Medicare Guide
Who may qualify for Medicare home health?
Medicare generally requires a qualifying skilled need, homebound status, provider certification and orders, a plan of care, and care from a Medicare-certified agency.
The essentials
What to know first.
- Need for intermittent skilled nursing, physical therapy, or speech-language pathology; continuing occupational therapy may also qualify in certain circumstances.
- A condition that makes leaving home difficult, requires help or equipment, or makes leaving medically inadvisable.
- A face-to-face assessment related to the need for home health.
- An individualized coverage review.
Important: Eligibility is not guaranteed. Confirm current requirements with Medicare and the ordering provider.
Qualifying skilled need
The person must need a service that requires clinical skill.
Medicare generally requires intermittent skilled nursing, physical therapy, or speech-language pathology, or a continuing need for occupational therapy under applicable rules. Personal assistance alone is not a qualifying skilled need.
Homebound status
Leaving home must be difficult, require help, or be medically inadvisable.
The person must also normally be unable to leave home, and leaving must require considerable effort. Medical trips and some short or infrequent absences may still be allowed.
Provider & plan
Assessment, certification, orders, and a plan of care connect the benefit.
- A related face-to-face assessment
- Provider certification of eligibility
- Orders for the needed disciplines
- An established and periodically reviewed plan of care
- Services from a Medicare-certified home health agency
Prepare for review
Bring facts, not a self-diagnosis of eligibility.
- The skilled reason home health is being considered
- Recent hospital, surgery, or provider information
- How the person leaves home and what help is required
- The requested disciplines and patient location
- The exact Medicare or Medicare Advantage plan
Safety & escalation
Know when not to wait.
This page is general education. The ordering provider documents clinical eligibility, and Medicare or the patient’s plan makes the coverage determination.
Frequently asked questions
Clear answers before the next step.
Is a hospital referral enough to qualify?
No. A referral starts the process, but eligibility, documentation, coverage, agency acceptance, and service availability still must be reviewed.
Does homebound mean never leaving home?
No. Medicare recognizes medical trips and certain short or infrequent absences. The full two-part standard still must be documented.
Can a diagnosis alone establish eligibility?
No. Eligibility depends on the person’s skilled need, homebound status, provider certification, plan of care, and other applicable requirements.