Medicare Home Health Benefit

Five requirements must all be met:

• The patient is homebound, meaning leaving home requires a considerable and taxing effort
• The patient needs intermittent skilled nursing care, physical therapy, or speech-language pathology, or has a continuing need for occupational therapy
• Care is furnished under a plan of care established and periodically reviewed by a certifying practitioner
• A face-to-face encounter related to the primary reason for home health occurred within 90 days before or 30 days after the start of care
• Services come from a Medicare-certified home health agency

Since the CARES Act in 2020, nurse practitioners, physician assistants, and clinical nurse specialists can certify home health alongside physicians.

Covered services include skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social services, and home health aide services. Aide services are covered only while the patient also receives a qualifying skilled service. Routine medical supplies are bundled into the agency's payment. Durable medical equipment is covered separately at 80 percent, leaving the beneficiary a 20 percent coinsurance, which is the only cost-sharing connected to a home health episode. The benefit does not cover 24-hour care at home, home-delivered meals, homemaker services unrelated to the care plan, or custodial personal care when that is the only care needed.

Care is authorized in 60-day certification periods. The certifying practitioner signs the plan of care and recertifies continued eligibility every 60 days. Payment runs on a different clock: Medicare pays agencies in 30-day periods under PDGM, so each certification period contains two payment periods. Agencies must submit a Notice of Admission (NOA) within 5 calendar days of the start of care, and a late NOA reduces payment for each late day. As long as the patient remains eligible and the practitioner recertifies, there is no lifetime limit on the benefit.

Three misunderstandings cause avoidable non-admits and denials. First, homebound does not mean bedbound. Patients may leave home for medical appointments, religious services, adult day care, and infrequent short outings and still qualify. Second, no prior hospital stay is required. Community referrals qualify on the same criteria, though admission source affects PDGM payment. Third, the benefit is not time-capped. Medicare pays for medically necessary care as long as eligibility criteria continue to be met and documentation supports them, though longer lengths of stay draw more medical review attention. Agencies that train intake and field staff on the actual rules capture referrals that competitors wrongly screen out.