Medicare Home Health Plan of Care: The 60-Day Certification That Controls Everything

The home health agency told you they're "updating the plan of care" and your parent might lose some therapy visits. You have no idea what this document is, who controls it, or whether you can push back.

The plan of care — often recorded on the CMS-485 or an electronic equivalent — is the document that governs the services in your parent's Medicare home health benefit. It dictates which services are provided, how often, and for how long. Understanding this document gives you real leverage over the care your parent actually receives.

What the Plan of Care Contains

The agency prepares the plan of care, often using the CMS-485 or an electronic equivalent, and the responsible physician or allowed practitioner reviews and signs it. It covers:

• Diagnoses — both the primary condition driving the home health need and all relevant comorbidities
• Types of services ordered — skilled nursing, physical therapy, occupational therapy, speech-language pathology, home health aide, medical social services
• Frequency and duration — how many visits per week for each discipline, and for how many weeks
• Specific treatment goals — what each discipline is trying to achieve or maintain
• Medications — the complete medication list, including dosages
• Functional limitations and activities permitted — what your parent can and can't do safely
• Safety measures — fall precautions, infection control, emergency protocols

The plan of care isn't just paperwork. Medicare requires covered services to be included in it. If physical therapy visits aren't in the plan of care, they generally aren't covered — even if your parent clearly needs them.

The 60-Day Certification Period

Medicare home health operates in 60-day certification periods. For initial certification and ongoing care, track:

1. A face-to-face encounter for certification with the certifying physician (or an allowed non-physician practitioner) within 90 days before the start of home health care or within 30 days after care begins, documenting that your parent meets the homebound criteria and needs skilled services
2. A plan of care — the plan must be established and signed by the responsible physician or allowed practitioner, and updated as your parent's condition or needs require
3. Recertification — the responsible physician or allowed practitioner must review and re-sign the plan at least once every 60 days for care to continue

There's no hard limit on how many 60-day periods a beneficiary can receive. Your parent can stay on home health for months or years as long as each recertification demonstrates continued eligibility — homebound status, a skilled care need, and medical necessity.

The catch is that each recertification is a decision point. The agency evaluates whether your parent still qualifies, and the physician reviews whether to continue, modify, or end services. This is where care often gets cut — not because the need disappeared, but because documentation didn't adequately support continuation.

How Care Gets Cut at Recertification

Three common patterns:

Frequency reductions. Physical therapy drops from three visits per week to one. The agency's clinical team decided your parent is "progressing" and needs less intensive treatment. Sometimes this is appropriate. Sometimes it's the agency managing its caseload under financial pressure from CMS's prospective payment system, which generally pays a case-mix-adjusted amount per 30-day period rather than a per-visit rate.

Discipline discharge. A therapy discipline gets dropped entirely. The therapist documents that goals have been met, even when the real picture is that your parent is maintaining function — not recovering — and still needs skilled maintenance therapy under the Jimmo standard.

Full discharge. The agency determines your parent no longer meets homebound criteria or no longer needs skilled services. If you disagree, this triggers the NOMNC process and your right to a fast appeal through the BFCC-QIO.

What Caregivers Can Do

You're not just a bystander in the plan of care process. Here's where you have actual influence:

Attend the SOC visit. The initial Start of Care assessment, conducted by an RN (or appropriate therapist) within 48 hours of referral, within 48 hours of your parent's return home, or on the physician-ordered SOC date, sets the baseline for everything. Be present. Describe your parent's worst days, not their best. If your parent tends to rally in front of clinicians (common with dementia), explain what the other 23 hours look like.

Review the CMS-485 before each recertification. You have the right to see the plan of care. Ask the agency for a copy. Read through the frequency and duration for each discipline. If something looks too low — two PT visits per week when your parent fell twice last month — raise it with the supervising nurse and the physician before the plan is finalized and signed.

Document declines between visits. Keep a simple log of falls, pain episodes, confusion events, missed medications, or functional losses that happen when clinicians aren't there. This documentation can support the case for maintaining or increasing visit frequency at recertification. Without it, the clinical record only reflects what therapists observe during their scheduled visits — which may not capture the full picture.

Invoke the Jimmo standard. If the agency says your parent has "plateaued" and is being discharged from therapy, remind them that under Jimmo v. Sebelius, Medicare covers skilled services to maintain function or prevent decline — not only services aimed at improvement. The clinical question isn't whether your parent is getting better. It's whether the maintenance program requires the specialized skills of a licensed therapist to be performed safely.

The OASIS Assessment and Its Timing

Alongside the plan of care, the agency completes a comprehensive OASIS assessment (Outcome and Assessment Information Set) within five calendar days of the Start of Care. This standardized clinical assessment contributes to determining the agency's Medicare payment through the Patient-Driven Groupings Model.

The OASIS matters to you because it captures your parent's functional status — mobility, self-care ability, cognitive function — and that baseline drives both the payment the agency receives and the clinical justification for services. An OASIS that understates your parent's limitations can lead to a lower payment group, which creates financial pressure on the agency to provide fewer visits.

Again: be present for the assessment. Ensure the clinician captures your parent's actual functional limitations, not a sanitized version.

Our Medicare Home Health and Skilled Nursing Benefit guide includes a complete plan-of-care review checklist, documentation templates for tracking symptoms between visits, and a Jimmo citation letter you can hand directly to the agency if they attempt to discharge your parent based on a plateau. The 60-day certification window is where most home health care quietly erodes — knowing how to engage with the process is the difference between getting the full benefit and watching it get cut incrementally.

See more United States guides →