEDICARE, and 

say “Medicaid” to get the telephone number for your State Medical 

Assistance (Medicaid) office. You can also visit www.medicare.gov. 
Section 4: Getting the Help You Need 25

Medicare Savings Programs (Help with Medicare 

costs) 

States have programs that pay Medicare premiums and, in some cases, 

may also pay your Part A (Hospital Insurance) and Part B (Medical 

Insurance) deductibles and coinsurance. These programs help people 

with Medicare save money each year. 

To qualify for a Medicare Savings Program, you must meet all of these 

conditions: 

■ Have Part A 

■ Single person—Have monthly income less than $1,239 and 

resources less than $8,100 

■ Married and living with a spouse—Have monthly income less than 

$1,660 and resources less than $12,910 

Note: These amounts may change each year. Many states figure your 

income and resources differently or may not have limits at all, so you 

may qualify in your state even if your income is higher. Resources 

include money in a checking or savings account, stocks, and bonds. 

Resources don’t include your home, car, burial plot, up to $1,500 for 

burial expenses (per person), furniture, or other household items. 

For more information 

■ Call or visit your State Medical Assistance (Medicaid) office, and ask 

for information on Medicare Savings Programs. The names of these 

programs and how they work may vary by state. Call if you think 

you qualify for any of these programs, even if you aren’t sure. 

■ Call 1-800-MEDICARE (1-800-633-4227), and say “Medicaid” 

to get the telephone number for your state. TTY users should call 

1-877-486-2048. 

■ Visit http://go.usa.gov/loA to view the brochure, “Get Help With 

Your Medicare Costs: Getting Started.” 

■ Contact your State Health Insurance Assistance Program (SHIP)

for free health insurance counseling. To get their number, call 

1-800-MEDICARE. You can also visit www.medicare.gov, and under 

“Help & Support” select “Useful Phone Numbers and Websites.” 

Then, search by the word “organization” or “SHIP.” 
26 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’re in Original Medicare, call 1-800-MEDICARE 

(1-800-633-4227). TTY users should call 1-877-486-2048. If you get 

your Medicare benefits through a Medicare health plan, call your plan. 

You may also call the State Health Insurance Assistance Program 

(SHIP). Every State and territory, plus Puerto Rico, the Virgin Islands, 

and the District of Columbia has a SHIP with counselors who can give 

you free health insurance information and help. The SHIP counselors 

answer questions about Medicare’s home health benefits and what 

Medicare, Medicaid, and other types of insurance pay for. In addition, 

these counselors help with the following: 

■ Medicare payment questions. 

■ Questions about buying a Medigap (Medicare Supplement 

Insurance) policy or long-term care insurance. 

■ Concerns about payment denials and appeals. 

■ Medicare rights and protections. 

■ Complaints about your care or treatment. 

■ Choosing a Medicare health plan. 

To get the telephone number for your SHIP, visit www.medicare.gov

on the web, or call 1-800-MEDICARE. 
Section 4: Getting the Help You Need 27

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’re important in the fight to prevent fraud, 

waste, and abuse in the Medicare Program. 

You should look for the following: 

■ 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 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. 
28 Section 4: Getting the Help You Need 

Reporting fraud

If you suspect fraud, here’s what you can do: 

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

■ Call the Office of Inspector General Hotline: 

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

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

By E-Mail: HHSTips@oig.hhs.gov 

By Mail: Office of the Inspector General 

HHS TIPS Hotline 

P.O. Box 23489 

Washington, DC 20026 

Please note that it is current Hotline policy not to 

respond directly to written communications. 

■ If you live in Florida, call Medicare’s Florida Fraud Hotline: 

By Phone: 1-866-417-2078 

By E-Mail: floridamedicarefraud@hp.com 

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

1-877-486-2048. 

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

please 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. 
29

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 the 

following: 

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

that you think you should be able to get 

■ Your request for payment for health care or a prescription drug 

you already got 

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

prescription drug 

You can also appeal if you are already getting coverage and 

Medicare or your plan stops paying. 

Durable Medical Equipment—Certain medical equipment, 

such as a walker, wheelchair, or hospital bed, that is 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 Medicare 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 

Advantage Plan, Medicare services are covered through the plan 

and aren’t paid for under Original Medicare. Most Medicare 

Advantage Plans offer prescription drug coverage.

Definitions 
30

Medicare Health Plan—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. 

Medigap Policy—Medicare Supplement Insurance sold by private 

insurance companies to fill “gaps” in Original Medicare coverage. 

Original Medicare—Original Medicare is fee-for-service coverage 

under which the government pays your health care providers directly 

for your Part A and/or Part B benefits. 

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. 

Definitions 
31

A

Appeal 11–14, 29

C

Complaint 21

D

Durable Medical Equipment 9, 29

E

Eldercare Locator 18

Eligibility 5–6

Episode of Care 7

F

Fraud 27–28

H

Homebound 5

Home Health Advance Beneficiary 

Notice (HHABN) 11–12

Home Health Agency 15

Home Health Compare 15

L

Long-term Care Ombudsman 18

M

Medicaid 24, 25, 29

Medical Social Services 9

Medical Supplies 9

Medicare Advantage Plan 15, 29

Medicare-approved Amount 9, 10

Medicare Health Plan 4, 15, 26, 30

Medigap (Medicare Supplement 

Insurance) Policy 26, 30

Index 

O

Occupational Therapy 5, 8

Official Decision 12

Original Medicare 4, 26, 30

P

Payment 26

Physical Therapy 5, 8

Plan of Care 5, 9, 19, 20

Prescription Drugs 23

Q

Quality 15–16

Quality Improvement 

Organization (QIO) 12–13

S

Skilled Nursing Care 5, 8

Speech-Language Pathology 

Services 5, 8

State Health Insurance Assistance 

Program (SHIP) 25, 30

State Survey Agency 18
To get this publication in Spanish, visit www.medicare.gov

on the web, or call 1-800-MEDICARE (1-800-633-4227). 

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

¿Necesita una copia en Español? Visite www.medicare.gov

en el sitio Web. Para saber si esta publicación esta 

impresa y disponible (en español), llame GRATIS al 

1-800-MEDICARE (1-800-633-4227). Los usuarios de 

TTY deben llamar al 1-877-486-2048. 

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 

CMS Product No. 10969 

Revised May 2010