CMS “Homebound” Clarification for Medicare Home Health Claims

On October 18, 2013, the Centers for Medicare and Medicaid Services (CMS) released a change request, which was intended to clarify the Medicare Benefit Policy Manual language of “confined to the home” for purposes of Medicare home health eligibility. Change Request 8444 aims to bring the manual language closer in line with the statutory definition of “confined to the home.”

The revised manual language essentially creates a two-prong test for determining whether a patient is homebound for purposes of the Medicare home health benefit.  The patient is considered “confined to the home” if:

1. Criteria-One:  The patient must either:

– Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; OR

– Have a condition such that leaving his or her home is medically contraindicated.

– If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.

2. Criteria-Two:

– There must exist a normal inability to leave home; AND

– Leaving home must require a considerable and taxing effort.

The revised manual language removes the somewhat vague lead-in phrase “generally speaking,” which at times was held up in Medicare home health audits and audit appeals as a justification that a beneficiary requiring the use of an assistive device or the assistance of another person did not satisfy the definition of homebound for Medicare home health purposes.  From a provider perspective, the revisions may assist providers combating Medicare audits on the issue of homebound status.  The clarification appears to creates a more objective, bright-line definition of “confined to the home” that providers, both certifying physicians and home health agencies, can apply prospectively when evaluating a patient set to receive home health services.

Notably, the revised homebound definition also shifts the language of Criteria Two from “should” to “must” – making it obligatory that there both be a normal inability to leave home and that leaving home require a considerable and taxing effort.  The Medicare beneficiary advocacy group known as the Center for Medicare Advocacy, Inc. has taken the position that this change effectively removes the flexibility built into the statutory definition and will result in Medicare beneficiaries losing coverage of home health services on the issue of homebound.

The clarification to the Medicare Benefit Policy Manual language is scheduled to take effect on November 19, 2013.

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