Medicare & Home Health Care
This ocial government booklet tells you:
■ Who’s eligible
■ What services are covered
■ How to nd and compare home health agencies
■ Your Medicare rights
CENTERS for MEDICARE & MEDICAID SERVICES
e information in this booklet describes the Medicare Program at the time this
booklet was printed. Changes may occur aer printing. Visit Medicare.gov, or call
1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY
users can call 1-877-486-2048.
“Medicare & Home Health Care” isn’t a legal document. Ocial Medicare
Program legal guidance is contained in the relevant statutes, regulations, and
rulings.
3
Table of Contents
Section 1: Medicare Coverage of Home Health Care ������������������������� 5
Who’s eligible ������������������������������������������������������������������������ 5
How Medicare pays for home health care ��������������������������������������������� 7
What’s covered ����������������������������������������������������������������������� 7
What isn’t covered �������������������������������������������������������������������10
What you pay ������������������������������������������������������������������������10
“Advance Beneciary Notice of Noncoverage “ (ABN) ��������������������������������10
Your right to a fast appeal �����������������������������������������������������������12
Section 2: Choosing a Home Health Agency �����������������������������������15
Finding a Medicare-certied home health agency �����������������������������������15
Home Health Agency Checklist ������������������������������������������������������16
Special rules for home health care ���������������������������������������������������17
Find out more about home health agencies �����������������������������������������17
Section 3: Getting Home Health Care �������������������������������������������19
Your plan of care ��������������������������������������������������������������������19
Your rights getting home health care ������������������������������������������������20
Where to le a complaint about the quality of your home health care ���������������21
Home Health Care Checklist ���������������������������������������������������������22
Section 4: Getting the Help You Need �������������������������������������������23
Help with questions about home health coverage �����������������������������������23
What you need to know about fraud ������������������������������������������������24
Denitions �����������������������������������������������������������������������������27
4
Home health care
Many health care treatments that were
once oered only in a hospital or a doctor’s
oce can now be done in your home.
Home health care is usually less expensive,
more convenient, and as eective as care
you get in a hospital or skilled nursing
facility. In general, the goal of home
health care is to give treatment for an
illness or injury. Where possible, home
health care may help you recover, regain
your independence, and become more
self-sucient. Home health care may also
help you maintain your current condition
or level of function, or slow decline.
Medicare pays for you to get health care services in your
home if you meet certain eligibility criteria, and the
services are considered reasonable and necessary for the
treatment of your illness or injury.
If you get your Medicare benets through a Medicare
health plan (not Original Medicare) check with your plan
to learn what home health benets are covered.
Words in red
are dened on
pages 27–28.
5
Section 1:
Medicare Coverage of Home Health Care
Who’s eligible
If you have Medicare, you can use your home health benets if:
●
You’re under the care of a doctor or other health care
provider (including a nurse practitioner, a clinical nurse
specialist, and physician assistant), and you’re getting
services as part of a care plan that your doctor or allowed
provider established and reviews regularly.
●
Your doctor or allowed provider certies that you need one
or more of these:
■ Intermittent skilled nursing care (other than drawing
blood)
■ Physical therapy
■ Speech-language pathology services
■ Continued occupational therapy
■ Home health aide services
(Read page 9 for more details on these services.)
●
e home health agency caring for you is Medicare-certied.
●
Your doctor or allowed provider certies that you’re
homebound. To be homebound means:
■ You have trouble leaving your home without help (like
using a cane, wheelchair, walker, or crutches; special
transportation; or help from another person) because of an
illness or injury, or leaving your home isn’t recommended
because of your condition.
■ You’re normally unable to leave your home, but if you do it
requires a major eort.
■ You may leave home for medical treatment or short,
infrequent absences for non-medical reasons, like an
6 Section 1: Medicare Coverage of Home Health Care
occasional trip to the barber, a walk around the block, or
attendance at a family reunion, funeral, graduation, or other
infrequent or unique event. You can still get home health care if
you attend adult day care or religious services.
●
Your doctor or allowed provider documents that they’ve had a
face-to-face encounter with you (like an appointment with your
primary care doctor) within the required timeframes and that the
encounter was related to the reason you need home health care.
Who isn’t eligible
If you need more than intermittent skilled nursing care, you don’t
qualify for home health services. Medicare denes “intermittent” as
skilled nursing care that’s needed:
■ Fewer than 7 days each week.
■ Daily for less than 8 hours each day for up to 21 days.
Medicare may extend the three-week limit in exceptional
circumstances.
If you’re expected to need full-time skilled nursing care over an
extended period, you won’t usually qualify for home health benets.
7Section 1: Medicare Coverage of Home Health Care
How Medicare pays for home health care
Medicare pays for covered home health services you get during a 30-
day period of care. You can have more than one 30-day period of care.
Payment for each 30-day period is based on your condition and care
needs.
Getting treatment from a home health agency that’s Medicare-certied
can lower your out-of-pocket costs. AMedicare-certied home health
agency agrees to:
■ Be paid by Medicare
■ Accept only the amount Medicare approves for their services
Medicare’s home health benet only pays for services you get from
the home health agency. Other medical services and equipment are
generally still covered as part of your other Medicare benets.
Note: Before your home health care begins, the home health agency
should tell you how much of your bill Medicare will pay. e agency
should also tell you if Medicare doesn’t cover any of the items or
services they give you, and how much you’ll have to pay for them. ey
should explain it to you both verbally and in writing.
What’s covered
If you’re eligible for home health care, Medicare covers these services
if they’re reasonable and necessary for the treatment of your illness or
injury. Medicare covers skilled nursing and therapy services when your
doctor or allowed provider determines that the care you need requires
the specialized judgment, knowledge, and skills of a nurse or therapist.
●
Skilled nursing care: Medicare covers skilled nursing care when the
services you need:
■ Require the skills of a nurse.
■ Are reasonable and necessary for the treatment of your illness
or injury.
■ Are given on a part-time or intermittent basis (Medicare
8 Section 1: Medicare Coverage of Home Health Care
won’t cover a visit if you’re only having blood drawn). “Part-
time or intermittent” means you may be able to get home
health aide and skilled nursing services (combined) any
number of days per week as long as the services are given:
■ Fewer than 8 hours each day.
■ 28 or fewer hours each week (or up to 35 hours a week in
some limited situations).
You can get skilled nursing services from a registered nurse or a licensed
practical nurse. If you get services from a licensed practical nurse, a
registered nurse will supervise your care. Home health nurses give
direct care and teach you and your caregivers about your care. ey also
manage, observe, and evaluate your care.
Examples of skilled nursing care include: giving certain IV drugs, certain
injections, or tube feedings; changing dressings; and teaching about
prescription drugs or diabetes care. Any service that you could get safely
and eectively from a non-medical person (including yourself) without
the supervision of a nurse isn’t skilled nursing care.
●
Physical therapy, occupational therapy, and speech-language
pathology services: Your therapy services are considered reasonable
and necessary in the home setting if:
■ ey’re a specic, safe, and eective treatment for your
condition
■ ey’re complex enough that you can only get them safely and
eectively from a qualied therapist (or under the supervision
of a qualied therapist)
■ Your condition requires one of these:
■ erapy to restore or improve functions aected by your
illness or injury
■ A skilled therapist or therapist assistant to safely and
eectively perform therapy to help you maintain your
current condition or prevent your condition from getting
worse
■ e amount, frequency, and duration of the services are
reasonable
9Section 1: Medicare Coverage of Home Health Care
●
Home health aide services: Medicare will pay for part-time or
intermittent home health aide services (like personal care) if you
need them to maintain your health or treat your illness or injury and
if they’re oered by your home health provider. However, Medicare
doesn’t cover home health aide services unless you’re also getting
skilled care. Skilled care includes:
■ Skilled nursing care
■ Physical therapy
■ Speech-language pathology services
■ Continuing occupational therapy, if you no longer need any of
the above
●
Medical social services: Medicare covers these services when a doctor
or allowed provider orders them to help you with social and emotional
concerns that may interfere with your treatment or how quickly you
recover. is might include counseling or help nding resources in
your community. However, Medicare doesn’t cover medical social
services unless you’re also getting skilled care as mentioned above.
●
Medical supplies: Medicare covers supplies (like wound dressings)
when your doctor or allowed provider orders them as part of your
care.
Medicare pays for durable medical equipment separately from your
home health care. e equipment must meet certain criteria, and your
doctor or allowed provider must order it. Medicare usually pays 80% of
the Medicare-approved amount for certain medical equipment, like a
wheelchair or walker. If your home health agency doesn’t supply durable
medical equipment directly, the home health agency sta will usually
arrange for a supplier to bring you the items.
e home health agency must perform an initial assessment of all your
care needs and must communicate those needs to the doctor or allowed
provider responsible for your plan of care. Aer that, the home health
agency must routinely assess your needs. e home health agency is
responsible for meeting all of your medical, nursing, rehabilitative, social,
and discharge planning needs, as noted in your home health plan of care.
Words in red
are dened on
pages 27–28.
10 Section 1: Medicare Coverage of Home Health Care
What isn’t covered
Medicare doesn’t pay for:
■ 24-hour care at home
■ Meals delivered to your home
■ Services, like shopping, cleaning, and laundry
■ Custodial or personal care like bathing, dressing, and using the
bathroom (when this is the only care you need)
Talk to your doctor (or allowed provider) or the home health agency
if you have questions about whether certain services are covered. You
can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call
1-877-486-2048.
Note: If you have a Medicare Supplement Insurance (Medigap) policy or
other health coverage, be sure to tell your health care provider so your
bills get paid correctly.
What you pay
You may have to pay for:
■ Services and supplies that Medicare never pays for, like routine foot
care.
■ Services and supplies that Medicare usually pays for, but won’t
pay for in this instance, when you’ve agreed to pay for them. e
home health agency must give you a notice called the “Advance
Beneciary Notice of Noncoverage” (ABN) in these situations.
■ 20% of the Medicare-approved amount for Medicare-covered
medical equipment, like wheelchairs, walkers, and oxygen
equipment.
“Advance Beneciary Notice of Noncoverage” (ABN)
e home health agency must give you a written notice called an
“Advance Beneciary Notice of Noncoverage” (ABN) before giving you a
home health service or supply that Medicare probably won’t cover for any
of these reasons:
■ e care isn’t medically reasonable and necessary
Words in red
are dened on
pages 27–28.
11Section 1: Medicare Coverage of Home Health Care
■ e care is only nonskilled personal care, like help with
bathing or dressing
■ You’re not homebound
■ You don’t need skilled care on an intermittent basis
When you get an ABN, the notice should describe the service and/
or supply and explain why Medicare probably won’t pay. eABN
gives clear directions for getting an ocial decision from Medicare
about payment for home health services and supplies and for ling
an appeal if Medicare won’t pay.
In general, to get an ocial decision on payment, you should:
■ Keep getting the home health services and/or supplies if
you think you need them. e home health agency must tell
you how much they’ll cost. Talk to your doctor or allowed
provider and family about this decision.
■ Understand you may have to pay the home health agency for
these services and/or supplies.
■ Ask the home health agency to send your claim to Medicare
so that Medicare will make a decision about payment. You
have the right to have the home health agency bill Medicare
for your care.
If Original Medicare pays for your care, you’ll get back all of your
payments, except for any applicable coinsurance or deductibles,
including any coinsurance payments you made for durable medical
equipment.
e home health agency must also give you a “Home Health
Change of Care Notice” (HHCCN) before they reduce or stop
providing any home health services or supplies that end up
changing your plan of care.
Examples:
■ e home health agency makes a business decision to reduce
or stop giving you some or all of your home health services or
supplies.
■ Your doctor or allowed provider has changed or hasn’t
renewed your orders.
Words in red
are dened on
pages 27–28.
12 Section 1: Medicare Coverage of Home Health Care
Your right to a fast appeal
When all of your covered home health services are ending, you
may have the right to a fast appeal if you think these services are
ending too soon. During a fast appeal, an
independent reviewer called a Beneciary and
Family Centered Care Quality Improvement
Organization (BFCC-QIO) looks at your case and
decides if you need your home health services to
continue.
Your home health agency should give you a
written notice called the “Notice of Medicare
Non-Coverage” (NOMNC) at least 2 days before
they end your services. If they don’t give you a notice, ask for it.
Readthe notice carefully. It contains important information about:
■ e date all your covered services will end
■ How to ask for a fast appeal
■ Your right to get a detailed notice about why your services are
ending
■ Any other information Medicare requires
If you ask for a fast appeal, the BFCC-QIO will ask why you
think coverage of your home health services should continue.
eBFCC-QIO will also look at your medical information and talk to
your doctor or allowed provider. You should expect a response from
the BFCC-QIO, generally no later than 3 days aer the eective date of
the NOMNC.
If the BFCC-QIO decides your home health services should
continue, Medicare may continue to cover your home health care
services, except for any applicable coinsurance or deductibles.
If the BFCC-QIO decides that your coverage should end, you’ll have
to pay for any services you got aer the date on the NOMNC that says
when your covered services should end. Your home health agency
must give you an ABN with a cost estimate for these services.
Words in red
are dened on
pages 27–28.
13Section 1: Medicare Coverage of Home Health Care
You may choose to stop getting services on or before the date given
on the NOMNC to avoid paying for any further services. If you
don’t ask for a fast appeal and want to continue getting services
aer the date listed on the NOMNC, your home health agency
must give you an ABN to let you know what you must pay.
For more information on your right to a fast appeal and other
Medicare appeal rights, visit Medicare.gov/appeals. You can also
call 1-800-MEDICARE (1-800-633-4227). TTY users can call
1-877-486-2048.
14
Section 1: Medicare Coverage of Home Health Care
15
Section 2:
Choosing a Home Health Agency
Finding a Medicare-certied home health
agency
If your doctor or allowed provider decides you need home
health care, you may choose an agency from the participating
Medicare-certied home health agencies that serve your area.
Home health agencies are certied to make sure they meet
certain federal health and safety requirements. Find home
health services on Medicare.gov/care-compare.
You have a say in which agency you use, and your doctor (or
allowed provider), hospital discharge planner, or other referring
agency should honor your choice. However, your choices
may be limited by agency availability, the services the agency
provides, or your insurance coverage. If you have a Medicare
Advantage Plan or other Medicare health plan, it may require
that you get home health services from agencies they contract
with. Call your plan for more information.
Words in red
are dened on
pages 27–28.
16 Section 2: Choosing a Home Health Agency
Home Health Agency Checklist
Use this checklist when choosing a home health agency.
Name of the home health agency:
Question Yes No Comments
1. Is it Medicare-certied?
2. Does it oer the specic health care services
I need, like skilled nursing services or
physical therapy?
3. Does it meet my special needs, like language
or cultural preferences?
4. Does it oer the personal care services I
need, like help bathing, dressing, and using
the bathroom?
5. Does it oer the support services I need, or
can help me arrange for additional services,
like a meal delivery service, that I may need?
(Note: ese types of services aren’t
generally covered by Medicare).
6. Can the sta give the type and hours of care
my doctor or allowed provider ordered, and
can they start when I need them?
7. Is this agency recommended by my hospital
discharge planner, doctor (or allowed
provider), or social worker?
8. Is sta available at night and on weekends
for emergencies?
9. Has the agency explained what my insurance
will cover and what I must pay out of pocket?
10. Does it have letters from satised patients,
family members, and doctors/providers that
testify to the home health agency providing
good care?
17Section 2: Choosing a Home Health Agency
Special rules for home health care
In general, most Medicare-certied home health agencies will accept
all people with Medicare. An agency doesn’t have to accept you if it
determines that it can’t meet your medical needs. An agency shouldn’t
refuse to take you because of your condition, unless the agency would
also refuse to take other people with the same condition.
Medicare will only pay for you to get care from one home health agency
at a time. You may decide to end your relationship with one agency and
choose another at any time. Contact your doctor or allowed provider
to get a referral to a new agency. You should tell both the agency you’re
leaving and the new agency you choose that you’re changing home health
agencies.
Find out more about home health agencies
State Survey Agencies inspect and certify home health agencies for
Medicare. Ask them for the state survey report on any home health
agency you’re considering. You can also call 1-800-MEDICARE
(1-800-633-4227). TTY users can call 1-877-486-2048.
In some cases, your local long-term care ombudsman may have
information on the home health agencies in your area. Visit
ltcombudsman.org, eldercare.acl.gov, or call the eldercare locator at
1-800-677-1116.
To nd out more about home health agencies, you can:
■ Ask your doctor (or other provider), hospital discharge planner, or
social worker
■ Ask friends or family about their home health care experiences
■ Use a senior community referral service, or other community
agencies that help you with your health care
18 Section 2: Choosing a Home Health Agency
19
Section 3:
Getting Home Health Care
You need a doctor or allowed provider’s order to start
and continue home health care. Usually, once you’ve been
referred for home health services, sta from the home health
agency will come to your home to talk to you about your
needs and ask you some questions about your health. e
home health agency will also talk to your doctor or allowed
provider about your care and keep them updated on your
progress.
Your plan of care
Your home health agency will work with you and your doctor
or allowed provider to develop your plan of care. A plan of
care lists what kind of services and care you should get for
your health condition. You have the right to be involved in
decisions about your plan of care. Your plan of care includes:
■ What services you need and how they’ll be provided
■ Which health care professionals should give these
services
■ How oen you’ll need the services
■ e visit schedule
■ e medical equipment you need
■ What results your doctor or allowed provider expects
from your treatment
■ Any services provided over the phone or by video
Your home health agency must give you all of the home care
listed in your plan of care, including services and medical
supplies. e agency may do this through its own sta or
through an arrangement with another agency. e agency
could also hire nurses, therapists, home health aides, and
medical social workers to meet your needs.
20 Section 3: Getting Home Health Care
Your plan of care (continued)
Your doctor or allowed provider and home health team will review your
plan of care as oen as necessary, but at least once every 60 days. If your
health condition changes, the home health team should tell your doctor
or allowed provider right away. Your home heath team will:
■ Review your plan of care and work with your doctor or allowed
provider to make any necessary changes.
■ Tell you about any changes in your plan of care. If you have a
question about your care, or if you feel your needs aren’t being met,
talk to both your doctor or allowed provider and the home health
team.
■ Teach you, as appropriate (and family or friends who are helping
you, as applicable), to continue ongoing care you may need,
including wound care, therapy, and disease management to help in
your recovery or to help you stay in your own home. You should
learn to recognize problems like infection or shortness of breath,
and know what to do or whom to contact if they happen.
Your rights when you get home health care
You have a right to:
■ Get a written notice of your rights before your care starts
■ Have your home and property treated with respect
■ Be told, in advance, what care you’ll be getting and when your plan
of care is going to change
■ Participate in your care planning and treatment
■ Get written information about your privacy rights and your appeal
rights
■ Have your personal information kept private
■ Get written and verbal information about how much Medicare is
expected to pay and how much you’ll have to pay for services
■ Make complaints about your care and have the home health agency
follow up on them
■ Know the home health hotline in your state where you can call with
complaints or questions about your care
Words in red
are dened on
pages 27–28.
21Section 3: Getting Home Health Care
Visit Medicare.gov to learn more about your rights and protections.
You can also call 1-800-MEDICARE (1-800-633-4227). TTY users
can call 1-877-486-2048.
Where to le a complaint about the quality of
your home health care
If you have a complaint about the quality of care you’re getting from
a home health agency, you can call:
■ Your state home health hotline. Your home health agency
should give you this number when you start getting home
health services.
■ e Beneciary and Family Centered Care Quality
Improvement Organization (BFCC-QIO) in your state. You
can call 1-800-MEDICARE to get the phone number for your
BFCC-QIO.
22 Section 3: Getting Home Health Care
Home Health Care Checklist
is checklist can help you (and family or friends who are helping you) monitor your
home health care. Use this checklist to help make sure that you’re getting good quality
care.
When I get my home health care Yes No Comments
1. e sta is polite and treats me and my
family with respect.
2. e sta explains my plan of care to
me and my family, lets us participate in
creating the plan, and lets us know ahead
of time of any changes.
3. e sta is properly trained and licensed
to perform the type of health care I need.
4. e agency explains what to do if I have
a problem with the sta or the care I’m
getting.
5. e agency responds quickly to my
requests.
6. e sta checks my physical and
emotional condition at each visit.
7. e sta responds quickly to changes in
my health or behavior.
8. e sta checks my home and suggests
changes to meet my special needs and to
ensure my safety.
9. e sta has told me what to do if I have
an emergency.
10. e agency and its sta protect my
privacy.
23
Section 4:
Getting the Help You Need
Help with questions about coverage
If you have questions about your coverage and you
have Original Medicare, you can visit Medicare.gov, or
call 1-800-MEDICARE (1-800-633-4227). TTY users
can call 1-877-486-2048.
If you get your Medicare benets through a Medicare
Advantage Plan (Part C) or other Medicare health
plan, call your plan.
You can also call the State Health Insurance
Assistance Program (SHIP). SHIPs are state programs
that get money from the federal govenment to give
free local health insurance counseling to people with
Medicare.
SHIP counselors can answer questions about
Medicare’s home health benets and what Medicare,
Medicaid, and other types of insurance pay for. To get
the phone number for your SHIP, visit shiphelp.org or
call 1-800-MEDICARE.
Words in red
are dened on
pages 27–28.
24 Section 4: Getting the Help You Need
What you need to know about fraud
In general, most home health agencies are honest and use correct
billing information. Unfortunately, there may be some that commit
fraud. Fraud wastes Medicare dollars and takes away money that
could be used to pay claims. You play an important role in the ght to
prevent Medicare fraud.
Look for these signs of fraud:
■ Home health visits that your doctor or allowed provider
ordered, but you didn’t get.
■ Visits by home health sta that you didn’t ask for and don’t need.
■ Bills for services and equipment you never got.
■ Fake signatures (yours or your doctor/allowed provider’s) on
medical forms or equipment orders.
■ Pressure to accept items and services that you don’t need or
Medicare doesn’t cover.
■ Items listed on your “Medicare Summary Notice” (MSN) that
you don’t think you got or used.
■ Home health services your doctor or allowed provider didn’t
order. e doctor or allowed provider who approves home
health services for you should know you and should be involved
in your care. If your plan of care changes, make sure your doctor
or allowed provider is involved in making those changes.
■ A home health agency that oers you free goods or services in
exchange for your Medicare Number. Treat your Medicare card
like a credit card or cash. Never give your Medicare or Medicaid
number to people who tell you a service is free, and they need
your number for their records.
e best way to protect your home health benet is to know what
Medicare covers and what your doctor or allowed provider has
planned for you. If you don’t understand something in your plan of
care, ask questions.
Words in red
are dened on
pages 27–28.
25Section 4: Getting the Help You Need
Reporting fraud
If you suspect fraud, you can:
■ Contact your home health agency to be sure the bill is correct.
■ Contact the Oce of Inspector General:
Phone: 1-800-HHS-TIPS (1-800-447-8477)
Fax: 1-800-223-8164 (no more than 45 pages)
Online: http://oig.hhs.gov/fraud/report-fraud/index.asp
Mail: U.S. Department of Health and Human Services
Oce of the Inspector General
ATTN: OIG HOTLINE OPERATIONS
P.O. Box 23489
Washington, DC 20026
Please note that it’s current hotline policy not to
respond directly to written communications.
■ Call 1-800-MEDICARE (1-800-633-4227). TTY users can call
1-877-486-2048.
Important: If you’re reporting a possible case of Medicare fraud,
give as much information as possible. Include the person or
company’s name, address, and phone number, and the basics of
who, what, when, where, why, and how.
26 Section 4: Getting the Help You Need
Fraud Notes
Contact Name:
Company Name:
Address:
Phone Number:
Details: (who, what, when, where, why and how)
Appeal—An appeal is the action you can take if you disagree
with a coverage or payment decision made by Medicare, your
Medicare health plan, or your Medicare drug plan. You can
appeal if Medicare or your plan denies one of these:
■ Your request for a health care service, supply, item, or
prescription drug that you think you should be able to get
■ Your request for payment for a health care service, supply,
item, or prescription drug you already got
■ Your request to change the amount you must pay for a
health care service, supply, item or prescription drug
You can also appeal if Medicare or your plan stops providing
or paying for all or part of a health care service, supply, item, or
prescription drug you think you still need.
Durable medical equipment—Certain medical equipment,
like a walker, wheelchair, or hospital bed, that’s ordered by your
doctor for use in the home.
Medicaid—A joint federal and state program that helps
with medical costs for some people with limited income and
resources. Medicaid programs vary from state to state, but most
health care costs are covered if you qualify for both Medicare
and Medicaid.
Medicare Advantage Plan (Part C)—A type of Medicare
health plan oered by a private company that contracts with
Medicare. Medicare Advantage Plans provide all of your Part A
and Part B benets, with a few exclusions, for example, certain
aspects of clinical trials which are covered by Original Medicare
27
Denitions
28 Denitions
even though you’re still in the plan. Medicare Advantage Plans include:
■ Health Maintenance Organizations
■ Preferred Provider Organizations
■ Private Fee-for-Service Plans
■ Special Needs Plans
■ Medicare Medical Savings Account Plans
If you’re enrolled in a Medicare Advantage Plan:
■ Most Medicare services are covered through the plan
■ Most Medicare services aren’t paid for by Original Medicare
■ Most Medicare Advantage Plans oer prescription drug coverage.
Medicare health plan—Plans oered by a private companies that
contract with Medicare to provide Part A, Part B, and in many cases, Part
D benets. Includes Medicare Advantage Plans and certain other types of
coverage (like Medicare Cost Plans, PACE programs and demonstration/
pilot programs).
Medicare Summary Notice (MSN)—A notice you get aer the doctor,
other health care provider, or supplier les a claim for Part A or Part B
services in Original Medicare. It explains what the doctor, other health
care provider, or supplier billed for, the Medicare-approved amount, how
much Medicare paid, and what you must pay.
Medigap policy—Medicare Supplement Insurance sold by private
insurance companies to ll “gaps” in Original Medicare coverage.
Original Medicare—Original Medicare is a fee-for-service health
plan that has 2 parts: Part A (Hospital Insurance) and Part B (Medical
Insurance). Aer you pay a deductible, Medicare pays its share of the
Medicare-approved amount, and you pay your share (coinsurance and
deductibles).
29
Accessible Communications
Medicare gives free auxiliary aids and services, including information in
accessible formats like braille, large print, data or audio les, relay services
and TTY communications. If you request information in an accessible format
from CMS, you won’t be disadvantaged by any additional time necessary to
provide it. is means you’ll get extra time to take any action if there’s a delay
in fullling your request.
To request Medicare or Marketplace information in an accessible format, you
can:
1. Call us:
For Medicare: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
For Marketplace: 1-800-318-2596
TTY: 1-855-889-4325
2. Email us: altformatrequest@cms.hhs.gov
3. Send us a fax: 1-844-530-3676
4. Send us a letter:
Centers for Medicare & Medicaid Services
Oces of Hearings and Inquiries (OHI)
7500 Security Boulevard, Mail Stop DO-01-20
Baltimore, MD 21244-1850
Attn: Customer Accessibility Resource Sta (CARS)
Your request should include your name, phone number, type of information
you need (if known), and the mailing address where we should send the
materials. We may contact you for additional information.
30
Note: If you’re enrolled in a Medicare Advantage Plan or Medicare drug plan, contact
your plan to request its information in an accessible format. For Medicaid, contact
your State or local Medicaid oce.
e information provided in this document is intended only to be a general
informal summary of technical legal standards. It is not intended to take the place
of the statutes, regulations, or formal policy guidance upon which it is based. is
document summarizes current policy and operations as of the date it was presented.
We encourage readers to refer to the applicable statutes, regulations, and other
interpretive materials for complete and current information.
is product was produced at U.S. taxpayer expense.
Nondiscrimination Notice
e Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny
benets to, or otherwise discriminate against any person on the basis of race,
color, national origin, disability, sex (including sexual orientation and gender
identity), or age in admission to, participation in, or receipt of the services
and benets under any of its programs and activities, whether carried out by
CMS directly or through a contractor or any other entity with which CMS
arranges to carry out its programs and activities.
You can contact CMS in any of the ways included in this notice if you have
any concerns about getting information in a format that you can use.
You may also le a complaint if you think you’ve been subjected to
discrimination in a CMS program or activity, including experiencing
issues with getting information in an accessible format from any Medicare
Advantage Plan, Medicare drug plan, State or local Medicaid oce, or
Marketplace Qualied Health Plans. ere are three ways to le a complaint
with the U.S. Department of Health and Human Services, Oce for Civil
Rights:
1. Online:
https://www.hhs.gov/civil-rights/ling-a-complaint/complaint-process/index.html
2. By phone:
Call 1-800-368-1019. TTY users can call 1-800-537-7697.
3. In writing: Send information about your complaint to:
Oce for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
31
Additional Notes
is booklet is available in Spanish. To get a free
copy, visit Medicare.gov or call 1-800-MEDICARE
(1-800-633-4227). TTY users can call 1-877-486-2048.
Esta publicación está disponible en Español. Para
obtener una copia gratis, visite Medicare.gov o llame al
1-800-MEDICARE (1-800-633-4227). Los usuarios de
TTY pueden llamar al 1-877-486-2048.
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-1850
Ocial Business
Penalty for Private Use, $300
CMS Product No. 10969
August 2023
