Access to home health services is important for people with chronic conditions or disabilities, and those who
need short-term medical help after being discharged from the hospital. Many rural people depend on home health
services to retain a degree of independence, and to avoid or delay hospitalization or a move to a
nursing home or assisted living facility. This type of care is less costly than hospitalization, improves
recovery and well-being, and eliminates the need to travel for appropriate services. However, rural populations
are at risk of having inadequate access to affordable home health services.
Frequently Asked Questions
What is included in home health services and what is the difference between home health
services and home care services?
Home health services involve medical care, and must be provided by medical professionals, such as registered
nurses (RNs), occupational or physical therapists, and speech-language pathologists. It can be prescribed
An inpatient hospitalization, or a stay at a rehabilitation center or a skilled nursing facility when
continued care at home is needed
A medication change, so that a medical professional can check for possible side effects and make sure the
medicine is effective
A decline in health, necessitating therapy or acquisition of different skills and coping mechanisms
Additionally, home health services can be used to maintain the patient's condition, prevent or slow
deterioration of the condition, or improve the condition. Unlike skilled nursing facilities, a patient does not
need to be hospitalized prior to receiving home health services. WWAMI Rural Health Research Center published two briefs describing the differences in
characteristics of patients who receive home health services in rural areas after a hospitalization and those
who do not (“community entry”).
Home health services can include:
Injections and administration of medicine
Skilled nursing care, furnished by, or under supervision of, an RN
Physical, speech-language, and occupational therapy
Monitoring health status
Provision of medical supplies (other than drugs) and medical equipment
Medical social services
Limited home health aide services for routine health-related tasks that do not require the skills of a nurse
or therapist, as well as for assistance with activities of daily living
Home care services, however, are not medical in nature, and are provided by home care aides who
usually do not have medical training. Medicare does not reimburse for these services except when provided in
conjunction with skilled nursing or therapy. Home care aides offer help with activities of daily living, such
- Dressing, grooming, and bathing
- House cleaning
- Grocery shopping and meal preparation
- Help with bill paying
- Medication reminders
Why are home health services especially important for rural populations?
According to the 2014 study Differences
in Case-Mix between Rural and Urban Recipients of Home Health Care, rural home health patients are more
likely than their urban counterparts to:
- Be severely ill or in fragile condition
- Have more risk factors for hospitalization
- Need respiratory treatments and therapies
- Have a surgical wound requiring treatment
It is important for people to have access to home health services, both as a post-acute care option and for
longer-term treatment. With this type of medical care, they may be able to delay hospitalization, keep costs
down, and remain in their homes as long as possible.
To what extent are home health services available in rural communities?
The Medicare Payment Advisory Commission's March
2023 chapter on home
health care services states that almost all Medicare beneficiaries live in a county with at least
one home health agency, 98% of beneficiaries live in a ZIP code served by two or more home health agencies, and
87.6% percent lived in a ZIP code served by five or more home health agencies. However, it is important to
consider that the Medicare beneficiaries who live in an area that is not served by at least one home
health agency are more likely to live in rural areas. A February
2022 WWAMI Rural Health Research Center brief notes that 22% of home health agencies located in urban
areas had a patient population of at least 10% rural beneficiaries. Additionally, Variation
in Use of Home Health Care among Fee-for-Service Medicare Beneficiaries by Rural-Urban Status and Geographic
Region: Assessing the Potential for Unmet Need reports that while the utilization of home health
services among Medicare beneficiaries in 2013 decreased as rurality increased, there was not a significant
difference when the number of home health visits and episodes were adjusted by population.
Rural Health Clinics (RHCs) can be certified to provide home health services if there is no functioning home
health agency in their service area. According to the Medicare Learning Network's Information for
Rural Health Clinics, RHCs can supply visiting nurse services to homebound patients in areas where
CMS has certified a shortage of home health agencies.
Medicare.gov's Care Compare tool
allows users to find and compare home health agencies in their area in terms of services offered and quality of
care compared to national and state averages.
Who can order skilled home health services for Medicare beneficiaries and what is
required of them?
Medicare regulations specified prior to March 2020 that services must be ordered by a physician, defined as a
doctor of medicine, a doctor of osteopathy, or a podiatrist. In response to the COVID-19 pandemic, Section 3708
of the Coronavirus Aid, Relief, and
Economic Security (CARES) Act extended this authority to nurse practitioners, clinical nurse
specialists, and physician assistants. The certifying provider, or a practitioner working with the provider,
have a face-to-face encounter with the patient related to the reason the patient needs home care within 90 days
before the start of care or within 30 days after the start of care. The face-to-face encounter may be performed
via telehealth if the patient is at a qualified originating site. The home health provider, working with the
patient's certifying provider, must then create an individualized plan of care and review it with the physician
no less frequently than every 60 days. According to the Medicare Conditions of
Participation, the plan should include:
- All pertinent diagnoses
- Patient's mental, psychosocial, and cognitive status
- Services, supplies, and equipment required for treatment
- Frequency and duration of home visits
- Prognosis and potential for rehabilitation
- Functional limitations and permitted activities
- Prescribed medicines and treatments, and nutritional needs
- Recommended safety measures, to avoid injury
- Measurable outcomes and goals
- Any additional orders the provider wishes to include
For more information, visit Medicare's home
health services webpage.
Who qualifies for Medicaid and Medicare reimbursement of rural home health services?
Home health services are considered a mandatory benefit for states to provide under the Medicaid program.
However, coverage and eligibility for home health services vary by state and type of Medicaid coverage.
Medicare covers the cost of home health services for homebound beneficiaries who need intermittent, short-term,
episodic skilled care, provided by a Medicare-certified home health agency (HHA) or visiting nurse service. The
term homebound does not refer to people who can literally never leave their homes. Instead, it signifies people
who are unable to leave home without assistance or great effort, or who have a condition that would preclude
their safely leaving home alone. Patients who leave their homes for medical appointments may still be considered
CMS implemented regulations
in 2018 intended to improve the quality of services and strengthen the rights of home health patients and their
caregivers. As a result, home health agencies must take into consideration whether informal caregivers are
willing, able, and available. Patients can also select personal representatives who can aid in making decisions
about the patient's care, even if that person does not have legal status as guardian.
Who provides rural home health services, and where can they occur?
Home health agencies (HHAs) are certified by Medicare and/or Medicaid, are licensed by their state, and provide
skilled medical care. Rural HHAs can be for-profit, nonprofit, or government-run and can be freestanding or
within a facility. The Quality
of Home Health Agencies Serving Rural Medicare Beneficiaries reports that a significantly higher
percentage of rural HHAs are nonprofit and government-run compared to urban HHAs. According to the Medicare
Payment Advisory Committee's March
2023 analysis of CMS claims data, 11.8% of the nation's freestanding home health agencies provided more
than half of their services to Medicare beneficiaries in rural areas in 2021.
Facility-based HHAs may be operated by a hospital, skilled nursing facility, or other facility. According to Community
Impact and Benefit Activities of Critical Access, Other Rural, and Urban Hospitals, 2021, 19.8% of
Critical Access Hospitals (CAHs) and 32.7% of other rural hospitals offer home health services compared to 20.7%
of urban hospitals. When including hospitals that include home health services as part of a health system or
joint venture, however, 50.1% of CAHs and 61.8% of other rural hospitals offer these services. Rural Health
Clinics and Federally Qualified Health Centers can also provide visiting nurse services in Home Health Shortage
Areas, as noted in Section 190.1 of the Medicare Benefit
Policy Manual. In some instances, rural hospitals will operate HHAs because it is a necessary service
that is not being provided by others in the community, regardless of whether it is financially advantageous to
provide the services. The Financial Importance of
Medicare Post-Acute and Hospice Care to Rural Hospitals notes that about a third of rural PPS hospitals
and less than a quarter of Critical Access Hospitals reported Medicare income for home health services in 2015.
Care usually takes place in the patient's home. However, if the necessary equipment is too large or cumbersome
bring to a home, care can take place in a hospital, skilled nursing facility, or rehabilitation center.
Medicare.gov’s Care Compare tool provides a list of home
health agencies, including contact information, type of ownership, lists of services provided, and quality
Where can rural home health agencies find additional financial support?
According to the policy brief Home is Where the Heart
Is: Insights on the Coordination and Delivery of Home Health Services in Rural America, many rural home
health agencies must rely in part on financial support from outside sources in order to remain in operation.
Some report receiving money from mill levies, county health-specific or general funds, or local foundation
grants. Home health agencies affiliated with or owned by hospitals may also receive funding directly from that
Additional funds for home health services may be available from:
Community nonprofit organizations
Local Area Agencies on Aging
State-level elder affairs or aging departments
Federal social services block grant programs
The Veterans Health Administration (for veterans who are at least 50% disabled, due to a service-related
What are some challenges faced by rural home health agencies?
to Rural Home Health Services: Views from the Field outlines the following
challenges rural home health agencies face:
Compliance with Medicare's regulations and reimbursement policies
A prospective payment model that is not well-suited to low-volume agencies
Equipment procurement regulations that may be impractical in rural areas
High turnover rates among rural healthcare workers
High poverty rates, population loss, and healthcare facility closures, all of which affect home health
Where the Heart Is: Insights on the Coordination and Delivery of Home Health Services in Rural America
cites other barriers to providing home health services, including:
- Insufficient reimbursement from Medicare
- High costs of implementing and maintaining electronic health records systems
- Limitations in insurance coverage affecting service provision
- Different interpretations in the definition of homebound status
Home health workers in rural areas face other difficulties, such as traveling long distances on poor roads or in
inclement weather. In addition, as rural areas become more ethnically diverse, providers may experience
challenges in effectively serving people from different cultures and those who may not speak the same language.
Moreover, the WWAMI Rural Health Research Center policy brief Post-acute
Care Trajectories for Rural Medicare Beneficiaries: Planned versus Actual Hospital Discharges to Skilled
Nursing Facilities and Home Health Agencies found that only 58.7% of rural beneficiaries with a planned
discharge to home health following hospital discharge received these services, indicating challenges with care
Some communities actively foster partnerships that allow home health professionals to maximize their time and
provide the highest possible level of service. The Rural Monitor article Rural Post-Acute Care:
Healthcare Leaders Offer Practical Solutions to Workforce Challenges describes creative ways in which
one home health agency in Maine reaches patients in remote areas who might not otherwise receive needed care.
Can telehealth visits fulfill the Medicare face-to-face requirement?
Telehealth visits can fulfill the requirement, as long as they originate at an approved site. This means that
the patient can be located in a doctor's office, a hospital, or a skilled nursing facility to receive the
telehealth service, but not the patient's home.
How is telehealth used to complement traditional home health services in rural areas?
Rural Post-Acute Care:
Healthcare Leaders Offer Practical Solutions to Workforce Challenges notes the financial challenges of
providing home health services in rural and frontier areas due to not receiving reimbursement for the travel
time to patient homes. For example, remote patient monitoring (RPM) can provide home health providers with
reliable patient information without the need to travel long distances to the home. The 2018
Medicare Payment Advisory Commission (MedPAC) Report to Congress notes that some home health agencies
found that RPM improved access, quality, and convenience and lowered readmissions for post-acute care patients.
Telehealth to Improve Home-Based Care for Older Adults and Family Caregivers outlines other examples of
telehealth services that can supplement home-based healthcare services.
According to MedPAC,
Medicare requires home health agencies to report the costs associated with telehealth services cost reports.
However, Medicare claims are not used to report telehealth visits or other telehealth services. As a result,
there is a lack of information on how these services complement traditional home health services, including
health outcomes and utilization of other care.
What effect do recent federal policy changes have on rural home health agencies (HHAs)?
In 2016, CMS implemented the Home
Value-Based Purchasing (HHVBP) Model in nine states across the country.
This program is designed to promote increased efficiency and better patient outcomes, linking payments to
performance while moving away from a volume-based payment model. Evaluation of the
Value-Based Purchasing (HHVBP) Model: Fifth Annual Report describes how disparities in the percent of
home health episodes provided by higher quality agencies across race, ethnicity, and urban-rural residence
disappeared in HHVBP states over the course of the model. The Calendar Year 2022 Home Health Prospective
Payment System final rule finalized a proposal to expand the model nationwide in 2022.
The Bipartisan Budget Act of 2018 established new requirements for home health payment reform called the
Patient-Driven Groupings Model (PDGM). The PDGM includes eliminating therapy thresholds for case-mix adjustment
and changing units of payments from 60-day periods to 30-day periods. These changes took effect on January 1,
2020, and are intended to realign Medicare payments for home health services with a patient's
clinical characteristics and needs. Home health agencies may need to have increased contact with each patient's
provider to complete the documentation required to bill for each 30-day period of care.
Since 2000, Congress has repeatedly passed legislation providing an increased payment to rural home health
agencies above the base reimbursement rate. The Bipartisan Budget Act of 2018 extended a 3% payment
increase for all home health episodes provided in rural areas through calendar year 2019. The Act also divided
rural counties into three categories, which will determine the rate and duration of the supplemental payment,
with all additional payments phased-out after 2022. For more information, read the March 2019 Medicare Payment
Advisory Commission's chapter
on home health care services.
What effect did the COVID-19 public health emergency have on home health agencies?
In response to the declared public health emergency (PHE) regarding the COVID-19 pandemic, the U.S.
Department of Health and Human Services Secretary can issue waivers that modify regulatory requirements
so that providers can continue to meet the needs of patients during the emergency. Home
Health Agencies: CMS Flexibilities to Fight COVID-19 and Guidance
for the Expiration of the COVID-19 Public
Health Emergency (PHE) outline temporary waivers and new regulations that apply to home health
agencies as a result of the COVID-19 pandemic and public health emergency, including:
Increasing the permitted use of telehealth services, including for face-to-face encounters.
Expanding who can order home health services, perform initial and comprehensive assessments, and
certify/recertify patient eligibility.
Updating the definition of homebound to include Medicare beneficiaries advised by their healthcare providers
to not leave the home because of a confirmed or suspected COVID-19 diagnosis or if the patient has an
underlying condition that makes them more vulnerable to contracting COVID-19.
Modifying Quality Assurance and Performance Improvement (QAPI) and other reporting requirements.
Health Agencies: CMS Flexibilities to Fight COVID-19 and Guidance for the Expiration of the COVID-19 Public
Health Emergency (PHE) also describe whether each waiver or flexibility was terminated; ended at the
conclusion of the PHE on May 11, 2023; or continued beyond the PHE.
Calendar Year 2022 Home Health Prospective Payment System final rule made permanent changes to allow
the use of telehealth services in assessment visits and in limited cases when performing the 14-day
supervisory visit requirement. This rule also updated the home health Conditions of Participation to
permit an occupational therapist to conduct the initial home health assessment visit and complete the
comprehensive assessment under certain circumstances.