What happens when the 60 days are up?

The rule says "recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode," and that it "must be signed and dated by the physician or allowed practitioner who reviews the plan of care." Medicare's manual says Medicare "does not limit the number of continuous 60-day recertifications for beneficiaries who continue to be eligible for the home health benefit," and that the practitioner "does not have to estimate how much longer skilled services will be needed for the recertification." Medicare's manual says coverage of skilled nursing care "does not turn on the presence or absence of a patient's potential for improvement" but on the patient's need for skilled care. CMS's payment page says that although the unit of payment is a 30-day period, "there are no changes to timeframes for re-certifying eligibility and reviewing the home health plan of care, both of which will occur every 60-days (or in the case of updates to the plan of care, more often as the patient's condition warrants)."

The rule's wording is the assessment must be updated in "the last 5 days of every 60 days beginning with the start-of-care date." Due dates "are calculated from the original Start of Care date rather than from the Resumption of Care date." A visit "can be made for only the purpose of performing a comprehensive assessment including OASIS, but it will not be considered a billable visit unless skilled services are performed." The agency "should not discharge and readmit the patient" and should send a clinician "as soon as the oversight is identified," and "payment implications may arise from this missed assessment." The days 56 to 60 count is CMS's manual.

The rule says the updated assessment is due "within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests," or on the "physician or allowed practitioner-ordered resumption date." CMS's OASIS manual counts that deadline as within two calendar days of the hospital discharge, or of learning the patient is home. The OASIS manual says "Medicare requires a new start of care assessment" when a stay spans the end of the 60 days. Another CMS manual describes an exception: if the recertification assessment was done in days 56 to 60, the patient comes home on day 61 and the payment group stays the same, the care counts as continuing. CMS says most of the transfer assessment data can be collected by phone.

The full list is that the agency and the practitioner agree the agency can no longer meet the patient's needs; the patient or the payer will no longer pay; the practitioner and the agency agree the plan's goals "have been achieved" and the patient no longer needs the services; the patient refuses services or chooses to leave; discharge for cause; the patient's death; and the agency closing. Discharge for cause applies when the behavior of the patient, or of other persons in the patient's home, is "disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired."

The discharge summary is due "within 5 business days of the patient's discharge." When the patient moves to a facility, a transfer summary is due within two business days of a planned transfer, or of the agency learning of an unplanned one. The agency must send "all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences."

CMS's instructions say "the two-day advance requirement is not a 48-hour requirement." The fast appeal request is due "by no later than noon of the calendar day following receipt" of the notice. The other forms cover an agency reducing or stopping a service because of the practitioner's orders or the agency's own limits, and care Medicare is expected not to cover, so the patient can decide whether to pay for it.

Medicare pays once for each 30-day period, adjusted for the patient's payment group and local wages. If a period has fewer visits than its payment group's threshold, Medicare pays by the visit instead: the low-utilization payment adjustment, or LUPA. The first 30-day period of a patient's care is "early" and every later one is "late" unless more than 60 days pass without home health. For 2026 the national base amount is $2,038.22 for a 30-day period, for agencies that report quality data. There are 432 payment groups. The amount changes every January, and the 2027 rule had not been finalized when this was written. For 2026 the thresholds run from 2 to 5 visits, and a period below its threshold "is paid the national per-visit amount by discipline": $176.96 for a skilled nursing visit and $193.42 for a physical therapy visit, before the local wage adjustment and the amount added when it's a patient's first or only period. About 7% of periods in 2024 were paid this way. The plan of care rule requires the plan to "specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment." The HHS Office of Inspector General has audited claims near the visit threshold. Under the earlier four-visit rule it estimated $191.8 million in overpayments on 2017 claims, and wrote that agencies "have an incentive to improperly bill claims with visits slightly above the LUPA threshold." MedPAC reports that for patients on traditional Medicare in 2024, the average was 3.1 full 30-day periods per patient in the year and about 8 in-person visits per period. CMS reports a national discharge-to-community rate of 77.7% for 2023 and 2024. A patient counts toward that rate only if they have no unplanned admission to an acute care or long-term care hospital, no skilled nursing facility stay and no death in the 31 days after discharge, and no potentially preventable hospitalization or observation stay during the home health stay or the day after.