MCR is a not-for-profit organization dedicated to ensuring that older adults and people with disabilities
get good, affordable health care. The MRC website offers helpful and reliable Medicare information for consumers
and professionals.
MCR's Medicare Rights on Home Health
& Hospice Care Consumer Booklet
Advanced illnesses create new needs for patients and place new demands on families. People with
advanced illnesses may have special skilled nursing or skilled therapy needs, or may need help to manage uncomfortable symptoms.
They may prefer to receive care at home, and families may need assistance with care giving and counseling responsibilities
to help them cope with advanced illnesses .
Medicare offers two benefit options that can help cover these needs. The Medicare Home Health
Benefit can be combined with other Medicare hospital and medical benefits to meet the needs of any advanced illness. The Medicare
Hospice Benefit will organize a team to help people who are terminally ill live as comfortably and as well as possible for
the duration of their lives. Patients can get these benefits whether they are in traditional Medicare or a Medicare HMO.
Home Health
Care
Home health care is care provided at home for homebound patients who need skilled nursing or
skilled therapy. Whether the illness is acute, chronic or advanced, a home health agency can:
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Deliver skilled nursing, skilled therapy, and home health aide services in the patient's
home and supplement the care giving of the family. |
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Provide practical guidance on planning for the illness, and counseling to the patient
and family |
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Provide rehabilitative, maintenance or palliative care in the home. |
Home health care provides the services necessary to care for patients with many different
kinds of illnesses.
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Definition of Skilled Care
Medically reasonable and necessary care performed by a skilled
nurse or therapist. If a home health aide (someone who provides help with bathing, eating and toileting) or other person can
perform this service, it is not considered "skilled care." |
Hospice
Hospice (pronounced HOS-pis) is a unique kind of service provided to people with advanced illness
and limited life expectancies. When the treatment goals have changed from cure to care, a hospice can:
- Manage the patient's pain and other symptoms so that the patient and family can make the most
of the time that remains.
- Deliver palliative care in the patient's home, or in a homelike setting, and supplement the
care giving of the family.
- Provide practical, emotional and spiritual support to both the patient and the family.
Hospice neither shortens nor prolongs life. Instead, it concentrates on improving the quality
of life as much as possible.
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Definition of Palliative Care
The care of patients whose disease is not responsive
to curative treatments or interventions. Palliative care consists of relief of pain and nausea, and psycho-logical, social
and spiritual support services. |
Eligibility
Home Health Care
Under Medicare, home health patients must:
- Have Medicare Part A or B.
- Be homebound. Leaving home must require a considerable and taxing effort.
- Require skilled nursing or skilled therapy services on an intermittent or part-time basis. Home
health aide services will not be covered without an accompanying skilled need.
You need not have been hospitalized to qualify. You can be eligible whether your condition
is acute, chronic or terminal.
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Hospice
15 pages available to print out.
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The 6 month rule is gone! Respite care no longer limited to twice a year! Also see article "Hospice Six-month "Limit" Clarified by Congress: [I]t is the attending physician's and medical director's clinical
judgment regarding the normal course of the individual's illness, and not the accurate prediction of the patient's life expectancy
that is the deter-minant for admission [to hospice]" - Benefits Improvement and Protection Act of 2000 (BIPA) recently adopted
by Congress." |
Under Medicare, hospice patients must:
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Have Medicare Part A. |
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Be certified by an attending physician and the hospice medical director to have an advanced illness with a
life expectancy of six months or less. NOTE: See new ruling at top. |
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Consent in writing to choose palliative rather than curative care. You need not be in a severely deteriorated
physical condition or in a medical crisis to qualify. |
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Talking With Physicians About Home Health and Hospice
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| Doctors and social workers who work with patients with advanced illnesses recommend the following
tips: |
| 1. |
Do not wait for your doctor to suggest home health care or hospice. Feel free to start discussions
about care options. |
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Ask your doctor for a clear statement of prognosis for the advanced illness. Ask what symptoms and
clinical evidence the prognosis is based upon, and what criteria or new evidence would change the prognosis. |
| 3. |
Ask what needs or symptoms that you now have or might have would qualify you for home health or
hospice. |
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Bring up the treatment goals that are important to you, whether they be maximizing the possibility
of cure, maximizing the length of life, managing pain and discomfort, or staying home as much as possible. |
| 5. |
Discuss the practical implications
of choosing the home health or hospice benefit with a social worker. |
Home
Health Coverage
If you qualify, you may receive up to a total of 35 hours per week of skilled nursing and home health aide
services. You may receive additional hours of skilled therapy and medical social services. The amount of care allowed in the
plan of care depends upon your health status. Go to above section to read full details.
Hospice
Coverage
The hospice benefit provides four levels of care: I) routine home care; 2) continuous home nursing care; 3)
respite care; and 4) general inpatient care. Covered services include: (go to link)
- You must be certified byyour doctor to meet the requirements for eligi-bility. Your doctor should specify
the skilled services, frequency and duration of care needed.
- Your doctor's referral or letter of certification must be sent to a Medicare-Certified Home Health Agency
(CHHA). The CHHA will send a nurse to evaluate you for a plan of care.
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What Can You Do If Your Are Disatisfied or Denied Care? |
| The procedures for grievances and appeals in home health agencies and hospice
agencies are included in the papers given to patients by agency nurses during the initial evaluation.
1. You should discuss complaints and requests
for further services with the nurse administering the care plan.
2. You should complain to the program administrator
(or, in hospice, the supervising physician) of the agency. Also, your doctor may be able to help you work with the CHHA to
obtain care. Ask your doctor to communicate with the CHHA about necessary changes to your plan of care.
3. You may contact the State
Department of Health, or the federal government at 1-800-HHS-TIPS, with complaints. You may also try changing agencies until
you find one that delivers satisfactory care. You may change CHHAs at any time, and hospices once every benefit period.
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