To qualify for home health care under Medicare, you need to meet four basic requirements: a doctor must certify that you need medical care at home, you must be considered “homebound,” you must need skilled nursing or therapy services, and the care must come from a Medicare-certified agency. There’s no prior hospital stay required, and Medicare covers these services at $0 out of pocket for you.
Each of these requirements has specific details that determine whether you’ll be approved, and understanding them can help you avoid a denied claim.
The Four Qualifying Requirements
Medicare evaluates home health eligibility based on four criteria, and you must meet all of them simultaneously.
1. Doctor certification. A physician or nurse practitioner must formally certify that you need skilled care at home and establish a plan of care. This isn’t just a referral. The certifying provider must have a face-to-face encounter with you, either within 90 days before home health care starts or within 30 days after it begins. This encounter documents the clinical reasons you need services at home.
2. Homebound status. You must be considered homebound, which doesn’t mean you can never leave your house. It means that leaving home requires a considerable and taxing effort due to your medical condition. You might need a wheelchair, walker, crutches, or the help of another person to get out. Or your condition might be such that leaving home is medically inadvisable. You can still leave for medical appointments, religious services, or occasional short trips without losing your homebound status. The key is that your normal inability to leave home is due to illness or injury, not personal preference.
3. Skilled care need. You must need at least one of the following: skilled nursing care on a part-time or intermittent basis, physical therapy, speech-language pathology services, or (in some cases) occupational therapy. “Part-time or intermittent” generally means fewer than 8 hours per day and no more than 28 hours per week, though in some circumstances Medicare allows up to 35 hours weekly for a limited time. The care must be medically necessary and related to a condition that requires a trained professional’s skills.
4. Medicare-certified agency. Your care must be provided by a home health agency that’s certified by Medicare. Not all home care companies meet this standard. You can search for certified agencies in your area through Medicare’s Care Compare tool online.
What Services Medicare Covers at Home
Once you qualify, Medicare covers a broad range of skilled services delivered in your home. Skilled nursing care includes wound care for pressure sores or surgical wounds, IV therapy and nutrition therapy, injections, monitoring of serious or unstable health conditions, and patient and caregiver education about managing your condition.
Therapy services include physical therapy, occupational therapy, and speech-language pathology. Medical social services are also covered to help you with emotional or social concerns related to your illness.
Home health aide services are covered too, but only when you’re already receiving skilled nursing or therapy. An aide can help with bathing, grooming, walking, changing bed linens, and feeding. Medicare also covers durable medical equipment like wheelchairs, walkers, and hospital beds, plus medical supplies you need at home.
What Medicare Does Not Cover
The biggest gap in the home health benefit is custodial care. If your only need is help with daily activities like bathing, dressing, or cooking, and you don’t also need skilled nursing or therapy, Medicare won’t pay for home health services. Round-the-clock care is also excluded. Medicare’s benefit is specifically for part-time, intermittent skilled care, not for a full-time caregiver.
Meal delivery, homemaker services (like cleaning and laundry), and personal care that isn’t tied to a skilled care plan fall outside the benefit as well.
What It Costs You
For covered home health services, you pay $0. There are no copayments and no deductible for the skilled nursing visits, therapy sessions, aide services, or medical supplies included in your plan of care. The one exception is durable medical equipment, which requires you to pay 20% of the Medicare-approved amount. So if Medicare approves a hospital bed or walker, you’ll owe a share of that cost, but the visits themselves are fully covered.
The Plan of Care and Recertification
Your doctor creates a formal plan of care that spells out exactly which services you need, how often, and for how long. This plan is the blueprint your home health agency follows, and Medicare won’t pay for services that aren’t included in it. If your needs change, the plan needs to be updated by your doctor.
Medicare home health operates in 60-day episodes. At the end of each 60-day period, your doctor must recertify that you still meet all the eligibility requirements and still need skilled care. There’s no hard limit on how many 60-day episodes you can receive, as long as you continue to qualify. Your doctor reviews your plan of care at each recertification and signs off that continued home health services are medically necessary.
How to Start the Process
The process typically starts in one of two ways. You’re either being discharged from a hospital or skilled nursing facility and your care team arranges home health before you leave, or you’re living at home and your doctor determines you need skilled services. In either case, your doctor initiates the certification and refers you to a Medicare-certified home health agency.
If you believe you need home health care but your doctor hasn’t brought it up, ask directly. Describe the specific difficulties you’re having at home, whether that’s managing wounds, recovering from surgery, handling medications, or struggling with mobility. The more concrete you are about your functional limitations and skilled care needs, the easier it is for your doctor to document the medical necessity Medicare requires.
If your claim is denied, you have the right to appeal. The home health agency is required to give you a written notice explaining why services are being reduced or ended, and that notice includes instructions for requesting a review.