Home Health After Hospital Discharge in New Jersey

Two Kinds of Home Health, Two Different Payers

When your parent leaves the hospital and goes home, "home health" can mean two very different levels of care — and they are funded by different programs with different eligibility rules.

Skilled home health is clinical care delivered by licensed professionals: registered nurses, physical therapists, occupational therapists, speech-language pathologists. Medicare can cover this when the patient meets specific criteria. This is short-term, goal-oriented care designed to get your parent stable at home.

Custodial home care is personal assistance: bathing, dressing, toileting, meal preparation, medication reminders. Medicare does not cover this. In New Jersey, custodial home care is funded through the Managed Long Term Services and Supports (MLTSS) program under NJ FamilyCare — or paid out of pocket.

Most families coming out of a hospital discharge need both. Understanding which program covers what prevents surprises.

Medicare Home Health: The Homebound Requirement

Medicare covers skilled home health services if all four conditions are met:

1. The patient is under the care of a physician who certifies a plan of care
2. The patient needs intermittent skilled nursing care, physical therapy, or speech-language pathology services
3. The patient is homebound
4. A Medicare-certified home health agency provides the services

The homebound requirement trips families up. "Homebound" does not mean your parent cannot leave the house. It means leaving the home requires considerable and taxing effort — and absences are infrequent, short, or for medical care. A parent who needs a walker and a companion to get to the car, gets winded walking to the mailbox, and only goes out for doctor appointments qualifies as homebound.

Once these requirements are met, Medicare can cover skilled nursing visits, physical therapy, occupational therapy, speech therapy, medical social work, and a limited amount of home health aide services tied to the skilled care plan. SNF three-day qualifying-stay rules do not determine home health eligibility.

What Medicare Home Health Looks Like in Practice

A typical post-discharge home health plan might include a visiting nurse two to three times per week to manage wound care and monitor vitals, a physical therapist three times per week to rebuild strength and balance, and an occupational therapist to evaluate the home for fall risks and train your parent on safe bathing and dressing techniques.

The care is not around the clock. Skilled home health visits are intermittent — usually 30 to 90 minutes per session. If your parent needs someone present for extended hours or overnight, that crosses into custodial care territory and Medicare will not cover it.

The physician must recertify the plan of care every 60 days. Services may continue as long as your parent remains homebound and continues to need skilled care. If your parent no longer meets these criteria, Medicare coverage may end; ask the agency to explain the coverage decision.

MLTSS Home Care: Long-Term Custodial Support

If your parent needs ongoing personal assistance — not just clinical visits — New Jersey's MLTSS program funds home-based custodial care for individuals who meet Nursing Facility Level of Care (NFLOC) criteria. The clinical requirement is functional deficits in three or more activities of daily living or severe cognitive impairment requiring constant supervision.

MLTSS is administered through NJ FamilyCare Managed Care Organizations. Once enrolled, an MCO care coordinator develops a person-centered service plan that can include:

• Personal care assistant hours (bathing, dressing, grooming)
• Homemaker services (light housekeeping, laundry, meal preparation)
• Home-delivered meals
• Adult day health services
• Respite care for family caregivers
• Home modifications (grab bars, ramps, stair lifts)

The financial eligibility requirements for MLTSS are strict: a gross monthly income cap of $2,982 and a countable asset limit of $2,000 for a single applicant. Income above the cap requires a Qualified Income Trust (QIT).

The Personal Preference Program

New Jersey's Personal Preference Program (PPP) allows MLTSS beneficiaries to hire their own caregivers — including family members. Instead of receiving services through an agency, the beneficiary manages a monthly budget and directly hires, trains, and supervises their own workers.

This is significant for families where an adult child or other relative is already providing daily care. Under PPP, that family member can be paid for the caregiving work they are already doing, through Medicaid funding.

Enrollment in PPP requires MLTSS eligibility and assignment to a participating MCO. The beneficiary (or their representative) must demonstrate the ability to manage employer responsibilities, including hiring, scheduling, and payroll.

Coordinating Both Tracks

The strongest post-discharge setup combines Medicare skilled home health with MLTSS custodial support. Medicare covers the clinical visits — the nurse checking the surgical site, the therapist rebuilding strength. MLTSS covers the daily personal care — the aide helping your parent bathe and dress every morning.

The two programs run in parallel. They have different eligibility requirements, different application processes, and different oversight structures. But they are not mutually exclusive.

The Hospital-to-Home in New Jersey guide walks through both application processes, the homebound documentation checklist, and the PPP enrollment steps.

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