Who qualifies for Medicare home health? The four rules, in plain English

I get a version of this question every week, usually from an adult child: "Mom is struggling, but she is not bedridden. Does she even qualify?" More often than people expect, the answer is yes. Medicare's rules are stricter in the imagination than on paper. Here they are, without the jargon.

Rule 1: A doctor has to order it

A physician, nurse practitioner, clinical nurse specialist, or physician assistant must certify that you need home health and sign a plan of care. Nurse practitioners and physician assistants have been able to do this since 2020, which helps in Northeast Florida where many patients see an NP as their primary provider.

Part of that certification is a face to face visit related to the reason you need care. It can happen up to 90 days before home health starts or up to 30 days after, and a hospital stay counts. Practically, if you have seen your provider recently, this rule is already met.

Rule 2: You need skilled care, part time

You have to need at least one of these: skilled nursing, physical therapy, speech therapy, or continuing occupational therapy. "Skilled" means it takes a licensed clinician to do it safely and correctly: wound care, injections, medication management for a complicated regimen, teaching a new diagnosis, or therapy to restore strength and function after surgery, a stroke, or a fall.

"Part time or intermittent" means visits, not round the clock care. A few visits a week is the norm.

Rule 3: You are homebound

This is the rule families misread. Homebound does not mean you never leave the house. Medicare's definition has two parts:

• Because of illness or injury, you need help to leave home, whether that is another person, a walker, a wheelchair, or special transportation, or your doctor believes leaving home is not medically advisable.
• Leaving home takes a considerable and taxing effort, and you do not do it often.

You can still go to the doctor, to dialysis, to adult day care, to religious services, or to an occasional short outing like a haircut or a family event and remain homebound. The test is whether it is hard and infrequent, not whether it is impossible.

Rule 4: The agency is Medicare certified

Only a Medicare certified agency can bill Medicare for home health. Certification means the agency is surveyed against federal conditions of participation and reports its outcomes publicly on Medicare Care Compare. Access Home Health has been Medicare certified since 2019, our CMS certification number is 687026, and we are also accredited by ACHC and licensed by the Florida Agency for Health Care Administration.

What you do not need

• You do not need a prior hospital stay. Your primary care provider can order home health from the office.
• You do not need to be bedridden.
• You do not need a specific diagnosis. Need is based on your condition and what skilled care can do for it.
• You do not need to pay anything for covered services under Medicare. It pays 100%, with no deductible or copay. Durable medical equipment is the exception, at 20% of the Medicare approved amount.

Medicare Advantage, the VA, and everyone else

Medicare Advantage plans must cover home health, and the Medicare Advantage plans we accept cover home health visits at 100%. Some require prior authorization, which we request for you. VA Community Care can cover home health for eligible veterans with a referral. We verify benefits before the first visit so nobody is surprised.

How long it lasts

Care is certified in 60 day periods. At the end of each period your clinician reassesses, and if you still meet the rules and still need skilled care, your physician can recertify. There is no cap on the number of periods.

The fastest way to find out

Call 844-808-9096 and describe the situation. A clinician can usually tell you in a few minutes whether someone is likely to qualify, and we will call the physician's office to get the order started. If you are a physician or case manager, fax orders and a face sheet to 904-638-8752.

This article is general information about Medicare rules as of 2026, not legal or medical advice. Coverage decisions are made by Medicare and your plan.