Medicare Home Health Coverage: Who Qualifies, What's Covered and What You Pay in Florida
Under Original Medicare you pay nothing for covered home health services. No deductible, no coinsurance, no limit on the number of visits. The catch is the door you have to walk through first: you must be homebound, need skilled care only part-time or intermittently, and have a doctor or allowed practitioner who saw you within a fixed window and signed off on a plan of care.
Most of the arguments families have with home health agencies come down to those words. "Homebound" doesn't mean bedbound. "Intermittent" has a statutory definition measured in hours. And Medicare home health was never designed to pay for someone to stay with Mom all day. Here's how the rules actually read, what you pay for equipment, what to do when an agency says coverage is ending, and the Florida pieces: licensing, a review program Florida agencies operate under, and where to get unbiased help.
Source: Medicare.gov, Home health services; CMS 2026 Parts A and B fact sheet; 42 CFR 424.22(a)(1)(v).
The five tests to qualify
The federal regulation, 42 CFR 409.42, lists every condition, and you have to meet each one. Then 42 CFR 424.22 says Medicare Part A or Part B pays only if a physician or allowed practitioner certifies them in writing. Allowed practitioners include nurse practitioners, clinical nurse specialists and physician assistants, per the CMS booklet.
| Test | What it means in practice | Rule |
|---|---|---|
| Homebound | Leaving home takes a considerable and taxing effort, and you normally can't (details in the next section) | 42 CFR 409.42(a) |
| Under a doctor's or allowed practitioner's care | That clinician sets up your plan of care and reviews it | 42 CFR 409.42(b), (d) |
| Needs a skilled service | Intermittent skilled nursing, physical therapy, speech-language pathology, or continuing occupational therapy | 42 CFR 409.42(c) |
| Face-to-face encounter | An in-person or allowed telehealth visit, related to the main reason you need home health, no more than 90 days before or 30 days after care starts | 42 CFR 424.22(a)(1)(v) |
| Medicare-certified agency | Services come from, or are arranged by, a participating home health agency | 42 CFR 409.42(e) |
Source: 42 CFR 409.42; 42 CFR 424.22; Medicare Benefit Policy Manual, ch. 7, sec. 30.5.1.1.
Two details trip people up.
Occupational therapy can't open the door by itself. Medicare.gov says your provider must first order OT along with nursing, physical therapy or speech therapy. After that, OT alone can keep you on service, even once you no longer need the others.
The face-to-face visit has to be about the right thing. A routine checkup two months ago for something unrelated doesn't count. Under the CMS manual, if home health is ordered for a new condition that wasn't evident at a visit in the prior 90 days, the clinician has to see you again within 30 days after admission. The visit can be done by any doctor, nurse practitioner, clinical nurse specialist, physician assistant or certified nurse-midwife (42 CFR 424.22(a)(1)(v)), including one who treated you in the hospital. CMS broadened that list in its CY 2026 home health final rule; before, it had to be the certifying clinician or one who cared for you in the facility you came home from.
And you don't have to be getting better. Medicare home health covers care that helps you "maintain your current condition or level of function, or slow your rate of decline," in Medicare.gov's words. That's the Jimmo settlement at work: coverage turns on the need for skilled care, not on whether you'll improve. If an agency tells you a parent has "plateaued" and therefore can't be covered, that alone isn't a valid reason.
What "homebound" really means
The Medicare Benefit Policy Manual, chapter 7 splits homebound status into two criteria, and you need both.
- Criterion one (meet either): because of illness or injury you need a cane, crutches, walker or wheelchair, special transportation, or another person's help to leave home; or leaving home is medically inadvisable.
- Criterion two (meet both): you have a normal inability to leave home, and leaving takes a considerable and taxing effort.
You can still leave. Trips for medical care never count against you: dialysis, chemotherapy or radiation, or a licensed adult day program. Religious services are treated by law as short or infrequent absences. The manual's own examples of acceptable occasional outings include a trip to the barber, a walk around the block or a drive, and a family reunion, funeral or graduation.
What hurts a claim is a pattern that shows you could get the care outside the home. The manual's test is whether your outings show "the capacity to obtain the health care provided outside rather than in the home." My read: regular errands you run on your own are the kind of pattern that undercuts a homebound finding. The manual also says a chart that just repeats the phrase "taxing effort" isn't enough on its own; the record needs real clinical detail about the diagnosis, how long it's lasted, and functional limits. If you're the family member, make sure the nurse's notes describe what leaving the house actually takes.
One more misconception: having a spouse or daughter at home doesn't disqualify you. Under section 20.2 of the manual, a patient who meets the criteria is entitled to covered services regardless of whether someone else is available, though if a family member is already adequately doing a given task, the agency doesn't need to duplicate it.
Part-time or intermittent: the hour limits
There are two different definitions, and agencies sometimes blur them. One decides whether you qualify (do you need skilled nursing on an intermittent basis?). The other caps how much nursing and aide time Medicare pays for once you're in. Both come from section 1861(m) of the Social Security Act, as restated in the CMS manual.
| Rule | Limit | What it's for |
|---|---|---|
| "Intermittent" skilled nursing | Needed fewer than 7 days a week, or daily for less than 8 hours a day for 21 days or less (extensions possible when the need is finite and predictable) | Qualifying for the benefit |
| Minimum frequency | Usually at least one skilled nursing visit every 60 days (a documented, predictable need) | Qualifying for the benefit |
| "Part-time or intermittent" care | Skilled nursing plus home health aide time combined: less than 8 hours a day and 28 or fewer hours a week | How much Medicare pays for |
| Short-term higher level | Less than 8 hours a day and up to 35 hours a week, reviewed case by case | How much Medicare pays for |
| Number of visits | No limit, as long as you keep qualifying | Duration |
Source: Medicare Benefit Policy Manual, ch. 7, secs. 40.1.3, 50.7 and 70.1; Medicare.gov, Home health services; Medicare & Home Health Care (CMS Product No. 10969, July 2025).
Here's the practical consequence. If someone needs full-time skilled nursing for an extended period, the CMS booklet says they won't usually qualify for home health at all. That person needs a different setting, often a skilled nursing facility for a while (see Medicare skilled nursing facility coverage).
But needing more help than Medicare pays for doesn't knock you out. The manual's section 50.7.1 gives this example: a patient who needs a monthly catheter change and round-the-clock aide care. The agency bills Medicare for covered hours up to 35 a week and bills the family or another payer for the rest. Paying privately for extra aide hours doesn't cost you the Medicare-covered visits.
What's covered and what isn't
| Covered when it's in your plan of care | Not covered |
|---|---|
| Part-time or intermittent skilled nursing: wound care, injections, IV or tube feeding, monitoring an unstable condition, teaching you and your caregiver | 24-hour-a-day care at home |
| Physical therapy, occupational therapy, speech-language pathology | Home-delivered meals |
| Home health aide care (bathing, grooming, help walking) only while you're also getting skilled care | Homemaker services like shopping, cleaning and laundry unrelated to your care plan |
| Medical social services, alongside skilled care | Custodial or personal care when that's the only care you need |
| Medical supplies for use at home, like wound dressings | A nursing visit whose only purpose is drawing blood |
| Durable medical equipment (billed separately, with 20% coinsurance) | Services from more than one home health agency at a time |
| Injectable osteoporosis drugs for women who meet certain criteria |
Source: Medicare.gov, Home health services; Medicare & Home Health Care booklet, pp. 3-4 and 9.
The line that surprises families is personal care. An aide who helps with a shower is covered only while a nurse or therapist is also on the case. When the skilled need ends, the aide goes too, even if Dad still can't bathe alone. Medicare isn't long-term care insurance. For people with limited income and assets, Florida Medicaid is the program to look into; how the two fit together is covered in Florida Medicaid and Medicare.
If the goal is comfort care for a terminal illness rather than recovery or maintenance, that's a different benefit with different rules. See Medicare hospice coverage.
What you pay
Section 60.4 of the CMS manual is short: there's no coinsurance, copayment or deductible for home health services and supplies, with two exceptions. Durable medical equipment carries 20% coinsurance. So does the injectable osteoporosis drug, which is a Part B-only item that's also subject to the Part B deductible.
For equipment, Medicare.gov puts it this way: after you meet the Part B deductible, you pay 20% of the Medicare-approved amount. The 2026 Part B deductible is $283, up from $257 in 2025 (CMS fact sheet). As of November 3, 2026, CMS hasn't announced the 2027 Part B premium or deductible; when it does, the deductible for equipment you get in 2027 changes with it.
What else can show up on a bill: things Medicare never covers, and services you agreed in writing to pay for after the agency gave you a notice (more on that below). The booklet says the agency should tell you before care starts, out loud and in writing, how much Medicare will pay and what you'd owe.
If you have a Medigap policy, tell your providers so the equipment claims get paid correctly. For how Medigap works in this state, see our Medicare Supplement insurance in Florida page.
30-day periods, 60-day certifications
You'll hear agencies talk about "periods" and "episodes." Medicare pays a certified agency one payment for each 30-day period of care, based on your condition and needs (CMS booklet). Your certification runs 60 days, so each one covers two payment periods.
Under 42 CFR 424.22(b), care that continues past the first 60 days has to be recertified at least every 60 days by the clinician who reviews the plan of care. The manual adds that Medicare doesn't limit the number of continuous recertifications, and that the agency's reassessment usually happens in the last 5 days of the period (days 56 to 60 of the first one). That reassessment is often where a cutoff gets decided. If you think care is ending too soon, say so to the nurse and the doctor before then, not after.
Part A or Part B: who pays the agency
Home health is paid from either trust fund depending on how you got there. For you, the cost is the same (nothing for covered services), but it explains the "100 visits" figure some people have heard. Per section 60 of the CMS manual:
| Your situation | Who pays | Visit limit |
|---|---|---|
| Part A and Part B, home health starts within 14 days after a hospital stay of at least 3 consecutive days (or after a covered SNF stay) | Part A, for up to 100 visits in a home health spell of illness; Part B after that | None overall |
| Part A and Part B, coming from the community or after a shorter hospital stay | Part B | None |
| Part A only | Part A | None (the 100-visit split doesn't apply) |
| Part B only | Part B | None |
Source: Medicare Benefit Policy Manual, ch. 7, secs. 60.1-60.3 and 70.1. A home health spell of illness ends after 60 consecutive days without hospital inpatient care, a covered SNF stay or home health.
In other words, the 100 visits is a bookkeeping split between Part A and Part B, not a cap on your care.
Notices, and how to fight a cutoff
Three notices matter. Learn their names, because the agency is required to hand them to you, and each one triggers a different right (CMS booklet).
| Notice | When you get it | What you can do |
|---|---|---|
| Advance Beneficiary Notice of Noncoverage (ABN) | Before a service or supply Medicare probably won't cover: not medically necessary, personal care only, you're not homebound, or you don't need intermittent skilled care | Keep the service if you think you need it, and ask the agency to bill Medicare so you get an official decision. If Medicare pays, you get your money back (minus any coinsurance or deductible). |
| Home Health Change of Care Notice (HHCCN) | Before the agency reduces or stops services in a way that changes your plan of care, including its own business decision or your doctor changing the orders | Talk to your doctor about the orders; ask the agency why |
| Notice of Medicare Non-Coverage (NOMNC) | At least 2 days before all covered home health services end | Ask the BFCC-QIO for a fast appeal by noon the day before the end date on the notice |
Source: Medicare & Home Health Care booklet, pp. 5-6; Medicare.gov, Fast appeals.
The fast appeal goes to a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), an independent reviewer that works for Medicare, not for the agency. Medicare.gov says to follow the instructions on the NOMNC no later than noon the day before the termination date. The QIO asks why you think care should continue, looks at your records and talks to your doctor; the booklet says to expect an answer generally no later than 3 days after the NOMNC's effective date. The phone number for the BFCC-QIO for Florida is on the notice, or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048).
If you lose, you owe for services after the date on the notice, and the agency must give you an ABN with a cost estimate. You can always stop on or before that date to avoid charges. If you miss the fast-appeal deadline, regular appeals are still open; the full ladder is in the Medicare appeal process.
No notice? Ask for one. An agency winding down visits without paperwork is a red flag.
If you're in a Medicare Advantage plan
Medicare Advantage plans have to cover all medically necessary services Original Medicare covers, and home health is one of them. What changes is the process. Per Medicare & You 2027, you may need approval from the plan (prior authorization) before it covers certain services, which in most cases Original Medicare doesn't require. The CMS booklet adds that a plan may require you to use home health agencies it contracts with.
The cost-sharing description in this article is Original Medicare's. If you're in a plan, check its Evidence of Coverage for home health and equipment, and ask before care starts whether the agency is in network and whether authorization is on file.
Plan members have a fast-track appeal when home health is ending too: under 42 CFR 422.626, you ask the independent reviewer by noon of the day after you get the termination notice. If you're weighing Original Medicare against a plan during open enrollment, SHINE can walk through the trade-offs with you, and the bigger picture is on our Medicare in Florida page.
Florida: licensing, pre-claim review and SHINE
State license plus Medicare certification. Florida requires a license or registration from the Agency for Health Care Administration (AHCA) to operate a home health agency, and licenses issued since July 1, 2018 must list the services the agency is authorized to provide and whether they're skilled care (s. 400.464, Florida Statutes). The governing law is Chapter 400, Part III, with rules in Chapter 59A-8 of the Florida Administrative Code (AHCA). A state license isn't the same as Medicare certification. Medicare pays only Medicare-certified agencies, and AHCA's own rules page addresses licensed agencies that aren't Medicare- or Medicaid-certified and don't provide skilled care. Ask directly.
Where to check an agency. Medicare Care Compare is where Medicare.gov points you to find and compare Medicare-certified home health agencies. FloridaHealthFinder, run by AHCA, lets you compare home health agencies, locate licensed facilities, read inspection reports and final orders, and file a complaint. You choose the agency; the booklet says your doctor or hospital discharge planner should honor that choice, and Medicare.gov says your provider must tell you if their organization has a financial interest in any agency on the list they give you.
Fraud warning signs. Most agencies bill correctly, but the CMS booklet lists what to watch for: visits on your Medicare Summary Notice you never got, visits you didn't ask for, a doctor you've never met ordering care, and anyone offering goods or services in exchange for your Medicare Number. Report it to 1-800-MEDICARE or the HHS Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477).
Unbiased help. SHINE (Serving Health Insurance Needs of Elders), run by the Florida Department of Elder Affairs with local Area Agencies on Aging, offers one-on-one Medicare counseling at no charge: 1-800-96-ELDER (1-800-963-5337), or floridashine.org. For quality-of-care complaints, the booklet points to your state home health hotline (the agency should give you that number when care starts) or the BFCC-QIO.
How many people use it
From the Medicare Payment Advisory Commission's March 2026 report: in 2024, about 2.7 million people in traditional Medicare got home health care, Medicare spent $16.0 billion on it, and more than 12,000 agencies were certified. The number of users has drifted down since 2019, which MedPAC attributes partly to enrollment shifting from traditional Medicare to Medicare Advantage (plan members aren't in these counts).
Source: MedPAC, March 2026 Report to the Congress, Table 8-2. Excludes Medicare Advantage enrollees.
Show the numbers
| Users (millions) | |
|---|---|
| 2019 | 3.3M |
| 2020 | 3.1M |
| 2021 | 3.0M |
| 2022 | 2.8M |
| 2023 | 2.7M |
| 2024 | 2.7M |
Source: MedPAC, March 2026 Report to the Congress, Table 8-2.
Show the numbers
| Share using home health | |
|---|---|
| 2019 | 8.5% |
| 2020 | 8.1% |
| 2021 | 8.3% |
| 2022 | 8.0% |
| 2023 | 7.9% |
| 2024 | 7.9% |
Roughly 1 in 13 people in traditional Medicare used home health in 2024 (7.9%). MedPAC also reports that users averaged 3.1 thirty-day periods of care each that year. My read: this is a common benefit, not an exotic one, and families often meet it for the first time at a hospital or rehab discharge. If someone in your family is being discharged, ask the discharge planner about home health before the day of discharge, and ask for the list of agencies that serve your area.
Questions
Does Medicare pay for home health care?
Yes. Original Medicare covers part-time or intermittent skilled nursing, therapy, home health aide care alongside skilled care, medical social services and supplies if you're homebound, under a plan of care, and certified by a doctor or allowed practitioner. You pay nothing for covered home health services.
How many hours of home health care will Medicare pay for?
Skilled nursing and home health aide time combined must be less than 8 hours a day and 28 or fewer hours a week, or up to 35 hours a week for a short time if your provider decides it's needed. There's no limit on the number of visits while you qualify.
Can you leave the house and still be considered homebound?
Yes. Absences for medical care, adult day care and religious services don't count against you, and occasional short outings like a trip to the barber or a family event are allowed if they're infrequent or brief.
Does Medicare cover a home health aide without skilled care?
No. Medicare covers home health aide services only while you're also getting skilled nursing, physical therapy, speech-language pathology or continuing occupational therapy. Personal care alone isn't covered.
What can I do if my home health agency says Medicare coverage is ending?
You should get a Notice of Medicare Non-Coverage at least 2 days before services end. Follow its instructions by noon the day before the end date to ask the BFCC-QIO for a fast appeal.
Federal Medicare rules, Florida law and your plan's own documents control what's covered. Confirm your situation with 1-800-MEDICARE, SHINE or a licensed agent, and talk to an attorney for legal questions.
Sources
- Medicare.gov: Home health services
- CMS: Medicare & Home Health Care (Product No. 10969, July 2025)
- CMS: Medicare Benefit Policy Manual, Chapter 7, Home Health Services
- eCFR: 42 CFR 409.42, beneficiary qualifications for coverage of services
- eCFR: 42 CFR 424.22, requirements for home health services (certification)
- CMS: Calendar Year 2026 Home Health Prospective Payment System final rule (CMS-1828-F) fact sheet
- eCFR: 42 CFR 422.626, fast-track appeals for Medicare Advantage enrollees
- CMS: 2026 Medicare Parts A and B premiums and deductibles fact sheet
- CMS: Jimmo Settlement
- Medicare.gov: Fast appeals
- CMS: Medicare & You 2027
- Medicare.gov: Care Compare (home health)
- MedPAC: March 2026 Report to the Congress, Chapter 8, Home health care services
- Florida Statutes s. 400.464 (2026)
- Florida AHCA: Home health agencies, state laws and rules
- Florida AHCA: FloridaHealthFinder
- SHINE, Florida Department of Elder Affairs
This article is for general educational purposes only and is not legal, tax or insurance advice. Coverage depends on the actual policy, its terms, conditions and exclusions, and state law. Maru Insurance · WA License (WAOIC) #1365574 · FL License #G363233 · NPN 22261820.