General questions about home health care
Home health care is a wide range of health care services that can be given in your home for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility (SNF).
If your doctor or referring health care provider decides you need home health care, they should give you a list of
agencies that serve your area. They must tell you whether their organization has a financial interest in any agency listed.
Original Medicare covers 100 percent of the cost for home health services.
If you are enrolled in a Medicare Advantage Plan (MAP), you are covered by Medicare Part C, and no longer have Medicare Part A or Part B. In that situation, check with your plan to see:
1) What coverage for home health services your plan provides;
2) What home health agencies are in network with your plan; and
3) What, if any, co-pay or co-insurance you will need to pay for home health services?
Medicare will pay for skilled nursing, physical therapy, occupational therapy, speech therapy, and medical social work in the comfort of the patient’s home. However, there are several other services under the umbrella of those disciplines.
Medicare will not pay for the following services:
1) 24-hour-a-day care at your home;
2) Meals delivered to your home;
3) Homemaker services (like shopping, cleaning, and laundry) that aren’t related to your care plan; or
4) Custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need.
All people with Original Medicare (Parts A and B) who meet all of the following conditions qualify:
1) You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.
2) You must need, and a doctor must certify that you need, one or more of these:
a) Intermittent skilled nursing care (other than drawing blood).
b) Physical therapy, speech-language pathology, or continued occupational therapy
services. To be eligible, either:
i) Your condition must be expected to improve in a reasonable and generally predictable period of time; or
ii) You need a skilled therapist to safely and effectively make a maintenance program for your condition; or
iii) You need a skilled therapist to safely and effectively do maintenance therapy for your condition.
3) The home health agency caring for you is approved by Medicare (Medicare certified).
4) You must be homebound, and a doctor must certify that you’re homebound.
You’re not eligible for the home health benefit if you need more than part-time or “intermittent” skilled nursing care. You may leave home for medical treatment or short, infrequent absences for non-medical reasons–like attending religious services. You can still get home health care if you attend adult day care.
In order to qualify as being “homebound,” Medicare requires ONE of the following criteria to be met:
1) Because of illness or injury, the patient must need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence; or
2) Have a condition such that leaving his or her home is medically contraindicated.
Medicare ALSO requires BOTH of the following criteria to be met:
1) There must exist a normal inability to leave the home; and
2) Leaving home must require a considerable and taxing effort.
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.
These recommendations are from medicare.gov.
Your home health agency will work with you and your doctor to create your plan of care listing:
1) What services you need;
2) Which health care professionals should give these services;
3) How often you’ll need the services;
4) The medical equipment you need; and
5) What results your doctor expects from your treatment?
Your home health agency must give you or arrange for all the home care listed in your plan of care, including services and medical supplies.
Your doctor and home health team should 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 home health team should also tell you about any changes in your plan of care and only change it with your doctor’s approval.
If you have a question about your care, or if you feel your needs aren’t being met, talk with both your doctor and the home health team.
Questions about Love My Nurse
Yes. Love My Nurse is Medicare certified.
Love My Nurse does not provide Home Health Aides to new patients at present.
Occupational Therapy (OT) may be assigned to a patient needing assistance with bathing for up to 60 days. This is dependent on whether the patient will be able to benefit/bathe themselves once OT has provided adaptive measures to do so independently and safely.
Questions about insurance
Original Medicare
1) Includes hospital coverage (Part A) and medical coverage (Part B)
2) Does not provide prescription drug coverage, so purchase of a separate drug plan (Part D) is highly recommended.
3) People often purchase separate Medigap/Medicare Supplement coverage (F, G, K, L, M, N) to lower their out of pocket expenses when using their benefit.
4) Does not provide additional health benefits.
5) Provided by the federal government.
6) Allows freedom to seek treatment at any hospital or with any doctor or provider within the U.S. who accepts Medicare.
Medicare Advantage Plan (MAP)
1) Combines hospital coverage (Part A), medical coverage (Part B), and additional health benefits, including some—if not all—of the following: dental, vision, hearing, and fitness.
2) Often includes prescription drug coverage.
3) Provided by private insurance companies, with varying benefits, costs, and coverage options based on location and provider.
4) Can result in out-of-pocket expenses adding up to $3400 to $6700 per year.
5) The insurance company has the option to renew or drop the plan each year.
6) Plans are limited to specific networks and geographic areas, so specific hospitals or providers may not be covered.
Learn more about Medigap vs. Medicare Advantage plans.
Yes… and no.
While premiums can be as low as $0, out-of-pocket expenses can be as high as $6700 per year.
Learn more about Medigap vs. Medicare Advantage plans.
To start, HMO stands for Health Maintenance Organization, and the coverage restricts patients to a particular group of physicians called a network. PPO is short for Preferred Provider Organization and allows patients to choose any physician they wish, either inside or outside of their network. HMOs and PPOs are both types of managed care, which is a way for insurers to help control costs.
A network is a group of healthcare providers that have contracted with an insurance company to offer discounted services. These networks typically include general physicians and specialists (chiropractors, dermatologists, neurologists, etc.). They may also include labs, X-ray facilities, and providers of medical equipment.
The biggest differences between an HMO and a PPO plan are:
1) With an HMO, patients must always first see their primary care physician (PCP). If your PCP can’t treat the problem, they will refer you to an in-network specialist. With a PPO plan, you can see a specialist without a referral. (However, there are exceptions for emergencies or routine-care, in-network visits to a gynecologist or obstetrician).
2) With an HMO plan, you must stay within your network of providers to receive coverage. Under a PPO plan, patients still have a network of providers, but they aren’t restricted to seeing just those physicians. You have the freedom to visit any healthcare provider you wish.
Staying in your network with an HMO, you can expect the maximum insurance coverage for the services you receive according to your plan. Go outside of your network and your coverage disappears. With a PPO, you can visit doctors outside of your network and still get some coverage, but not as much as you would if you remained in your network.
General questions about home health documents
When the home health agency believes Medicare may not pay for some or all of your home health care, the agency must give you an Advance Beneficiary Notice of Noncoverage (ABN).
Home health agencies are required to give you an ABN before you get any items or services Medicare may not pay for because of any of these reasons:
1) They’re not considered medically reasonable and necessary;
2) The care is only non-skilled, personal care, like help with bathing or dressing;
3) You aren’t homebound; and/or
4) You don’t need skilled care on an intermittent basis.
When you get an ABN because Medicare isn’t expected to pay for a medical service or supply, the notice should describe the service and/or supply and explain why Medicare probably won’t pay. The ABN gives clear directions for getting an official decision from Medicare about payment for home health services and supplies, and for filing an appeal if Medicare won’t pay.
Your Personal Health Information (PHI) is kept private by medical practitioners (including Love My Nurse). For us to get the information necessary to set up home health care, Love My Nurse needs its patients to complete an “Authorization for Release and Collection of Medical Information.” This allows us to collaborate and coordinate with the rest of your health care team.
Your home health agency will give you a Detailed Explanation of Non-Coverage (DENC) when it’s informed by the BFCC-QIO that you’ve requested a BFCC-QIO review of your case. The DENC will explain why your home health agency believes that Medicare will no longer pay for your home health care.
The home health agency must also give you an ABN or a Home Health Change of Care Notice (HHCCN) when they reduce or stop providing home health services or supplies because of one of these:
1) The home health agency makes a business decision to reduce or stop giving you some or all of your home health services or supplies; or
2) Your doctor changed your orders, which may reduce or stop giving you certain home health services or supplies that Medicare covers.
The HHCCN lists the services or supplies that will be changed, and it gives you instructions on what you can do if you don’t agree with the change.
The home health agency isn’t required to give you a HHCCN when it issues the “Notice of Medicare Non-coverage” (NOMNC).
Your home health agency will give you a Notice of Medicare Non-Coverage NOMNC at least two (2) days before all covered services end. This written notice will tell you when your covered services will end and how to appeal if you think the services are ending too soon. The NOMNC tells you how to contact your Beneficiary And Family Centered Care Quality Improvement Organization (BFCC-QIO) to ask for a fast appeal. If you don’t get this notice, ask for it.
If you decide to ask for a fast appeal, call the BFCC-QIO within the timeframe listed on the notice. After you request a fast appeal, you’ll get a second notice with more information about why your care is ending. The BFCC-QIO may ask you questions about your case. To help your case, ask your doctor for information, which you can submit to the BFCC-QIO.
