What Isn’t Covered By Medicare Under the Home Health Benefit: For Providers

Just because a service can be delivered in a patient’s home, doesn’t mean it’s covered under the Medicare home health benefit.

That distinction matters more than many leadership teams realize. Coverage assumptions can affect how services are structured, how staff are utilized, how documentation is written, and how claims are submitted. When those assumptions are wrong, the result can be denials, recoupments, or unnecessary compliance exposure.

*This article was written in consultation with Mariam Treystman.

At The Home Health Consultant (THHC), we work with Medicare-certified home health agencies nationwide on compliance, infrastructure and survey readiness.

In this article, we’ll explain where Medicare draws the line so agencies can evaluate their own systems, documentation, and operational decisions with greater confidence.

What Does Medicare Mean by a “Separately Billable Home Health Visit”?

Before reviewing specific exclusions, it is important to clarify a concept that causes frequent confusion: what qualifies as a separately billable home health visit.

Under the Medicare home health benefit, not every in-home encounter is considered a billable visit. Medicare recognizes specific covered disciplines during a home health period of care, such as:

• Skilled nursing
• Physical therapy
• Occupational therapy
• Speech-language pathology
• Medical social services
• Home health aide services

When one of these recognized disciplines furnishes a covered skilled service under an approved plan of care, that visit may be reported and counted as a reimbursable home health visit.

However, Medicare does not recognize every clinician type or every service as its own billable discipline.

For example:

• A respiratory therapist visit during a home health episode is not recognized as a separate billable skilled visit.
• A dietician visit is not separately billable.
• A visit solely to set up remote monitoring equipment is not separately billable.

In these situations, the costs may be treated as administrative or operating expenses, but they cannot be billed as independent skilled visits under the home health benefit.

This distinction matters because many coverage misunderstandings stem from assuming that if a licensed professional enters the home and provides care, the visit must be billable. Under Medicare policy, that is not always the case.

With that framework in mind, the following sections explain specific services and items that Medicare excludes from coverage under the home health benefit.

Are Drugs and Biologicals Covered Under the Medicare Home Health Benefit?

No, drugs and biologicals are not covered by Medicare under the home health benefit.

The home health chapter of the Medicare Benefit Policy Manual defines:

• A drug as any chemical compound used in diagnosis, treatment, prevention of disease, pain relief, or to control or improve physiological or pathologic conditions.
• A biological as a medicinal preparation made from living organisms and their products, including serums, vaccines, antigens, and antitoxins.

These items are not reimbursed under the home health benefit.

However, there is one narrow statutory exception: the osteoporosis drug benefit. The osteoporosis drug benefit is part of the home health benefit, but only when very specific conditions are met. This exception allows Medicare to cover the drug itself (not just its administration) in limited circumstances.

To qualify for the osteoporosis drug benefit, the patient must:

• Be eligible for the home health benefit
• Have a diagnosis of osteoporosis
• Have a history of a bone fracture related to osteoporosis
• Be unable to self-administer the injectable drug
• Have the drug ordered by a physician

When these requirements are satisfied, Medicare allows coverage of the injectable osteoporosis drug itself, along with its administration.

This is a rare carve-out from the general rule that drugs and biologicals are excluded from the home health benefit. Agencies should be cautious not to interpret this exception outside of the specific circumstance broadly.

In some cases, agencies may also provide certain services, such as vaccines, outside the home health benefit. However, those services are not reimbursed as part of a standard home health episode.

It is important to distinguish between the administration of a medication, which may qualify as a skilled service, and the drug itself, which is not covered under the home health benefit. That distinction frequently becomes relevant during audits and billing reviews.

Is Transportation of the Patient Covered Under Home Health?

No, transportation of a patient is excluded from Medicare home health coverage. This is true whether the transportation is to receive covered care, or for any other reason.

However, Medicare clarifies that costs associated with transporting equipment, materials, supplies, or staff may be allowable as administrative costs. These are not separately billable services. They are operating expenses incorporated into the agency’s overall cost structure.

Issues arise when agencies attempt to separately account for or bill transportation services outside of administrative costs. Under the home health benefit, that is not allowed.

Are Services Automatically Covered Just Because They Are Provided in the Home?

No. Medicare excludes services that would not be covered if furnished as inpatient hospital services.

In other words, the home setting does not expand Medicare coverage. If a service would be non-covered in the inpatient hospital setting, it is also excluded from home health coverage.

This reinforces a foundational principle of Medicare exclusions in home health: coverage is based on Medicare policy, not on where the care is delivered.

Agencies evaluating new service lines should consider this rule carefully. Delivering a service in the home does not, by itself, make it a covered home health service.

Are Housekeeping or Custodial Services Covered Under the Home Health Benefit?

Services whose sole purpose is to allow the patient to continue residing in the home are not covered under the Medicare home health benefit.

Some examples of these kinds of services include, but are not limited to…

• Cooking
• Shopping
• Meals on Wheels
• Cleaning
• Laundry

…when they are not considered "medically necessary”. To learn more about medical necessity in home health, check out our article on home health eligibility requirements below.

The key phrase in the policy is “sole purpose.” When the service exists only to maintain the household environment and not to provide skilled care under a plan of care, it is excluded from home health coverage.

This is an area where documentation nuance matters. Plans of care must reflect skilled medical necessity. When documentation begins to resemble custodial support rather than skilled, medically necessary intervention, agencies increase their chances for audit findings.

Understanding that boundary helps clinical teams chart more precisely and leadership structure services appropriately.

How Does the ESRD Program Affect What Home Health Can Cover?

To understand this exclusion, it helps to first understand how Medicare pays for dialysis.

Patients with End Stage Renal Disease (ESRD) have permanent kidney failure requiring dialysis or transplant. These patients receive dialysis services through a separate Medicare payment system called the ESRD Prospective Payment System (PPS).

Under the ESRD PPS, Medicare makes a bundled payment to the ESRD facility for dialysis treatment and for items and services that are directly related to that dialysis care.

This bundled ESRD PPS payment is comprehensive. It includes dialysis treatment itself as well as drugs, biologicals, laboratory services, and other items that are considered directly related to dialysis.

Because Medicare already pays for those dialysis-related services under the ESRD PPS, the Medicare home health benefit cannot duplicate payment for the same services.

As a result, the following are excluded from home health coverage:

• Renal dialysis services covered under the ESRD PPS
• Any item or service furnished to an ESRD beneficiary that is directly related to that individual’s dialysis

The phrase “directly related” is the key here.

If a service is directly connected to dialysis treatment, it falls under the ESRD PPS and cannot be billed under the home health benefit.

However, not every service provided to a patient with ESRD is automatically excluded.

If the service is unrelated to dialysis, and all other home health coverage requirements are met (homebound status, skilled need, physician-ordered plan of care, etc.), the service may be covered under the home health benefit.

For example, a skilled nursing visit to furnish wound care for an abandoned shunt site could be covered, as long as that wound care is not directly related to ongoing dialysis treatment.

Importantly, Medicare beneficiaries can simultaneously receive:

• ESRD PPS services through their ESRD facility (including home dialysis services)
• Home health services that are unrelated to dialysis

For agency leadership, this means services must be evaluated carefully when a patient has ESRD. The presence of ESRD alone does not eliminate home health coverage. The determining factor is whether the specific service being furnished is directly related to dialysis care already reimbursed under the ESRD PPS.

Misunderstanding this distinction can lead to duplicate billing exposure or improper claim denials. Clear documentation identifying the purpose of the skilled service, and how it is unrelated to dialysis, is essential.

Are Prosthetic Devices Covered Under the Home Health Benefit?

Prosthetic devices are not covered under the Medicare home health benefit.

Medicare also provides important clarification as to what’s considered a prosthetic device. The following items are not considered prosthetic devices, for purposes of this exclusion, when furnished under a home health plan of care:

• Catheters
• Catheter supplies
• Ostomy bags
• Supplies related to ostomy care

When provided under a home health plan of care, these items are not subject to the prosthetic exclusion. Instead, they are bundled while the patient is under a home health plan of care.

This distinction directly affects how agencies categorize supplies and understand episode-based reimbursement.

Are Medical Social Services Provided Only to Family Members Covered?

Medicare does not cover medical social services that are provided solely to family members.

However, medical social services are covered under the home health benefit when they are part of the patient’s plan of care and directed toward the patient’s medical and psychosocial needs.

The distinction centers on who the service is for.

For example, If a social worker is…

• addressing the patient’s emotional adjustment to illness,
• helping coordinate community resources for the patient,
• or assisting with discharge planning that directly impacts the patient’s care,

…those services may be covered, even if family members are involved in the conversation.

But when services are directed exclusively toward the needs of family members, and not connected to covered services being furnished to the patient, Medicare does not consider them covered home health services.

Medicare uses the term “not incidental to covered medical social services being furnished to the patient.” In practical terms, this means:

• If the interaction with family members is part of delivering care to the patient, it may be covered.
• If the interaction is for the family’s benefit alone, without relation to the patient’s plan of care, it is excluded.

For agencies, documentation is critical. Notes should clearly reflect how the social service intervention ties back to the patient’s condition, treatment plan, or medical needs. When documentation shifts focus entirely to family counseling or support that is unrelated to the patient’s covered care, it moves outside the home health benefit.

Can Respiratory Therapy Be Billed as a Separate Home Health Visit?

Generally speaking, respiratory therapy cannot be billed as a separate home health visit. Medicare billing does not recognize respiratory therapy as a separate discipline.

But, there is an important distinction that often causes confusion.

During an active Medicare home health episode, respiratory therapy is not recognized as a separate billable discipline. A respiratory therapist’s visit cannot be billed as its own skilled home health visit. Those costs are treated as administrative and are not separately reimbursed.

However, Medicare also ensures to clarify something slightly different:

Respiratory-related skilled care is not automatically non-covered. What matters is who is providing the service and under what plan of care.

For example, if a licensed nurse or physical therapist furnishes respiratory-related skilled care (for example, respiratory assessment, airway management education, monitoring, or other skilled interventions within their scope of practice) under a home health plan of care, that visit may be billable. BUT, it is billed under the nurse’s or therapist’s recognized discipline, not as “respiratory therapy.”

So the real distinction is this:

• Respiratory therapy as a discipline is not separately billable under the home health benefit.
• Respiratory-related skilled care may still be covered when provided by a recognized home health discipline (such as nursing or physical therapy).

This is why agencies must be careful when structuring respiratory-focused service lines. Hiring a respiratory therapist does not create a new reimbursable visit category under the home health benefit.

Are Dietician or Nutritionist Visits Billable Under Home Health?

No, dietician or nutritionist visits are not separately billable visits under the Medicare home health benefit.

Similar to a few of the other specialties we’ve reviewed, if dieticians or nutritionists provide overall training or consultative advice to HHA staff and incidentally furnish dietetic or nutritional services to patients, those professional costs are allowable only as administrative costs.

Agencies using dietary professionals must account for those services within their operating expense structure rather than as revenue-generating skilled visits.

Can Remote Patient Monitoring or Telehealth Count as a Billable Home Health Visit?

Telecommunications technology may be ordered as part of a home health plan of care, but it cannot be reported as a visit without the provision of another skilled service.

Telecommunications technology can include:

• Remote patient monitoring (collection and digital transmission of physiologic data such as ECG, blood pressure, or glucose readings)

• Teletypewriter (TTY) technology

• Two-way audio-video telecommunications technology allowing real-time interaction

However:

• Telecommunications services cannot be reported as a visit on their own.
• Visits solely to supply, connect, or train the patient on the technology, without providing a skilled service, are not separately billable.
• Equipment, set-up, and service costs related to the technology are allowable only as administrative costs.

Home health agencies may include telecommunications technology costs as allowable operating expenses if the technology is used to aid the care planning process.

As agencies expand into remote monitoring and digital care models, this distinction becomes increasingly important.

Why Is Understanding Home Health Coverage Exclusions Essential for Your Agency?

Specific exclusions define the outer boundaries of the home health benefit.

When agencies step outside those boundaries, even unintentionally, the risks include:

• Claim denials
• Recoupments
• Targeted or additional audits
• Survey scrutiny

Home health reimbursement is bundled and structured. Administrative costs are built into the payment methodology. Attempting to separately bill excluded services contradicts Medicare policy.

Strong compliance programs do not focus only on what Medicare covers. They also rigorously define what Medicare does not.

If you would like to strengthen your broader understanding of Medicare compliance requirements, including how patient rights intersect with Conditions of Participation and survey risk, we encourage you to read our related article:

Clear boundaries protect your reimbursement. Clear documentation protects your certification.

*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.