The numbers that decide whether you're covered.
Here's what to do, in 4 steps.
Here's the order I'd take this in if it were my mom. Get the homebound documentation right, lock in the face-to-face encounter, and know your rights when an agency tries to discharge for the wrong reason.
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Confirm a certifying clinician will sign the plan of care
Medicare requires a physician, nurse practitioner, physician assistant, or clinical nurse specialist to certify that you're homebound, need skilled care, and are under their care — then sign and review the plan of care every 60 days. Pick the clinician who knows the condition best and confirm they'll do the paperwork before you start an agency.
Time: Same week Cost: Free 42 CFR 424.22 (certification requirements)
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Lock in the face-to-face encounter
A face-to-face encounter with the certifying clinician (or a permitted non-physician practitioner) must happen no more than 90 days before home health starts or within 30 days after care begins, related to the primary reason you need home health. Telehealth counts. Get the date on the certification form.
Time: 90 days before / 30 days after Cost: Free Medicare.gov — home health services
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Push back if anyone says you have to be 'improving'
The Jimmo v. Sebelius settlement (2013) and 42 CFR 409.44(c)(2)(iii)(B)–(C) say Medicare covers skilled care to maintain function or slow decline — improvement is not required. If a home health agency tells you otherwise, ask for the denial in writing, request a Beneficiary Notice, and call your SHIP at 1-877-839-2675.
Time: Same day Cost: Free Center for Medicare Advocacy — Improvement Standard
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Pick a Medicare-certified home health agency
Only services from a Medicare-certified home health agency are covered. Use Medicare's Care Compare to look up agencies in your ZIP, check star ratings and patient survey scores, and ask the agency to confirm they accept your specific Medicare coverage (Original Medicare or your Medicare Advantage plan) before the first visit.
Time: 1–2 days Cost: Free Medicare Care Compare — home health
Dr. Ed explains Medicare home health
Video coming soon
I'm filming a walkthrough on the homebound rule, the Jimmo settlement, and how to push back when an agency says "Medicare won't cover this anymore." When it's up, you'll see it here.
Which of these sounds more like you?
Eight situations I see most often when families call about home health. Pick whichever sounds closest — the answer underneath gives you the rule and what to do next.
I'm 'homebound' but I leave the house sometimesFor medical care, religious services, or short outings
Homebound doesn't mean bedridden. CMS says you're homebound if leaving home requires considerable and taxing effort — you need help, a wheelchair, or your condition makes it medically inadvisable to leave often. You can still leave for medical appointments, religious services, adult day care, family events like a graduation or funeral, and short, infrequent absences.
What trips families up: leaving for a haircut every two weeks is fine. Driving yourself to the grocery store every Tuesday probably isn't. The agency's nurse will document your homebound status at the start of care and during recertification.
The agency said Medicare won't pay because Mom isn't improvingThe 'improvement standard' was settled in 2013
This is the single most damaging myth in Medicare home health. The Jimmo v. Sebelius settlement (approved by the U.S. District Court for Vermont in January 2013) confirmed that Medicare covers skilled care to maintain a patient's condition, prevent deterioration, or slow decline — even when the patient won't improve. CMS reaffirmed this in 2017.
What to do: ask for the denial in writing. Quote 42 CFR 409.44(c)(2)(iii)(B) and (C), which spell out the maintenance therapy standard. Call your SHIP at 1-877-839-2675 or the Center for Medicare Advocacy. File a fast appeal if you get a discharge notice.
I just want a home health aide — no nurse neededAide alone is not covered under Medicare home health
Medicare home health aides are covered only as an add-on to skilled nursing or therapy. If you don't need skilled care — just bathing, dressing, meal help — Medicare won't pay for the aide.
Alternatives that may pay for aide-only personal care: Medicaid (in most states), state-funded HCBS waivers, Veterans Affairs Aid and Attendance, long-term care insurance, or out-of-pocket. PACE programs cover personal care for participants who qualify.
Mom needs round-the-clock care at homeMedicare home health is intermittent, not 24-hour
Medicare home health is by statute part-time and intermittent. Skilled nursing is covered when it's needed fewer than 7 days a week or less than 8 hours per day for episodes of 21 days or less (longer with case-by-case review). It is not built for round-the-clock care.
If round-the-clock home care is what you need, the path is usually: Medicaid HCBS waivers, PACE in the counties where it's available, the VA's housebound or aid-and-attendance benefit if eligible, or long-term care insurance and private pay. A skilled nursing facility may be the right answer when home care can't safely cover the hours.
I'm being discharged from the hospital with home health ordersWhat to ask before you leave the hospital
Hospital discharge planners often pre-arrange home health. That's fine — but you don't have to take whichever agency they suggest first. By law, the hospital must offer you a list of Medicare-certified agencies serving your ZIP, and you have the right to choose.
Before you sign discharge papers, ask: which clinician is signing the certification, when did the face-to-face encounter happen, what's on the plan of care, and is the agency in-network for my Medicare coverage. Get the agency's name and phone number in writing.
I'm on a Medicare Advantage plan — are the rules different?MA plans must cover at least Original Medicare's home health benefit
Medicare Advantage plans are required to cover at least the same home health services Original Medicare covers. What can differ: prior authorization (many MA plans require it), the network of home health agencies, cost-sharing for items like durable medical equipment, and supplemental in-home benefits some MA plans add (like in-home support services).
Before care starts, call your plan's member services line and ask: Do you require prior authorization? Which agencies are in network? What's the cost-share for DME? If a denial comes, the appeal goes through the plan first — you have a right to an expedited appeal when the timing is urgent.
I'm helping my parent navigate thisCaregiver path — paperwork, conversations, advocacy
Caregiver shortlist for Medicare home health: get the certifying clinician's name, get the date of the face-to-face encounter, get a copy of the plan of care, and read the OASIS assessment when the agency completes it. Confirm whether the homebound box is checked and why.
If you're not the listed contact on Medicare's records and you'll be making calls, the parent can sign Form SSA-1696 (representative for Social Security) and a CMS authorization to disclose for Medicare. Without those, Medicare can't talk to you about specifics. Plan for that conversation early.
If you're filing for yourself instead of a parent, the rules are the same — but the paperwork shortcuts are different. → See the self-filer view
None of these match my situationIf your situation isn't here, here's where to go
If your situation didn't show up above, two free options to try: 1-800-MEDICARE (1-800-633-4227), available 24/7, can answer questions about Original Medicare coverage and refer you to local resources. SHIP — the State Health Insurance Assistance Program at 1-877-839-2675 — connects you with trained counselors in your state who give free, unbiased Medicare help.
If you want a licensed Medicare advisor to walk through a Medicare Advantage plan denial or coverage question, the Chapter card above is a free service. Either way, the next call is free — don't sit with the question alone.
Everything people ask me about home health
What does it mean to be 'homebound' for Medicare?
You're considered homebound when leaving home requires a considerable and taxing effort — you need help (a person, a wheelchair, a walker, crutches, special transportation), or your doctor advises against leaving because of your condition. You can still leave for medical care, religious services, adult day care, family events like a graduation or funeral, or short, infrequent absences. Homebound is not the same as bedridden.
What home health services does Medicare cover?
Medicare covers part-time or intermittent skilled nursing care, physical therapy, speech-language pathology, occupational therapy (continuing or as a qualifying service in some cases), medical social services, home health aide services (only when you're also getting skilled care), durable medical equipment, and medical supplies that relate to your treatment. It does not cover 24-hour care, meals delivered to your home, homemaker services unrelated to your care plan, or personal care alone when you don't need skilled care.
Do I have to be improving for Medicare to keep paying?
No. The Jimmo v. Sebelius settlement, approved in January 2013 by the U.S. District Court for Vermont, confirmed that Medicare covers skilled nursing and therapy needed to maintain your condition, prevent deterioration, or slow decline. CMS reaffirmed this in 2017 and codified it at 42 CFR 409.44(c)(2)(iii)(B) and (C). If a home health agency tells you coverage stops because you've 'plateaued,' that's the old improvement-standard myth. Push back and appeal.
Who can certify me for home health?
Under 42 CFR 424.22, a physician, nurse practitioner, physician assistant, clinical nurse specialist, or certified nurse-midwife can certify that you're eligible for home health and sign your plan of care. The certifying clinician must have had a face-to-face encounter with you (in person or via telehealth) related to the primary reason you need home health.
What is the face-to-face encounter rule?
Medicare requires a face-to-face encounter with the certifying clinician (or a permitted nurse practitioner, PA, clinical nurse specialist, or certified nurse-midwife) within 90 days before the home health start of care date or within 30 days after care begins. The encounter must be related to the primary reason you need home health, and the date must be documented on the certification. Telehealth encounters count, when they comply with Medicare telehealth rules.
How often does the plan of care need to be recertified?
The plan of care is certified for an episode of up to 60 days. If you still need home health after that, the certifying clinician must recertify before each new 60-day episode. Recertification happens when the plan of care is reviewed and must be signed and dated by the clinician. Recertification stops only if you elect to transfer agencies or are discharged because goals are met or you no longer need home health.
Can I get a home health aide without skilled nursing or therapy?
Not under Medicare. Aide services are covered only as an add-on when you're also receiving skilled nursing, physical therapy, speech-language pathology, or qualifying occupational therapy. If you don't need any skilled service, Medicare won't pay for aide visits. Look at Medicaid HCBS waivers, VA Aid and Attendance, long-term care insurance, PACE, or private pay for aide-only personal care.
What does Medicare home health cost me?
For services Medicare covers, you pay nothing for skilled nursing, therapy, home health aide services, or medical social services. For durable medical equipment ordered through home health, you pay 20% of the Medicare-approved amount after meeting the Part B deductible. Medicare does not cover prescription drugs given through home health (those run through Part D).
What if my home health is denied or cut off?
Ask for the denial in writing. If you're on Original Medicare, you have appeal rights through the Medicare claims process — starting with redetermination by the Medicare Administrative Contractor, then reconsideration, an Administrative Law Judge hearing, the Medicare Appeals Council, and federal court. If you're on Medicare Advantage, the appeal goes through the plan first, with an expedited path for urgent cases. SHIP at 1-877-839-2675 and the Center for Medicare Advocacy provide free help with Jimmo-related denials in particular.
Are home health rules different on Medicare Advantage?
Medicare Advantage plans must cover at least the same home health services as Original Medicare. What can vary: prior authorization (many plans require it), the network of home health agencies, cost-sharing for durable medical equipment, and any supplemental in-home benefits the plan adds. Call your plan before care starts. If a denial comes, you have the right to appeal through the plan, with an expedited timeline for urgent decisions.
Other programs that pair with home health
Medicare home health is intermittent and skilled — it's not 24-hour care, it's not personal care alone, and it caps out fast. These programs fill the gaps when you need more.
Medicaid HCBS waivers
If your needs go beyond Medicare's part-time and intermittent rule — personal care, homemaker services, more hours — you may qualify for Medicaid Home and Community-Based Services waivers. Eligibility, hours, and waitlists vary state by state.
Long-term care Medicaid
If home health care isn't enough and a nursing facility is on the table, long-term care Medicaid may pay when income and assets are below state limits. Many states also offer Medicaid-funded in-home alternatives to nursing-home placement.
Medicare skilled nursing facility (SNF) coverage
If a hospital stay leaves you needing rehab beyond what's safe at home, you may qualify for Medicare-covered skilled nursing facility care after a qualifying hospital stay. Coverage rules and cost-share are different from home health.
Medicare hospice benefit
If the prognosis is six months or less and the goal is comfort rather than cure, you may qualify for the Medicare hospice benefit — a different benefit from home health, with much broader in-home support and no homebound requirement.
VA Aid and Attendance / Housebound
If you're a wartime veteran or surviving spouse who needs help with daily activities or is housebound, you may qualify for VA Aid and Attendance or Housebound monthly payments on top of your VA pension. The benefit can pay for in-home care.
Medicare DME (durable medical equipment)
Hospital beds, oxygen equipment, walkers, wheelchairs, and similar medically necessary equipment may be covered under Medicare's DME benefit alongside home health. Cost-share is typically 20% of the Medicare-approved amount.
Help me keep it.
If a home health agency tries to drop your skilled coverage because you're not "improving," I'll send you the Jimmo letter, the CFR sections, and the script I use when I make the call.
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