What Medicare actually covers for home health
Medicare pays nothing out of pocket for covered home health visits — no copay, no deductible. This plain-English guide explains exactly what is covered, what is not, how to qualify, and how to get started in Central Florida.
Original Medicare pays $0 for covered home health visits — no copay, no deductible, no coinsurance. To qualify, a Medicare beneficiary must be under a doctor’s care, need intermittent skilled nursing or therapy, be certified as homebound, and receive care from a Medicare-certified agency. More than 3.5 million Americans used the benefit in 2023, according to MedPAC. 1
Five terms you need to know before calling any agency
Medicare eligibility rules use specific legal terms. Knowing what each one means prevents the most common misunderstandings families have when coverage is questioned or denied.
- Skilled care
- Care that must be provided by or under the direct supervision of a licensed professional: a registered nurse (RN), licensed practical nurse (LPN), physical therapist (PT), occupational therapist (OT), or speech-language pathologist (SLP). Injections, wound care, medication management, gait training, and swallowing therapy are examples of skilled care. Bathing, dressing, and meal preparation alone are not — those are custodial tasks.
- Homebound
- A Medicare legal term, not a medical diagnosis. A patient is homebound if leaving home requires a considerable and taxing effort. Short trips are allowed — doctor visits, adult day programs, church, a haircut — but leaving home must be infrequent, brief, or require help. The key misconception is that "homebound" means bedbound or housebound permanently. It does not. 4
- Intermittent care
- Skilled visits that are scheduled, time-limited, and predictably finite — not around-the-clock. CMS defines this as up to 28 hours of skilled nursing per week (or up to 35 hours under exceptional circumstances). Most patients receive two to five nursing visits per week, each lasting 45 to 90 minutes. Medicare home health does not cover continuous 24-hour care. 2
- Plan of care
- Also called the CMS-485 or simply "the 485." A physician-signed document listing the patient's diagnoses, the disciplines that will visit, the frequency of visits, medications, and goals. Medicare requires a signed plan of care before visits can be billed. Care can begin on verbal order, but the physician has 30 days to sign the written plan. 2
- Home health aide
- A trained caregiver who helps with bathing, dressing, grooming, toileting, and safe mobility. Under Medicare home health, aide visits are covered only when a skilled nursing or therapy need is also present in the plan of care. The aide benefit ends when the skilled need ends. Aide visits are intermittent — typically two to three times per week — not daily and not all-day.
The five conditions Medicare requires
All five must be met at the time care begins. A Medicare contractor can review any of these conditions during or after a claim.
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You must be enrolled in Medicare Part A or Part B
The home health benefit is covered under both Part A and Part B, depending on the specific circumstances. Most community-based home health (not following a qualifying hospital stay) is billed under Part B. If you are enrolled in a Medicare Advantage plan, the plan must cover the same benefit but may have network and prior-authorization requirements.
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A physician or allowed practitioner must certify the need
A doctor, nurse practitioner, clinical nurse specialist, or physician assistant must examine the patient and document that they are homebound and need skilled care. This face-to-face encounter must occur no more than 90 days before or 30 days after the start of home health care. The clinician who certifies is legally prohibited from having a financial interest in the home health agency they refer to. 3
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You must need intermittent skilled nursing, PT, OT, or SLP
At least one of these skilled disciplines must be medically necessary. Physical therapy, occupational therapy, and speech-language pathology can now qualify independently as the primary skilled need — they no longer require a nursing need to "open" the case. Under Jimmo v. Sebelius (2013), improvement is not required; a skilled clinician needed to maintain the patient's condition or prevent deterioration qualifies as a skilled need.
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You must be certified as homebound
Leaving home must require a considerable and taxing effort due to illness, injury, or functional limitation. A patient can leave home for medical appointments, adult day programs, or brief personal outings and still qualify. The test is the effort required to leave, not whether leaving ever happens. Assistive devices, a wheelchair, or needing another person's help to leave are all consistent with homebound status. 4
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The agency must be Medicare-certified
Only agencies that have completed CMS certification, passed a state survey, and maintain compliance with the Medicare Conditions of Participation can bill Medicare for home health services. In Florida, you can verify an agency's Medicare certification and state license through the Florida AHCA HealthFinder at HealthFinder.fl.gov. Kassy Health’s Florida AHCA License is #299993031. 5
What Medicare covers — and what it does not
The boundary between covered and not covered is one of the most misunderstood parts of the Medicare home health benefit. Both columns below are official CMS policy. 2
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Skilled nursing visits (RN or LPN)Wound care, injections, IV therapy, medication management, disease teaching, vital sign monitoring, OASIS assessment.
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Physical therapy (PT)Strength, balance, gait training, fall prevention, safe transfer techniques, exercise programs.
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Occupational therapy (OT)Adaptive strategies for bathing, dressing, cooking, and daily activities; home safety assessments and modifications.
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Speech-language pathology (SLP)Swallowing evaluation and treatment, communication disorders, cognitive rehabilitation.
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Home health aide (when skilled need is active)Bathing, dressing, grooming, personal hygiene, safe mobility assistance.
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Medical social worker (MSW)Counseling, community resource referrals, advance directive assistance, family support.
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Medical supplies (wound care, catheters)Supplies used during home health visits — dressings, catheters, injection supplies — are covered with no copay.
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Durable medical equipment (DME) — 80%Walkers, wheelchairs, hospital beds, oxygen equipment billed under the home health benefit are covered at 80% after the Part B deductible. You pay the remaining 20%.
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24-hour or around-the-clock careMedicare home health is intermittent by definition. Continuous, 24-hour nursing or aide coverage is not covered regardless of medical complexity.
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Custodial-only home health aideIf the only need is personal care without any active skilled nursing or therapy order, Medicare does not cover the aide visit.
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Meal delivery or homemaker servicesGrocery shopping, cooking, housekeeping, laundry, and meal programs are not home health services. They may be available through community programs such as Medicaid waiver or the Older Americans Act.
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TransportationRides to medical appointments, pharmacies, or other destinations are not part of the home health benefit. Some Medicare Advantage plans cover transportation separately.
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Prescription drugsMedicare Part D (not the home health benefit) covers outpatient prescription medications. Drugs administered by a nurse during a skilled visit may be covered if they meet specific clinical criteria.
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Companion or supervision servicesSitting with a patient for companionship, supervision only (no personal care), or safety monitoring is not a Medicare-covered home health service.
How to start Medicare home health in six steps
Most families go from "the doctor mentioned home health" to a visiting nurse at the door within two to five business days. Here is the path.
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Talk to the treating physician
Tell the doctor you want home health care. Ask specifically whether the patient qualifies as homebound and whether there is a skilled nursing, physical therapy, occupational therapy, or speech therapy need. Physicians are often not the ones who raise home health — families frequently have to ask first. If your parent was just discharged from a hospital or rehab facility, the case manager or discharge planner will typically initiate the referral on your behalf.
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Arrange the face-to-face encounter
Medicare requires a physician or allowed practitioner to examine the patient and document homebound status and skilled-care need. This face-to-face encounter must occur within 90 days before or 30 days after the home health start date. A recent hospital discharge visit, an outpatient office visit, or a telehealth encounter all qualify. The physician documents the findings separately from the plan of care — this is a CMS requirement that became effective in 2011. 3
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Choose a Medicare-certified agency
Medicare law gives you the right to choose any Medicare-certified agency that serves your address. Hospital discharge planners are required to give you a list of all qualifying agencies — they cannot steer you to one agency without disclosing alternatives. Compare agencies on CMS Care Compare at medicare.gov/care-compare using quality ratings and patient experience scores. In Florida, verify agency licensing at HealthFinder.fl.gov. 5
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The agency schedules the start-of-care visit
Once the agency receives the physician's referral, they will call you within 24 to 48 hours to schedule the first visit. A registered nurse (RN) will come to the home, introduce the team, and open the case. Expect the first visit to take 60 to 90 minutes — it is longer than later visits because the paperwork happens at the start.
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The RN completes the OASIS-E2 assessment
During the start-of-care visit, the registered nurse completes the OASIS-E2 — a comprehensive, federally required assessment that measures the patient's functional status, medications, diagnoses, and care needs. Effective April 1, 2026, OASIS-E2 is the current version (superseding OASIS-E1). The OASIS drives the plan of care, the visit schedule, and Medicare payment. Families do not fill it out; the nurse handles the entire assessment. 6
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The physician signs the plan of care
The agency prepares the plan of care (CMS-485) and sends it to the certifying physician for signature. Medicare requires the physician to sign before visits can be billed. Care can begin on a verbal order, but the written plan must be signed within 30 days of the start of care. The agency follows up with the physician's office — you do not have to chase the paperwork.
The data behind the benefit
Home health is one of Medicare’s most used benefits. The Medicare Payment Advisory Commission (MedPAC) reported that approximately 3.5 million Medicare beneficiaries received home health services in 2023, at a total program cost of approximately $17.8 billion. 1
Florida consistently ranks among the highest-volume home health states in the country, driven by its disproportionately large Medicare-age population. Florida AHCA licenses and regulates all home health agencies operating in the state. You can verify any agency’s current licensure and complaint history at HealthFinder.fl.gov. 5
Florida is also one of the states participating in the Review Choice Demonstration (RCD), a CMS pilot program that adds a pre-claim review step for some Medicare home health episodes. Under RCD, an agency may be asked to submit documentation for CMS review before payment is made. This does not affect patient eligibility or care, but it does mean your agency must maintain thorough clinical documentation throughout the episode. Agencies that have strong documentation practices are far less likely to experience delays or denials under RCD.
Kassy Health has served Central Florida since 2006. The agency holds CHAP accreditation (Community Health Accreditation Partner), a CMS-deemed accrediting organization, and earned a 4-star CMS Quality of Patient Care rating — the primary quality measure families should check on CMS Care Compare. Florida AHCA License #299993031.
Questions families ask about Medicare home health
No. Original Medicare pays 100 percent of approved home health visits with no copay, no deductible, and no coinsurance — as long as the patient meets the four eligibility conditions. You should not receive a bill for covered nursing, therapy, aide, or social-work visits. Durable medical equipment ordered under the home health benefit is covered at 80 percent after the Part B deductible. 2
There is no fixed visit limit. Medicare covers as many visits as a physician certifies are medically necessary, as long as the patient remains homebound and needs intermittent skilled care. Care is authorized in 60-day certification periods, and a physician can recertify indefinitely. The Jimmo v. Sebelius settlement (2013) confirmed that Medicare cannot deny coverage simply because a patient is not improving — maintenance nursing and therapy are covered when a skilled clinician is needed to maintain the patient’s condition safely.
Each certification period is 60 days. If the patient still meets the homebound and skilled-care requirements at the end of 60 days, the physician can recertify for another 60-day period, and again after that. There is no statutory maximum number of periods. Coverage ends when the patient no longer needs skilled care, no longer meets the homebound criterion, or chooses to stop.
Yes, but only when there is also a skilled nursing or therapy need in the plan of care. The home health aide — who helps with bathing, dressing, personal hygiene, and safe mobility — is a dependent benefit, not a standalone one. If the skilled need ends, aide visits end too. Medicare does not cover a home health aide when the only need is personal care or homemaking.
Medicare home health is skilled medical care — nursing, therapy, aide — ordered by a physician and delivered by a licensed, Medicare-certified agency under a plan of care. It covers intermittent visits, not continuous or 24-hour care. Private home care (sometimes called custodial care or companion care) is non-medical help with activities of daily living — bathing, meals, companionship — paid out of pocket, by long-term care insurance, or by Medicaid waiver programs. The two are frequently used together for patients who need both skilled care and ongoing personal support.
Medicare Advantage (MA) plans are required by law to cover the same home health benefit as Original Medicare, but plans may require prior authorization and may have network restrictions — meaning the agency must be in the plan’s network. Some MA plans offer expanded benefits beyond what Original Medicare covers, such as more aide hours, meal delivery, or transportation. Always confirm your specific plan’s requirements before starting care.
You have the right to appeal. When an agency issues a Notice of Medicare Non-Coverage (NOMNC), you have until noon of the day before services end to request a review by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The QIO must issue a decision within one business day. You can also file a formal redetermination with your Medicare Administrative Contractor (MAC). Do not give up based solely on the agency’s word — improper denials are common, and beneficiaries who appeal frequently succeed.
Yes. Medicare does not require a patient to be improving to qualify for home health. The Jimmo v. Sebelius settlement (2013) established that maintenance nursing and therapy are covered when a qualified clinician is needed to maintain the patient’s condition or slow deterioration. Chronic heart failure, COPD, Parkinson’s disease, multiple sclerosis, and other stable but complex conditions frequently qualify — as long as the homebound and intermittent skilled-care criteria are met and a physician certifies the need.
Sources cited in this guide
Every clinical and policy claim in this article is drawn from primary government sources, peer-reviewed literature, or official CMS program guidance. Verified May 2026.
- Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare Payment Policy. March 2025. Chapter 8: Home Health Services. medpac.gov →
- Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual, Chapter 7: Home Health Services. Publication 100-02. Updated 2024. cms.gov →
- Centers for Medicare & Medicaid Services (CMS). Home Health Face-to-Face Encounter Requirement. 42 CFR §424.22. Updated 2023. ecfr.gov →
- Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual, Chapter 7, §30.1: Criteria for Homebound Status. Publication 100-02. cms.gov →
- Florida Agency for Health Care Administration (AHCA). Florida Health Finder — Provider Verification. Accessed May 2026. healthfinder.fl.gov →
- Centers for Medicare & Medicaid Services (CMS). OASIS-E2 Guidance. Effective April 1, 2026. Home Health Quality Reporting Program. cms.gov →
- Medicare.gov. Home Health Services Coverage. U.S. Centers for Medicare & Medicaid Services. medicare.gov →
- Medicare.gov. Your Medicare Coverage: "Medicare & Home Health Care" (Publication 10969). medicare.gov →
Have questions about your family member’s coverage?
Our intake nurses can confirm whether your family member qualifies, explain what Medicare will cover in your specific situation, and schedule a start-of-care visit — usually within 24 to 48 hours of the physician referral.
(407) 875-1801 Mon–Fri 8 am–5 pm · Bilingual (English · Español) Browse other resourcesKassy Health · Medicare-certified home health agency founded by Sandra Morales, RN in 2006. Serving Orange, Seminole, Osceola, Lake, and Volusia counties. CHAP-accredited · 4-star CMS Quality of Patient Care.
