Medicare Advantage and Home Health in Los AngelesWhat Changes and What to Ask Your Plan

Your parent's doctor says home health would help. Then you look at the insurance card and see the name of a private plan, not just "Medicare." Now you wonder if the rules are different.

Some are. This guide explains how home health works for people with a Medicare Advantage plan, what may change, and the questions to ask your plan before the first visit. It is written for families in Los Angeles, and the steps work anywhere.

What a Medicare Advantage plan is

Medicare Advantage is also called Medicare Part C. A private company runs the plan, and Medicare pays the company to provide your Medicare benefits. According to medicare.gov, these plans must cover the same services Original Medicare covers, and that includes home health. But the plan can set its own rules for how you get those services.

In Los Angeles, many older adults have this kind of plan. The first thing to do is look at the card. If it shows the name of a private company, your parent likely has Medicare Advantage. If it is the red, white, and blue Medicare card only, your parent likely has Original Medicare. If you are not sure, call 1-800-MEDICARE (1-800-633-4227) and ask.

What stays the same

• The reason for home health. A doctor still has to decide that home health is needed. Only the doctor decides, and the plan reviews it.
• The kinds of care. Skilled nursing, physical therapy, occupational therapy, speech therapy, and medical social work are the same services families ask about under Original Medicare. Our guide on what Medicare covers lists them.
• The goal. Care at home, with a plan set by the doctor and the care team.
• The face-to-face visit. Medicare requires a face-to-face visit with a doctor or nurse practitioner, within 90 days before or 30 days after home health starts. Some doctors make house calls. Ask us, and we will help you find one. That doctor is independent of Comfort Care, and the choice is yours.

What may change

Medicare Advantage plans may use their own networks and rules. Here is what that can mean in everyday life.

1. A network of agencies

With Original Medicare, you may choose any Medicare-certified home health agency that serves your area. Many Medicare Advantage plans work with a list of agencies, called a network. Some plans pay for care only from agencies on that list. Some pay less for agencies outside it. The rules depend on the plan, so ask.

2. Approval before care starts

A plan may ask for approval before home health begins. This is often called prior authorization. The agency or the doctor's office usually sends the request. It can take a little time, so ask the plan how long it usually takes.

3. A referral from the primary care doctor

Some plans want a referral from your parent's primary care doctor before they pay for specialists or services. Ask if home health needs one.

4. Costs

Under Original Medicare, covered home health services cost $0, and equipment is 20% of the Medicare-approved amount after the Part B deductible. Medicare Advantage plans may use their own costs and rules. Your parent's plan may charge a copay for some services or for equipment. Ask the plan for the numbers in writing. Our coverage page explains what we check before care starts.

5. Who decides how many visits

The doctor writes the plan of care. A Medicare Advantage plan may review it and ask questions. If the plan says no to something the doctor ordered, you have the right to appeal. The plan must tell you how, in writing.

Eight questions to ask your plan

Call the number on the back of the card. Have the card and a pen ready. Ask:

1. "Does my plan cover home health after a hospital stay, or after a doctor's order?"
2. "Do I have to use agencies in your network? Can I check if Comfort Care Home Health Services is in it?"
3. "If an agency is out of network, what happens? Will you pay anything?"
4. "Do you need to approve home health before it starts? Who sends the request?"
5. "How long does approval usually take?"
6. "Do I need a referral from my primary care doctor?"
7. "What will I pay for home health visits and for equipment?"
8. "If you say no, how do I appeal, and how fast do you answer?"

Write down the date, the name of the person you spoke with, and what they said. If a call takes a long time, you will be glad you did.

What to do on discharge day

If your parent is leaving the hospital, tell the discharge planner right away that they have a Medicare Advantage plan. Give them the name of the plan and the member number. The hospital team often works with the plan every day and knows which agencies it uses. Our hospital discharge checklist shows what else to ask before you leave.

If you want a certain agency, say so. Then ask if the plan will cover that agency. If it will not, ask what the options are. You may still be able to ask for an exception. The plan will tell you the steps.

Calling an agency about your plan

A good agency will look at the plan with you. When you call us at Comfort Care, we check your benefits before care starts and tell you in writing what, if anything, you would pay. We accept Medicare and private insurance. Families may call first, and we coordinate the order with the doctor. Our guide on how to choose a home health agency lists what else to ask.

Only the doctor decides whether home health fits your parent. What we can do is explain the steps and help you get the paperwork moving.

If you want to understand plan choices

Each fall, Medicare has an open enrollment period when people can compare plans. If your parent's plan makes home health hard, look at the options then. Free, unbiased help is available. In California, the HICAP program (the state's Medicare counseling program) offers counseling. You can find it through medicare.gov or by calling 1-800-MEDICARE.