If your home health agency believes Medicare will not pay for your care before it starts, your rights will depend upon whether the home health agency is willing to treat you anyway and whether you have a Medicare Advantage plan (Medicare private health plan) or Original Medicare.  

Original Medicare

If your home health agency will not agree to treat you and will not charge you for its initial assessment, you will need to find another home health agency.

If your home health agency will agree to treat you even though it believes Medicare will not cover your care, it must typically provide you with a Home Health Advance Beneficiary Notice (HH ABN).  The HH ABN will give you three options:

• You can turn down care. In this case, you can look for another Medicare-certified home health agency (HHA).
• You can ask for care and agree to pay for care yourself without billing Medicare.
• You can ask for care and ask the HHA to try to bill Medicare and/or other insurance. This is called demand billing.

If you choose the last option and ask the agency to demand bill Medicare, you will get a Medicare Summary Notice showing Medicare’s payment decision. You may need to pay for your home health care before you get the MSN. If Medicare approves coverage, the home health agency must pay you back. If Medicare denies the claim, you can appeal to Medicare for coverage by following the appeal instructions on your MSN.

Medicare Advantage plan

If you are in a Medicare private health plan, and your plan refuses to approve home health services that you need, you will generally have to ask for an “expedited reconsideration” of this decision.