Medicare home health care: who qualifies, homebound rules and what you pay

After a hospital stay, a surgery or a serious illness, many people would rather recover at home than anywhere else. Medicare's home health benefit is what makes that possible for a lot of families: a nurse who comes to the house to change dressings or manage medications, a therapist who helps you walk safely again, an aide who helps with bathing while you recover. It is also one of the benefits people understand least, because it comes with a specific set of rules about who qualifies, how many hours are covered and what is never covered.

This guide explains those rules in plain terms: who is eligible, what "homebound" really means, which services Medicare pays for, what you pay, the notices an agency must give you, how to choose and switch agencies, your rights at home and how to spot fraud. It is based on the Centers for Medicare & Medicaid Services (CMS) booklet Medicare & Home Health Care, with cost details from the Medicare & You 2027 handbook.

Why home health care matters

CMS points out that many treatments once offered only in a hospital or doctor's office can now be done at home. In the booklet's words, home health care is usually less expensive, more convenient and just as effective as care in a hospital or skilled nursing facility. Where possible, it helps you get better, regain your independence and become more self-sufficient. It may also help maintain your current condition or level of function, or slow decline. That last point is important: home health care is not only for people who are expected to improve.

Medicare pays for home health services if you meet the eligibility rules and the services are reasonable and necessary to treat your illness or injury. Home health is covered under Part A and/or Part B. This guide covers Original Medicare. If you are in a Medicare Advantage Plan or another Medicare health plan, CMS says to check your plan's membership materials and contact the plan about its home health rules.

Who is eligible

You can use the home health benefit if you are under the care of a doctor or another allowed provider and you get services under a care plan that they set up and review regularly. Allowed providers include a nurse practitioner, a clinical nurse specialist and a physician assistant.

Your doctor or allowed provider must certify that you need one or more of these:

• Intermittent skilled nursing care (other than drawing blood)
• Physical therapy
• Speech-language pathology services
• Continued occupational therapy

Two more conditions apply:

• The care must come from a home health agency that is Medicare-certified.
• A doctor or allowed provider must certify that you are homebound.

The Medicare & You 2027 handbook adds that before you can get home health services, a doctor or other health care provider must see you in person and confirm you need home health care, and must order your care. The booklet describes the same requirement: your provider documents a face-to-face encounter with you, such as an appointment with your primary care doctor, within required timeframes, and the encounter must be related to the reason you need home health care.

The occupational therapy rule

Occupational therapy works a little differently. The handbook explains that if you need occupational therapy, your provider must first order it along with nursing care, physical therapy or speech-language pathology. After that, you can keep getting occupational therapy on its own, even if you no longer need the other services. That is why the eligibility list says "continued" occupational therapy.

What "homebound" means

Homebound is the rule that trips up the most families, partly because the word sounds stricter than it is. CMS says you are homebound if you have trouble leaving your home without help, or if leaving takes a major effort. You are normally unable to leave home, or leaving is not recommended because of an illness or injury. You may need help such as:

• A cane
• A wheelchair or walker
• Crutches
• Special transportation
• Help from another person

Homebound does not mean you can never leave the house. CMS says you may leave home for medical treatment, or for short, infrequent absences for non-medical reasons. The booklet's own examples are an occasional trip to the barber, a walk around the block, or attending a family reunion, funeral, graduation or other infrequent or unique event. You can still get home health care if you attend adult day care or religious services.

How much skilled nursing qualifies

The home health benefit is for intermittent care, not full-time care. CMS says if you need more than intermittent skilled nursing care, you do not qualify for home health services, and if you are expected to need full-time skilled nursing care over an extended period, you usually will not qualify. For eligibility, Medicare defines intermittent as skilled nursing care that is needed:

• Fewer than 7 days each week, or
• Daily for less than 8 hours each day for up to 21 days. Medicare may extend the 3-week limit in exceptional circumstances.

Once you qualify, a second limit applies to how much care you can get. CMS calls it "part-time or intermittent," and it covers skilled nursing and home health aide services combined. You may get them any number of days per week, as long as they are provided:

• Fewer than 8 hours each day, and
• 28 or fewer hours each week (or up to 35 hours a week in some limited situations).

These two definitions are easy to mix up. The first decides whether your nursing need is intermittent enough to qualify at all. The second caps the combined nursing and aide hours Medicare covers each week once you are on the benefit.

What Medicare covers

The home health agency must first assess all your care needs and share them with the doctor or allowed provider responsible for your plan of care, then keep reassessing them. CMS says the agency is responsible for meeting all your medical, nursing, rehabilitative, social and discharge planning needs in your plan of care. If you are eligible, Medicare covers the following when they are reasonable and necessary to treat your illness or injury.

Skilled nursing care

Medicare covers skilled nursing when the services you need:

• Require the skills of a nurse.
• Are reasonable and necessary to treat your illness or injury.
• Are provided on a part-time or intermittent basis. Medicare will not cover a visit if you are only having blood drawn.
• Come from a registered nurse or a licensed practical nurse. If a licensed practical nurse provides care, a registered nurse supervises it.

CMS's examples of skilled nursing include giving certain IV drugs, certain injections or tube feedings; changing dressings; and teaching about prescription drugs or diabetes care. Home health nurses provide direct care and teach you and your caregivers, and they manage, observe and evaluate your care. Skilled nursing does not include services you could get safely and effectively from a non-medical person, including yourself, without a nurse's supervision.

Physical therapy, occupational therapy and speech-language pathology

Medicare considers therapy at home reasonable and necessary if:

• It is a specific, safe and effective treatment for your condition.
• It is complex enough that only a qualified therapist, or someone under a qualified therapist's supervision, can provide it safely and effectively.
• Your condition requires either therapy to restore or improve functions affected by your illness or injury, or a skilled therapist or therapist assistant to safely and effectively help you maintain your current condition or keep it from getting worse.
• The amount, frequency and duration of the services are reasonable.

Note the maintenance language again. Therapy to keep you from getting worse can be covered, not only therapy that makes you better.

Home health aide services

Medicare pays for part-time or intermittent home health aide services, such as personal care, if you need them to maintain your health or treat your illness or injury. The catch is that aide services are only covered if you are also getting skilled care: skilled nursing, physical therapy, speech-language pathology, or continuing occupational therapy if you no longer need any of the others.

Medical social services

When a doctor or allowed provider orders them, Medicare covers medical social services to help with social and emotional concerns that may get in the way of your treatment or recovery. This might include counseling or help finding resources in your community. Like aide services, these are only covered if you are also getting skilled care.

Medical supplies and equipment

Medicare covers supplies such as wound dressings when your doctor or allowed provider orders them as part of your care. Durable medical equipment, such as a wheelchair or walker, is paid separately from home health care. It must meet certain criteria and be ordered by your provider. If the agency does not supply the equipment itself, its staff will usually arrange for a supplier to bring it to you.

What Medicare does not cover at home

Medicare does not pay for:

• 24-hour-a-day care at home
• Meals delivered to your home
• Services like shopping, cleaning and laundry
• Custodial or personal care like bathing, dressing and using the bathroom, when this is the only care you need

The last item is the key distinction. Help with bathing and dressing can be covered as aide services while you are getting skilled care, but not when it is the only help you need. Our guide to what Medicare doesn't cover explains this and Medicare's other gaps.

What you pay

The handbook is clear: you pay nothing for covered home health services. Costs come from equipment and from things Medicare does not cover.

Routine foot care is CMS's example of something Medicare never pays for. Wheelchairs, walkers and oxygen equipment are its examples of durable medical equipment billed at 20%. The current Part B deductible is on our Part B premium page.

Before care begins, the agency should tell you how much of your bill Medicare will pay, whether any items or services are not covered, and how much you would pay for them. CMS says the agency should explain this both verbally and in writing. If you have a Medigap policy or other coverage, tell your providers so your bills are paid correctly.

How Medicare pays the agency

Medicare pays a Medicare-certified agency one payment for the covered services you get during a 30-day period of care. You can have more than one 30-day period, and each payment is based on your condition and care needs. Using a certified agency can reduce your costs, because a certified agency agrees to be paid by Medicare and to accept only the amount Medicare approves. The home health benefit only pays for services from the agency; other medical services and equipment are generally covered under your other Medicare benefits.

The notices an agency must give you

Three written notices protect you when coverage is in doubt or changing. Knowing their names helps you recognize them when they arrive.

Advance Beneficiary Notice of Noncoverage (ABN)

The agency must give you an ABN before providing a service or supply that Medicare probably will not cover because:

• The care is not medically reasonable and necessary.
• The care is only nonskilled personal care, like help with bathing or dressing.
• You are not homebound.
• You do not need skilled care on an intermittent basis.

The ABN should describe the service or supply, explain why Medicare probably will not pay, and give directions for getting an official Medicare decision and filing an appeal. To get an official decision, CMS says you should generally:

1. Keep getting the services or supplies if you think you need them. The agency must tell you what they will cost; talk with your provider.
2. Understand that you may have to pay the agency for them.
3. Ask the agency to send your claim to Medicare so Medicare makes a payment decision. You have the right to have the agency bill Medicare for your care.
4. If Original Medicare pays, you get back all your payments except any applicable coinsurance or deductibles, including coinsurance you paid for durable medical equipment.

Home Health Change of Care Notice (HHCCN)

The agency must give you an HHCCN before it reduces or stops any services or supplies in a way that changes your plan of care. CMS gives two examples: the agency makes a business decision to cut back or stop some or all of your services, or your doctor or allowed provider changed or did not renew your orders.

Notice of Medicare Non-Coverage (NOMNC) and your right to a fast appeal

When all your covered home health services are ending, the agency should give you a Notice of Medicare Non-Coverage at least 2 days before. If you do not get one, ask for it. The notice tells you the date covered services end, how to ask for a fast appeal, and your right to a detailed notice explaining why services are ending.

If you think services are ending too soon, you can ask for a fast appeal. An independent reviewer called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) will ask why you think coverage should continue, look at your medical information and talk to your provider. CMS says to expect a response generally no later than 3 days after the effective date of the NOMNC.

• If the BFCC-QIO decides services should continue, Medicare may keep covering your home health care, except for any applicable coinsurance or deductibles.
• If it decides coverage should end, you pay for services after the end date on the NOMNC, and the agency must give you an ABN with a cost estimate for them.

You can stop services on or before the NOMNC date to avoid paying for more. If you do not appeal but want to keep getting services after that date, the agency must give you an ABN telling you what you will pay. Our guide to Medicare appeals covers the other appeal levels.

Choosing a home health agency

If your provider decides you need home health care, you may choose from the Medicare-certified agencies that serve your area. Certification means the agency meets federal health and safety requirements. Medicare's Care Compare tool at Medicare.gov/care-compare can help you find and compare them.

You have a say in which agency you use, and CMS says your doctor, hospital discharge planner or other referring agency should honor your choice. Your choices may be limited by which agencies are available or by your insurance. A Medicare Advantage Plan may require you to use agencies it contracts with.

CMS's agency checklist

The booklet suggests asking these questions about any agency you are considering:

1. Is it Medicare-certified?
2. Is it Medicaid-certified, if you have both Medicare and Medicaid?
3. Does it offer the specific services you need, like skilled nursing or physical therapy?
4. Does it meet your special needs, like language or cultural preferences?
5. Does it offer the personal care services you need, like help bathing, dressing and using the bathroom?
6. Does it offer the support services you need, or can it help arrange more? (Medicare does not usually cover these.)
7. Can the staff give the type and hours of care your provider ordered, and start when you need them?
8. Is it recommended by your hospital discharge planner, doctor or social worker?
9. Is staff available at night and on weekends for emergencies?
10. Has the agency explained what Medicare will cover and what you must pay out of pocket?
11. Does it have letters from satisfied patients, family members and doctors?

For more information, your State Survey Agency, which inspects and certifies home health agencies for Medicare, can give you the state survey report on any agency you are considering. Your local long-term care ombudsman may also have information; CMS points to ltcombudsman.org and the Eldercare Locator at 1-800-677-1116.

Special rules

• Most Medicare-certified agencies accept all people with Medicare.
• An agency does not have to accept you if it decides it cannot meet your medical needs.
• An agency should not refuse you because of your condition unless it would also refuse other people with the same condition.
• Medicare only pays for care from one home health agency at a time.
• You can end your relationship with an agency and choose another at any time. Get a referral to the new agency from your provider, and tell both agencies you are changing.

Your plan of care

You need a doctor's or allowed provider's order to start and continue home health care. Usually, after a referral, agency staff come to your home to talk about your needs and ask about your health. The agency talks with your doctor and keeps the doctor updated on your progress.

The agency works with you and your provider to write your plan of care, which can include services given over the phone or by video. You have the right to be involved in decisions about it. The plan includes:

• What services you need and how they will be provided
• Which health care professionals should give them
• When and how often you will get them
• The medical equipment you will need
• What results your provider expects from your treatment

The agency must give you all the care in your plan, through its own staff or an arrangement with another agency. Your provider and home health team review the plan as often as necessary, but at least once every 60 days. If your condition changes, the team should tell your provider right away, tell you about any changes, and teach you and your helpers to continue care such as wound care, therapy and disease management, including how to recognize problems like infection or shortness of breath and whom to contact.

Your rights at home

When you get care from a Medicare-certified home health agency, you generally have the right to:

• Get a written notice of your rights before care starts
• Have your home and property treated with respect
• Be told in advance what care you will get and when your plan of care will change
• Participate in your care planning and treatment
• Get written information about your privacy rights and appeal rights
• Have your personal information kept private
• Get written and verbal information about how much Medicare is expected to pay and how much you will pay
• Make complaints about your care and have the agency follow up on them

For complaints about quality of care, CMS says to call your state home health hotline (the agency should give you the number when services start) or your state's BFCC-QIO, whose number you can get from 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048).

CMS's quality checklist

The booklet offers a second checklist to monitor care once it starts. Ask whether:

• The staff is polite and treats you and your family with respect.
• The staff explains your plan of care, lets you take part in it and tells you ahead of time about changes.
• The staff is properly trained and licensed for the care you need.
• The agency explains what to do if you have a problem with staff or care.
• The agency responds quickly to your requests.
• The staff checks your physical and emotional condition at each visit.
• The staff responds quickly to changes in your health or behavior.
• The staff checks your home and suggests changes for your needs and safety.
• The staff has told you what to do in an emergency.
• The agency and its staff protect your privacy.

Medigap and other coverage

Because covered home health services cost nothing under Original Medicare, the main cost left is the 20% for durable medical equipment and the Part B deductible, which Medigap plans help with in different ways. In Minnesota, where Medigap is standardized differently, the basic benefits include cost sharing for home health services and supplies. Our guide to Medigap plans explains each plan. If you need care that goes beyond the home health rules, our guides to skilled nursing facility care and hospice cover the other settings.

Spotting home health fraud

CMS says most home health agencies are honest and bill Medicare correctly, but some commit fraud. The booklet lists these warning signs:

• Home health visits your doctor ordered that you did not get
• Visits by home health staff that you did not ask for and do not need
• Bills for services or equipment you never got
• Fake signatures, yours or your doctor's, on medical forms or equipment orders
• Pressure to accept items and services you do not need or that Medicare does not cover
• Items on your Medicare Summary Notice that you do not think you got or used
• Home health services your provider did not order. The provider who approves your services should know you and be involved in your care, including any changes to your plan.
• An agency offering free goods or services in exchange for your Medicare Number

CMS's advice is to treat your Medicare Number like a credit card number and never give it to people who say a service is free but need your number for their records. The best protection, the booklet says, is knowing what Medicare covers and what your provider put in your plan of care.

If you suspect fraud, first contact the agency to make sure the bill is correct. You can report it to the HHS Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477) or OIG.hhs.gov, or call 1-800-MEDICARE. Give as much detail as you can: who, what, when, where, why and how, including the person or company's name, address and phone number.

Where to get help

With Original Medicare, call 1-800-MEDICARE or visit Medicare.gov. With a Medicare Advantage Plan, call your plan. Your State Health Insurance Assistance Program (SHIP) can answer questions about home health benefits and about what Medicare, Medicaid and other insurance pay for; find your SHIP at shiphelp.org. The booklet is also available in Spanish at es.Medicare.gov.

Home health care lets people recover where they are most comfortable, with family close by. Knowing the homebound rule, the hour limits and the notices you are owed means you can spend less time worrying about coverage and more time getting better.