Medical Review Topic of the Month – November 2007: Home Health Services and Homebound Status (Revised January 11, 2008)
This article was revised January 11, 2008 to provide further clarification concerning beneficiary absences from the home.
Beneficiary Confined to the Home
Eligibility for the Medicare home health benefit requires that a physician certify that the beneficiary is confined to the home. This does not mean that the beneficiary should be bed bound. There should exist a normal inability of the beneficiary to leave the home, and when leaving the home, a considerable and taxing effort is required.
The beneficiary may leave the home:
- When the absences are infrequent
- For periods of short duration, or
- When the beneficiary is to receive health care.
When the absence from the home is attributed to the need for health care treatment, this may include, but is not limited to the following:
- Visits to the physician’s office
- Visits to a wound care center for treatment
- Attendance at adult day care centers 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 a state
- Ongoing receipt of outpatient kidney dialysis, or
- The receipt of outpatient chemotherapy or radiation therapy.
Occasional absences from the home for non-medical purposes may include, but are not limited to:
- An occasional trip to the barber or beauty salon
- A walk around the block
- Attendance at a family reunion, funeral, graduation
- Attending a religious service, or
- Other infrequent or unique events
Absences from the home must be undertaken on an infrequent basis, of relatively short duration and require a considerable and taxing effort on behalf of the beneficiary.
Generally, a beneficiary will be considered to meet the qualifications of homebound when they have a medical condition due to an illness or injury that restricts their ability to leave their place of residence except with:
- The aid of supportive devices such as crutches, canes, wheelchairs, and walkers
- The use of special transportation
- The assistance of another person, or
- When leaving home is medically contraindicated
An elderly beneficiary who does not leave the home due to feebleness and insecurity would not be considered homebound for Medicare home health benefit purposes unless they meet the Medicare requirements for being confined to the home.
When some services cannot be provided at the beneficiary’s place of residence due to unavailability of special equipment, the home health agency may make arrangements with a hospital, skilled nursing facility (SNF), or a rehabilitation center to provide these services as outpatient services. The beneficiary must still meet the Medicare home health benefit requirements of being confined to the home, and documentation should include the condition of the patient upon return from the outing.
For example: Patient stated she goes to the wound care center once a week. She takes pain medication prior to going and upon return home. She states the trip is very stressful and requires her to go to bed and rest.
The Centers for Medicare & Medicaid Services (CMS) defines a beneficiary’s residence as wherever he/she makes their home. Examples include, but are not limited to:
- The beneficiary’s private dwelling
- An apartment
- A relative’s home
- A home for the aged
- A vacation home
- A caretaker’s home
- A personal care home
- An assisted living facility (ALF), or
- A group home
When a beneficiary resides in an ALF, personal care home, or group home, it must be established that these facilities are not primarily engaged in providing inpatient services. The Medicare home health benefit does not cover services provided in this situation. In addition, the services furnished by the home health agency must not be duplicative of those services that are included under the facility’s contract. If duplicative services are provided by a home health agency, those services will not be covered under the Medicare home health benefit. Hospitals, skilled nursing facilities and most nursing facilities under Medicaid do not meet the qualifications to be considered a beneficiary’s residence. When a beneficiary remains in a participating SNF following discharge from skilled care, the facility may not be considered a residence under the home health benefit.
When a beneficiary has more than one residence and/or resides in more than one place during an episode of care, and must be transported from one to the other, does not disqualify the beneficiary from utilizing the Medicare home health benefit as long as the homebound requirements are met. This means that leaving the home requires a considerable and taxing effort and generally the use of assistive devices and/or personal assistance.
The following examples of homebound situations are taken from the CMS Manual System, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30:
- A patient paralyzed from a stroke, confined to a wheelchair who requires the aid of crutches to walk;
- A patient who is blind or senile and requires the assistance of another person in leaving their place of residence;
- A patient who has lost the use of his/her upper extremities and is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their place of residence;
- A patient in the late stages of ALS or a neurodegenerative disability;
- A patient who has just returned from a hospital stay involving surgery and is suffering from resultant weakness and pain whose physician has restricted the patient’s actions to specified and limited activities such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.;
- A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity; and
- A patient with a psychiatric illness that is manifested in part by a refusal to leave home or that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.
Documentation of homebound status must be clear, concise and accurate. The ability of the beneficiary must be documented as well as the medical condition of the beneficiary when they return home. Examples of documentation may include, but are not limited to:
- Patient stated when she returned home she was very tired, short of breath, and had to lie down for about an hour.
- Patient stated upon returning home he had to take additional pain medication due to increased pain from walking. He rated his pain at a 6 on a pain scale of 1-10. It is normally at a 2.
- Patient stated he uses a walker in the home, but must use a wheelchair when he goes to the
doctor.
- Patient stated she occasionally goes to church with her daughter, but it tires her out so much she has to go to bed the rest of the day
- When determining homebound status, the home health agency must look at the beneficiary’s overall medical condition over a period of time within the home health stay. There should exist a normal inability of the beneficiary to leave the home, and when leaving the home, a considerable and taxing effort is required. The beneficiary may require the use of supportive devices, special transportation, and/or personal assistance. Generally, a beneficiary is considered homebound when their overall condition is such that they meet these requirements. For Medicare coverage purposes, documentation in the medical records must substantiate homebound status.
Reference:
CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30
To access this manual on the CMS Internet-only Manuals (IOMs) Web Page:
1. Go to http://www.cms.hhs.gov/Manuals/IOM/list.asp
2. Scroll down and select Pub 100-02 under Publication # heading
3. Select Chapter 7 and go to Section 30