Paying for Home Care & Hospice

Valley Home Care accepts assignment of benefits from Medicare A, pending any regulatory changes. This means your home care services are covered if assessed to meet Medicare criteria. Your nurse will let you know in advance when you no longer meet the criteria and discharge is planned.

You may receive a letter from the Medicare Benefits Administrator/United Government Services regarding Utilization of Services. This is not a bill. It is to keep you informed of services we have billed for.

What is not covered by Medicare?

Services not covered by Medicare include:

• Unskilled care/custodial care
• Non-medical equipment
• Live-in caregiver
• Private duty requests

What are the basic Medicare qualifying criteria?

• You are under doctor’s orders for care.
• You are confined to home for illness/injury.
• You need skilled care.
• You required “part-time” care.
• Your care meets Medicare’s description of “Reasonable and Necessary.”

If you qualify for Medicare home care services:

• Medicare regulations state that the Home Health Agency is responsible for payment of outpatient rehabilitation therapy and certain medical supplies and so must be billed with your home care services.
• You must tell your nurse or therapist if you are already receiving or will be starting outpatient rehabilitation therapy services while you are on service with Valley Home Care.
• You must tell your nurse or therapist if you are using any medical supplies (e.g., ostomy supplies).
• You must tell your nurse or therapist if your services are related to a motor vehicle accident or liability case.

Medicare HMO:

Your insurance company will be notified by phone, and authorization will be obtained for all services. Depending on the agency’s contracts with the HMO, claims are submitted and reviewed by your insurance company. Payment is always subject to provisions of your policy.

You must tell your nurse or therapist if there is a change in your insurance and you have recently enrolled in a Medicare HMO.

Valley Home Care accepts assignment of benefits from Medicaid. This means your home care services are covered if assessed to fit Medicaid criteria by the admitting professional.

Medicaid HMO: New Jersey Medicaid contract HMO’s require pre-authorization. Not all HMOs are contracted with this agency. Payment will be based on authorization, contracting and provisions of the Medicaid HMO policy.

You must tell your nurse or therapist if your insurance recently changed or switched to a Medicaid HMO.

Your insurance company will be notified by phone for authorization of services. Claims are reviewed by your insurance company, and payment is subject to provisions of your policy.

We will make every attempt to resolve any billing or claim issue with your insurance company. However, the patient is ultimately responsible for balances not reimbursed by the insurance company, i.e., deductibles, coinsurance/copay, out of network penalties, out of pocket expenses, policy limits and denials of coverage. There are no guarantees of payment, although pre-authorization may have been obtained. You will be informed of any additional costs to you that are not covered. Please contact your insurance company directly if you have any questions about your coverage.

Medicare Part B deductible and co-payments are the beneficiary's responsibility. Non-covered services can be paid for privately. Installment plans and credit card payment can be arranged by the Billing Department. If you cannot afford to pay, patients may apply with Valley Home Care for charity care based on New Jersey State Department of Health guidelines.

The amount of services and length of time you receive services will depend upon what your physician has ordered and your insurance authorization. We will notify you and your physician if your insurance will not cover all of the services ordered and will discuss other care and/or payment options.

Skilled professional and support services are provided in your place of residence. The services are provided on a part-time basis under your physician’s orders.

Staff are scheduled to make visits from 8 a.m. to 6 p.m., Monday through Friday. Weekend, evening and holiday visits are scheduled and made as needed. The office and switchboard are open from 8 a.m. to 5 p.m., weekdays. Calls made to the agency after 5 p.m. or on a weekend or holiday are picked up by the answering service, who will contact the on-call nurse to respond to you or take a message when appropriate.

Account inquiries should be directed to these Billing Department numbers:

• Medicare – 201-291-6333
• Medicaid – 201-291-6000, ext. 7467
• Commercial/managed care – 201-291-6000, ext. 7465 or 7468
• No insurance/ credit card – 201-291-6225 or 6215
• Charity care – 201-291-6234

Medicare has a comprehensive hospice benefit that covers the full cost of standard hospice services and appropriate durable medical equipment such as hospital beds, wheelchairs and walkers. Medicare also pays for prescribed medications related to the patient's primary hospice diagnosis. Valley Hospice is reimbursed by the Medicare hospice benefit on a per diem (daily) rate.

Medicare HMOs

Medicare HMOs are required to make hospice care available. Those enrolled in these types of programs are entitled to hospice services through Medicare, Part A. When the Hospice Medicare Benefit is elected, the patient does not give up other HMO services to receive hospice care. Patients enrolled in Medicare HMOs have the right to choose any Medicare-certified hospice program.

Advantages of electing the Medicare hospice benefit:

• It provides support and services to the patient and family in a team approach.
• It gives Valley Hospice the freedom to make more frequent visits when needed.
• It reduces the financial strain of costly drugs.
• It reduces the financial burden of medical equipment.
• It allows loved ones respite care when a break is needed.

If a patient elects the Medicare hospice benefit, does the patient give up all other Medicare benefits?

Absolutely not. In order to elect the Medicare hospice benefit, the patient must be enrolled in Medicare Part A. However, the patient may still use all appropriate Medicare Part A and Part B benefits, if enrolled, for the treatment of health problems unrelated to his or her terminal illness. When standard benefits are used for conditions unrelated to terminal illness, the patient is responsible for Medicare’s deductible and coinsurance amounts.

Medicaid also has a hospice benefit for patients who qualify. It pays for 100 percent of the interdisciplinary team services, durable medical equipment and all medications related to the patient's terminal diagnosis. If the patient is dually eligible for Medicare and Medicaid, approved nursing homes’ room and board will also be covered by Medicaid.

HMOs, PPOs and private insurance plans provide a hospice benefit in most cases. Depending on the individual’s policy, hospice services may require pre-authorization. Valley Hospice will contact the patient’s insurance on his or her behalf. Coverage is subject to policy limitations which may include deductibles and co-pays.

In general, once elected, most hospice insurance programs will not pay for:

• Treatment of services not related to the terminal illness
• Care provided by another hospice
• Care from another provider that duplicates care the patient's hospice is required to furnish
• Room and board
• 24-hour live-in caregiver

Any services outside the Hospice Plan of Care must be pre-authorized by the Hospice team.

Valley Hospice will contact your insurance for verification of coverage and authorization of hospice services, supplies, durable medical equipment and drugs.

• Not all insurance policies cover these services. Your plan may have benefit limits, co-pays, deductibles or will deny services. The responsible party will be billed as determined by your insurance company.
• For additional information about your insurance benefits or hospice coverage, please contact your insurance company directly or contact your employer benefits department.
• Remember to inform your nurse of any insurance changes during your hospice services.

As an independent community-based, not-for-profit healthcare provider, Valley Hospice accepts eligible hospice patients, regardless of their ability to pay. The goal at Valley Hospice is never to deny care to those who need it. Charity care applications are available to these individuals.

Valley Hospice will provide hospice services in a cost-effective way for our patients. If you cannot afford to pay, we offer Charity care sliding fee schedules, payment plans and credit card payment options for your convenience.

Account inquiries should be directed to these Billing Department numbers:

• Medicare hospice benefit - 201-291-6000, ext. 7074
• Medicaid hospice benefit - 201-291-6000, ext. 7467
• Commercial/managed care - 201-291-6000, ext. 7468 or 7465
• No insurance/credit cards - 201-291-6225 or 6215
• Charity care - 201-291-6234