Home health care: the complete guide for families

Home health brings nurses and therapists to the home of someone who is recovering from a hospital stay, a surgery or a hard turn in an illness, and who can’t easily get out to an office. Under Original Medicare, people who qualify pay nothing for covered home health services.¹ This guide covers all of it: who qualifies, what Medicare covers, how care starts, who comes to the house, how long it lasts, what it costs, your rights and how to choose an agency. Each part links to a note that goes deeper.

The short answer

• Home health is skilled care at home: nursing, physical therapy, occupational therapy, speech-language pathology and medical social services, with a home health aide when skilled care is part of the plan.¹
• Medicare covers it when a doctor or allowed provider orders it, the person needs part-time or intermittent skilled care, and the person is homebound.^1,2
• Under Original Medicare, covered home health services cost nothing. Medical equipment costs 20% of the Medicare-approved amount after the Part B deductible.¹
• The first visit comes within 48 hours of the referral or of getting home from the hospital, unless the doctor orders a different start date.³
• There’s no set end date. The plan of care is reviewed at least every 60 days, and care continues while the person still qualifies.^2,4

What home health is, and what it isn’t

Home health is medical care. A registered nurse checks a healing wound, teaches someone a new medicine or watches a condition that could turn serious. A physical therapist helps someone walk safely again. A speech-language pathologist works on swallowing or speech after a stroke. The visits are part time: the nurse or therapist comes, does the work, teaches the family and leaves.

Home health isn’t round-the-clock help. Medicare doesn’t cover 24-hour care at home, meal delivery, homemaker services like shopping and cleaning that aren’t part of the care plan, or personal care when that’s the only care someone needs.¹ That kind of help is usually called home care, and it’s paid for differently. Home health or home care explains the difference.

Who qualifies

Medicare covers home health when all of these are true:²

• A doctor or allowed provider is in charge. The person is under the care of a doctor or an allowed provider, which includes a nurse practitioner, a clinical nurse specialist or a physician assistant, who sets up the plan of care and reviews it regularly.
• The person needs skilled care part time. That means intermittent skilled nursing, other than drawing blood, or physical therapy, speech-language pathology or continued occupational therapy.
• The person is homebound. Leaving home isn’t recommended because of their condition, or they have trouble leaving without help, and they’re normally unable to leave home because leaving takes a lot of effort.¹
• The doctor or allowed provider saw the person about it. The visit, called a face-to-face encounter, has to happen within the 90 days before home health starts or within 30 days after, and it has to be about the reason for home health.⁵
• The agency is Medicare-certified.

Homebound doesn’t mean never leaving. Brief trips for medical care, and short, infrequent outings like religious services or adult day care, don’t disqualify someone.² Who qualifies for home health care goes through each condition with examples.

What Medicare covers

• Part-time or intermittent skilled nursing, such as wound care for a pressure sore or a surgical wound, teaching the patient and caregiver, IV or nutrition therapy, injections, and monitoring a serious illness or unstable health¹
• Physical therapy, occupational therapy and speech-language pathology, when the person meets certain conditions¹
• Medical social services¹
• Part-time or intermittent home health aide care, such as help with walking or bathing, but only while the person is also getting skilled nursing or therapy¹
• Durable medical equipment and medical supplies for use at home¹
• Injectable osteoporosis drugs for women who meet certain criteria¹

Part time has a limit. Skilled nursing has to be needed fewer than 7 days a week, or every day for less than 8 hours a day for up to 21 days.² Medicare also pays only one home health agency at a time.²

How care starts

Home health starts with an order from a doctor or allowed provider, who has to order it both to start and to continue it.² Most referrals come from a hospital, a doctor’s office or a skilled nursing facility. A family can also call an agency directly, and the agency works with the doctor on the order.

The first visit comes within 48 hours of the referral, or within 48 hours of the person getting home from the hospital, unless the doctor orders a different start date.³ A registered nurse makes it, unless therapy is the only service ordered, when a therapist can.³ Within 5 days of the start of care, the agency finishes a full assessment of the person’s health, home and medicines.³

From that assessment and the doctor’s orders comes the plan of care: the diagnoses, the services and how often they come, the medicines and treatments, the safety measures, the goals, and what the person and family will be taught.⁴ The agency gives the person and family a written copy of the visit schedule, the medication schedule, the treatments, and the name and contact information of the agency’s clinical manager.⁴ The first home health visit covers what to have ready and what to ask.

Who comes to the house

Depending on the plan, the team can include registered nurses, physical and occupational therapists, a speech-language pathologist, a medical social worker and a home health aide, each working under the plan the doctor signed.⁶ An aide works from written instructions a nurse or therapist prepares, and when the person is also getting skilled care, a nurse or therapist checks the aide’s work in the home at least every 14 days.⁷ The home health team, role by role explains what each person does.

How long it lasts

There’s no set number of visits or weeks. Medicare pays agencies in 30-day periods, and a person can have more than one.² The doctor or allowed provider recertifies the need for care at least every 60 days, and the plan of care is reviewed at least that often.^4,5

Home health ends when the goals of the plan are met, when Medicare or another payer will no longer pay for it, or when the person chooses to stop.⁸ Before Medicare-covered services end, the agency has to give a Notice of Medicare Non-Coverage at least 2 days ahead. It explains how to ask an independent reviewer for a fast appeal.² How long home health lasts walks through recertification, discharge and appeals.

What it costs

Under Original Medicare, covered home health services cost nothing, and medical equipment costs 20% of the Medicare-approved amount after the Part B deductible.¹ Before care begins, the agency should tell the person how much of the bill Medicare will pay, both out loud and in writing.² If it expects Medicare won’t pay for a service or supply, it has to say so in writing first, on a form called an Advance Beneficiary Notice.^1,2

A Medicare Advantage plan may require an agency in its network, so call the plan before choosing.² Who pays for home health covers Medicare Advantage, Medi-Cal and having both.

Your rights

Before care starts, the agency has to give the person a written notice of their rights, in a form they can understand, with the name and phone number of the administrator to call with a complaint.⁸ The person has the right to take part in planning their care, to be told about it and to refuse it, to be told what Medicare pays and what they’ll owe, to complain without retaliation, and to get language help and disability aids at no cost.⁸ Your rights as a home health patient lists them all and says who to call.

Choosing an agency

The person chooses the agency, and the doctor, the hospital discharge planner or whoever makes the referral should honor that choice. Insurance and availability can narrow the list.² Medicare’s Care Compare, at Medicare.gov, lists Medicare-certified agencies by area.² Medicare’s own checklist suggests asking any agency:²

• Is the agency Medicare-certified, and does it give every service the plan calls for?
• Does it have staff for the person’s special needs, like a language or a condition?
• How soon can care start?
• Who answers at night and on weekends if something goes wrong?
• Will someone explain what Medicare covers and what the person might owe?

Notes on specific conditions

Rounds has notes on caring for common conditions at home:

• The first weeks home after a hospital stay
• Keeping medicines straight after the hospital
• Heart failure at home
• COPD at home
• Diabetes at home
• Stroke recovery at home
• Joint replacement recovery at home
• Wound care at home
• Dementia care at home
• Parkinson’s disease at home
• Preventing falls at home