Qualifying Criteria for Home Health Services
Home health agencies (HHAs) have numerous regulations to abide by when
providing care under the Medicare home health benefit. Knowing the
regulations for qualifying criteria for home health is important to avoid
survey deficiencies and medical review denials. These
regulations are found in the Conditions
of Participation 
and in the Medicare
Benefit Policy Manual, (CMS
Pub. 100-02, Ch. 7.)
The following are basic conditions that must always be met before services provided by a home health agency can be covered by Medicare:
- The patient is an eligible Medicare beneficiary.
- The home health agency has a valid agreement to participate in the Medicare program.
- Medicare is the appropriate payer.
- The services billed are not excluded from payment.
Once these conditions are met, the following criteria must also be met:
- Physician Orders, Plan of Care and Certification
- Homebound
- Skilled Services — Medicare
Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.4)
- Intermittent, if Skilled Nurse
- Medically Necessary and Reasonable
Page last updated: March 10, 2008
