By the VerifyDoc team
If you or a family member received Medicare-covered home health care, your agency bills in 30-day periods — and any charge for services delivered outside that approved period, without proper advance notice, may be one you're not legally required to pay.
This post explains how Medicare's home health billing episode works under the Patient-Driven Groupings Model (PDGM), which services fall inside the covered period, what can legally be billed outside it, and what the rules say about when an agency must warn you before charging you out of pocket. We walk through a labeled illustrative scenario at each step so you can apply the same logic to your own bill.
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Check my bill — free preview →How the 30-Day Home Health Period Works in 2026
Since January 1, 2020, Medicare's home health payment system has used the 30-day period of care as its fundamental billing unit. Starting in CY 2020, the Secretary was required by section 1895(b)(2)(B) of the Social Security Act to change the unit of payment under the Home Health Prospective Payment System from a 60-day episode of care to a 30-day period of care. That shift is still in effect for 2026, and it defines everything about what your agency can and cannot charge you.
The 30-day period of care is the unit of payment under the HH PPS. The period of care payment is specific to one individual homebound beneficiary. It pays all Medicare-covered home care that is reasonable and necessary for the patient's care, including routine and nonroutine supplies used by that beneficiary during the period of care. In plain terms: the agency collects one bundled payment for the 30-day block, and cannot invoice you separately for covered visits or supplies that fall within that block.
The PDGM case-mix methodology bases 30-day period payment rates on the patient's clinical characteristics and resource needs, and assigns each 30-day period to one of 432 case-mix groups called home health resource groups. Your specific group — determined by diagnosis, referral source, and functional impairment level — sets the payment amount the agency receives. You don't get to see that calculation on your bill, which is exactly why understanding the rules matters when you're reviewing charges.
For CY 2026, this final rule sets forth routine updates to the Medicare home health payment rates and recalibrates the case-mix weights, functional impairment levels, comorbidity subgroups, and LUPA thresholds. CMS estimates a $220 million decrease in aggregate Medicare payments to home health agencies for CY 2026, with these regulations effective January 1, 2026.
What Must Be on Your Plan of Care — and Why It Matters for Your Bill
Every covered service must appear on a physician-authorized plan of care (POC). An individualized plan of care must be established and periodically reviewed by the certifying physician or allowed practitioner. For HHA services to be covered, the individualized plan of care must specify the services necessary to meet the patient-specific needs identified in the comprehensive assessment.
To qualify for coverage in the first place, you must meet specific legal eligibility requirements under 42 CFR § 409.42. To qualify for Medicare coverage of home health services, a beneficiary must be confined to the home or in an institution that is not a hospital, SNF, or nursing facility, and must be under the care of a physician or allowed practitioner who establishes the plan of care. Additionally, you must need skilled care — not simply custodial or personal care services like help with bathing.
The plan of care must also be renewed on a defined cycle. A physician or allowed practitioner who meets the certification and recertification requirements in 42 CFR 424.22 must sign and date the POC or any changes in the POC before submitting the claim for each 30-day period. The plan of care must be reviewed by the physician or allowed practitioner at least every 60 days, or more frequently when there is a discharge with goals met and the patient returns to home health care within 60 days. Any service delivered without a valid, signed POC sits on shaky ground — and if it hits your bill, you have grounds to dispute it.
HHS OIG audits have consistently found that billing for services not ordered in the plan of care is a recurring error pattern. In one recent OIG audit, multiple skilled visits were billed that were not ordered in the plan of care. That type of error — a visit that happened but wasn't authorized by the POC — can generate a charge that shouldn't appear on your statement at all. For more on how hospitals and agencies pad bills with unauthorized services, see our post on phantom charges on your hospital bill.
Illustrative Scenario: What Falls Inside vs. Outside the Covered Period
Note: The following scenario is illustrative only. Patient names and details are fictional. The billing rules applied are based on actual federal regulations.
Suppose a Medicare beneficiary — call her Maria — is discharged from the hospital after a hip replacement on September 1, 2026. Her home health agency opens a 30-day period of care starting that day, running through September 30. Her plan of care authorizes skilled nursing visits three times per week and physical therapy visits twice per week.
On September 22, a home health aide provides personal care assistance (bathing, grooming). Because Maria is also getting skilled nursing and therapy, Medicare covers part-time aide care like this, and she pays nothing for covered home health services. Home health agencies must give a patient an ABN before providing any items or services that Medicare may not pay for, including care that is only non-skilled personal care, like help with bathing or dressing. That notice is for people whose only care is personal care. Maria's aide visit is covered, so any charge to her for it is an error to dispute.
Now suppose Maria's physical therapy goals are met by September 25, and the therapist documents this in the record. The agency continues sending a PT for two more visits anyway, on September 27 and 29. When a patient has achieved all their physical therapy goals but insists on continuing visits, Medicare will likely not cover additional visits because the patient has already met their goals — and the agency must issue an ABN before providing the additional care. Without issuing the ABN, if Medicare retroactively denies the claim, the agency is responsible for the full cost. Maria should not see those visits billed to her without a prior ABN in her file.
Finally, suppose Maria's 30-day period ends September 30, and the agency opens a new period starting October 1. A skilled nursing visit occurs on October 2, which falls inside the new period and is covered — provided the new POC is signed and the recertification requirements are met. But if the agency bills a "bridge" skilled nursing visit that occurred on October 1 under the September period that has already closed, that charge doesn't belong in the old period's claim.
The Low-Utilization Payment Adjustment (LUPA): When Bundled Payment Breaks Down
There's an important exception to the bundled payment rule. LUPA thresholds determine whether a 30-day home health period is paid as a full episode or on a per-visit basis, depending on whether the required visit count is met. If the number of visits during a 30-day period falls below the LUPA threshold for your specific case-mix group, the agency receives individual per-visit payments instead of the lump-sum amount.
In the CY 2026 final rule, CMS updated the LUPA thresholds using CY 2024 claims data, consistent with the agency's annual recalibration policy. CMS reports that visit patterns in 2024 were largely unchanged from 2023, with 18 case-mix groups experiencing a one-visit decline in their LUPA threshold. Why does this matter to patients? HHS OIG has documented a pattern of agencies adding just enough visits to cross the LUPA threshold and capture the much higher bundled payment. According to an HHS OIG report, CMS could have saved $192 million by targeting home health claims with visits slightly above the threshold that triggers a higher Medicare payment.
If your Medicare Summary Notice (MSN) or Explanation of Benefits shows a 30-day period with a very low visit count, and the agency has still billed as a full episode, that's worth a closer look. Our guide on how to read your Medicare Summary Notice vs. a commercial EOB can help you find that information on your documents.
Common Charge Types That Fall Outside the Covered Period
The table below summarizes the most common scenarios in which charges appear on home health bills but fall outside — or beyond — what the covered period actually includes. Use it as a checklist when reviewing your itemized statement. For a broader guide to interpreting line-item charges, see how to read every line of your itemized bill.
| Charge Type | Covered by 30-Day Period? | Required ABN Before Billing Patient? | Red Flag to Watch For |
|---|---|---|---|
| Skilled nursing visits on the plan of care | Yes — bundled into episode payment | N/A (should not appear on patient bill) | Any separate charge for these visits within the period |
| Physical/occupational/speech therapy on the plan of care | Yes — bundled | N/A | Visits billed after documented goals were met, without ABN |
| Personal care only, with no skilled care (bathing, grooming, dressing) | No — Medicare does not cover custodial-only care | Yes — required before service is delivered | Bill for aide visits given alongside skilled care, or with no ABN in your records |
| Visits after homebound status lapses | No — coverage requires homebound status per 42 CFR § 409.42 | Yes — required once agency knows you no longer qualify | Continued billing after documented recovery of mobility |
| Visits not on the signed plan of care | No | Yes | Visit dates that don't match authorized services in POC |
| Services during a hospitalization | No — home health cannot be billed during an inpatient stay | N/A (billing is improper regardless) | Home health dates that overlap with hospital admission dates |
| Visits in a new 30-day period billed to the closed prior period | No | N/A (billing error — wrong period) | Visit dates falling outside the period's start/end dates on the claim |
What to Do When You Spot a Suspect Charge
Start by requesting your itemized bill and asking the agency for a copy of your signed plan of care and any ABNs on file. These are documents you're entitled to. Cross-reference every visit date and service type against what your POC authorized. If a visit date falls outside your 30-day period window, check whether a new period was properly opened with a recertified POC.
If you find a charge for non-covered services but cannot locate a signed ABN, that's a strong basis for a formal dispute. Under 42 CFR § 484.50(c)(8), a patient has the right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes the service may be non-covered care. No prior written notice means the agency, not you, generally bears the financial risk of a Medicare denial.
If the agency's billing errors have escalated to a collections threat, the federal rules that govern that process are separate from the home health billing rules. Our post on when a hospital or agency can send a bill to collections covers your rights there. And if you're seeing line items on the claim that don't match the services you received — a different but related problem — the same dispute process applies as documented in our guide on how upcoding inflates your bill and how to spot it.
According to CMS compliance data, insufficient documentation accounted for 51.4% of improper payments for home health services during the 2024 reporting period, while medical necessity issues accounted for 33.7%. That means errors overwhelmingly come from the agency's side — not from patients receiving care they didn't need. When you see a charge you don't recognize, the odds favor it being an agency documentation or billing problem, not a legitimate patient debt.
About VerifyDoc: We help patients identify errors and overcharges on medical bills. We publish guides on hospital billing, the No Surprises Act, and disputing medical charges, updated as federal and state rules change.
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Check my bill — free preview →Frequently asked questions
Can a home health agency bill me separately for individual skilled nursing visits that occurred during my 30-day period?
No. Under Medicare's Home Health Prospective Payment System, the 30-day period of care is a bundled payment that covers all covered skilled nursing, therapy, and related supplies for that period (42 CFR § 484.205). The agency collects one lump-sum amount from Medicare and cannot separately charge you for individual visits within that window. If you see a line-item charge for a specific skilled visit during an open period, that's a billing error you can dispute by requesting your itemized statement and confirming the dates against your plan of care.
What is an Advance Beneficiary Notice (ABN) and when must a home health agency give me one?
An ABN is a written notice that a home health agency is required to give you before providing a service that Medicare may not cover. According to Medicare.gov, agencies must issue an ABN before delivering services that aren't considered medically reasonable and necessary, that are only non-skilled personal care, or when you no longer meet the homebound status requirement under 42 CFR § 409.42. The ABN must estimate the cost and give you the choice of whether to proceed and pay out of pocket. If you received a service and were never given an ABN beforehand, the agency generally cannot bill you if Medicare denies the claim.
My home health agency billed for visits on dates when I was hospitalized. Is that legal?
No. Home health services cannot be billed to Medicare during an inpatient hospital stay — those dates of overlap are a recognized billing error pattern documented by HHS OIG auditors. You should pull your hospital admission and discharge dates and compare them to any home health claim dates. If they overlap, the home health claim for those dates is improper. You can report the discrepancy to your Medicare Administrative Contractor (MAC) and request a correction to your Medicare Summary Notice.
My plan of care expired and the agency kept sending nurses before the physician signed a new one. Am I responsible for those visits?
Coverage of home health services depends on a plan of care that the physician or allowed practitioner signs and dates before the agency submits the claim for each 30-day period, under 42 CFR § 409.43 and 42 CFR § 424.22. Care can continue on verbal orders, but those orders must be written down and countersigned before the agency bills, and visits with no valid order may not meet Medicare coverage requirements. If those visits appear on your bill, request copies of both POCs and any verbal orders with their dates, and dispute any visit that no order covers.