Georgia Medicare Home Health Benefit: Coverage Guide

::: hero

By Brevy Care Team · Last verified May 13, 2026

The Medicare Home Health Benefit is one of the most important and most misunderstood parts of the Medicare program. For Georgia beneficiaries recovering from a hospital stay, managing a chronic condition that requires skilled monitoring, or rehabilitating after a stroke or surgery, home health allows skilled care to be delivered in the home rather than in a facility. The benefit is anchored in two statutes: Section 1814(a)(2)(C) of the Social Security Act establishes the Part A post-institutional home health benefit covering the first 100 visits following a qualifying hospital or skilled nursing facility stay; Section 1835(a)(2)(A) of the Social Security Act establishes the Part B home health benefit, which is unlimited in number of visits and serves as the primary home health benefit for most beneficiaries. The definition of home health services and the homebound requirement are established by Section 1861(m). The face-to-face encounter requirement was added by Section 6407 of the Affordable Care Act of 2010. The Patient-Driven Groupings Model (PDGM), which restructured payment into 30-day periods and eliminated therapy volume as a payment driver, was implemented effective January 1, 2020 under Section 51001 of the Bipartisan Budget Act of 2018. The Home Health Value-Based Purchasing Program, which adjusts agency payment by up to 5% based on quality performance, was expanded nationwide effective January 1, 2023.

This guide explains how the Medicare Home Health Benefit operates for Georgia beneficiaries. It walks through the homebound and skilled need requirements, the face-to-face encounter, what services are covered (skilled nursing, physical therapy, speech-language pathology, occupational therapy, medical social services, home health aide services, medical supplies), what services are NOT covered (24-hour care, custodial care, homemaker services, meal delivery), the PDGM payment model, the Home Health Value-Based Purchasing Program, and the practical pathway for Georgia families to access home health care from agencies serving every region of the state. :::

Federal Statutory and Regulatory Authority

Section 1814(a)(2)(C) of the Social Security Act (42 USC 1395f(a)(2)(C))

Section 1814(a)(2)(C) of the Social Security Act establishes the Medicare Part A post-institutional home health benefit. Under this provision, a beneficiary who has been hospitalized for at least 3 consecutive days (or who has had a Medicare-covered skilled nursing facility stay) is entitled to up to 100 home health visits during a post-institutional spell of illness. The Part A home health benefit was originally the primary home health benefit but became the post-institutional benefit when the Balanced Budget Act of 1997 restructured the home health benefit.

Section 1835(a)(2)(A) of the Social Security Act (42 USC 1395n(a)(2)(A))

Section 1835(a)(2)(A) establishes the Medicare Part B home health benefit. The Part B benefit is unlimited in number of visits. For visits beyond the first 100 post-institutional visits (or for beneficiaries who were not recently hospitalized), all home health is billed to Part B. Most home health visits are billed to Part B.

For beneficiaries, the Part A and Part B home health benefits operate as a unified benefit. The first 100 post-institutional visits are billed to Part A; subsequent visits and all non-post-institutional visits are billed to Part B. The beneficiary experiences a continuous home health benefit and pays nothing out-of-pocket for the home health services themselves (durable medical equipment provided alongside home health, billed separately under the DME benefit, carries 20% coinsurance).

Section 1861(m) of the Social Security Act (42 USC 1395x(m))

Section 1861(m) defines home health services and establishes the homebound requirement. Home health services include part-time or intermittent skilled nursing care, physical therapy, occupational therapy, speech-language pathology, medical social services, part-time or intermittent home health aide services, medical supplies, and durable medical equipment. The services must be provided to a beneficiary who is confined to the home.

Section 1861(o) of the Social Security Act

Section 1861(o) defines "home health agency" for Medicare purposes. A home health agency must be primarily engaged in providing skilled nursing services and other therapeutic services, maintain clinical records on all patients, have professional advisory groups, and meet federal Conditions of Participation. Most Georgia home health agencies are also licensed under O.C.G.A. 31-7-300 et seq.

Section 1895 of the Social Security Act

Section 1895 establishes the Medicare home health prospective payment system. Under PPS, CMS pays home health agencies a prospective amount per period based on case-mix adjustment rather than reimbursing actual costs.

42 CFR Part 484: Home Health Conditions of Participation

The regulations implementing the home health benefit are at 42 CFR Part 484. Key subparts include:

• Subpart A: General provisions and definitions
• Subpart B: Patient care including patient rights (42 CFR 484.50), comprehensive assessment (42 CFR 484.55), care planning (42 CFR 484.60), Quality Assessment and Performance Improvement (42 CFR 484.65), and home health aide services (42 CFR 484.80)
• Subpart C: Organizational environment including clinical records (42 CFR 484.110)
• Subpart E: Prospective Payment System (42 CFR 484.200-484.245)
• Subpart F: Home Health Value-Based Purchasing Program (42 CFR 484.300-484.370)

42 CFR 409.40 through 409.50: Home Health Coverage Requirements

The coverage requirements are at 42 CFR 409.40 through 409.50, particularly:

• 42 CFR 409.41: services must be furnished by a Medicare-certified home health agency
• 42 CFR 409.42: beneficiary qualifications (homebound, plan of care, physician certification, skilled need)
• 42 CFR 409.43: plan of care requirements
• 42 CFR 409.44: skilled services requirements
• 42 CFR 409.45: covered services
• 42 CFR 409.49: excluded services
• 42 CFR 409.50: payment

42 CFR 424.22: Physician Certification

42 CFR 424.22 establishes the certification requirements including the face-to-face encounter. The certifying physician (or eligible non-physician practitioner) must document homebound status, skilled need, and necessity of services, and must have completed a face-to-face encounter within the required timeframe.

Statutory History

The Medicare home health benefit was part of the original Medicare program established by the Social Security Amendments of 1965. The Omnibus Budget Reconciliation Act of 1980 removed the post-hospitalization requirement, creating an unrestricted home health benefit. The Omnibus Budget Reconciliation Act of 1987 (Public Law 100-203) established the home health Conditions of Participation. The Balanced Budget Act of 1997 (Public Law 105-33) Sections 4601 through 4615 restructured the benefit into the current Part A post-institutional and Part B unlimited structure and authorized the home health prospective payment system implemented by the Balanced Budget Refinement Act of 1999 (Public Law 106-113).

The Affordable Care Act of 2010 (Public Law 111-148) added Section 6407 face-to-face encounter requirements and Section 3131 home health payment reform provisions. The IMPACT Act of 2014 (Public Law 113-185) standardized quality measures across post-acute care settings. The Bipartisan Budget Act of 2018 (Public Law 115-123) Section 51001 created the Patient-Driven Groupings Model. The Consolidated Appropriations Act of 2021 permanently authorized nurse practitioners, physician assistants, and clinical nurse specialists to certify home health (effective January 1, 2021). The CY 2022 home health final rule expanded the Home Health Value-Based Purchasing Program nationwide effective January 1, 2023.

::: callout Key Takeaways

• Section 1814(a)(2)(C) of the Social Security Act establishes the Part A post-institutional home health benefit (first 100 visits). Section 1835(a)(2)(A) establishes the Part B home health benefit (unlimited). Together they form a unified Medicare home health benefit.

• To qualify for Medicare home health, the beneficiary must be under the care of a physician, under a plan of care reviewed at least every 60 days, homebound, and in need of skilled nursing care (intermittent) or therapy services. The home health agency must be Medicare-certified.

• Homebound under Section 1861(m) means that leaving home requires a considerable and taxing effort. Homebound does not mean bedbound. Absences for medical care, religious services, adult day care (limited basis), and special family events are permitted.

• A face-to-face encounter under Section 6407 of the Affordable Care Act must occur within 90 calendar days before or 30 calendar days after the start of care. The encounter may be conducted by a physician or eligible non-physician practitioner. Documentation must support homebound status, skilled need, and necessity of services.

• Effective January 1, 2021, nurse practitioners, physician assistants, and clinical nurse specialists may certify home health in addition to conducting the face-to-face encounter, under the Consolidated Appropriations Act of 2021.

• The Patient-Driven Groupings Model implemented January 1, 2020 changed payment from 60-day episodes to 30-day periods, eliminated therapy volume as a payment driver, and established 432 case-mix groups based on admission source, timing, clinical grouping, functional impairment, and comorbidity.

• The Home Health Value-Based Purchasing Program, expanded nationwide effective January 1, 2023, adjusts agency payment by up to 5% upward or downward based on quality performance measured by OASIS, HHCAHPS, and claims-based outcomes.

• Medicare home health covers skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social services, home health aide services (when receiving skilled service), and medical supplies. Durable medical equipment is covered under a separate Part B benefit with 20% coinsurance.

• Medicare home health does NOT cover 24-hour care, custodial care, homemaker services, meal delivery, or personal care without a concurrent skilled need. Beneficiaries needing those services may qualify for Medicaid Personal Care Services or other community programs.

• For Georgia beneficiaries, home health is delivered by national chains (Amedisys, LHC Group, Encompass), regional providers, and hospital-affiliated agencies (Emory, Piedmont, Wellstar, Memorial Health, Augusta University Health, Northeast Georgia Health System). :::

The Homebound Requirement

The homebound requirement is the gateway to Medicare home health coverage. Section 1861(m) of the Social Security Act provides that services must be furnished to an individual "who is confined to his home." The implementing regulations and CMS guidance have developed a two-part test that operationalizes this requirement.

The Two-Part Test

A beneficiary is homebound if BOTH of the following criteria are met:

Criterion 1: One of the following is true:

• Because of illness or injury, the beneficiary needs the aid of supportive devices (such as crutches, canes, wheelchairs, or walkers), the use of special transportation, or the assistance of another person to leave the home, OR
• The beneficiary has a condition that makes leaving home medically contraindicated.

Criterion 2: BOTH of the following are true:

• There exists a normal inability to leave home, AND
• Leaving home requires a considerable and taxing effort.

What Homebound Is NOT

The homebound requirement is often misunderstood. Common misconceptions:

• Homebound does NOT mean bedbound. A homebound beneficiary may be ambulatory but require considerable and taxing effort to leave home.

• Homebound does NOT mean never leaves home. Permitted absences include absences for medical care, religious services, adult day care (limited basis), and special family events (such as funerals, weddings, graduations).

• Homebound is NOT a social determination. A beneficiary who is physically capable of leaving home but chooses not to is not homebound for Medicare purposes. The inability to leave home must be due to illness or injury.

• Homebound does NOT require permission to leave home. The standard is whether leaving requires taxing effort and is generally infrequent; it does not require the beneficiary to have prior approval for each absence.

Permitted Absences

Under CMS guidance, the following absences do not affect homebound status:

1. Medical treatment: outpatient therapy, dialysis, chemotherapy, radiation, physician office visits, dental visits, mental health visits, and other medical services that cannot be provided at home

2. Religious services: weekly worship attendance is generally permitted

3. Adult day care: attendance is permitted on a limited basis. CMS does not provide a bright-line rule, but cases have held that adult day care 2 to 3 days per week is permitted while 5 days per week is excessive (because it suggests the beneficiary is not actually confined to home)

4. Unique events: occasional attendance at funerals, weddings, family reunions, graduations, and similar events of unique significance

5. Short walks or porch sitting: occasional brief outings (such as walking to the mailbox or sitting on the porch) do not affect homebound status

Documentation of Homebound Status

The certifying physician must document:

• The clinical reasons the beneficiary is homebound (the underlying illness or injury)
• The specific manifestations that make leaving home a taxing effort (gait instability, severe dyspnea, oxygen dependence, post-surgical limitations, severe pain, severe cognitive impairment, advanced disease, etc.)
• The supportive devices or assistance required to leave home

The home health agency at each visit documents the beneficiary's ongoing homebound status and any permitted absences during the period.

The Skilled Need Requirement

Under 42 CFR 409.44, the beneficiary must require either:

• Intermittent skilled nursing care, OR
• Physical therapy, OR
• Speech-language pathology services, OR
• Continuing occupational therapy services (only if OT was part of the initial plan of care that qualified the beneficiary for home health)

Skilled Nursing Care

Skilled nursing means care that must be performed by or under the supervision of a registered nurse for the care to be safe and effective. Examples:

• Wound care (complex wounds, surgical wounds, pressure ulcers stage 3 or 4, venous ulcers, diabetic ulcers)
• Medication management (teaching, monitoring, IV medications, complex regimens)
• Catheter care (Foley catheters, suprapubic catheters, complex urological needs)
• Ostomy teaching (new colostomies, ileostomies, urostomies)
• Diabetes management (new-onset, insulin teaching, complications)
• Cardiopulmonary assessment (CHF monitoring, COPD assessment, oxygen monitoring)
• IV therapy (antibiotics, fluids, blood products)
• Skilled observation and assessment (for unstable conditions requiring frequent reassessment)
• Tracheostomy care
• Tube feeding management

Intermittent vs. Continuous

Medicare home health is intermittent, not 24-hour care. CMS guidance generally defines intermittent as up to 8 hours per day and 28 hours per week (with rare expansion to 35 hours per week in unusual circumstances). Beneficiaries needing 24-hour care should be evaluated for nursing facility placement, residential care, or alternative arrangements.

Physical Therapy

Physical therapy includes:

• Gait training and assistive device training
• Transfer training
• Balance training
• Strengthening
• Range of motion exercises
• Functional mobility
• Pain management techniques

Speech-Language Pathology

Speech-language pathology includes:

• Speech production (dysarthria, apraxia)
• Language (aphasia, cognitive-communication)
• Swallowing (dysphagia evaluation and treatment)
• Voice (dysphonia)

Dysphagia management is particularly important after stroke, traumatic brain injury, advanced dementia, Parkinson's disease, and head and neck cancer.

Occupational Therapy

Occupational therapy includes:

• Activities of daily living (ADL) training
• Adaptive equipment training
• Fine motor coordination
• Cognitive function

OT can independently qualify a beneficiary for home health ONLY if OT was part of the initial plan of care that qualified the beneficiary. If a beneficiary's initial skilled need was nursing or PT or SLP, and that need has resolved, OT alone cannot continue home health.

Plan of Care

Under 42 CFR 409.43, a plan of care must be established and reviewed by a physician (or eligible NPP). The plan of care must include:

• All diagnoses
• Mental status
• Types of services and supplies required
• Frequency of visits
• Prognosis
• Rehabilitation potential
• Functional limitations
• Activities permitted
• Nutritional requirements
• Medications and treatments
• Safety measures to protect against injury
• Instructions for timely discharge or referral
• Any additional items the home health agency or physician chooses to include

The plan of care must be reviewed and signed by the certifying physician (or eligible NPP) at least every 60 days. Verbal orders are permitted but must be followed by signed orders.

The Face-to-Face Encounter

Section 6407 of the Affordable Care Act of 2010 and 42 CFR 424.22(d) require a face-to-face encounter for home health certification. The face-to-face encounter is one of the most heavily scrutinized aspects of home health compliance.

Timing

The face-to-face encounter must occur:

• Within 90 calendar days before the start of home health care, OR
• Within 30 calendar days after the start of home health care

If the encounter does not occur within this window, the home health agency cannot bill Medicare for the services.

Who Can Conduct the Encounter

The encounter may be conducted by:

• A physician (MD, DO)
• A nurse practitioner working in collaboration with the certifying physician
• A physician assistant under the certifying physician's supervision
• A clinical nurse specialist working in collaboration with the certifying physician
• A certified nurse-midwife (in limited circumstances)
• The certifying physician (if directly conducted)

Telehealth

The face-to-face encounter may be conducted via telehealth. CMS expanded telehealth permission during the COVID-19 public health emergency and made certain telehealth flexibilities permanent under subsequent rulemaking.

Documentation

The certifying physician must document in the medical record:

• The date of the face-to-face encounter
• That the encounter was related to the primary reason for home health
• Clinical findings supporting homebound status
• Clinical findings supporting skilled need
• The medical necessity of home health services

The home health agency may not supply the F2F documentation; it must be from the physician's medical record. The home health agency may supplement with additional clinical evidence, but the foundational documentation is from the physician.

Effective January 1, 2021: NP, PA, CNS Certification

Under the Consolidated Appropriations Act of 2021, nurse practitioners, physician assistants, and clinical nurse specialists may CERTIFY home health (not just conduct the F2F encounter). This was a significant expansion that allowed beneficiaries whose primary care provider is an NP, PA, or CNS to receive home health without involving a supervising physician for the certification step.

Covered Services

Skilled Nursing Services

Provided by or under supervision of a registered nurse. Intermittent (typically up to 8 hours per day or 28 hours per week).

Physical Therapy, Occupational Therapy, Speech-Language Pathology

Provided by qualified therapists. Visits and frequency determined by the plan of care.

Medical Social Services

Provided under physician direction by a qualified social worker. Includes assessment of social factors affecting health, counseling, advocacy, and referral to community resources.

Home Health Aide Services

Personal care services (bathing, dressing, toileting, grooming, transferring) provided by a home health aide under nurse supervision. Aide services are only covered when the beneficiary is also receiving skilled service (nursing, PT, OT, or SLP). Aide services alone do not qualify.

Medical Supplies

Wound care supplies, ostomy supplies, IV supplies, urinary catheter supplies, and other medical supplies provided as part of the home health benefit (no separate billing).

Durable Medical Equipment

DME (wheelchairs, hospital beds, oxygen, walkers, commodes, CPAP) is covered under a separate Part B benefit. Standard 20% coinsurance applies. DME is NOT included in the home health PPS payment.

What Medicare Home Health Does NOT Cover

• 24-hour care: Medicare home health is intermittent, not continuous.

• Custodial care: Long-term personal care without a concurrent skilled need is not covered.

• Homemaker services: General housekeeping, laundry, and household management are not covered. Light meal preparation related to medical need is permitted but does not extend to general meal planning.

• Personal care without skilled need: Aide services alone (without a concurrent nursing or therapy need) are not covered.

• Meal delivery: Meals on Wheels and similar programs are not Medicare home health.

• Transportation: Medicare home health does not cover transportation. Beneficiaries needing transportation should explore Medicaid Non-Emergency Medical Transportation (NEMT), Medicare Advantage supplemental transportation benefits, or community programs.

• Drugs and biologicals: Except for limited categories (osteoporosis drugs administered to women in certain circumstances), drugs are not covered under home health. They are covered under Part B (for certain physician-administered drugs) or Part D (for self-administered drugs).

The Patient-Driven Groupings Model (PDGM)

PDGM was implemented January 1, 2020 under Section 51001 of the Bipartisan Budget Act of 2018. PDGM is the most significant home health payment reform since the implementation of the home health prospective payment system in 2000.

Key Changes from the Prior HHPPS

PDGM changed home health payment in fundamental ways:

The Five PDGM Variables

PDGM payment is determined by five variables:

1. Admission Source: Community or Institutional

A 30-day period is classified as Institutional if the beneficiary was hospitalized or in a SNF in the 14 days before the start of the 30-day period. Otherwise, the period is Community.

Institutional periods are paid more than Community periods, reflecting the higher resource needs of post-acute patients.

2. Timing: Early or Late

The first 30-day period in a sequence of periods is Early. All subsequent 30-day periods are Late.

A "sequence" continues as long as there is no gap of more than 60 days between periods. If a beneficiary is discharged and re-admitted more than 60 days later, the new period is Early.

Early periods are paid more than Late periods.

3. Clinical Grouping: 12 Categories

The clinical grouping is determined by the primary diagnosis on the home health claim:

1. Musculoskeletal Rehabilitation (joint replacement, fractures, spinal conditions)
2. Neuro/Stroke Rehabilitation (stroke, Parkinson's, neuropathy)
3. Wound Care (ulcers, surgical wounds, complex wounds)
4. Medication Management, Teaching, and Assessment (MMTA) Surgical (post-surgical care)
5. MMTA Cardiac/Circulatory (heart failure, hypertension, vascular)
6. MMTA Endocrine (diabetes, thyroid, adrenal)
7. MMTA Gastrointestinal/Genitourinary (GI, GU conditions)
8. MMTA Infectious Disease/Neoplasms/Blood Disease
9. MMTA Respiratory (COPD, pneumonia, respiratory failure)
10. MMTA Other
11. Behavioral Health
12. Complex Nursing Interventions (parenteral nutrition, complex care)

4. Functional Impairment Level: Low, Medium, High

Determined by responses to OASIS items measuring:

• Grooming
• Current ability to dress upper body
• Current ability to dress lower body
• Bathing
• Toilet transferring
• Transferring
• Ambulation/locomotion
• Risk of hospitalization

5. Comorbidity Adjustment: None, Low, High

Based on secondary diagnoses on the claim:

• None: no qualifying secondary diagnoses
• Low: one qualifying comorbidity
• High: multiple comorbidities or a high-cost comorbidity combination

How the Variables Combine

The five variables (2 × 2 × 12 × 3 × 3 = 432) yield 432 case-mix groups. Each group has a CMS-determined case-mix weight applied to the base period payment rate.

Low Utilization Payment Adjustment (LUPA)

If the number of visits in a 30-day period is below the LUPA threshold for the case-mix group, payment is per-visit rather than case-mix payment. The LUPA threshold varies by group (typically 2 to 6 visits). LUPA periods are designed for very short courses of home health.

Effects of PDGM

PDGM has produced several observed effects since implementation:

• Reduced incentive to provide therapy (since therapy volume no longer drives payment)
• Some shift in service mix from therapy to nursing
• Earlier discharge planning and shorter average lengths of stay
• Concerns about access for therapy-intensive patients
• More attention to admission source and clinical coding

The Home Health Value-Based Purchasing Program (HHVBP)

Original Pilot and Nationwide Expansion

The Home Health Value-Based Purchasing Program was piloted in 9 states (Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, Washington) from 2016 to 2022. The pilot demonstrated quality improvements and cost savings. Effective January 1, 2023, CMS expanded HHVBP nationwide through the CY 2022 home health final rule, codified at 42 CFR 484.300-484.370.

Structure

HHVBP operates on a performance year + payment year structure:

• CY 2023: First nationwide performance year
• CY 2024: Second performance year
• CY 2025: First nationwide payment year (based on CY 2023 performance)

Each year, agencies receive a payment adjustment of up to 5% upward or 5% downward based on quality performance.

Quality Measures: Total Performance Score (TPS)

The TPS includes three categories of measures:

OASIS-Based Measures:

• Improvement in ambulation
• Improvement in bed transferring
• Improvement in bathing
• Improvement in management of oral medications
• Improvement in dyspnea
• Total normalized composite for self-care
• Total normalized composite for mobility

HHCAHPS Survey Measures:

• Care of patients (professionalism and care)
• Communication (communication between providers and patient)
• Specific care issues (medication, pain, home safety)
• Overall rating of the agency
• Recommendation of the agency

Claims-Based Measures:

• Acute care hospitalization during the first 60 days of home health
• Emergency department use without hospitalization during the first 60 days of home health
• Discharge to community

Adjustment Calculation

For each agency, CMS calculates the Total Performance Score (TPS) based on achievement and improvement on the measures. The TPS is compared to national and cohort benchmarks. The TPS is translated into a payment adjustment via a linear exchange function. The adjustment applies to all Medicare home health payments for the payment year.

Quality Reporting Program (HH QRP)

Under the IMPACT Act of 2014 and 42 CFR 484.245, home health agencies must report quality data through OASIS. The current OASIS instrument is OASIS-E (effective January 1, 2023). Failure to comply with HH QRP reporting requirements results in a 2 percentage point reduction in the annual home health payment update. Quality measures and agency-level results are publicly reported on the Medicare.gov Care Compare website.

How Georgia Beneficiaries Access Home Health Care

Step 1: Recognize the Need

Common triggers for home health referral:

• Recent hospital discharge (especially after surgery, stroke, heart failure exacerbation, or COPD exacerbation)
• Skilled nursing facility discharge
• New chronic condition requiring teaching and monitoring (diabetes, anticoagulation, heart failure)
• New ostomy, catheter, or feeding tube
• Wound requiring skilled care
• Functional decline requiring rehabilitation
• Medication change requiring monitoring and teaching

Step 2: Physician (or NPP) Order and Face-to-Face Encounter

The physician, nurse practitioner, physician assistant, or clinical nurse specialist orders home health. The certifying provider (or eligible NPP) conducts the face-to-face encounter within 90 days before or 30 days after start of care. The provider documents homebound status, skilled need, and necessity of home health.

Step 3: Select a Medicare-Certified Home Health Agency

The beneficiary or family selects a Medicare-certified home health agency. Selection factors:

• Geographic coverage
• Quality scores on Medicare.gov Care Compare (HHCAHPS results, quality measures)
• Services offered (specialty programs for wound care, cardiac care, joint replacement, behavioral health)
• Hospital affiliations
• Bilingual staff if needed
• 24/7 on-call availability

For Georgia, major agencies include:

• National chains: Amedisys, LHC Group, Encompass Health, BAYADA, Interim HealthCare, Brookdale, Humana at Home
• Hospital-affiliated: Emory Home Healthcare, Piedmont Healthcare at Home, Wellstar Home Health, Memorial Health Home Care, Augusta University Health Home Health, Northeast Georgia Health System Home Care, Phoebe Putney Home Health
• Regional and independent agencies: numerous local agencies serving specific markets

Step 4: Admission

Within 48 hours of referral (or by date specified in physician orders), the home health agency conducts an admission visit. The admission RN completes the comprehensive assessment including OASIS-E within 5 days. The agency develops a plan of care for physician (or NPP) signature.

Step 5: Care Delivery

Skilled nursing visits, therapy visits, and aide visits are provided per the plan of care. Visits are documented; communication with the physician occurs at regular intervals. The plan of care is updated as the beneficiary's status changes.

Step 6: Recertification

Every 60 days, the plan of care is reviewed and recertified if continued care is needed. The certifying physician (or eligible NPP) signs the recertification. The face-to-face encounter is NOT required at recertification (only at initial certification).

Step 7: Discharge

When skilled need is met, the beneficiary is discharged from home health. The agency provides a discharge summary, communicates with the primary care provider, and may refer the beneficiary to outpatient services, community resources, or other long-term services.

Worked Examples

Example 1: Margaret, 78, Atlanta, Hip Replacement Post-Acute Home Health

Margaret has elective total hip replacement at Emory University Hospital. She is hospitalized for 3 days and discharged home with orders for home health. Emory Home Healthcare is her agency.

Margaret meets homebound criteria: she needs a walker and assistance to leave home, leaving home requires taxing effort, and her orthopedic surgeon has advised limited weight-bearing and limited outings during the first 6 weeks postoperatively.

She has skilled need: physical therapy for gait training, transfer training, balance, and quad strengthening; skilled nursing for incision assessment, pain management, deep vein thrombosis prophylaxis teaching, and oral anticoagulant monitoring.

The face-to-face encounter is completed during her hospital stay; her orthopedic surgeon documents homebound status, skilled need, and medical necessity.

First 30-day PDGM period: Admission Source = Institutional (recent hospitalization), Timing = Early (first period in sequence), Clinical Group = Musculoskeletal Rehabilitation, Functional Level = Medium (moderate impairment), Comorbidity = Low. Payment applies based on the case-mix weight.

Margaret receives:

• Skilled nursing: 2 to 3 visits in the first 2 weeks for wound assessment and anticoagulant management
• Physical therapy: 3 visits per week for 6 weeks
• Home health aide: 2 visits per week for bathing assistance (covered because she is receiving skilled service)

Second 30-day PDGM period: Admission Source = Institutional (still within the 14-day institutional window at start of second period if applicable; otherwise Community), Timing = Late, Clinical Group = Musculoskeletal Rehabilitation, Functional Level = Low (improvement), Comorbidity = Low.

By the end of the second 30-day period (60 days post-surgery), Margaret has achieved her PT goals. She is discharged from home health. Total visits: approximately 24 across PT, SN, and HHA.

Billing: First visits billed to Medicare Part A (post-institutional benefit covering first 100 visits per Section 1814(a)(2)(C)).

Example 2: Robert, 82, Savannah, CHF Unlimited Part B Home Health

Robert has New York Heart Association Class III congestive heart failure. He has not been recently hospitalized, but his cardiologist at Memorial Health is concerned about declining functional status, recent weight gain (suggesting fluid retention), and medication adjustments. The cardiologist orders home health for skilled nursing assessment and teaching.

Robert meets homebound criteria: dyspnea on exertion requires taxing effort to leave home; he uses supplemental oxygen; his cardiologist documents that frequent absences would jeopardize his medical management.

He has skilled need: skilled nursing assessment of cardiopulmonary status (lung sounds, peripheral edema, weight, vital signs, oxygen saturation), medication titration teaching, fluid restriction teaching, daily weight monitoring teaching.

The face-to-face encounter is completed during a recent cardiology office visit (within 30 days of start of care).

PDGM: Admission Source = Community (no recent hospitalization), Timing = Early, Clinical Group = MMTA Cardiac/Circulatory, Functional Level = Medium, Comorbidity = High (diabetes, chronic kidney disease, atrial fibrillation).

Robert receives skilled nursing 2 to 3 times per week for the first 60 days. At the first recertification, his cardiologist documents continued need and recertifies. Robert continues home health for 6 months (six 30-day PDGM periods).

Billing: All visits are billed to Medicare Part B (unlimited home health under Section 1835(a)(2)(A)) because Robert was not recently hospitalized.

After 6 months, Robert is stable and self-managing well. He is discharged. He remains under his cardiologist's care for ongoing CHF management.

Example 3: Linda, 75, Macon, Homebound Assessment Despite Family Events

Linda has advanced Parkinson's disease and lives alone in Macon. She uses a walker and a wheelchair for longer distances. Her neurologist orders home health for PT (balance, gait, fall prevention), speech-language pathology (dysphagia evaluation and management), and skilled nursing assessment.

Linda meets homebound criteria: she requires a walker, leaves home only with great difficulty, and her neurologist has documented that her medical condition makes frequent outings inadvisable.

Permitted absences:

• Weekly Baptist church services (a permitted religious absence)
• Twice-monthly visits to her neurologist (medical care, always permitted)
• One-time attendance at her grandson's wedding 2 months ago (a permitted unique event)
• Adult day care 2 days per week (permitted on a limited basis)

The home health nurse documents each absence and the reason at each visit. Homebound status is supported because Linda's outings are limited to permitted categories and require taxing effort with assistance.

Linda receives home health for 4 months, then is discharged when her skilled needs are met. She continues at adult day care, attends church weekly, and continues outpatient PT for maintenance.

Example 4: Charles, 80, Augusta, Face-to-Face Encounter by Nurse Practitioner

Charles is hospitalized at Augusta University Health for pneumonia complicated by new-onset insulin-dependent diabetes. He is discharged home with orders for home health: skilled nursing for diabetes teaching, insulin administration education, and post-pneumonia respiratory monitoring.

Charles's primary care provider is a nurse practitioner at a federally qualified health center in Augusta. Under the Consolidated Appropriations Act of 2021 (effective January 1, 2021), the NP may certify home health and conduct the face-to-face encounter.

The NP conducts the face-to-face encounter 12 days after Charles's discharge (within the 30-day post-SOC window). The NP documents:

• Homebound status: post-pneumonia weakness, requires assistance to leave home, taxing effort
• Skilled need: diabetes teaching for newly diagnosed insulin-dependent diabetes; respiratory assessment
• Medical necessity of home health

The NP signs the certification and plan of care.

PDGM: Admission Source = Institutional, Timing = Early, Clinical Group = MMTA Endocrine (primary diagnosis newly diagnosed diabetes), Functional Level = Medium, Comorbidity = Low.

Charles receives 21 days of skilled nursing visits. He is discharged when he is independent with insulin self-administration and blood glucose monitoring. He is referred to outpatient diabetes education for continued support.

Example 5: Patricia, 73, Columbus, PDGM 30-Day Periods After Stroke

Patricia has an ischemic stroke and is hospitalized at Piedmont Columbus Regional. After 5 days of acute care and 10 days of acute inpatient rehabilitation, she is discharged home with mild right-sided weakness, mild expressive aphasia, and mild dysphagia.

Home health is ordered with Piedmont Healthcare at Home:

• Skilled nursing: stroke teaching, anticoagulation teaching, fall prevention
• Physical therapy: gait, balance, transfers
• Speech-language pathology: aphasia treatment, dysphagia treatment
• Occupational therapy: ADL retraining

First 30-day PDGM period: Admission Source = Institutional (recent hospitalization AND IRF stay), Timing = Early, Clinical Group = Neuro/Stroke Rehabilitation, Functional Level = High (significant impairment), Comorbidity = High (diabetes, hypertension, atrial fibrillation contributed to stroke).

Patricia receives intensive home health: PT 3x/week, SLP 2x/week, OT 2x/week, SN 1-2x/week, HHA 3x/week.

Second 30-day PDGM period: Admission Source becomes Community (after the 14-day post-discharge institutional window has expired), Timing = Late, Clinical Group = Neuro/Stroke Rehabilitation, Functional Level = Medium (improving), Comorbidity = High.

Patricia continues intensive therapy. At the 60-day recertification, her physician (or NPP) reviews the plan and continues.

Third 30-day PDGM period: similar to second period but Functional Level = Low (continued improvement).

By the end of the third 30-day period (90 days post-stroke), Patricia is independent with modified independence in ADLs and is walking with a cane. She is discharged from home health and continues outpatient therapy for ongoing improvement.

Example 6: Henry, 85, Athens, Dual-Eligible Home Health and Medicaid PCS Coordination

Henry is 85 years old, lives in Athens, and is dual-eligible for Medicare and Georgia Medicaid. He has moderate Parkinson's disease. His wife Eleanor (82) is his primary caregiver.

Medicare home health: Henry's neurologist orders home health with Northeast Georgia Health System Home Care for skilled nursing (medication management, fall prevention teaching) and PT (balance, gait). Medicare home health is the primary skilled benefit. Henry meets homebound (walker required, taxing effort) and skilled need.

After 8 weeks, Henry's skilled needs are met and Medicare home health discharges. He has stable Parkinson's, is independent with his medications with Eleanor's assistance, and is at his baseline functional status.

Medicaid Personal Care Services: Eleanor needs more help with Henry's bathing, dressing, and personal care than the Medicare home health aide benefit provided. The Georgia Department of Community Health Aging and Disability Services Division enrolls Henry in Medicaid Personal Care Services (PCS) through the Elderly and Disabled Waiver. PCS provides up to 30 hours per week of personal care, delivered by a Medicaid-enrolled PCS provider.

The Medicaid PCS:

• Does NOT require homebound status (PCS is provided in the home; there is no Medicare-style homebound requirement for PCS)
• Does NOT require skilled need (PCS addresses ADLs; it does not require a concurrent skilled service)
• Provides ongoing long-term services that Medicare does not cover

Henry's care is now coordinated:

• His PCP and neurologist manage medical care
• He attends outpatient PT at a clinic 1x per week
• Eleanor manages day-to-day caregiving with PCS aide support 6 days per week for ADL assistance
• He attends a Parkinson's support group monthly (a permitted outing)

When Henry has a fall later and is hospitalized for a fracture, Medicare home health re-engages for the post-acute skilled need (PT and SN). The home health and PCS providers coordinate their schedules so Henry receives both Medicare skilled care and Medicaid PCS without duplication.

Common Mistakes

1. Believing 24-hour home care is covered. Medicare home health is intermittent (up to 8 hours per day or 28 hours per week). 24-hour care requires a different setting or service.

2. Believing homebound means bedbound. Homebound means leaving home requires taxing effort, not that the beneficiary is unable to ambulate.

3. Believing permitted absences disqualify. Medical care, religious services, adult day care on a limited basis, and unique family events do not affect homebound status.

4. Missing the face-to-face encounter. F2F must occur within 90 days before or 30 days after start of care. Missing F2F results in claim denial.

5. Confusing home health with home care. Medicare home health is skilled medical care under a plan of care. "Home care" generally refers to non-medical personal care, which is not a Medicare benefit.

6. Believing therapy visits are unlimited but always covered. While there is no fixed visit limit, services must be reasonable and necessary. PDGM eliminated therapy volume as a payment driver, which has affected access patterns at some agencies.

7. Believing aide services are available without skilled need. Home health aide services are only covered when the beneficiary is also receiving skilled service.

8. Believing PDGM shortened total coverage. PDGM changed payment from 60-day episodes to 30-day periods. It did not limit total length of coverage. Beneficiaries who remain homebound with skilled need can continue indefinitely with periodic recertification.

9. Believing Medicare covers homemaker or meal services. Medicare home health does not cover homemaker services (general housekeeping, laundry) or meal delivery. Light meal preparation related to medical need is permitted.

10. Believing DME is included in home health. Durable medical equipment is a separate Part B benefit. DME coverage and copays are separate from the home health benefit.

11. Believing a hospital stay is required for home health. Hospital stay is NOT required for Part B home health (the unlimited benefit). Only the Part A post-institutional benefit (first 100 visits) requires recent hospitalization or SNF stay. Most home health is billed to Part B without a hospital stay requirement.

12. Confusing Medicare home health with Medicaid home health or Personal Care Services. Medicare home health is skilled care for limited duration. Medicaid home health and Medicaid PCS may include longer-term, lower-acuity services. Dual-eligible beneficiaries often use both.

13. Underutilizing Medicare.gov Care Compare. The Care Compare website publishes HHCAHPS results, OASIS-based outcome measures, and other quality data for every Medicare-certified home health agency. Families should review these data when selecting an agency.

14. Failing to appeal a denial. If Medicare denies a home health claim, the beneficiary can appeal through the 5-level Medicare appeals process. KEPRO handles certain quality-of-care concerns. The Center for Medicare Advocacy and Medicare Rights Center can assist with appeals.

::: accordion

What is the Medicare Home Health Benefit?

The Medicare Home Health Benefit is a Medicare entitlement established by Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act. It allows beneficiaries who are homebound and need skilled care to receive that care at home rather than in an institution. Covered services include skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social services, home health aide services (when receiving skilled service), and medical supplies. The beneficiary pays nothing out-of-pocket for the home health visits themselves.

Who qualifies for Medicare home health?

A beneficiary qualifies if they are: under the care of a physician (or eligible NPP), under a plan of care reviewed at least every 60 days, homebound, and in need of skilled nursing (intermittent) or physical therapy or speech-language pathology or continuing occupational therapy. A face-to-face encounter with a physician or eligible NPP must occur within 90 days before or 30 days after start of care.

What does "homebound" mean?

Homebound means leaving home requires considerable and taxing effort, due to illness or injury. The beneficiary may need supportive devices (walker, wheelchair), special transportation, or assistance to leave home, OR may have a medical condition that makes leaving home medically contraindicated. Homebound does NOT mean bedbound or never leaving home. Absences for medical care, religious services, adult day care on a limited basis, and unique family events are permitted.

What is the face-to-face encounter requirement?

Under Section 6407 of the Affordable Care Act, the certifying provider (physician or eligible NPP) must conduct a face-to-face encounter with the beneficiary within 90 calendar days before or 30 calendar days after the start of home health care. The provider must document homebound status, skilled need, and necessity of services. The encounter may be conducted via telehealth.

Can a nurse practitioner certify home health?

Yes, effective January 1, 2021. Under the Consolidated Appropriations Act of 2021, nurse practitioners, physician assistants, and clinical nurse specialists may certify home health and conduct the face-to-face encounter, in addition to physicians. This permanent change was a significant expansion that improved access for beneficiaries whose primary care provider is an NPP.

Is there a limit on the number of home health visits?

The Part A post-institutional benefit (Section 1814(a)(2)(C)) covers the first 100 visits following a qualifying hospital or SNF stay. The Part B home health benefit (Section 1835(a)(2)(A)) is unlimited. For most beneficiaries, the benefit operates as a unified, effectively unlimited benefit as long as homebound and skilled need are met. Most visits are billed to Part B.

What services does Medicare home health cover?

Skilled nursing (intermittent), physical therapy, occupational therapy, speech-language pathology, medical social services, home health aide services (only when receiving skilled service), and medical supplies. Durable medical equipment is covered under a separate Part B benefit with 20% coinsurance.

What does Medicare home health NOT cover?

24-hour care, custodial care, homemaker services, meal delivery, personal care without a concurrent skilled need, drugs and biologicals (with limited exceptions), transportation, and care from a non-Medicare-certified provider.

What is the Patient-Driven Groupings Model (PDGM)?

PDGM is the Medicare home health payment model effective January 1, 2020, replacing the prior Home Health Prospective Payment System (HHPPS). PDGM changed payment from 60-day episodes to 30-day periods, eliminated therapy volume as a payment driver, and established 432 case-mix groups based on five variables: admission source (Community vs Institutional), timing (Early vs Late), clinical grouping (12 categories), functional impairment (Low/Medium/High), and comorbidity (None/Low/High).

What is the Home Health Value-Based Purchasing Program (HHVBP)?

HHVBP is a Medicare program that adjusts home health agency payments by up to 5% upward or downward based on quality performance. Originally piloted in 9 states from 2016 to 2022, HHVBP was expanded nationwide effective January 1, 2023. CY 2023 is the first nationwide performance year; CY 2025 is the first payment year. Quality measures include OASIS-based outcomes, HHCAHPS survey results, and claims-based measures (hospitalizations, ED use, discharge to community).

How often is home health recertified?

The plan of care is reviewed and recertified at least every 60 days. The face-to-face encounter is NOT required at recertification (only at initial certification or within 30 days after start of care). The certifying provider signs the recertification confirming continued need.

Can a hospice patient also receive home health?

Generally no. When a beneficiary elects hospice, the hospice covers all care related to the terminal illness. Home health for the same conditions is not separately billable. If the beneficiary has an unrelated condition requiring home health, separate home health may be billed.

Does Medicare home health require a hospital stay?

Not for Part B home health (the primary, unlimited benefit). A hospital stay (or SNF stay) is required for Part A post-institutional home health (the first 100 visits). Most home health is billed to Part B and does not require a prior hospital stay.

What is the difference between home health and home care?

"Home health" specifically refers to the Medicare-defined benefit that requires homebound status, skilled need, and a plan of care, and is provided by a Medicare-certified home health agency. "Home care" generally refers to non-medical personal care or homemaker services, which are not Medicare benefits. Home care may be covered by Medicaid, long-term care insurance, or private pay.

How does Medicare home health interact with Medicaid?

For dual-eligibles, Medicare home health is the primary skilled benefit. Medicaid Personal Care Services may provide longer-term, lower-acuity personal care that Medicare does not cover. The two benefits coordinate; the beneficiary may receive both simultaneously without duplication.

How much does Medicare home health cost the beneficiary?

For the home health visits themselves, the beneficiary pays nothing out-of-pocket. Durable medical equipment provided alongside home health carries 20% coinsurance under the separate Part B DME benefit. Medicare Supplement (Medigap) plans may cover the DME coinsurance for Original Medicare beneficiaries.

Can a Medicare Advantage beneficiary receive home health?

Yes. Medicare Advantage plans must cover all Original Medicare benefits including home health. The MA plan may have its own network of home health agencies, prior authorization requirements, and care management protocols. The beneficiary should confirm the MA plan's procedures with the plan.

What happens if a home health claim is denied?

The beneficiary can appeal through the 5-level Medicare appeals process: (1) redetermination by the contractor, (2) reconsideration by a Qualified Independent Contractor, (3) ALJ hearing, (4) Medicare Appeals Council review, (5) federal court. The Center for Medicare Advocacy and Medicare Rights Center can assist with appeals.

What if I disagree with a home health discharge?

If the home health agency notifies you of discharge and you disagree, you can request an expedited review by the Quality Improvement Organization (KEPRO for Georgia, 1-844-455-8708). The QIO will review the discharge decision and rule on whether the discharge was clinically appropriate.

How do I choose a home health agency?

Use Medicare.gov Care Compare to compare quality scores, HHCAHPS survey results, and services offered. Consider geographic coverage, hospital affiliations, specialty programs (wound care, cardiac care, behavioral health), language services, and 24/7 on-call availability. Hospital discharge planners, primary care providers, and the Georgia SHIP (GeorgiaCares) can provide referrals.

Are there special home health services for veterans?

Veterans may receive home health through the VA Home Based Primary Care (HBPC) program or VA-purchased care from community providers. The VA program is separate from Medicare home health and has different eligibility requirements. Veterans dual-enrolled in Medicare and VA may use either system. The VA Caregiver Support Line (1-855-260-3274) provides information.

How does OASIS work?

The Outcome and Assessment Information Set (OASIS) is a standardized data collection instrument used at admission, recertification, and discharge. The current version is OASIS-E (effective January 1, 2023). OASIS data drives the PDGM case-mix calculation, supports quality reporting under HH QRP, contributes to HHVBP measurement, and informs care planning. OASIS data is collected by the home health agency and submitted to CMS.

What is the role of home health aides?

Home health aides provide personal care services (bathing, dressing, toileting, grooming, transferring) and may perform certain delegated tasks under nurse supervision. Aides are typically certified nursing assistants (CNAs) or home health aides who have completed federally approved training and competency evaluation. Aide services are only covered when the beneficiary is also receiving skilled service.

Can home health be provided in an assisted living facility?

Yes. The beneficiary's "home" for Medicare home health purposes can be a private residence, assisted living facility, or other non-institutional residential setting. The beneficiary must still meet homebound and skilled need requirements.

What is the future of Medicare home health?

Major recent and ongoing changes include the nationwide expansion of HHVBP (effective 2023), ongoing PDGM refinements, expanded telehealth flexibilities, and continued attention to access for beneficiaries with complex therapy needs after PDGM eliminated therapy as a payment driver. Future legislation may address access, payment adequacy, and quality. :::

::: cta

Talk to Someone About Medicare Home Health in Georgia

If you are considering Medicare home health for yourself or a family member in Georgia, or if you have questions about coverage, the homebound requirement, the face-to-face encounter, or appeals, these organizations can help.

Government Programs and Direct Services

• Georgia Department of Community Health Medicaid Member Services: 1-866-211-0950
• Medicare: 1-800-MEDICARE (1-800-633-4227); TTY 1-877-486-2048
• KEPRO (Georgia Quality Improvement Organization): 1-844-455-8708 (for home health discharge appeals)
• GeorgiaCares (Georgia SHIP): 1-866-552-4464 (free Medicare counseling)
• Social Security Administration: 1-800-772-1213

Federal Oversight and Civil Rights

• HHS Office of Civil Rights: 1-800-368-1019
• HHS Office of Inspector General: 1-800-447-8477 (home health fraud reporting)
• CMS National Hotline: 1-800-MEDICARE

Beneficiary Advocacy

• Medicare Rights Center: 1-800-333-4114
• Center for Medicare Advocacy: 1-860-456-7790
• Eldercare Locator: 1-800-677-1116

Home Health Industry Resources

• National Association for Home Care and Hospice: 1-202-547-7424
• Georgia Association for Home Health Agencies (state trade association)

Legal Assistance

• Atlanta Legal Aid Senior Citizens Law Project: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469
• 211 Georgia (general social services referrals): dial 211

Veterans

• VA Caregiver Support Line: 1-855-260-3274

About Brevy

Brevy is building America's most trustworthy, comprehensive, and up-to-date online resource on eldercare. This guide is one of an ongoing series on Georgia Medicare and Medicaid topics published on brevy.com. Information is current as of May 2026 and is provided for educational purposes. The Medicare Home Health Benefit is a federal benefit governed by the Social Security Act and the regulations at 42 CFR Part 484, and operates the same in Georgia as in every state. Home health clinical decisions, payment determinations, and care planning should be made in consultation with a Medicare-certified home health agency, your physicians, and qualified counsel. This guide is educational and does not constitute medical, legal, or financial advice. :::