Medicare Requirements for Home Health Services

To qualify for home health services, Medicare beneficiaries must (1) be homebound; (2) need intermittent skilled nursing care or physical, speech, or occupational therapy; (3) be under the care of a physician; and (4) be under a plan of care that has been established and periodically reviewed by a physician.3 For a home health agency (HHA) to receive payment from Medicare, a physician must certify the beneficiary’s need for home health services and must recertify the need at least every 60 days.

Homebound Status 

Medicare considers beneficiaries homebound if, because of illness or injury, they have conditions that restrict their ability to leave their places of residence. Homebound beneficiaries do not have to be bedridden, but should be able to leave their residences only infrequently with “considerable and taxing effort” for short durations or for health care treatment

Intermittent Skilled Nursing or Therapy Services 

The Social Security Act defines “part-time or intermittent services” as skilled nursing and home health aide services furnished any number of days per week as long as the combined services are less than 8 hours each day and 28 or fewer hours per week.6 A registered nurse or licensed vocational nurse must provide the skilled nursing care.7 Home health aide services include personal care, such as bathing and dressing, feeding, and simple dressing changes that do not require the skills of a licensed nurse.8 Therapy services must be performed by a qualified therapist or therapy assistant under the supervision of a qualified therapist.

Requirement To Be Under the Care of a Physician 

Medicare requires that beneficiaries be under the care of a doctor of medicine, osteopathy, or podiatric medicine.10 CMS expects the physician who signs the plan of care to see the beneficiary;11 however, prior to April 2011, CMS did not require the ordering physician to see the beneficiary in person as a condition of payment for home health car

Established Plan of Care

Medicare pays for home health services only if they are provided under a plan of care that a physician establishes, approves, and periodically reviews.13 A plan of care should list 12 items, including all pertinent diagnoses, functional limitations, frequency of visits to be made, and the types of services required.14 The physician establishes the plan of care and must review, sign, and date it at least once every 60 days. If a beneficiary does not receive at least one covered home health visit within the 60-day episode, CMS considers the plan to be terminated.15 Medicare reimburses physicians for establishing and reviewing the plan of care.