Home health after a hospital stay: what Medicare covers and what actually shows up

Home health is one of Medicare’s best benefits and one of its least understood. Families hear “home health was ordered” and imagine an aide moving in. Or they hear it and assume it will cost thousands. Neither is right. Here is what it is, who qualifies, what it costs, and how to make sure it actually happens.

Medicare covers home health when all of the following are true:

• A doctor or allowed practitioner certifies that she needs skilled care: intermittent skilled nursing, physical therapy, speech-language pathology, or continued occupational therapy.
• She is homebound. This does not mean bedbound. It means leaving home takes a considerable and taxing effort, and she needs help or a device to do it, or leaving is medically inadvisable. She can still go to the doctor, to church, to the barber occasionally. Many families wrongly assume their parent is “too well” to qualify.
• She had a face-to-face visit with the certifying practitioner within 90 days before or 30 days after home health starts, related to the reason for care. A hospital stay usually satisfies this.
• The agency is Medicare-certified.

• Skilled nursing: wound care, injections, medication management and teaching, monitoring of a condition, catheter care.
• Physical therapy: strength, balance, walking, transfers, fall prevention.
• Occupational therapy: bathing, dressing, kitchen safety, adapting the home.
• Speech-language pathology: speech, language, cognition and swallowing.
• Medical social services: counseling, connecting to community resources, help with planning.
• Home health aide: bathing, dressing, personal care, but only while she is also receiving skilled nursing or therapy.
• Medical supplies related to the care, such as wound dressings.

Medicare pays the agency directly; there is no deductible or coinsurance for home health services. Durable medical equipment ordered alongside it, a walker or hospital bed, is covered separately under Part B with the usual 20% coinsurance.

• 24-hour care at home.
• Meals delivered to the home.
• Housekeeping, shopping or laundry when that is the only care needed.
• A home health aide alone, without skilled nursing or therapy.
• Custodial care, meaning help with daily activities, as the only need.

You have the right to choose any Medicare-certified agency that serves your area, and the hospital must give you a list and tell you if it has a financial interest in any of them. In practice the case manager often suggests one and families accept it. That is fine if it is a good agency. Medicare’s Care Compare tool rates agencies on quality measures and patient surveys; a five-minute look is worth it. Ask the case manager how soon the agency can start, because some are booked out.

Agencies are expected to make first contact within 48 hours of the referral or discharge. The first visit is a comprehensive assessment by a nurse or therapist, usually 60 to 90 minutes: medications, vital signs, the home, safety, what she can do, what she needs. They will build a plan of care that the doctor signs, covering which disciplines will visit, how often, and for what goals. Be there for this visit if you can. It is the moment to raise everything: the stairs, the pills, the bathroom, the diet.

Care is certified in 60-day periods and can be recertified as long as she still meets the criteria and still needs skilled care. Typical episodes after a hospital stay run several weeks. Home health ends when goals are met, when she no longer needs skilled care, or when she is no longer homebound. The agency must give written notice before Medicare-covered care ends, and you can ask for a fast appeal if you disagree.

1. 1.At 48 hours with no contact, call the agency directly. Have her name, date of birth and discharge date. Ask whether they received the referral and when the first visit is.
2. 2.If they have no referral, call the hospital case management department. Referrals get lost between systems more often than anyone admits.
3. 3.If the agency has the referral but cannot start for a week or more, ask the case manager for another agency. You are not obliged to wait.
4. 4.If home health was never ordered and you believe she qualifies, call her primary care doctor. Any physician can order it; it does not have to come from the hospital.