Medicare Home Health Eligibility in Texas: A Plain-English Guide (2026)

Home health care is a critical service for Texans recovering from illness, surgery, or managing chronic conditions from the comfort of home. But navigating Medicare’s requirements can be confusing. In 2026, while the core eligibility rules remain consistent, new federal updates have introduced additional flexibility and administrative changes to ensure clarity and support for those who need it most.

Who Qualifies for Medicare Home Health Benefits?

To qualify for home health services under Medicare Part A or B in 2026, specific criteria must be met. These requirements ensure that care is provided to those who truly cannot access traditional outpatient services:

• Homebound Status: A physician or allowed practitioner must certify the patient as homebound. This means leaving the home requires a considerable and taxing effort or the assistance of another person or device.

• Skilled Need: The care must be medically necessary and intermittent. This includes skilled nursing or therapy services rather than full-time or long-term custodial care.

• Certified Agency: Services must be delivered by a Medicare-certified home health agency.

• Face-to-Face Encounter: The patient must have an in-person or allowed telehealth visit related to the primary reason for home health care. This encounter must occur within 90 days before or 30 days after the start of care.

In 2026, Medicare finalized a change to the face-to-face regulation. This update allows a broader range of physicians—not just the certifying practitioner or the acute care physician—to perform the encounter, provided they are the most knowledgeable about the patient's current clinical condition.

What Services Are Covered?

Medicare typically covers a comprehensive range of services when provided by a certified agency:

• Skilled Nursing: Including wound care, injections, and patient education.

• Therapy Services: Physical, occupational, and speech-language pathology.

• Medical Social Work: Support for social and emotional factors related to the illness.

• Home Health Aides: Part-time assistance with personal care, provided the patient is also receiving skilled care.

• Medical Supplies: Specific items required for home-based treatment.

It is important to note that Medicare does not cover 24-hour care at home, meal delivery, or "homemaker services" (like shopping or cleaning) if that is the only care required.

The Role of the Plan of Care

Every Medicare-approved home health case is driven by a detailed "Plan of Care." This document is developed collaboratively by the physician and the home health agency. It specifies the goals of treatment, the types of professionals who will visit, and the frequency of those visits. For 2026, Medicare has recalibrated case-mix weights to better reward the accurate coding of high-acuity patients, ensuring those with the most complex needs receive appropriate resources.

Common Reasons for Denial of Coverage

Even if a patient appears eligible, Medicare claims can be denied if certain administrative hurdles are missed. Common pitfalls include:

• Insufficient Documentation: Failing to clearly document the "taxing effort" required for the patient to leave the home.

• Missing Certifications: Lack of a signed certification or plan of care from an allowed practitioner.

• Timing Issues: Face-to-face encounters occurring outside the 90-day/30-day window.

• Lack of Skilled Need: If the care is deemed primarily "custodial" rather than requiring a licensed professional.

How Recertification Works

Medicare home health benefits are provided in 60-day "episodes." To continue care beyond the initial period, a patient must be recertified. This process involves a review by the physician and the agency to verify that the patient remains homebound and still requires skilled, intermittent care. Under the 2026 final rule, providers are encouraged to perform comprehensive assessments every 60 days to maintain compliance with updated payment adjustment (LUPA) thresholds.

Cost to Patients

For those with Original Medicare (Part A and Part B), home health services are generally provided at $0 out-of-pocket cost. However, there is a 20% coinsurance for Durable Medical Equipment (DME), such as walkers or wheelchairs, ordered as part of the care.

For 2026, the standard Medicare Part B monthly premium is $202.90, and the annual deductible is $283. While these costs don't apply directly to the home health visits themselves, they are part of maintaining the overall coverage that allows for the benefit.

Partnering With the Right Home Health Provider

Navigating the 2026 Medicare landscape requires a provider that stays current on shifting regulations and clinical standards. Whether you are recovering from surgery in Waco or managing a chronic condition in the surrounding areas, a certified agency handles the documentation and coordination with your physician, allowing you to focus on recovery.

If you’re unsure about eligibility or how to get started, contact Texas Quality Home Health today. Our team can walk you through the process and provide compassionate, Medicare-certified care you can trust.