Stroke Survivor Blog

Today at 2:30 Steve sees the doctor for an evaluation which will determine the plan for the rest of his care. If he is declared “homebound”, he will be eligible for home health care which would greatly help me.

The social worker at the nursing home said Steve is not considered homebound because I have taken him home after church. However, in a care conference with the nursing home staff about a month ago, they told me I could do that without compromising Medicare benefits. They even said it would be therapeutic for him to spend some time at home.

Now this “not homebound” determination disqualifies him of home health care. But after checking with the Medicare code (see below), it is the doctor who makes that call, not the nursing home. So PLEASE PRAY that we find favor with the doctor today and that he will rule justly.

This is so important because home health care will greatly relieve me of the many duties in Steve’s daily care.

Thanks so much.

Love, Kathy

MEDICARE HOME HEALTH PROVISION ENHANCES HOMEBOUND DEFINITION
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