Getting a referral for home health care starts with your doctor. A physician must order and certify home health services before any agency can begin providing care, and for Medicare to cover those services, specific eligibility requirements must be met. The process is straightforward once you understand what’s required and how to communicate your needs effectively.
Who Qualifies for Home Health Care
Medicare covers home health services when two conditions are met: you need part-time or intermittent skilled care, and you’re considered “homebound.” Skilled care means services that require a trained professional, such as wound care after surgery, injections, IV therapy, physical therapy, occupational therapy, or speech therapy. If the care could safely be done by you or an untrained caregiver, it won’t qualify.
The homebound requirement doesn’t mean you can never leave your house. It means leaving home is a considerable and taxing effort because of your condition. Specifically, you must meet one of these criteria: you need a cane, walker, wheelchair, or other assistive device to get around; you require special transportation; or you need another person’s help to leave. On top of that, there must be a normal inability to leave home, or leaving must be medically inadvisable due to your condition. You can still attend medical appointments, religious services, or adult day care and maintain your homebound status.
“Part-time or intermittent” generally means up to 8 hours per day of combined skilled nursing and aide services, with a maximum of 28 hours per week. In some cases, your provider can authorize up to 35 hours weekly for a short period. If you need more than part-time skilled care, home health won’t be the right fit, and a higher level of care like a skilled nursing facility may be more appropriate.
How to Talk to Your Doctor About a Referral
Your primary care doctor, a specialist, or a hospital physician can all initiate a home health referral. The key is giving your doctor a clear picture of why you need skilled care at home and why getting to an outpatient clinic is difficult or unsafe. Many referrals stall because the doctor doesn’t have enough detail about the patient’s daily functional limitations.
When you bring up home health care, be specific about what you’re struggling with. Rather than saying “I’m having trouble getting around,” describe exactly what happens: you get winded walking from the bedroom to the bathroom, you need someone to hold your arm going down the front steps, or you can’t safely get in and out of a car. The more concrete your description, the easier it is for your doctor to document your homebound status. Think through these areas before your appointment:
- Mobility limitations: What devices do you use? How far can you walk before resting? Do you need help with stairs?
- Safety concerns: Falls, confusion, dizziness, or balance problems that make leaving home risky
- Pain and fatigue: How often you need rest periods, whether pain limits your ability to travel
- Other factors: Oxygen use, incontinence issues, or psychological conditions like severe anxiety or agoraphobia that make outings medically inadvisable
Your doctor also needs to understand why a skilled professional is necessary. If you need wound care that requires sterile technique, or physical therapy to regain the ability to walk safely after a hip replacement, those are clear skilled needs. Explain what you can’t do for yourself and why a trained clinician is required.
What Your Doctor Must Do
A physician’s referral for home health care isn’t just a quick note. Medicare requires a face-to-face encounter, meaning your doctor (or a nurse practitioner or physician assistant working with them) must see you in person. This visit must happen within 90 days before home health care starts or within 30 days after it begins. If your doctor orders home health based on a new condition that wasn’t present during a recent visit, they’ll need to see you within 30 days of your admission to home health.
After the encounter, your doctor writes a brief narrative explaining how what they observed supports both your homebound status and your need for skilled services. This documentation must include the date of the visit and a description of your clinical condition. It can be written or typed, but rubber-stamped signatures aren’t accepted.
Your doctor then establishes a plan of care that lists the specific services you’ll receive at home. This plan must be signed and dated before any claims are submitted to Medicare. The same physician periodically reviews and recertifies the plan to confirm you still need services. Think of the plan of care as the blueprint that tells the home health agency exactly what to provide, and it carries your doctor’s authorization and certification that the services are medically necessary.
Getting a Referral After a Hospital Stay
One of the most common paths to home health care is through hospital discharge. If you’ve been hospitalized for surgery, a stroke, a fracture, or another serious condition, the hospital’s discharge planning team will typically assess whether you need home health services before you go home. This team can include nurses, social workers, case managers, physical and occupational therapists, and your hospital physician.
If the team determines you’ll need skilled care at home, they’ll coordinate the referral before discharge. They select or help you choose a home health agency, communicate your care needs, and ensure the physician’s orders and documentation are in place. You or a family member should be part of these conversations. Don’t hesitate to ask the discharge planner directly whether home health has been considered, especially if you live alone or your caregiver has limited ability to help with medical tasks like wound care or medication management.
If you feel you’re being discharged too quickly or without adequate home support, speak up during discharge planning. You have the right to be involved in decisions about your post-hospital care.
Can You Contact a Home Health Agency Directly?
You can call a home health agency yourself to ask questions and start the intake conversation, but the agency cannot begin Medicare-covered services without a physician’s order. What typically happens is the agency contacts your doctor’s office to obtain the necessary orders, documentation, and face-to-face encounter records. Some agencies are experienced at facilitating this process and will handle much of the coordination for you.
This route can be useful if your doctor is willing to refer you but isn’t familiar with the specific paperwork involved. The home health agency’s intake staff knows exactly what documentation Medicare requires and can guide your doctor’s office through it. Just make sure the agency you choose is Medicare-certified if you want Medicare to cover the services.
What Home Health Services Cover
Once the referral is in place, home health care can include several types of services depending on your needs. Skilled nursing covers things like wound care for pressure sores or surgical incisions, monitoring of unstable health conditions, injections, IV therapy, and education for you and your caregiver on managing your condition. Physical therapy, occupational therapy, and speech therapy are covered when specific conditions are met.
Home health aide services, which include help with bathing, grooming, walking, feeding, and changing bed linens, are only covered if you’re simultaneously receiving a skilled service like nursing or therapy. A home health aide alone, without an accompanying skilled service, won’t qualify for Medicare coverage.
Medical social services are also available through home health to help with emotional and social concerns related to your illness, such as connecting you with community resources or helping with care coordination.
If Your Referral Is Denied
Sometimes a doctor declines to refer a patient for home health care because they don’t believe the eligibility criteria are met. If this happens, ask your doctor to explain which requirement you don’t satisfy. Is it the homebound status, the skilled care need, or both? Understanding the gap helps you determine whether additional documentation or a different approach could change the outcome.
If you believe you qualify and your doctor disagrees, consider requesting a second opinion from another physician. You can also ask a family member or caregiver to accompany you to your appointment to describe firsthand what they observe at home, since patients sometimes understate their limitations. Details like needing 10 minutes to recover after walking to the mailbox or requiring someone to stand nearby during showers can make the difference between a referral that gets approved and one that doesn’t.