Understand Your RubyWell Journey
A few things you should know
Who is rubywell for?
- Homebound adults on Original Medicare and some Medicare Advantage plans who:
- need medical care provided by a skilled nurse, physical, occupational, or speech therapist, and the support of a home health aide in order to live safely at home (Medicare requires a need for skilled services to receive Home Health Services.)
- live in AZ, FL, and PA, with more states coming in 2026
- Family caregivers of eligible adults, who want professional support caring for their loved one.
How long does the process take?
- Eligibility Assessment: 1-5 days, depending on how quickly you submit your Medicare card for insurance verification
- Start of Care: 1-8 weeks, depending on how soon you can schedule an in-person or telehealth visit with your doctor to discuss a home health referral order. In some areas, we may be able to send a doctor to you.
What do I need?
- Access to a phone, tablet or computer to fill out the RubyWell eligibility form
- Medicare ID card of the person seeking care
- Access to the doctor of the person seeking care (in-person or telehealth)
- Permission to share details about the health condition and care needs of the person seeking care. The more we know, the more we can help!
Quick Explanation of RubyWell Process
A Deep Dive
Complete the RubyWell eligibility process
- If you may be eligible for home health.
- Which insurance you’re on.
- What services you’re currently on or have received in the past.
To qualify for Medicare-covered home health, your doctor must confirm two things:
- You meet homebound criteria, which means it's difficult or impossible to leave home without help of another person or a device like a cane, walker, crutches, or wheelchair. 12. You need skilled medical services such as nursing, physical therapy, occupational therapy, or speech therapy.
- You must also be covered. y Original Medicare or a Medicare Advantage plan that one of our partner agencies accepts.
Home health is skilled medical care provided in your home. It can include nursing, physical therapy, occupational therapy, and speech therapy, as well as home health aide support when required as part of a care plan that includes skilled care. The goal of home health is to help you stay safe, stable, and out of the hospital.
Medicare requires doctors to explain why home health is medically necessary. Understanding hospitalization risks helps the doctor decide whether home health can improve your ability to live safely at home. Recent hospitalizations and potentials risk factors could suggest that home health care is medically necessary.
Your insurance determines which home health agencies can provide care for you. We verify your insurance so we can match you with a home health agency that accepts your plan.
If you're already receiving home health services from a different agency and want to switch, Medicare requires an extra step to transfer care. It's completely doable — it just follows a slightly different process. We'll guide you through it.
Schedule a doctor appointment
You may not have to schedule another appointment in order to request a home health referral order if all of the following are true:
- Your appointment occurred within 90 days before your home health services will start.
- The reason for that appointment is clearly related to the primary reason that you need home health, and the doctor visit note mentions that primary condition.
- The doctor visit note confirms that you're homebound and need skilled services, and your doctor can point to that note in your home health referral order.
In this situation, your doctor can use the earlier visit as the required "face-to-face encounter" and then complete the home health referral order and plan of care based on that information.
Let them know the appointment is to talk about your current health conditions and care needs to see if home health care is appropriate for you. Specifically mention the primary condition that's making it difficult for you to live safely at home.
If you don't have a primary care doctor or can't get in to see your doctor soon enough, we may be able to connect you with a mobile doctor, depending on your location. This doctor does not replace your normal doctor. They meet with you once to discuss your health conditions, review your medical records, and write the home health referral order so you can start received services as soon as possible. The mobile doctor will also share the referral order with your regular doctor to keep your care team in the loop.
If you're interested in an appointment with a mobile doctor complete this form and a member of our team will reach out with next steps.
Review your Home Health Discussion Guide
Start by reviewing the Discussion Guide. Let us know if there's anything you don't understand or doesn't look correct.
Then bring it with you to your in-person or telehealth doctor appointment and share it with your doctor. There are several ways you can share it.
For an in-person visit:
- print it out
- have them look at it on your phone, tablet, or laptop that you bring with you
- email or upload it to their secure patient portal ahead of the visit For a telehealth visit:
- share it on your screen during the call
- email or upload it to their secure patient portal ahead of the call
The Discussion Guide contains all of the information you shared with us about your health conditions and care needs. So it will help ensure that you cover all the relevant information during the visit. It will also make it easier for your doctor write a complete home health order if they feel one is appropriate.
If there's anything you forgot to mention - symptoms, changes in mobility, falls, caregiver strain - bring it up directly with your doctor. They will use all of that information when deciding if home health is medically necessary.
You will receive 2 emails from RubyWell. One will have your password protected discussion guide and the other email will contain the password to unlock the guide. The other will contain the password. We do this because we want to protect your personal health information.
If you can't find both emails, check your spam folder or search "RubyWell" in your email app. If you still have trouble, we can resend it or walk you through opening it during a call.
Request a home health referral order
You have the right to choose which home health agency you work with. We strongly recommend our home health agency partners based on vetting process and, when available, their Medicare Star Ratings and customer satisfaction reviews. We're also working with our partner agencies to develop additional solutions for RubyWell families.
A referral order is a formal medical document your doctor must provide in order for home health services to begin and be covered by Medicare. It must include:
- Why the doctor believes home health is medically necessary
- The primary diagnosis (and any relevant secondary diagnoses) that indicate te need for skilled home health services
- Which skilled care you need why (e.g., skilled nursing for wound care)
- Any recent changes in your health
The doctor also has to include:
- Progress notes
- Discharge summaries
- History and physical
- Any other medical record entries that support your homebound status and need for skilled care
Meet your home health agency and start care
Once RubyWell receives your referral order from the doctor, we confirm that it's complete and complies with Medicare rules, we forward it to our partner home health agency. They'll contact you to schedule an in-home visit within 48 hours. During that visit, they'll create a care plan based on your doctor's recommendations. Then they'll assign your care team to you and begin providing the services. We'll let you know when we're received your referral order so you can keep an eye out for their call.
The home health agency must schedule the first visit (also called the initial assessment) to occur within 48 hours of receiving your referral order. When the care begins depends on the agency's staffing and your schedule.
Medicare covers home health services based on your medical needs. The frequency and length of your home health visits will depend on the medically necessary services you require.
Patients my receive:
- One or more visits per week for skilled nursing or therapy
- Additional support from a home health aide if requested in the care plan
- Meetings with a medical social worker for family counseling and education, and referrals to resources, if requested in the care plan
If your loved one needs help beyond skilled care, like housekeeping, errands, transportation, meal prep, etc., we may be able to refer you to a trusted home care partner. Home care, however, is not covered by Medicare.
No. Home health care is meant to support you, not replace you.
Nursing and therapy services help ensure your loved one is getting the medical care they need from medical professionals, to help them live safely at home and reduce hospital and ER visits. It also gives you a break from having to provide all the care and make all the medical decisions on your own.
The skilled professionals who provide home health services to your loved one can also answer your questions and give you guidance on how to provide the care tasks that fall outside of the home health care plan.
And you may be able to work with the agency's medical social worker, who can provide family counseling and education, as well as referrals to resources that can ease your caregiving intensity.
RubyWell can help you explore additional support, including:
- Home Care, which is "unskilled" care that includes companionship, errands, transportation, light housework, and help with activities of daily living. This is not covered by Medicare, but is covered by many long term care insurance policies.
- Healthcare Advocacy, which can help you navigate the health sysrem by scheduling appointments, explaining Medicare benefits, and resolving billing issues. This is covered by Medicare.
Click here to learn more about our partners that offer these services.
