I was recently doing a dangerous thing – reading federal regulations – which is apt to put one in a completely catatonic state. However, I happened to fall upon some interesting ones which concern the rights of Medicare beneficiaries and their Home Health Agency (HHA) benefits. Oddly, these regulations are not in the usual part of the Code of Federal Regulations which concern beneficiary rights, and don’t seem to be as well known as they should, so I felt I need to bring them to the attention of Medicare beneficiaries and their caregivers.
While researching this whole topic, I ran across several other items of interest. One is that there appears to be a growing concern that the current method which Medicare uses to reimburse Home Health Agencies for their services may not be the best from the perspective of Medicare beneficiaries. These matters have been raised, for example, in a 2010 Wall Street Journal article which indicated that when Medicare changed the way it paid agencies for therapy visits, the number of visits changed to reflect the new payment method, not necessarily therapeutic or medical needs of the beneficiaries. Recently, the Centers for Medicare & Medicaid Services (CMS) commissioned a study which raised concerns as to whether its reimbursement policies adequately ensure access to Home Health Agency care for beneficiaries who have a high severity of illness, have low income, or who live in a medically underserved area.
Best of all, I found on the Centre for Medicare Advocacy website, a “Medicare Home Health Self Help Packet,” which this outstanding Medicare advocacy organization, together with the Connecticut Department of Social Services, a fine office I worked with several years ago, produced to help with this whole issue. And while you may certainly wish to access this by going to their website, clicking on “Info by Topic,” then “Home Health Care,” then scrolling down a bit to “Self Help Packets,” you may find it bit more oriented toward advocates or counsellors than beneficiaries. (And I strongly urge these groups to review the entire package it is excellent.)
This advocacy organization makes clear three extremely important points:
- One is that the potential of a patient to improve is NOT a necessary criterion for getting these services. (It refers to this as the so-called “improvement standard.”) Rather, this is an arbitrary and unacceptable one. Home health visits are medically indicated even if they only prevent or slow the patient’s deterioration or the worsening of their condition.
- Another is that you may be wrongly told that artificial or arbitrary limits restrict the number of visits you may receive. For example, that daily nurse visits cannot be permitted (they can for a period of time), or that only one home health aide visit per day or three per week can ever be covered (not so).
- The third is that your physician is your key collaborator in making sure you get care you should receive. Having your physician willing to put into writing why you have a medical need for continuing visits and/or therapy is critical to making your case for continued or more Home Health Agency visits. This is because physicians are seen as the “gatekeepers” in fee-for-service Medicare, and their opinions must be strongly and carefully considered in making medical decisions.
The reason this topic is so important is that there is a fundamental tension in the Home Health Agency benefit, is because this is one of the few benefits in Medicare that you are not subject to any deductible or coinsurance liability. No matter how may visits you get, you pay nothing. Not a dime. On the other hand, Home Health Agencies are paid by Medicare under a “prospective payment system” which tends to incentivize them to limit the number of visits they make to you. You want more, they want less.
Remember that there is no time limit to the duration of your Home Health Agency benefits, and, if you have Part B, you get an unlimited number of visits. So there is no overall arbitrary time frame or visit limitation for this benefit.
So if you are trying to recuperate from an onset of illness or an accident, or if you are dealing with a longstanding or worsening chronic condition, you are going to want to get all the visits you need, but the agency will likely try to limit them. One purpose of this article is to give you some guidance on what to do if your agency indicates that it is going to stop or cut back on or even change the kind of visits you are getting when you or your caregivers think they should continue. And the other is to make sure you understand your special rights under this somewhat unique benefit.
Reductions in Visits
If your agency decides it should reduce the number of visits it is making to you, but will continue to visit, it must give you a Home Health Advance Beneficiary Notice (HHABN). For example, it mayreduce the number of your physical therapy visits from three to one aweek. The notice must also be given if it believes it should changethe type of visits you are getting, for example, that you should getoccupational therapy instead of physical therapy. (By the way,beginning April 1, 2011, your Home Health Agency must give you this notice on Form CMS-R-296; if they do not, you have NOT been properly notified.)
The key point here is that if you opt to have them continue past the cut-off or any changes shown in the notice, and to make visits it says are not covered by Medicare, you are out on a limb; if they make the visits and it turns out they are NOT covered by Medicare, you have to pay for them.
This notice from your Home Health Agency will tell you when some of the visits it is making will be reduced or ended or changed, although the agency will continue to give you some visits. It will also tell you how you can appeal this, which is by having them make the visits you feel are needed, and having them submit a “demand bill” to their Regional Home Health Intermediary (RHHI). That is, you demand that you get the care, and they submit a bill for it to their Regional Home Health Intermediary, which in turn makes the decision as to whether or not the care is covered by Medicare.
Regional Home Health Intermediaries are companies Medicare contracts with to process Home Health Agency bills and to make certain related medical decisions and appeals. Their contact information is shown below.)
The downside is that if you choose the option of having your care continue and the Regional Home Health Intermediary decides that the care was not covered, you will be responsible for the payment. Of course, you can appeal this decision. The appeals process, which starts with a request for a redetermination, is laid out beginning on page 194 of Managing Your Medicare the decision notice you get from the Regional Home Health Intermediary will also tell you how to appeal. But if a number of visits are made to you while this long process goes on you may run up quite a tab.
You also have other rights, which we’ll detail later, but among them is the right to complain or grieve your Home Health Agency’s decision to reduce or change your visits. This is because not only do you have the right to complain, but you also have the right to participate in your care planning. You can contact your Home Health Agency and formally complain to them about the reduction or change in visits, and they have to process this complaint in writing. You can also call your state’s agency or department that is responsible for licensing and certifying that a Home Health Agency may be in the Medicare program, and complain to them that your Home Health Agency is inappropriately ending the visits. You can call them on the special toll-free number used for Home Health Agency matters only (your Home Health Agency must give you this number when they begin your care), or their beneficiary number, or both. Finally, you can call the Centers for Medicare & Medicaid Services regional office which serves your state, and complain to them. Vital to all this is getting something from your physician that the reduction or change in the visits in question is medically inappropriate, or that a continuation of visits as currently being made is medically necessary. All this may result in the Home Health Agency modifying its decision to stop, reduce, or change the visits as they proposed, and to now view the visits as covered. However, you are again on a limb because if the Agency is still making the visits and ultimately they are not covered by Medicare, you are liable. Another possibility is calling other Home Health Agencies in your area and asking if they would be willing to serve you.
Cessation of Visits
This section applies when the Home Health Agency decides to completely stop serving you – that is, you will no longer get visits of any kind. Critically important is that, just as with hospital inpatient care, you have the right to have your discharge from a Home Health Agency looked at by disinterested third party PRIOR to your discharge. Your state’s Quality Improvement Organization (QIO) will do this, but you will have to be on “on your toes” to get this done.
In these cases you will always get a notice from the Home Health Agency that is treating you. This formal notice is called a “Notice of Medicare Provider Non-Coverage.” (This is Form CMS-10123. CMS also calls this the “FFS Expedited Review Generic Notice.”) You must get your written notice no later than two calendar days before your discharge or the discontinuation of your services, but in some cases you will get it earlier than this. It will not go into much detail.
This document will tell you when your covered services will end, how much you will have to pay the agency if you want them to be continued, how to get a fast-track appeal, as well as your right to get a more detailed notice about why your services are ending. You have only until noon on the day after the day you receive this notice to appeal to the Quality Improvement Organization. This is why you have to “be on your toes” and scrutinize all the paperwork you get from your Home Health Agency.
(Each state has a Medicare Quality Improvement Organization (QIO). These are companies composed of physicians, registered nurses, and other highly qualified medical professionals that Medicare contracts with to make independent medical decisions and improve qualify of care. Its toll-free number will be shown on the notice you receive.)
Once you have contacted the Quality Improvement Organization, your Home Health Agency will then have to give you a more in-depth rationale, in writing, regarding the reasons it has for discontinuing your services and discharging you. This notice is called a “Detailed Explanation of Non-Coverage.” (This is Form CMS-10124. CMS also calls this the “FSS Expedited Review Detailed Notice.”) The Quality Improvement Organization will use it and whatever other medical records it wishes to obtain, to make its decision as to whether your care should be extended or not. It will ask you and your physician why you think Medicare should continue paying for your home health services, and the Organization is supposed to rule in two days. What’s in your favor in these appeals is that the burden of proof is on your Home Health Agency to demonstrate that the termination of coverage is the correct decision.
If the decision reaffirms the discontinuation of visits and your discharge, you have to decide if you will go along with it. If your decision is that you need more care, you’ll be on your own. You can arrange for it, but you will have to either pay it out-of-pocket or hope that you get a favorable decision by using the next appeals step.
This next step of appeal is called the “Fast Track Reconsideration–72 Hour Turnaround Request”. It’s outlined in section 2.7a on page 198 of Managing Your Medicare. The notice you get from the Quality Improvement Organization will also tell you how to do this. Basically, it involves calling the toll-free number of the Qualified Independent Contractor (QIC) that will be in your notice, and requesting this appeal step. But remember if you do go for the fast track appeal, you have only until 12 Noon on the day before the day you your care will end to appeal to them. The reason that this is called the 72-hour turnaround is that you should get your decision in this time-frame, that is, 72 hours after you make your request. This can be highly beneficial you get a quick decision as to whether your care will be covered, or if you’re liable for its cost.
(The Qualified Independent Contractor is an outfit Medicare contracts with to make independent decisions in certain appeals steps. Additional information about contacting them is shown below.)
Your Special Home Health Agency Rights
As indicated above, you have some special rights with regard to the Home Health Agency benefit. To some extent these are similar to your other Medicare rights, but Medicare also recognizes that your contact with your Home Health Agency is in the privacy of your home, and, unlike hospitals or skilled nursing facilities where public inspections continue, Home Health Agency care is different because it takes place in a private domain. Reflecting this, for an example, is that Medicare requires a special toll-free phone service to your state’s health facility inspectors for beneficiaries to report problems with Home Health Agencies; this is not required for any other type of Medicare provider.
These are your rights under statue and regulation as a Medicare beneficiary with regard to Home Health Agency services. Remember, they are your rights. Use them!
- Notification of Rights: The Home Health Agency must provide the beneficiary with a written notice of the beneficiary’s rights in advance of furnishing care. And remember that the beneficiary’s guardian or family can exercise these rights if the beneficiary has been judged incompetent.
- Right to be Informed about and to Participate in Planning Care and Treatment: This right is critically important. The beneficiary has the right to be informed, in advance, about the care to be furnished, and of any changes in the care to be furnished. In addition, the Home Health Agency must advise the beneficiary – again, in advance – of the disciplines that will furnish the care (for example, a registered nurse, a physical therapist, etc.), and the frequency of the visits to be furnished. The Home Health Agency must also inform the beneficiary of any change in the plan of care before the change is made. And, at all times, the beneficiary has the right to participate in planning their care. Therefore, the Home Health Agency must advise the beneficiary – again, in advance – of their right to participate in the planning of their care and treatment, and in planning any changes to their care and treatment.
- Right to Formally Complain and to Grieve: The beneficiary has the right to make complaints or voice grievances regarding treatment or care that is (or fails to be) furnished, or about anyone furnishing the services, and must not be subject to discrimination or reprisal for doing so. The Home Health Agency must investigate complaints made by the beneficiary regarding treatment or care that is furnished (or fails to be) furnished, and must document both the existence of the complaint and the resolution of the complaint. See below about the Home Health Agency hotline.
- Right to be Informed of Liability for Payment: The beneficiary has the right to be advised, before care is initiated, of the extent to which payment for the Home Health Agency services may be expected from Medicare or other sources, and the extent to which payment may be required from the beneficiary. Therefore, before the care is initiated, the Home Health Agency must inform the beneficiary, orally and in writing, of the extent to which charges will be covered by Medicare, or by any other Federal program, and what charges the beneficiary will be expected to pay. In addition, as these changes, the Home Health Agency must inform the beneficiary as soon as possible. This must always be done within 30 calendar days of when it becomes aware of the change. All these notices must be given orally and in writing.
- Right to be Informed about the Home Health Agency Hotline: The beneficiary has the right to be notified of the availability of the Home Health Agency hotline in their state; when the Home Health Agency accepts the beneficiary, it must advise the beneficiary in writing of the toll-free telephone number, its hours of operation, and that the purpose of the hotline is to receive complaints and questions about Home Health Agencies.
- Right of Respect for Property: The beneficiary has the right to have his or her property treated with respect, and may also make complaints or voice grievances with regard to this right.
- Right to Information about Advanced Directives: The Home Health Agency must inform and distribute written information to the beneficiary, in advance, concerning its policies on advance directives, including a description of the applicable state laws.
- Right of Respect for Confidentiality: The beneficiary has the right to confidentiality of their medical records maintained by the Home Health Agency.
Additional Contact Information
Quality Improvement Organizations (QIO)
Each state has a Quality Improvement Organization. Its phone number may be found on the CD that comes with Managing Your Medicare; on the www.medicare.gov website; or by calling 1-800-MEDICARE; or you may get it from your State Health Insurance Counseling Program, whose number is on the back of your Medicare and You handbook.
Regional Home Health Intermediaries (RHHI)
If you are in this : The name of the Regional Home Health Intermediary (RHHI) for states or jurisdictions is shown below. You must go through 1-800-MEDICARE (1-800-633-4227) to reach it.
- Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont: Associated Hospital Services
- Delaware, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, Washington DC, West Virginia, Wyoming: Noridian Administrative Services
- Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas: Palmetto (GBA)
- Alaska, Arizona, California, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Oregon, Puerto Rico, Virgin Islands, Washington, Wisconsin: United Government Services
Qualified Independent Contractors (QIC)
Below is a list of states or jurisdictions, followed by the name and contact details for the Qualified Independent Contractor (QIC) serving them (note: the addresses and phone numbers are different):
- Colorado, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Georgia, Florida, Tennessee, South Carolina, North Carolina, Virginia, West Virginia, Puerto Rico, Virgin Islands, Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Jersey, New York, Delaware, Maryland, Pennsylvania, Washington DC
MAXIMUS Federal Services, Inc.
1040 First Avenue – Suite 400
King of Prussia, PA 19406
Phone: 1-484-688-2000 (not toll-free)
- Washington, Idaho, Montana, North Dakota, South Dakota, Iowa, Missouri, Kansas, Nebraska, Wyoming, Utah, Arizona, Nevada, California, Alaska, Hawaii, Oregon, Kentucky, Ohio, Indiana, Illinois, Minnesota, Michigan, Wisconsin
MAXIMUS Federal Services, Inc.
1040 First Avenue – Suite 310
King of Prussia, PA 19406
Phone: 1-484-688-8900 (not toll-free)
Centers for Medicare & Medicaid (CMS) Regional Offices
Following are Regional Office phone numbers for states and jurisdictions:
- Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont: 1-617-565-1232
- New Jersey, New York, Puerto Rico, Virgin Islands: 1-212-616-2222
- Delaware, Washington DC, Maryland, Pennsylvania, Virginia, West Virginia: 1-215-861-4140
- Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee: 1-404-562-7500
- Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin; 1-312-353-7180
- Arkansas, Louisiana, New Mexico, Oklahoma, Texas; 1-214-767-6401
- Iowa, Kansas, Missouri, Nebraska: 1-816-426-2866
- Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming: 1-303-844-4024
- Arizona, California, Hawaii, Nevada: 1-415-744-3602
- Alaska, Idaho, Oregon, Washington: 1-206-615-2354
George Jacobs is a retired Federal employee who worked for the Social Security Administration and the Centers for Medicare & Medicaid Services for over 30 years. Since retiring he has volunteered as a Medicare beneficiary counselor. He sits on the boards of two companies which perform services under Federal contracts for the Medicare Program.
His book, Managing Your Medicare, is available in our Web store.
Click image to enlarge