Maybe you’re coming home from the hospital after surgery. Perhaps you’ve had a stroke, a serious infection, or a fall. Or a chronic condition has gotten harder to manage and leaving home for appointments has become difficult.

Someone on your healthcare team may say:

“We’re going to order home health.”

That sounds reassuring.

But what exactly does it mean?

Who comes to your house? How often? Who decides what you need? Does Medicare pay for it? And perhaps most importantly, how do you get home health if nobody has offered it?

Home health is an important Medicare benefit, but it’s also one of the more misunderstood parts of healthcare.

Here’s what you need to know.

What Is Home Health?

Home health is skilled healthcare provided in your home.

Instead of traveling to a clinic or facility for certain services, qualified healthcare professionals come to you.

Depending on your medical needs, home health can include:

• Skilled nursing
• Physical therapy
• Occupational therapy
• Speech-language pathology
• Medical social services
• Limited home health aide services when Medicare requirements are met

Home health isn’t simply for older adults.

People may receive it after an operation, serious illness, injury, hospitalization, or because of a chronic medical condition.

For older adults, however, home health can be particularly valuable because getting to and from medical appointments may itself be difficult or unsafe.

Home Health Is Not the Same as Having a Caregiver All Day

This distinction is important enough to repeat.

Medicare home health generally involves visits from healthcare professionals, not someone remaining in the home throughout the day.

A nurse might come to assess a wound.

A physical therapist might work with you on walking and balance.

An occupational therapist might help you learn a safer way to shower or get dressed.

Then that professional leaves.

If you also need someone to prepare meals, do laundry, provide companionship, help throughout the day, or supervise a person with dementia, those needs may require home care, family caregiving, community services, or another form of support.

Home health can be extremely valuable, but knowing what it does—and doesn’t do—helps prevent disappointment.

Who Qualifies for Medicare Home Health?

Medicare has specific requirements.

Generally, to receive Medicare-covered home health services:

• You must be under the care of a doctor or another healthcare practitioner allowed by Medicare.
• You must need eligible skilled services.
• Your need for skilled nursing must generally be part-time or intermittent, or you must need qualifying therapy services.
• You must be considered homebound.
• Your care must be provided by a Medicare-certified home health agency.

Your healthcare provider must certify that you need home health care and establish or review a plan of care.

Eligibility is based on your individual situation—not simply your age or diagnosis.

What Does “Homebound” Mean?

This word causes a lot of confusion.

Homebound does not necessarily mean you are forbidden from leaving your house.

Under Medicare rules, someone may be considered homebound when leaving home requires considerable and taxing effort or when assistance is needed because of illness or injury.

For example, you might need:

• A walker
• A wheelchair
• Special transportation
• Another person’s assistance

You may also leave home for medical treatment and, under Medicare rules, certain infrequent or short-duration nonmedical absences can still be consistent with being homebound.

So don’t assume you’re automatically disqualified because you occasionally leave the house.

If you’re uncertain, talk with your healthcare provider or the home health agency about your circumstances.

What Kinds of Conditions Might Lead to Home Health?

There isn’t one master list of diagnoses that automatically qualify.

Home health is based on your medical and functional needs and whether you meet Medicare’s requirements.

Examples of situations in which someone might need home health include:

• Recovery after joint replacement
• Recovery following a stroke
• Wound care
• Difficulty walking after hospitalization
• Heart failure requiring skilled monitoring and education
• Complications related to diabetes
• Recovery after a serious infection
• Certain medication-management needs requiring skilled care
• Rehabilitation after injury
• A decline in function associated with a chronic illness

The important question isn’t simply:

“What diagnosis do I have?”

It’s:

“Do I have a skilled healthcare need that can appropriately be addressed in my home, and do I meet the coverage requirements?”

Who Can Order Home Health?

People often assume only a hospital can arrange home health.

That’s not the case.

Home health frequently begins after hospitalization because discharge planners identify the need before someone goes home. But eligible home health services can also be initiated from the community.

Under Medicare rules, physicians and certain other allowed practitioners, including nurse practitioners, clinical nurse specialists, and physician assistants, can perform required functions related to ordering and certifying home health within applicable rules.

Your primary care provider or another clinician managing your condition may therefore be an important starting point.

Can I Ask for Home Health?

Yes.

If you’re struggling at home and think skilled care might help, bring it up with your healthcare provider.

You don’t have to wait for someone else to think of it.

Explain specifically what is happening.

For example:

“I’ve fallen twice since I came home from the hospital, and I’m having trouble walking safely.”

Or:

“I can’t manage the stairs to get to outpatient physical therapy.”

Or:

“My wound is becoming difficult for us to manage at home.”

Specific information gives your healthcare provider a clearer picture of what has changed and whether home health evaluation may be appropriate.

Asking doesn’t guarantee that you will qualify, but it can start the conversation.

What Happens After Home Health Is Ordered?

Once a referral is made, a home health agency reviews the information to determine whether it can accept you and whether the services appear appropriate.

If the agency accepts the referral, it will arrange an initial assessment.

A home health clinician will evaluate things such as:

• Your medical condition
• Medications
• Mobility
• Ability to perform daily activities
• Safety in the home
• Risk of falls
• Skilled nursing needs
• Therapy needs
• Support available from family or caregivers

The agency then works within your provider-approved plan of care to determine which services are needed and how frequently they should occur.

What Happens During the First Visit?

Don’t worry about making your house perfect.

The clinician isn’t coming to inspect your housekeeping.

They’re trying to understand how you’re functioning in the environment where you actually live.

They may ask about:

• Recent hospitalizations
• Your medical history
• Medications
• Pain
• Falls
• Eating and drinking
• Bathroom habits
• Mobility
• Sleep
• Memory or confusion
• Who helps you
• What you’re having difficulty doing

They may also look at the physical environment.

Are there stairs?

Can you get into the shower safely?

Is there a loose rug you keep catching your walker on?

Can you get out of your favorite chair?

Can you reach the bathroom at night?

Seeing these things in the home is one of the advantages of home health.

What Does a Home Health Nurse Do?

The nurse’s role depends on why you were referred.

Services might include:

• Assessing your condition
• Monitoring symptoms
• Wound care
• Certain injections or treatments
• Medication education
• Teaching you or a caregiver how to manage aspects of your condition
• Monitoring response to treatment
• Communicating concerns to your healthcare provider
• Helping recognize warning signs that require medical attention

An important part of home health nursing is teaching.

The goal isn’t necessarily to have a nurse perform a task forever. When appropriate, the nurse may teach you or your caregiver how to manage safely between visits and after home health ends.

What Does Physical Therapy Do at Home?

Physical therapy may help with:

• Walking
• Strength
• Balance
• Transfers
• Stairs
• Fall prevention
• Using a walker or cane
• Getting in and out of bed
• Recovering function after illness, surgery, or injury

The therapist can also see how you actually move through your own home.

That’s different from walking down a perfectly clear hallway in a clinic.

At home, there may be a narrow bathroom doorway, three steps at the entrance, a low couch, or a bedroom on another floor.

Those details matter.

What About Occupational Therapy?

Occupational therapy focuses heavily on helping people perform the activities they need and want to do safely.

An occupational therapist might work on:

• Bathing
• Dressing
• Toileting
• Getting in and out of the shower
• Using adaptive equipment
• Preparing simple meals
• Conserving energy
• Performing everyday activities after illness or injury

They may also recommend changes to the home environment to make everyday activities safer.

How Long Does Home Health Last?

There isn’t one standard number of visits that everyone receives.

The amount and duration of care depend on your condition, skilled needs, progress, Medicare requirements, and your plan of care.

Some people need home health for a relatively short recovery period.

Others with ongoing qualifying skilled needs may receive services for longer.

Home health isn’t automatically limited to a few visits simply because someone is older or has a chronic illness. At the same time, it isn’t intended to provide unlimited custodial assistance.

Your agency should explain your plan of care and notify you when services are changing or ending.

Do I Have to Be Improving?

This is another area where patients and families can become confused.

Medicare coverage for skilled nursing or therapy isn’t based solely on whether a patient is expected to make dramatic improvement.

In appropriate circumstances, skilled services may be covered when they are needed to maintain a person’s condition or prevent or slow deterioration, provided Medicare’s other requirements are met and skilled care is necessary.

This principle became particularly important following the Jimmo v. Sebelius settlement, which clarified that Medicare does not have an “improvement standard” requiring beneficiaries to improve in order to receive covered skilled care.

That does not mean every maintenance service is covered. Skilled care must still be reasonable, necessary, and meet Medicare’s requirements.

But “you’re not improving” should not automatically be interpreted as “Medicare can never cover skilled care.”

Does Medicare Pay for Home Health?

For eligible beneficiaries who meet Medicare’s requirements, Original Medicare covers qualifying home health services from a Medicare-certified home health agency.

For covered home health services themselves, beneficiaries generally pay $0 under Original Medicare.

However, Medicare may require cost-sharing for certain durable medical equipment used at home.

Medicare Advantage plans must cover Medicare-covered home health services, but plan rules, networks, and procedures can differ. Check with your individual plan.

And remember: Medicare home health coverage does not mean Medicare pays for every kind of help you may need at home.

What Medicare Home Health Generally Doesn’t Cover

Medicare does not generally pay under the home health benefit for:

• 24-hour care at home
• Meal delivery
• Homemaker services such as shopping and cleaning when these are the only services needed
• Personal or custodial care when that is the only care needed

This is the gap that catches many families by surprise.

A person can qualify for a nurse and physical therapist while still needing several hours of additional help every day that Medicare doesn’t cover.

Understanding that before the first visit allows families to begin planning for the rest of the care.

What If a Home Health Agency Says It Can’t Take Me?

An order or referral doesn’t necessarily guarantee that a particular agency can accept you.

Agencies may have limitations involving:

• Geographic service areas
• Staffing
• Specialized services
• Insurance contracts
• Current capacity

If an agency can’t accept the referral, ask your healthcare provider, discharge planner, or case manager about alternatives.

For Medicare-certified agencies, you can also use Medicare Care Compare at Medicare.gov to identify agencies serving your area.

Questions Worth Asking

When home health is being arranged, don’t be afraid to ask:

• What services have actually been ordered?
• Which agency is receiving the referral?
• Has the agency accepted me?
• When should I expect the first visit?
• Which professionals will be coming?
• How often should I expect visits?
• What should I do if my condition changes?
• Who do I call after hours?
• What does Medicare or my insurance cover?
• What help will I still need that home health doesn’t provide?

That last question may be the most important one.

Home Health Can Be One Part of Staying at Home

Home health can bring nursing, rehabilitation, education, and monitoring directly into someone’s home.

For the right patient, it can make recovery safer and make it easier to manage illness without repeatedly traveling for care.

But home health isn’t a substitute for every other kind of support.

You may still need family assistance, paid home care, meal programs, transportation, home modifications, community resources, or other services.

Think of home health as one part of the support system that can help someone remain safely at home.

And if you’re struggling with a medical or functional problem at home and nobody has mentioned home health, it’s reasonable to ask your healthcare provider:

“Could home health help me?”

Sometimes the most important first step is simply knowing that the question exists.

Next in the Getting Help at Home series:
Medicare and Help at Home: What It Pays For—and What It Doesn’t

Helpful U.S. resources: For current Medicare home health eligibility and coverage information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). Medicare’s Care Compare tool can help you find and compare Medicare-certified home health agencies.

This article is for general educational purposes and is not a substitute for medical, legal, insurance, or financial advice. Medicare requirements and coverage can change, and individual eligibility depends on specific circumstances.