What qualifies a patient for Medicare home health?

The Medicare home health benefit is defined narrowly. First, a physician (or in most cases a nurse practitioner or physician assistant) must certify the need and sign the plan of care. Second, the patient must be homebound — meaning leaving home requires considerable and taxing effort, and absences are infrequent, short, or for medical care. Homebound does not mean bedbound; it means leaving the home is meaningfully difficult.

Third, the patient must need intermittent skilled care: nursing care that requires a licensed clinician, or therapy (physical, occupational, or speech) that requires a licensed therapist. Custodial-only need — help bathing, dressing, or with meals — does not qualify. If the only need is daily hours of hands-on support, that is home care, not home health, and Medicare will not pay for it.

Fourth, the care must be provided by a Medicare-certified home health agency and delivered under the OASIS assessment framework in 60-day episodes. Non-certified agencies cannot bill Medicare for skilled visits, even if their clinicians are qualified.

The most common qualifying events in Southeast Michigan: post-surgical recovery, post-hospitalization for a cardiac or respiratory event, stroke rehabilitation, new IV therapy, wound care, and diabetes management requiring skilled teaching. Once the skilled need resolves or the patient is no longer homebound, the episode ends.

For the full breakdown, see the cornerstone: Home Health vs. Home Care guide.