New Homebound rule???

FUNRN · Jan 8, 2005

And then you get the ones that say. "You have to tell me exactly what time you are going to be here because I'm going to the movies afterwards, I was told I was allowed to go to church but since I am not a church goer, I go to the movie theater" :stone

alintanurse · Jan 8, 2005

I was just wondering if anyone had heard of a new Medicare ruling regarding homebound status of a home care patient.....
Someone stated the other day at my office that there was a new ruling that stated that homecare patients could drive to "secure medications and food". Has anyone else heard or seen this???
My concern is the fact that if this is true, how many patients who are not actually homebound will use this to take advantage of the situation......... say when a nurse tries to see them... they are not home..... stating "I had to go to the drug store or grocery store" when actually they were gone doing whatever they wanted.

I haven't heard of any changes, Medicare allows outings once a week for shopping,church etc.but that is not new. Patients generally tell on themselves I have found over the years (that they are not homebound) by telling you that they go out for lunch 3 times a week, I had one 93 yr. old tell me she drove herself to play bridge with her friends almost everyday, when that happens ----they are discharged !

Traveler · Jan 8, 2005

I did hear that this was going to be for a trial period in several states. I remember that my state (Tennessee) was not included. I don't remember which states were listed. At my previous employer we took Tenncare (Tennessee's Medicaid and state insurance for uninsurables, etc) Their hb policy is more lax. This made for a really fun time when I would drive up to an hour to the patient's house and they weren't home. I always tell the pt/cg to let the office know when they have a MD appt, etc. but some just never can seem to remember. We do have a few who want to be called before we come. I always try to avoid that. As we all know, in hh you can get tied up and your schedule thrown off pretty fast. Then when I don't show up at the appointed time, they are aggravated. It can be very very frustrating.

chris_at_lucas_RN, RN · Jan 8, 2005

I haven't heard of any changes, Medicare allows outings once a week for shopping,church etc.but that is not new. Patients generally tell on themselves I have found over the years (that they are not homebound) by telling you that they go out for lunch 3 times a week, I had one 93 yr. old tell me she drove herself to play bridge with her friends almost everyday, when that happens ----they are discharged !

Thank you. And we wonder why insurance rates are through the roof and Medicare/Medicaid is going bankrupt.

If people don't need home care, it is up to the provider who observes this to make sure it is documented and the clients' status changed.

If it works for personal hygiene, it oughta work for home care.

If they can do it themselves, it is better to let them do it themselves. Period. Otherwise we are fostering dependence.

alintanurse · Jan 8, 2005

Thank you. And we wonder why insurance rates are through the roof and Medicare/Medicaid is going bankrupt.
If people don't need home care, it is up to the provider who observes this to make sure it is documented and the clients' status changed.
If it works for personal hygiene, it oughta work for home care.
If they can do it themselves, it is better to let them do it themselves. Period. Otherwise we are fostering dependence.

Patients are contacted prior to admission to homecare and asked questions re: homebound status. The purpose is to determine whether they are truly "homebound". it is up to each pt. to be honest with their answers. We proceed to open the case based on their answers,sometimes upon admission it is discovered the pt. does not meet criteria-and they are discharged at that time(my understanding is the provider must "eat" that one and only visit),other times it may take a little longer. Each SNV the nurse again must ask questions re:homebound status to assure they meet criteria necessary to recieve continuing homecare. As you can see by my previous examples the pt. may not always be truthful, and they are immediately discharged when it is found they are not "homebound". In the agency I worked at,these pts. comprised a small percentage.

renerian, BSN, RN · Jan 9, 2005

Ahhhhhhhhh the gray zone of home health..

renerian

hoolahan, ASN, RN · Jan 9, 2005

This is the latest that I am/was aware of...

http://www.cms.gov/manuals/11_hha/HH00.asp

Home Health Agency Manual

Manual Transmittals through Transmittal Number 305, dated August 1, 2003, are included in this update. Two other sites may have more recent information. Program Transmittals and Program Memoranda may include documents that reflect current policies not yet incorporated into this manual.

Table of Contents

Chapter IGeneral Information About the Program

Chapter IICoverage of Home Health Services

Chapter IIIStart of Care Procedures

Chapter IVHome Health Billing Procedures

http://www.cms.gov/manuals/11_hha/hh200.asp#sect_204_1

204.1 (Cont.) COVERAGE OF SERVICES07-02

A.Patient Confined to The Home.--In order for a patient to be eligible to receive covered home health services under both Part A and Part B, the law requires that a physician certify in all cases that the patient is confined to his/her home. (See 240.l.) An individual does not have to be bedridden to be considered as confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. Absences attributable to the need to receive health care treatment include, but are not limited to, attendance at adult day centers to receive medical care, ongoing receipt of outpatient kidney dialysis, and the receipt of outpatient chemotherapy or radiation therapy. 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 a 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 an 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 be an absence of infrequent or short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block, a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home. The examples provided above are not all-inclusive and are meant to be illustrative of the kinds of infrequent or unique events a patient may attend.

Generally speaking, a patient will be considered to be homebound if he/she has a condition due to an illness or injury that restricts his/her ability to leave his/her place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if leaving home is medically contraindicated. Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists would be: (1) a patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk; (2) a patient who is blind or senile and requires the assistance of another person to leave his/her residence; (3) a patient who has lost the use of his/her upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave his/her residence; (4) a patient who has just returned from a hospital stay involving surgery suffering from resultant weakness and pain and, therefore, his/her actions may be restricted by his/her physician to certain specified and limited activities such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.; (5) a patient with arteriosclerotic heart disease of such severity that he/she must avoid all stress and physical activity; (6) a patient with a psychiatric problem if the illness is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe to leave home unattended, even if he/she has no physical limitations; and (7) a patient in the late stages of ALS or a neurodegenerative disabilities.

In determining whether the patient has the general inability to leave the home and leaves the home only infrequently or for periods of short duration, it is necessary (as is the case 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, with 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 the home.

The aged person who does not often travel from home because of feebleness and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless he/she meets one of the above conditions. A patient who requires skilled care must also be determined to be confined to the home in order for home health services to be covered.

Although a patient must be confined to the home to be eligible for covered home health services, some services cannot be provided at the patient's residence because equipment is required that cannot be made available there. If the services required by a patient involve the use of such equipment, the HHA may make arrangements or contract with a hospital, skilled nursing facility, or a rehabilitation center to provide these services on an outpatient basis. (See 200.2 and 206.5.) However, even in these situations, for the services to be covered as home health services, the patient must be considered confined to his/her home; and to receive such outpatient services a homebound patient will generally require the use of supportive devices, special transportation, or the assistance of another person to travel to the appropriate facility.

If a question is raised as to whether a patient is confined to the home, the HHA will be asked to furnish the intermediary with the information necessary to establish that the patient is homebound as defined above.

B.Patient's Place of Residence.--A patient's residence is wherever he/she makes his/her home. This may be his/her own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered a patient's home if the institution meets the requirements of 1861(e)(1) or 1819(a)(1) of the Act. Included in this group are hospitals and skilled nursing facilities, as well as most nursing facilities under Medicaid.

Thus, if a patient is in an institution or distinct part of an institution identified above, the patient is not entitled to have payment made for home health services under either Part A or Part B since these institutions may not be considered his/her residence. When a patient remains in a participating SNF following his/her discharge from active care, the facility may not be considered his/her residence for purposes of home health coverage.

A patient may have more than one home and the Medicare rules do not prohibit a patient from having one or more places of residence. A patient, under a Medicare home health plan of care, who resides in more than one place of residence during an episode of Medicare covered home health services will not disqualify the patient's homebound status for purposes of eligibility. For example, a person may reside in a principal home and also a second vacation home, mobile home or the home of a caretaker relative. The fact that the patient resides in more than one home and, as a result, must transit from one to the other, is not in itself, an indication that the patient is not homebound. The requirements of homebound must be met at each location (e.g., considerable taxing effort etc).

1.Assisted Living Facilities, Group Homes & Personal Care Homes.--An individual may be "confined to the home" for purposes of Medicare coverage of home health services if he or she resides in an institution that is not primarily engaged in providing to inpatients diagnostic and therapeutic services for medical diagnosis, treatment, care of disabled or sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or skilled nursing care or related services for patients who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, sick, or disabled persons. If it is determined that the assisted living facility (also called personal care homes, group homes, etc.) in which the individuals reside are not primarily engaged in providing the above services, then Medicare will cover reasonable and necessary home health care furnished to these individuals.

If it is determined that the services furnished by the home health agency are duplicative of services furnished by an assisted living facility (also called personal care homes, group homes, etc.) when provision of such care is required of the facility under State licensure requirements, claims for such services should be denied under 1862(a)(1)(A) of the Act. Section 1862(a)(1)(A) excludes services that are not necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member from Medicare coverage. Services to people who already have access to appropriate care from a willing caregiver would not be considered to be reasonable and necessary to the treatment of the individual's illness or injury.

From the Medicare perspective, individuals who reside in assisted living facilities may be eligible for coverage of Medicare home health services. A major consideration is the location of the individual within the assisted living facility in terms of the level and type of care that is provided.

Medicare coverage would not be an optional substitute for the services that a facility that is required to provide by law to its patients or where the services are included in the base contract of the facility. An individual's choice to reside in such a facility is also a choice to accept the services it holds itself out as offering to its patients.

2.Day Care Centers and Patient's Place of Residence.--The law does not permit an HHA to furnish a Medicare covered billable visit to a patient under a home health plan of care outside his or her home, except in those limited circumstances where the patient needs to use medical equipment that is too cumbersome to bring to the home. Section 507 of the Medicare, Medicaid and SCHIP Beneficiary Improvement and Protection Act (BIPA) of 2000 amended 1814(a)(2)© and 1835(a)(2)(A) of the Act governing home health eligibility. The new law did not amend 1861(m) of the Act governing coverage. Section 1861(m) of the Act stipulates that home health services provided to a patient be provided to the patient on a visiting basis in a place of residence used as the individual's home. A licensed/certified day care center does not meet the definition of a place of residence.

3.State Licensure/Certification of Day Care Facilities.--In order to meet the requirements of 507 of BIPA, an adult day care center must be either licensed or certified by the State or accredited by a private accrediting body. State licensure or certification as an adult day care facility must be based on State interpretations of its process. For example, we understand that several States do not license adult day care facilities as a whole, but do certify some entities as Medicaid certified centers for purposes of providing adult day care under the Medicaid home and community based waiver program. We believe that it is the responsibility of the State to determine the necessary criteria for "State certification" in such a situation. A State could determine that Medicaid certification is an acceptable standard and consider its Medicaid certified adult day care facilities to be "State certified". On the other hand, a State could determine Medicaid certification to be insufficient and require other conditions to be met before the adult day care facility is considered "State certified".

4.Determination of the Therapeutic, Medical or Psychosocial Treatment of the Patient at the Day Care Facility.--We do not believe it is the obligation of the HHA to determine whether the adult day care facility is providing psychosocial treatment, but only to assure that the adult day care center is licensed/certified by the State or accrediting body. We believe that the intent of the law, in extending the homebound exception status to attendance at such adult day care facilities, recognizes that they ordinarily furnish psychosocial services.

alintanurse · Jan 9, 2005

Great information,thanks! :nurse:

Home Health Columnist / Guide · Jan 10, 2005

cahaba (www.iamedicare.com) is our local intermediary and offered great advice in form of " hh reference guide"

if you don't know who your intermediary is, check here:

http://www.cms.hhs.gov/providers/enrollment/providers/hha.asp

home health medicare referance guide for providers:

http://www.iamedicare.com/provider/newsroom/refguide/refguide.htm

from coverage guidelines

http://www.iamedicare.com/provider/newsroom/refguide/hh_coverage.pdf

70 [color=#231f20]conditions the patient must meet (see page 23-27)

70.5 [color=#231f20]confined to the home

[color=#231f20]

medicare benefit policy manual [color=#231f20](cms pub. 100-2, ch.7 30.1)

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according to law, the physician must certify that the beneficiary is homebound. the beneficiary is considered homebound when there is a normal inability to leave home and, therefore, leaving home requires a considerable and taxing effort.

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 does not disqualify an individual from being considered to be confined to the home. in addition, any absence for the purpose of attending a religious service does not disqualify an individual from being considered to be confined to the home.

occasional absences from the home for non-medical reasons such as attendance at afamily reunion, funeral, graduation or other infrequent or unique events are acceptable when the absences are of short duration, and do not indicate the beneficiary has the ability to obtain healthcare services in a setting other than the home.

documentation in the medical record [color=#231f20]must clearly indicate [color=#231f20]that it is a considerable and taxing effort for the beneficiary to leave home. documentation such as "short of breath" and "poor endurance" is not sufficient. acceptable documentation would include "short of breath after ambulating 5 feet and needs to rest."

[color=#231f20]

according to cms pub. 100-2, a beneficiary would be considered homebound when a condition due to an illness or injury restricts the ability to leave home except with the aid of supportive devices, special transportation, and/or the assistance of another person. however, the mere fact that a beneficiary uses supportive devices, special transportation, and/or the assistance of another person to leave home does not automatically make the benefi[color=#231f20]ciary homebound. [color=#231f20]the beneficiary would also be considered homebound when leaving home is medically contraindicated.

[color=#231f20]

70.10 [color=#231f20]beneficiaries who are not homebound

[color=#231f20]the following criteria are considered when determining homebound status. to be considered homebound, both

[color=#231f20]criteria 1 and 2 have to be met.

[color=#231f20]criteria 1. [color=#231f20]the beneficiary's medical condition should restrict the ability to leave home. if, however, the [color=#231f20]beneficiary chooses to leave home, even though leaving home requires a considerable and taxing [color=#231f20]effort, the beneficiary would not be considered homebound.

[color=#231f20]criteria 2. [color=#231f20]if the beneficiary leaves home to receive medical treatment that cannot be provided in the home [color=#231f20](e.g., hemodialysis, chemotherapy, or other treatments that require special equipment not available [color=#231f20]in the home), then the beneficiary may still be considered homebound. if the beneficiary leaves [color=#231f20]home on an infrequent basis for a short period of time, or leaves home to attend a religious service [color=#231f20]or a unique event such as a funeral or graduation, and these absences do not indicate the [color=#231f20]beneficiary has the ability to obtain health care provided outside the home, then the beneficiary [color=#231f20]may still be considered homebound. in determining whether the beneficiary has the general [color=#231f20]inability to leave the home, look at the beneficiary's condition over a period of time rather than for [color=#231f20]short periods within the home health stay.

[color=#231f20]

[color=#231f20]key words:

normal inability to leave home

considerable and taxing effort

[color=#231f20]infrequent basis

[color=#231f20]short period of time

[color=#231f20]leaving home is medically contraindicated (eg post surgery, severly immunocompromised)

[color=#231f20]if they go out to shop routinely, weekly hairdresser, play cards, discharged on the spot---with an abn notice of course!

[color=#231f20]

[color=#231f20]------------------------------

[color=#231f20]there is a new medicare program that has slightly different rules, that's what you may have heard about:

[color=#231f20]

see: home health information resource for medicare

http://www.cms.hhs.gov/providers/hha/

medicare home health independence demonstration

http://www3.cms.hhs.gov/researchers/demos/homehealthindependence.asp beneficiaries eligible for this demonstration are those with:

a permanent, severe disability
a permanent need for help with 3 of 5 activities of daily living (adls)
a permanent need for skilled nursing care
a need daily attendant visits to monitor, treat or provide adl assistance permanent skilled nursing care
a need for technological or personal assistance to leave home

and who are not working outside the home. in addition, eligible beneficiaries must meet all current medicare home health eligibility requirements other than those related to absences from the home.

the purpose of the demonstration is to study the efficacy and cost to medicare of providing home health services to medicare beneficiaries with severe chronic conditions who otherwise would not be deemed homebound under the medicare program. under the demonstration, medicare beneficiaries who qualify for medicare home health benefits and meet the demonstration criteria can leave their homes more frequently and for longer periods without risking the loss of those benefits.

on june 3, 2004, secretary tommy thompson held a press conference to announce the states selected for the homebound demonstration. the states selected are massachusetts, missouri, and colorado. implementation of a campaign within these 3 states to inform home health agencies (hhas), other pertinent providers, interest groups and beneficiaries began in september and the demonstration was implemented on october 4, 2004.

------------

also:

medicare awards programs to improve care of beneficiaries with chronic illnesses

overview: the medicare modernization act of 2003 (mma) authorized development and testing of voluntary chronic care improvement programs (ccips) to improve the quality of care and quality of life for people living with multiple chronic illnesses. the programs will help participants adhere to their physicians' plans of care and obtain the medical care they need to reduce their health risks. chronic conditions are a leading cause of illness, disability, and death among medicare beneficiaries and account for a disproportionate share of health care expenditures. about 14 percent of medicare beneficiaries have congestive heart failure but they account for 43 percent of medicare spending. about 18 percent of medicare beneficiaries have diabetes, yet they account for 32 percent of medicare spending. by better managing and coordinating the care of these beneficiaries, the new medicare initiative will help reduce health risks, improve quality of life, and provide savings to the program and the beneficiaries. the programs will be overseen by the centers for medicare & medicaid services and operated by health care organizations chosen through a competitive selection process. the first program is expected to be operational in spring of 2005 with others to follow...

organizations and locations: phase i pilot programs will be operated by aetna health management in chicago; american healthways inc. in the district of columbia and maryland; cigna healthcare in georgia; health dialog services corporation in pennsylvania; humana, inc. in central florida; lifemasters supported selfcare, inc. in oklahoma; mckesson health solutions in mississippi; visiting nurse service of new york in partnership with united healthcare services, inc.-evercare in queens and brooklyn in new york city; and xlhealth in tennessee.

the areas to be served have high prevalence of diabetes and congestive heart failure among medicare beneficiaries. the areas represent a mix of rural and urban areas and include ethnically and culturally diverse populations.

hoolahan, ASN, RN · Jan 12, 2005

Very interesting Karen. I didn't know about this at all, perhaps because I am not in a participating state, or because I am very per diem now.

So, can I ask if this would be your interpretation of this rule? If say a person who has all of these (and does it have to be all of these, or 3 of 5, or anyone of these conditions?? Usually they go hand in hand I realize...)

a permanent, severe disabilityMS w contractures

a permanent need for help with 3 of 5 Activities of Daily Living (ADLs)Cannot transfer self, bath self at all, dress self

a permanent need for skilled nursing carefoley

a need daily attendant visits to monitor, treat or provide ADL assistance permanent HHA

skilled nursing care?? foley??, new wound?? What is the diff between the third bullet and this one??

a need for technological or personal assistance to leave homePCA drives pt's van to mall and pt uses motorized chair to help pt shop and get to hair appt once every two weeks, go to health food store and pharmacy once a week.

In other words, this lady is very "independent" and tries to get out for her mental health as much as possible. We had her open for a SN only for foley, because it does require a considerable and taxing effort, and though she wants to leave often, she really doesn't.

So, now if this rule were to go into effect, would Medicare pay for the aide those 3-5 days? Increase the number of HHA hours? Change the HHRG system? Since this is a chronic condition? Or, if they have Medicaid suplement, would it still be split billing? This lady requires am and pm PCA, and my agency does not provide her with an aide, she was told to utilize her Medicaid benefit for PCA because it was too confusing for our agency.

I am not saying what my agency does is right OR wrong, there are always gray areas. And if you ever met this woman, you would have no doubt that she is 90% homebound. People are so afraid of breaking that homebound rule, paranoid even.

For those who are familiar with this can you give a few examples of when you would have put this kind of thing into effect?

Home Health Columnist / Guide · Jan 12, 2005

The Medicare Home Health Independence Demonstration is a project being sponsored by CMS that allows qualifying Medicare beneficiaries who receive Medicare home health benefits in COLORADO,MASSACHUSETTS, and MISSOURI ...Since PA not part of demonstration project, only know about program from MC newsletter. Must be part of this project for expanded benefit.

I'm guessing payment is from seperate pot of money associated with the program. Different sites would have various ways to staff case, but suspect one needs to provide all or include subcontact for aide services which porgram manages and pays for.

More info here:

Section 702 -- Demonstration Project to Clarify the Definition of Homebound.

The Secretary is required to conduct a two-year demonstration project to test an expanded definition of the term "homebound" for certain severely and permanently disabled individuals receiving home health care. This demonstration is limited to three sites and 15,000 beneficiaries. The Secretary is required to evaluate whether the provision of services under the demonstration adversely affected the provision of home health services under the Medicare program and any change in expenditures directly attributable to these services.

See: Medicare Coordinated Care Demonstration

http://www3.cms.hhs.gov/researchers/demos/HHAPac10_8_04.pdf

Our agency passed on being part of this program as we are involved with two LIFE programs and Philadelphia Ofice of Aging Wavier program, all designed for nursing home eligible residents to be maintained at home so don't see how we could improve on services in our community. However, we are one of five agencies in PA participating in a Medication Safety and Compliance program just starting.

Will report back if I hear anything more.

P.S.: Re HHA care

Medicaid is the payer of last resort. If client open to Medicare you better have it well documented that you offered aide services from your agency, but patient is refusing, only wants Medicaid aide. You can't say it's too hard to coordinate care. Otherwise you will be looking at "failure to provide needed/ordered services" and out of compliance. Our state reviewer looked at this closely on last visit.