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Sunday, November 18, 2007
Medicare resources for definition of homebound status.

 

 

In your Nov. 5, 2007 issue you addressed home bound status and the author of the article stated "In an attempt to prompt this desired functional status, today's homebound patient is able to independently leave the home (yes, driving is acceptable) . . .as not homebound."
 
Well I don't know what regulations you are reading or whom you have spoken with at CMS but our surveyor just came through and said if they are driving AT ALL, they are NOT homebound and CMS will NOT cover home health services.  This has always been CMS's stance in regards to homebound status.  I contacted our local State Rep and and our PIO and they both confirmed this information as correct.  That is that if a patient is driving they are NOT homebound.
 
 
Thanks for taking the time to respond to our recent article. We wanted to investigate the points you have raised because your interpretation is not unusual in today’s homecare industry. As a result of your communication, we researched how we had arrived at our belief system regarding homebound status. Much to our surprise, we found that our version was not nearly as liberal as the actual Medicare definition. The following documents on the topic (please note these are from 2000 and 2002) are directly from a Medicare website. Feel free to distribute this information throughout your agency and even consider enlightening your fiscal intermediary and state surveyors on the contemporary philosophies of homebound status.
 
 
MEDICARE HOME HEALTH PROVISION
ENHANCES HOMEBOUND DEFINITION

Introduction
Sections 501-508 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended 42 U.S.C. '' 1395f(n), 1395(n), 1395fff(b), 1395(x)(v) to modify the Medicare home health benefit. (Public Law 106-554, 12/21/2000.) The provisions discussed below clarified the threshold “homebound” criteria, making clear that individuals who attend adult day care or religious services may also qualify for Medicare home health coverage. These changes became effective upon date of enactment, December 21, 2000.

 

Homebound Definition
The statutory language clarified and broadened the homebound eligibility criterion in two ways:

Absences attributable to the need to receive health care treatment, including regular absences to participate in therapeutic, psychosocial, or medical treatment at a licensed or accredited adult day-care program, will not disqualify a beneficiary from being considered homebound. For many years beneficiaries who attended adult day-care programs were routinely denied home health services.

Absences for the purpose of attending a religious service are deemed to be absences of infrequent or short duration. (Generally a beneficiary whose absences from the home are not considered infrequent or of short duration will not be considered to be homebound.)

The Current Homebound Definition in the Medicare Act reads as follows (language added by BIPA is in italics):
An individual shall be considered to be “confined to his home” if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive devise (such as crutches, a cane, a wheelchair or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home, that leaving home requires a considerable and taxing effort by the individual, any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be “confined to his home”. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to an absence of infrequent or short duration. [42 U.S.C. '1395n(a)(2)(F)]
 

US HEALTH AND HUMAN SERVICES SECRETARY ISSUES CLARIFICATION TO MEDICARE HOMEBOUND DEFINITION:
DIRECTS PROVIDERS TO BE MORE FLEXIBLE IN ORDER TO PROTECT BENEFICIARIES

On July 26, 2002 Tommy Thompson, Secretary of the United States Department of Health and Human Services, issued a press release and changes to the Medicare Home Health Agency Manual. The Secretary directed Medicare providers and contractors to be more flexible in applying the Medicare homebound criteria. This is important to elders and disabled Medicare beneficiaries as an individual must be confined to home (homebound) in order to qualify for Medicare home health coverage.

In particular, the Medicare Home Health Agency Manual, §§204.1-204.2, was amended to include additional, not all inclusive examples of situations in which the homebound criteria is met. (Family reunion, funeral, graduation.) More importantly, the following general language was added to the Manual:

It is necessary (as in determining whether skilled nursing services are intermittent) to look at the patient's condition over a period of time rather than for short periods within the home health stay. For example, a patient may leave the home (under the conditions described above, e.g. severe and taxing effort, with the assistance of others) more frequently during a short period when, for example, the presence of visiting relatives provides a unique opportunity for such absences, than is normally the case. So long as the patient's overall condition and experience is such that he or she meets these qualifications, he or she should be considered confined to home. (Emphasis added)

Although the new examples may be helpful in particular cases, this new direction from CMS to look at a long view, not a limited snapshot, to determine whether the beneficiary meets the coverage standard (for intermittent nursing as well as homebound) is most significant. Advocates have long maintained that cases should be reviewed, and qualification for coverage judged, by looking at services provided over the course of a year, not in fragmented 1-2 month segments.
While the new language does not really add to the already existing homebound criteria, it does provide important direction that the criteria are to be applied flexibly and with a broad view of the patents’ condition. Advocates should use the Secretary’s press release language and the manual language to help make these points when clients are erroneously denied coverage.
 

A copy of the Secretary’s press release and Manual revisions are available from the Center for Medicare Advocacy (860)456-7790 and on the Centers for Medicare & Medicaid Services web site at: http://www.cms.gov/pubforms/transmit/R302HHA.pdf

 
Teri N. Thompson and Arnie Cisneros are physical therapists with more than 35 years of combined home care experience. They are co-owners of Home Health Strategic Management of East Lansing, MI; providing clinical service management and home care consulting expertise. They also lecture and provide OASIS, HHRG, OBQI and P4P training at seminars nationally.