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Exceeding your Expectations in Home Healthcare

   
  Home Health Primary Home Care/Familiy Care (PHC/FC)

 

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Frequently Asked Questions

 
   
   

Q: Does Medicare pay for my prescription drugs?

Original Medicare generally does not cover outpatient drugs. There are rare exceptions, which can be for:

 
  -Injectable osteoporosis drugs administered by a home health nurse   -Immunosuppressive drugs within 36 months after a covered organ transplant  
  -Oral anticancer drugs   -Antigens that are not self-administered  
  -Drugs used in connection with an infusion pump   -Pneumococcal, influenza and hepatitis B vaccine  
  -Epoetin for home dialysis   -Physician-administered drugs  
   -Blood clotting factors for hemophilia patients      

You may be able to obtain prescription drug coverage from other sources, such as Medicaid, Medicare supplemental ("Medigap") insurance, retiree insurance, or state-run programs. Medicare supplemental insurers and Medicare HMOs offer limited coverage.

 

Q: Can I use the home health benefit even without an acute illness or a prior hospitalization?

Yes. As long as you have a skilled need and are homebound, you can qualify for the home health benefit. An example is if you have multiple sclerosis and are homebound with a need for skilled maintenance therapy to maximize function, you qualify for the home health benefit.

 

But you would not qualify with just custodial care alone. An example where you would not qualify is if you have Alzheimer's disease and need home health aide services but do not need skilled nursing or skilled therapy, you would not qualify for the home health benefit.

 

Q: What are my rights to leave or stay in home health?

As long as you meet eligibility criteria, you are eligible for home health benefits. However, if a Medicare-certified Home Health Agency (HHA) believes that Medicare will no longer cover its services, it can terminate care even if your physician certifies your need for skilled care.

 

To appeal the HHA's determination, you must sign a waiver of liability (also called an Advanced Beneficiary Notice) and request that the HHA submit its claim to Medicare. While this claim is pending, the HHA is required to continue care. If the claim is denied by Medicare, however, you will be held liable for the charges.

 

You may discontinue to use the Home Health services whenever you would like.

 

Q: Is the HHA obligated to provide all the services that my physician says are needed?

Yes. However, if the HHA believes that your needs have changed, it can ask the physician to draw up a new plan of care.

 

Q: Can I get Medicare home health benefits if I am in a nursing home or assisted living facility?

No. Medicare will not pay for home health services in a nursing home or for home health services that are the responsibility of the assisted living facility. For example, if an assisted living facility is required to provide you with home health aide services, Medicare does not pay for additional home health aide services through the home health benefit.

 

Q: When does the Home Health Agency (HHA) won't accept a patient?

A HHA is not obligated to provide services to all patients who meet the eligibility criteria. The agency may select those whom it wants to treat, provided that it does not violate discrimination laws. If the first agency you call is unable treat you, try contacting other agencies. It is possible that another agency will be able to provide services.

Be aware of the Prospective Payment System (PPS) which is to slow the spending on home health care, Congress mandated the implementation of a prospective payment system (PPS) of fixed, predetermined rates for home health services. The limits give HHAs incentives to control per-visit costs, and the number and mix of visits provided to patients. Consequently, PPS has limited access to home health services and caused many home health agencies to close, resulting in fewer alternatives for patients.

 

When the HHA believes that Medicare won't pay:

HHAs sometimes limit plans of care to less than what Medicare covers. This is happening more frequently because of the pressures brought on by the Prospective Payment System (PPS). If the HHA provides you with written notice that it believes Medicare will not cover services; it may or can bill you for uncovered services, but you should first insist that the agency bill Medicare.

 

If the HHA does tries to bill you for care already received, you should insist that the HHA try to bill Medicare.

The HHA may be wrong and the only way to know whether Medicare will cover your services is if the HHA submits the bill to Medicare. Even if Medicare denies coverage, there is a good chance that Medicare will reverse its decision upon appeal.

 

If a HHA notifies you that it is discontinuing care but you still meet the eligibility criteria for home health care, there are several things you can do to continue using the Medicare home health benefit:
1) If the agency is misinformed about Medicare coverage rules, explain what is covered under Medicare.

2) Obtain a plan of care from your physician and request a re-evaluation from the home health agency.

3) Continue the care and demand that the HHA bill Medicare, but you may be responsible for any charges if Medicare does not pay.

4) Try another home health agency.

 

When you are dissatisfied with care or denied care:

The procedures for grievances (complaints) and appeals in home health agencies should be included in the paperwork.

 

If you are dissatisfied with or denied care:
1) Discuss the complaints and requests for services with the nurse administering the care plan.
2) Complain to the agency's program administrator. Talk to your doctor. Get your doctor to help you work with the agency to obtain care. Ask your doctor to communicate with the agency about necessary changes to your care plan.
3) Complain to the State Department of Health or the federal government at 1-800-HHS-TIPS (800-447-8477).
4) You may also try changing agencies until you find one that delivers satisfactory care. Although legally you may change HHAs at any time, it is not always easy to find another HHA once you have started care.

 

When you should make an appeal:
You should appeal if Medicare or your Medicare HMO denies payment for a service already rendered or durable medical equipment already purchased or if your HMO refuses to approve any services or supplies that you feel are necessary. It is simple and can costs you nothing except a postage stamp and will not have any effect on your other Social Security or health benefits. Patients are successful in 74 percent of first-level appeals in Original Medicare. Many appeals in Medicare HMOs are favorable to the patient as well.

 

To appeal a home health care claim after services have been provided:
1) Write a letter to your Medicare Intermediary. It is best to begin a paper trail as early as possible. You will find the address of the Medicare Intermediary at the bottom of your Medicare Summary Notice. You must write the letter within 60 days of receiving the Medicare Summary Notice.
2) The letter does not have to be long. It can be as simple as to write "Please review my claim" and sign your name. Write the claim control number (found below your name on the Summary Notice) and your Medicare number on your letter, and enclose with your letter a copy of your Medicare Summary Notice.
3) Include any evidence to support your request for reimbursement. This may include a letter from your doctor about the medical necessity of the service or copies of medical records.

 

To appeal a claim for durable medical equipment:
In general, follow the same appeal procedure as for home health care claims. There are only two differences:
1) Send the letter to your Durable Medical Equipment Regional Carrier instead of your Medicare Intermediary. The address of the Durable Medical Equipment Regional Carrier is should be also at the bottom of your Medicare Summary Notice.
2) You have 6 months, not 60 days, to appeal the denial.

 

TIP: Send your appeal by certified mail, return-receipt requested, so that you have proof that Medicare or the HMO received your letter.

 

To appeal to an HMO:
It is always best to begin a paper trail as early as possible. When your HMO makes a decision to deny payment for Medicare-covered services or refuses to provide Medicare-covered services that you had requested; it must provide you a "Notice of Initial Determination" and a full written explanation of your appeal rights. If you have not received this notice, you should demand the written notice from the HMO. While it is ideal to contest a written denial, you may also contest a verbal denial if the HMO refuses to provide a "Notice of Initial Determination."

 

First, write a letter to the HMO and request a reconsideration within 30 days of the denial. If the wait for the appeal could seriously jeopardize your life, your health, or your ability to regain maximum function, you can always request an expedited appeal and the HMO must decide your appeal within 72 hours of your request. It might also be ideal to ask your physician to request an expedited appeal from the HMO.

 

You may also make the request on your own and the HMO will determine whether your condition is sufficiently endangered by the denial to necessitate an expedited appeal. In the appeal request, include any written records of the HMO's denial of services that you may have, along a copy with your letter. Also include any evidence to support your request, such as a letter from your doctor about the medical necessity of the service and copies of medical records.

 

What happens after sending in an appeal:

If you are making an appeal to Original Medicare, a different employee of the Medicare Intermediary or the Durable Medical Equipment Regional Carrier who has never seen your claim before will read your letter and review the decision. After the review, you will either obtain a decision in your favor and an additional check or a denial letter explaining why the claim was denied.

 

If the decision is not in your favor, there are other steps of appeal that you may take. The next step after the initial review is to have a hearing before an States District Court follows if you want to pursue your appeal. For example, appeals for coverage of experimental treatments might have to get to the Appeals Council level before there is any chance of a favorable decision. Be patient and persistent.

 

If you appeal a Medicare HMO decision, the HMO must reconsider its initial determination within 30 days for a service or 60 days for payment (or the 72 hours if you are requesting an expedited appeal), and you are entitled to present supporting evidence in person or in writing. If the HMO decides in your favor, it issues you a notice and the appeal is successful and closed.

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