Medicare’s home health benefit is the most valuable thing in Medicare that people either do not know exists or cannot get approved. When it applies, the price is zero. No deductible, no coinsurance, no visit limit. Skilled nurses, physical therapists and an aide come to the house and Medicare pays the whole bill.
It applies less often than families hope, and the reason is almost always the same: the person needs help, but not the specific kind of help the benefit is written around. This guide walks the eligibility rules in the exact language CMS uses, states what you owe, lists what is excluded, and covers the notices and appeal that decide whether coverage keeps going. Figures are current as of September 2026.
Four Conditions, All of Them Required
CMS lists the eligibility tests in Chapter 7 of the Medicare Benefit Policy Manual, drawn from sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act. To qualify you must be:
- Confined to the home, meaning homebound.
- Under the care of a physician or allowed practitioner (a nurse practitioner, clinical nurse specialist or physician assistant can also certify and sign).
- Receiving services under a plan of care that the physician or allowed practitioner established and periodically reviews.
- In need of skilled nursing care on an intermittent basis, or physical therapy, or speech-language pathology services, or have a continuing need for occupational therapy.
Two mechanics sit alongside those. A provider must conduct a face-to-face encounter related to the reason for home health, and the agency furnishing the care has to be Medicare-certified. An excellent home care agency that is not certified cannot bill Medicare at all, so ask before you sign anything.
What “homebound” actually means
This is where denials happen, so read the test rather than the summary. CMS applies two criteria and you must meet both.
Criterion one. Because of illness or injury you need the aid of supportive devices such as crutches, canes, wheelchairs or walkers, or special transportation, or the assistance of another person in order to leave your residence. Or you have a condition such that leaving home is medically contraindicated.
Criterion two. There must exist a normal inability to leave home, and leaving home must require a considerable and taxing effort.
Homebound is not bedbound. CMS explicitly protects a long list of absences. Any absence to receive health care treatment, including regular attendance at a state-licensed, certified or accredited adult day-care program for therapeutic, psychosocial or medical treatment, outpatient dialysis, and outpatient chemotherapy or radiation, does not disqualify you. Attending a religious service is deemed an absence of infrequent or short duration. Occasional non-medical trips, a haircut, a walk around the block, a family funeral or a graduation, do not break homebound status either.
The manual also warns clinicians that repeating the phrase “taxing effort to leave the home” in a chart is not enough by itself. What supports the certification is longitudinal clinical detail: diagnosis, duration, clinical course, prognosis, functional limitations. If a denial is coming, this is usually where the documentation was thin.
What “intermittent” actually means
There are two different numbers here and people conflate them.
For benefit eligibility, CMS defines intermittent as skilled nursing care that is provided or needed on fewer than 7 days each week, or less than 8 hours a day for periods of 21 days or less, with extensions in exceptional circumstances when the additional need is finite and predictable.
For the care you receive, Medicare’s home health booklet defines part-time or intermittent home health aide and skilled nursing services combined as any number of days per week, as long as they are fewer than 8 hours each day and 28 or fewer hours each week, or up to 35 hours a week in some limited situations. There is no cap on the number of visits or 60-day episodes as long as you keep qualifying.
What You Pay
Covered home health services: $0. Medicare.gov states plainly that you pay nothing for covered home health services. Skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social services, home health aide visits and medical supplies such as wound dressings are all included in the payment Medicare makes to the agency.
Durable medical equipment: 20%. Medicare pays for DME separately from home health. Medicare covers 80% of the Medicare-approved amount for items like a wheelchair, walker, hospital bed or oxygen equipment, and you pay the remaining 20% after you meet the annual Part B deductible. CMS set that deductible at $283 for 2026, up from $257 in 2025. Our wheelchair cost guide and hospital bed cost guide show what the 20% works out to on real equipment.
For payment context, CMS issued the CY2026 Home Health Prospective Payment System final rule (CMS-1828-F) on November 28, 2025. It carries a 2.4% home health payment update, but after the permanent and temporary behavioral adjustments and the outlier change, CMS estimates aggregate Medicare payments to home health agencies fall about 1.3%, or $220 million, versus 2025. That does not change your $0, but it is the reason agencies are selective about which referrals they accept.
What Medicare Does Not Cover
This is the reason most people land on this page. Medicare’s own list of exclusions is short and blunt. Medicare does not pay for:
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services like shopping, cleaning and laundry
- Custodial or personal care such as bathing, dressing and using the bathroom, when that is the only care you need
You can get an aide for bathing under the home health benefit, but only while you are also receiving a skilled service. When the skilled need ends, the aide ends with it. That single rule is the cliff most families fall off.
What you pay instead is the open market. The 2025 CareScout Cost of Care Survey puts a non-medical caregiver at a $35 national median hourly rate, which is about $3,030 a month for 20 hours a week and roughly $25,500 a month for true 24-hour staffed coverage. Our home health care cost guide has the state spread and the 24-hour math, and nursing home cost is the comparison that usually follows it.
If the underlying situation is a terminal illness, the answer is a different benefit entirely. See our Medicare hospice benefit guide, which pays for the care team, medications and equipment related to the terminal illness at effectively no cost, and Medicare respite care for the 5-day caregiver break inside it.
The Three Notices, and the Fast Appeal
Home health coverage rarely ends with a letter from Medicare. It ends with a form from your agency, and which form you get tells you what to do.
Advance Beneficiary Notice of Noncoverage (ABN, CMS-R-131). The agency must give you this before providing a service or supply Medicare probably will not cover, for one of four reasons: the care is not medically reasonable and necessary, the care is only non-skilled personal care, you are not homebound, or you do not need skilled care on an intermittent basis. Signing it means you may owe the bill. It also tells you how to force an official Medicare decision, which is the useful part: keep receiving the care, ask the agency to bill Medicare anyway, and if Medicare pays, you get your money back except for applicable coinsurance and deductibles.
Home Health Change of Care Notice (HHCCN, CMS-10280). The agency must give you this before it reduces or stops any service or supply in your plan of care, whether because your provider changed the orders or because the agency made a business decision. It is a notification, not a coverage denial, but it is your written record of what was cut and why.
Notice of Medicare Non-Coverage (NOMNC, CMS-10123). This is the one to act on. CMS requires home health agencies, skilled nursing facilities, hospices and comprehensive outpatient rehabilitation facilities to deliver it when all covered services are ending, and Medicare says you should get it at least 2 days before your services end. If you do not receive it, ask.
To appeal, call the Beneficiary and Family Centered Care Quality Improvement Organization named on the notice within the timeframe printed on it. The BFCC-QIO is an independent reviewer that examines your records and speaks with your provider. CMS issues a Detailed Explanation of Non-Coverage only when you request the expedited determination, spelling out the specific reasons services are ending. Medicare says you should generally expect a decision no later than 3 days after the effective date on the NOMNC. If the review sides with you, coverage continues. If not, you owe for services after the date on the notice, and the agency must give you an ABN with a cost estimate first.
Where the Money Comes From When Medicare Stops
Medicaid home and community-based waivers. Section 1915(c) waivers let states cover exactly the services Medicare excludes: homemaker, home health aide, personal care, adult day health services and respite. Eligibility requires meeting the state’s institutional level-of-care standard plus its financial rules. See what Medicaid covers and how to pay for a nursing home.
Your Area Agency on Aging. The Older Americans Act National Family Caregiver Support Program, run by the Administration for Community Living, funds respite, counseling, training and limited supplemental services for caregivers of adults 60 and older and for caregivers of a person of any age with Alzheimer’s disease or a related disorder. The Eldercare Locator at 800-677-1116 is the free front door.
Substitution. A day at an adult day center runs a $95 national median, versus about $280 for eight hours of an in-home aide, and attending one does not break homebound status. Our adult day care cost guide covers the trade.
Check the bill. If an agency bills you for something you believe was covered, our guides to reading an itemized bill and negotiating medical bills apply to home health invoices, and the fair price checker will tell you whether a private-pay hourly rate is inside the national band.
The Bottom Line
Medicare covers home health care, at $0 to you, when a provider certifies you are homebound and need intermittent skilled nursing or therapy under a plan of care from a Medicare-certified agency. Your only routine cost is 20% of durable medical equipment after the $283 Part B deductible in 2026.
It does not cover the thing most families are actually shopping for, which is someone in the house for long stretches helping with daily life. That is custodial care, Medicare excludes it, and the market price is about $35 an hour. Before you buy those hours, ask the person’s doctor directly whether they meet the homebound and skilled-need tests, and if coverage is ending, use the NOMNC and the fast appeal rather than accepting the date on the form. Our hub guide on whether Medicare covers long-term care maps the rest of the payers.