Getting home health care starts with a doctor’s order. You can’t simply call an agency and sign up. A physician, nurse practitioner, or physician assistant must evaluate your condition, determine that you need skilled medical services at home, and certify that you meet specific eligibility requirements. From there, the process involves choosing an agency, getting assessed, and beginning a care plan tailored to your needs.
Who Qualifies for Home Health Care
Medicare, the most common payer for home health services, has two core requirements. First, you must be considered “homebound,” meaning that leaving your home requires considerable effort, the help of another person, or a supportive device like a wheelchair or walker, or that leaving is inadvisable because of your medical condition. You don’t have to be bedridden. People who leave home for medical appointments, religious services, or occasional short trips can still qualify. The key is that leaving takes a taxing effort due to your condition.
Second, you must need at least one skilled service: skilled nursing care, physical therapy, speech therapy, or occupational therapy. If you only need help with everyday tasks like bathing, dressing, or cooking, that alone won’t qualify you. Medicare draws a firm line between skilled care (which requires a trained professional) and custodial care (which helps with daily living but doesn’t involve medical expertise).
The Step-by-Step Process
The process typically unfolds in this order:
1. Talk to your doctor. Your physician evaluates whether your condition warrants home health services. This often happens after a hospitalization, surgery, or a new diagnosis, but it can also come up during a routine visit if your health has declined. The doctor writes an order specifying what types of services you need, how often you need them, and which professionals should deliver them.
2. Complete the face-to-face requirement. Medicare requires that a physician or qualified provider see you in person either within 90 days before home health care begins or within 30 days after it starts. During this visit, the provider documents why you’re homebound and why you need skilled care. If your doctor orders home health for a new condition that wasn’t apparent during a recent visit, the encounter must happen within 30 days of your admission to home health. The certifying physician then writes a brief narrative explaining how what they observed supports both your homebound status and your need for skilled services.
3. Choose a home health agency. You have the right to pick any Medicare-certified agency in your area. Your doctor or hospital discharge planner may suggest one, but the choice is yours. Medicare’s Care Compare tool at medicare.gov lets you search agencies by ZIP code and compare them using quality-of-care star ratings based on eight care measures, plus patient satisfaction survey scores. Looking at both ratings gives you a fuller picture than either one alone.
4. Get an initial assessment. Once the agency receives your doctor’s referral and supporting documentation, a nurse or therapist visits your home to evaluate your condition, your living situation, and your care needs. This assessment shapes your individualized care plan, which your doctor then reviews and approves.
5. Begin receiving services. Visits are scheduled based on your care plan. A nurse might come three times a week for wound care, or a physical therapist might visit twice a week after a hip replacement. The schedule adjusts as your condition improves or changes.
What Home Health Care Covers
Under Medicare, covered services include skilled nursing (wound care, IV therapy, injections, monitoring unstable conditions, and patient education), physical therapy, occupational therapy, speech therapy, medical social services, and medical supplies for use at home. You can also get durable medical equipment like hospital beds, walkers, and wheelchairs.
Home health aides can help with bathing, grooming, walking, changing bed linens, and feeding, but only if you’re also receiving a skilled service like nursing or therapy at the same time. The aide visits are an add-on, not a standalone benefit.
What’s not covered is equally important to understand. Medicare won’t pay for 24-hour care, meal delivery, housekeeping unrelated to your care plan, or personal care assistance when that’s the only service you need. The benefit is designed for part-time, intermittent medical care, not full-time caregiving.
What It Costs
If you qualify through Medicare, you pay $0 for covered home health services. There’s no copay and no deductible for the visits themselves. The one exception is durable medical equipment, where you’re responsible for 20% of the Medicare-approved amount. So the nursing visits and therapy sessions are free to you, but if you need a hospital bed or a specialized wheelchair, expect to cover a portion of that cost.
Getting Home Health Through Medicaid
If you don’t have Medicare or need services that go beyond what Medicare covers, Medicaid may be an option. Every state runs its own Medicaid program within federal guidelines, so eligibility rules and available services vary considerably by where you live.
Many states offer Home and Community-Based Services (HCBS) waivers, which are specifically designed for people who would otherwise need care in a nursing home but prefer to stay at home. These waivers can cover a broader range of services than Medicare, including personal care assistance, homemaker services, and respite care for family caregivers. To qualify, you generally must meet your state’s income and asset limits and demonstrate that you need a nursing-home level of care. States set a maximum number of people they serve under each waiver, so there may be a waiting list. Contact your state Medicaid office or local Area Agency on Aging to find out what’s available and how to apply.
Using Private Insurance
Private health insurance plans often cover home health care, but the rules differ from Medicare. Most private insurers require prior authorization before services begin. If your provider is in-network, they typically handle the authorization request for you. If you’re using an out-of-network provider, you may need to submit the request yourself, and skipping this step could mean paying the full cost out of pocket.
Insurance companies generally respond to prior authorization requests within 5 to 10 business days. They may approve the request, deny it, ask for additional documentation, or recommend a less costly alternative first. The number of approved visits, the types of services covered, and your copay or coinsurance amounts all depend on your specific plan. Call the member services number on your insurance card before starting the process so you know exactly what’s covered and what paperwork your provider needs to submit.
How to Compare Home Health Agencies
Not all agencies deliver the same quality of care. Medicare’s Care Compare website rates certified agencies on two separate scales: a quality-of-patient-care star rating (based on measurable outcomes like whether patients improved in walking or moving around) and a patient survey rating (based on what patients and caregivers reported about their experience). Both use a five-star system.
Beyond the ratings, ask practical questions when interviewing agencies. Find out how quickly they can start services, whether they have staff trained in your specific condition, how they handle emergencies or after-hours concerns, and how they communicate with your doctor. A good agency keeps your physician updated on your progress and adjusts your care plan as your needs change. You also have the right to switch agencies at any time if you’re not satisfied with the care you’re receiving.