1. Helping clients understand Medicare’s home health benefit

2. Medicare Rights Center
The Medicare Rights Center is a national, nonprofit
consumer service organization that works to
ensure access to affordable health care for older
adults and people with disabilities through
Counseling and advocacy
Educational programs
Public policy initiatives

3. National Council on Aging
This toolkit for State Health Insurance Assistance
Programs (SHIPs), Area Agencies on Aging (AAAs),
and Aging and Disability Resource Centers (ADRCs)
was made possible by grant funding from the
National Council on Aging.
The National Council on Aging is a respected national leader and trusted partner to help people aged 60+ meet the challenges of aging. They partner with nonprofit organizations, government, and business top provide innovative community programs and services, online help, and advocacy.

4. Learning objectives Understand Medicare basics
Outline home health basics and Original Medicare’s eligibility requirements for coverage
Review services covered under home health benefit
Know how to counsel clients about their rights when receiving home health care

5. Medicare basics

6. What is Medicare? Federal program that provides health insurance for
Those 65+
Those under 65 receiving Social Security Disability Insurance (SSDI) for a certain amount of time
Those under 65 with kidney failure requiring dialysis or transplant
No income requirements
Two ways to receive Medicare benefits
Original Medicare
Medicare Advantage
Traditional program offered directly through federal government
Private plans that contract with federal government to provide Medicare benefits

7. Medicare eligibility – 65+
After turning 65, individual qualifies for Medicare if they
Collect or qualify to collect Social Security or Railroad Retirement benefits
OR are a current U.S. resident and either
A U.S. citizen
OR a permanent resident having lived in the U.S. for five years in a row before applying for Medicare

8. Medicare eligibility – under 65
Individual under 65 qualifies for Medicare if
They have received Social Security Disability Insurance (SSDI) or Railroad Disability Annuity checks for total disability for at least 24 months  
Exception: If individual has amyotrophic lateral sclerosis (ALS) there is no waiting period, and they are eligible for Medicare when they start receiving SSDI
OR, they have End-Stage Renal Disease (ESRD or kidney failure), and they or a family member have enough Medicare work history

9. Parts of Medicare Medicare benefits administered in three parts
Part A – Hospital/inpatient benefits
Part B – Doctor/outpatient benefits
Part D – Prescription drug benefit
Original Medicare includes Part A and Part B
Part D benefit offered through stand-alone prescription drug plan
What happened to Part C?  Medicare Advantage Plans (MA Plans)
Way to get Parts A, B, and D through one private plan
Administered by private insurance companies that contract with federal government
Not a separate benefit: everyone with Medicare Advantage still has Medicare

10. Part A-covered services
Inpatient hospital care
Care provided to individual formally admitted into the hospital by attending physician
Inpatient skilled nursing facility care
Short-term, post-hospital extended care at lower level of care than inpatient hospital care
Home health care
Care to treat illness or injury in the home
Often provided by licensed nurse or therapist, including therapy, skilled nursing, and personal care (if skilled care also required)
Hospice care
Comprehensive care for people who are terminally ill

11. Part B-covered services
Physicians’ services
Medically necessary services provided to individual by doctor on outpatient basis
Emergency room visits
Preventive care
Care intended to detect and prevent illness or keep beneficiary healthy, such as cancer screenings
Home health care
Durable medical equipment (DME)
Equipment that serves medical purpose, is able to withstand repeated use, and is appropriate for use in home
Emergency ambulance transportation (in very limited cases)

12. Medicare excluded services
Most dental care
Most vision care
Routine hearing care
Most foot care
Most long-term care
Alternative medicine
Most care received outside the U.S.
Personal care if there is no need for skilled care
Most non-emergency transportation
Note: Medicare Advantage Plans (or Medicaid if beneficiary qualifies) may cover these services

13. Home health basics

14. Overview
Wide range of health and social services delivered in home to treat illness or injury
Covered services include skilled nursing, therapy, and home health aide care
Original Medicare pays in full for most services*
At minimum, Medicare Advantage Plans must provide same level of home health care as Original Medicare
May impose different rules, restrictions, and costs
*Excluding durable medical equipment.

15. Coverage requirements
Original Medicare covers home health services if:
Beneficiary is homebound
Beneficiary needs skilled nursing services and/or skilled therapy on an intermittent basis
Beneficiary has face-to-face meeting with doctor
Beneficiary’s doctor signs home health certification confirming that beneficiary is homebound and needs skilled care
And, beneficiary receives care from a Medicare- certified home health agency

16. Homebound requirement
Medicare considers an individual homebound if:
They need assistance from another person or medical equipment to leave home, or doctor believes their condition could worsen if they leave home
And, it is difficult for them to leave home and they typically cannot do so
Doctor must evaluate individual’s condition and certify that they are homebound
Beneficiary may leave home for medical treatment, religious services, and/or to attend licensed or accredited adult day care center without putting homebound status at risk. Short, infrequent absences for non-medical events (family reunion, funeral, graduation) also should not affect homebound status.

17. Intermittent care Intermittent means:
At least once every 60 days
At most once per day for up to three weeks
Period can be longer if need for care is predictable and finite
Individual must require skilled nursing of skilled therapy on intermittent basis to qualify for home health

18. Face-to-face meeting
Beneficiary required to have face-to-face meeting with doctor either:
Following qualify as face-to-face meeting:
Office visit
Hospital visit
In certain circumstances, meeting facilitated by technology (such as video conferencing)
Within 90 days before starting home care
Or, 30 days after first day individual receives care

19. Home health certification
Beneficiary’s doctor must sign home health certification confirming that:
Beneficiary is homebound
Beneficiary needs intermittent skilled nursing or therapy services
Doctor has approved plan of care for beneficiary
Face-to-face meeting requirement was met
Doctor should review and certify home health plan every 60 days
Face-to-face meeting not required for recertification

20. Plan of care
Home health agency (HHA) should assess beneficiary’s condition to create plan of care
Includes:
Types of health services an items individual needs
Frequency individual will receive services
Predicted outcomes of treatment
Doctor must sign plan of care
Initial plan of care and home health certification lasts 60 days
Both can be renewed for as many 60-day periods as necessary, as long as doctor continues to sign
Beneficiary should speak to their provider to suggest modifications to plan of care
Home health agency: organization that provides home care services, such as skilled nursing care, skilled therapy services, and personal care.

21. Part A and B coverage of home health
Beneficiaries with only Part A will have all their services covered under Part A
Beneficiaries with only Part B will have all their services covered under Part B
Part A covers up to 100 visits by a home health agency during a home health spell of illness, so long as the following conditions are met:
Hospital inpatient for three days in a row*
Receive home health care within 14 days of being discharged from a hospital or SNF
If beneficiary does not meet Part A coverage requirements, their home health services will be covered under Part B
The three-day qualifying stay is three nights spent as a hospital inpatient. A beneficiary must be formally admitted by their attending physician to the hospital to be considered an inpatient.
Note: Part A only covers 100 home health visits per spell of illness. After that, Part B will cover home health visits. If a beneficiary has only Part A or only Part B then the 100 visit limit does not apply.

22. Medicare Advantage home health coverage
Medicare Advantage Plans must follow Original Medicare’s rules for providing care, but can impose different network rules, restrictions, and costs
Plan may require:
Beneficiary uses in-network HHA
Prior authorization or referral before covering care
Copayment for care

23. Home health care-covered services

24. Skilled nursing care
Services performed by or under supervision of licensed or certified nurse
Includes:
Injections
Tube feedings
Catheter changes
Wound care
Observation and assessment of beneficiary’s condition
Management and evaluation of beneficiary’s plan of care

25. Amount of coverage
Original Medicare covers skilled nursing services up to seven days per week for no more than eight hours per day and 28 hours per week
In some circumstances, Original Medicare covers up to 35 hours per week

26. Skilled therapy services
Services reasonable and necessary to treat illness or injury, performed by or under supervision of licensed therapist
Includes:
Physical therapy (PT)
Speech-language pathology (SPL)
Occupational therapy (OT)
If a beneficiary only needs occupational therapy, they will not qualify for the Medicare home health benefit. However, if they qualify for Medicare coverage of home health care on another basis, they can also get occupational therapy.
Physical therapy includes gait training and supervision of and training for exercises to regain movement and strength to a body area. Speech-language pathology services include exercises to regain and strengthen speech and language skills. Occupational therapy helps individuals regain the ability to do usual daily activities by themselves, such as eating and putting on clothes.

27. Home health aide Aide that provides personal care
Up to seven days per week for no more than eight hours per day and 28 hours per week
In some circumstances, up to 35 hours per week
Includes activities such as:
Bathing
Toileting
Dressing
Medicare does not pay for aide if individual does not need skilled care

28. Other home health services
Medical social services
Medicare covers services ordered by doctor to help individual with social and emotional concerns related to illness
May include counseling or help finding community resources
Medical supplies
Medicare covers certain medical supplies, such as wound dressing and catheters
Durable medical equipment (DME)
Medicare covers certain pieces of medical equipment, such as wheelchair or walker
Original Medicare covers 80% of approved amount, beneficiary may owe coinsurance

29. Home health excluded services
Medicare’s home health care benefit does not cover:
24-hour-per-day care at home
Prescription drugs
Meals delivered to the home
Housekeeping services: light cleaning, laundry, and meal preparation
Home health aides may perform housekeeping services during visit for other health-related services, but cannot visit with sole purpose of performing housekeeping duties
Excluded services:
24-hour care

30. Home health care beneficiary rights

31. Home health agencies HHAs can: Beneficiaries have a right to home care
Choose their patients
Refuse to take patient if they do not believe they can ensure patient’s safety
Limit kinds of services they provide and types of conditions they will care for
Beneficiaries have a right to home care
Medicare should cover medically necessary home care when beneficiary qualifies
Original Medicare beneficiaries can call MEDICARE for help finding Medicare-certified HHA

32. Chronic care needs
Medicare should cover individual eligible for home health care regardless of whether condition is temporary or chronic
Skilled nursing or therapy services must be necessary to:
Help individual maintain ability to function
Help individual regain function or improve
Or, prevent or slow worsening of individual’s condition
Medicare should not deny medically necessary care that maintains individual’s condition or slows deterioration
Remember: HHA may choose to refuse to take patient. Beneficiaries should call MEDICARE or Medicare Advantage Plan for assistance finding HHA.

33. Out-of-network HHA agency
Medicare Advantage Plans must provide members with home health care if the beneficiary’s doctor says it is medically necessary
Plans must pay for care received from an out-of- network HHA if no in-network agencies will take the individual
Beneficiaries should speak to their plan about HHA options first if they cannot find an in-network HHA

34. When care is reduced
HHAs must give Original Medicare beneficiaries written notice, called a Home Health Advance Beneficiary Notice (HHABN), if they are reducing care
Notice explains why services are being reduced
HHA may believe Medicare will no longer cover these services
HHABN explains that beneficiaries have three options:
Request care and ask SNF or HHA to bill Medicare (demand bill)
Request care but agree to pay out-of-pocket
Or, turn down care and look for another HHA that might cover it
Beneficiary is not responsible for cost if If an HHA fails to send a beneficiary a HHABN and Medicare denies coverage for care, the beneficiary is not responsible for the cost

35. Demand bill
Beneficiary has right to demand bill if their care is being reduced because their HHA does not believe Medicare will cover it
HHA will bill Medicare for services supplied to beneficiary
HHAs can bill beneficiaries for home health services while Medicare makes its decision
There are situations when individual may receive HHABN but does not have the right to request demand bill
If doctor changes amount of care in beneficiary’s plan of care, beneficiary can either:
Ask doctor to change plan of care
Find new doctor to certify that same amount of care is necessary
Forgo these services
If HHA reduces care for staffing or safety reasons, beneficiary can either find another HHA or forgo services

36. Appealing
If Original Medicare denies coverage after demand bill, beneficiary can file appeal
Original Medicare beneficiaries should follow the typical process if health service or item is denied, starting with redetermination request
Beneficiaries in Medicare Advantage Plans typically have right to appeal if their HHA is reducing services*
Beneficiaries can request fast (expedited) review of this decision
*They do not go through the demand bill process

37. Conclusion

38. What you have learned Medicare basics
Home health basics and Original Medicare’s eligibility requirements for coverage
Services covered under home health benefit
Beneficiary rights when receiving home health care

39. Resources for information and help
State Health Insurance Assistance Program (SHIP)
Social Security Administration
Medicare
1-800-MEDICARE ( )
Medicare Rights Center
National Council on Aging

40. Medicare Interactive www.medicareinteractive.org
Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with Medicare
Easy to navigate
Clear, simple language
Answers to Medicare questions and questions about related topics
3+ million annual visits

41. Medicare Interactive Pro (MI Pro)
Web-based curriculum that empowers professionals to better help clients, patients, employees, retirees, and others navigate Medicare
Four levels with four to five courses each
Quizzes and downloadable course materials
Builds on 25 years of Medicare Rights Center counseling experience
For details, visit center/courses or contact Jay Johnson at or