Home health care provides skilled, physician-ordered services delivered to a patient’s residence following an illness, injury, or worsening medical condition. This care helps patients recover and regain function at home. To manage treatment and determine payment, payers—most notably Medicare—use a standardized unit of time called the “home health episode.” This episode organizes the patient’s care plan and calculates reimbursement for the home health agency.
Defining the Home Health Episode
The home health episode is a defined block of time during which a patient receives coordinated services under a physician-approved plan of care. It functions as the primary unit of measurement and payment calculation for the home health agency. The episode begins with the start of care (SOC) and triggers a comprehensive clinical assessment using the Outcome and Assessment Information Set (OASIS).
OASIS is a standardized tool used by Medicare-certified agencies to evaluate the patient’s clinical status, functional capabilities, and healthcare needs. Data from this assessment informs the individualized treatment plan and helps determine the severity and complexity of the patient’s condition. Medicare uses this information to calculate the prospective payment amount the agency receives.
The Standard 60-Day Certification Period
The standard length of a home health episode is 60 calendar days, formally called the certification period. This period begins on the first day the patient receives care. The 60-day period requires the patient’s physician to certify the need for services and approve the plan of care.
If the patient requires continued skilled care, the physician must sign a recertification to initiate a new episode. The agency must update the OASIS assessment during the last five days of the current period to demonstrate the ongoing need for services. While the certification period remains 60 days, Medicare’s payment structure, the Patient-Driven Groupings Model (PDGM), divides this period into two 30-day payment periods. Patients can receive an unlimited number of subsequent 60-day episodes as long as they meet eligibility requirements.
Essential Patient Eligibility Requirements
To qualify for a Medicare-covered home health episode, the patient must meet specific criteria related to their physical status and medical need.
Homebound Status
The patient must be “homebound,” which does not mean they are entirely confined to bed. Homebound status is met if leaving the home requires a considerable and taxing effort, often needing supportive devices, special transportation, or the assistance of another person due to illness or injury. Permissible absences, such as leaving for medical treatment or attending religious services, are allowed without jeopardizing the homebound status.
Intermittent Skilled Care
The patient must require “intermittent skilled care,” meaning skilled nursing or skilled therapy services are needed on a part-time basis. Skilled nursing care is defined as fewer than seven days a week, or less than eight hours a day for a maximum of 21 consecutive days.
Physician Supervision and Certification
The care must be under the supervision of a physician who establishes and regularly reviews the patient’s plan of care. The physician must certify that the home health services are medically necessary. A face-to-face encounter between the patient and the certifying physician or non-physician practitioner must occur within 90 days before the start of care or within 30 days after.
Services Covered During an Episode
The home health episode covers a range of skilled services requiring the expertise of a licensed healthcare professional.
- Skilled Nursing (SN) services include wound care, medication management, intravenous therapy, and patient education about their disease process.
- Rehabilitation services include Physical Therapy (PT) to restore mobility and strength, Speech-Language Pathology (SLP) for communication and swallowing issues, and Occupational Therapy (OT) to improve the ability to perform daily living activities.
- Home Health Aides (HHA) provide personal care assistance (bathing, dressing, and grooming), but this service is only covered if the patient is also receiving a skilled service.
- Medical Social Services address social and emotional concerns, offering counseling and helping to connect the patient with community resources.