homebound study archived

LONG AWAITED HOMEBOUND STUDY ISSUED
SECRETARY RECOMMENDS KEEPING CURRENT STANDARD

By Vicki Gottlich
Staff Attorney
National Senior Citizens Law Center

In order to receive Medicare home health benefits, a beneficiary must need skilled nursing care on an part-time or intermittent basis, physical therapy, speech-language pathology, or continued occupational therapy. The services must be ordered by a physician and provided by a licensed home health agency pursuant to a plan of care ordered and reviewed periodically by the physician. Finally, the beneficiary must be confined to the home. In adding the last eligibility criterion, Congress did not intend to prohibit or prevent a beneficiary from ever leaving home, nor did it intend to require that the beneficiary be totally bedridden.

The Health Care Financing Administration (HCFA) has tried over the years to restrict home health benefits by narrowly construing the "homebound" criterion. For example, HCFA issued proposed rules in 1991 that would have defined "confined to the home" in terms of hours away from the home. Rather than adopt a quantitative definition, as recommended in the President's budget proposal in 1997, Congress in the Balanced Budget Act of 1997 (BBA)ordered HCFA to conduct a study of the homebound criterion and file a report by October 1998. HCFA filed its report to Congress, six months late, on April 29,1999, and recommended that the definition of the homebound criterion for Medicare home health eligibility not be changed. This memo summarizes the findings in the report and raises issues for advocates to consider.

HCFA's report begins with background information about the Medicare home health benefit. It summarizes the legislative history, administrative proposals and enactments, and Duggan v. Bowen, 691 F.Supp. 1487 (D.D.C. 1988), a case often cited by HCFA as the catalyst for the growth in use of the home health benefit. General Accounting Office (GAO) and Inspector General reports on problems with the current determinations of "homebound" are cited and summarized. HCFA also acknowledges that environmental and other factors, such as whether the beneficiary lives in a building without an elevator, may influence a homebound determination, and that beneficiaries who make a greater effort to achieve independence are less likely to receive Medicare home health services. These factors, the report concludes, make it difficult to implement the homebound requirement.

The real substance of the report is in the delineation and discussion of four options for the homebound criterion that HCFA considered. In considering each option, HCFA assumed that the other Medicare home health eligibility criteria would be retained. It also assumed that Medicare intermediaries would administer the homebound criterion in the context of the current claims process. HCFA states that the assessment of whether a patient is homebound is part of the Outcome and Assessment Information Set (OASIS) data that will be collected, and that the OASIS data may help HCFA to better define the homebound criterion in the future.

The four options that were considered by HCFA are:

Retain the homebound definition. HCFA states, "Though the definition remains a challenge to enforce uniformly, leaving it unchanged avoids the potential unintended consequences that may occur by adopting specific criteria." The report indicates that HCFA is working with the regional home health intermediaries to develop revised policies that it will send to providers, physicians, and beneficiaries for comment.

Use a "bright line" test such as standards for number and duration of absences from the home. This is the approach taken by HCFA in its 1991 proposed regulations and by the President's budget recommendations in 1997. HCFA in this report finally acknowledges that previous objections to this approach are valid. The bright line could become a ceiling, with beneficiaries remaining at home simply for the purpose of receiving benefits.

Use a functional capacity-based standard. While HCFA rejected the feasibility of adopting this approach at this time, it noted that OASIS data that will be available in the future may make the approach more useable. Currently, if eligibility was based on dependency in a specified number of activities of daily living (ADLs), many people who don't meet the current homebound definition would be eligible for benefits while current home health recipients with medical problems that do not interfere with ADLs would be excluded. Another variation on this approach, using ADL measures that identify people with mobility impairments as objective indicators, would not capture other physical, cognitive, and mental conditions that confine beneficiaries to the home. Cost factors may also be a consideration in determining the utility of this option.

Expand the homebound concept to include specific groups or categories of beneficiaries. This option addresses the argument that beneficiaries who leave the home to attend adult day care should be considered homebound. HCFA contends that this option would increase costs without addressing the problems caused by implementing the homebound definition.

ISSUES FOR ADVOCATES
HCFA's recommendation not to change the current definition of the homebound criterion for Medicare home health eligibility is generally a good result for beneficiaries, considering some of the alternatives HCFA has proposed in the past. However, some of the comments in the report raise issues of concern for advocates.

Use of assistive devices to leave the home: As stated earlier, HCFA rejected the use of ADL measures that identify people with mobility impairments as objective indicators of homebound status. In addition to the reason for its conclusion noted above, HCFA also states that using mobility indicators would expand eligibility to individuals who, though unable to walk, leave the home with the use of mobility and other devices. According to HCFA, a beneficiary who would be homebound without adaptive equipment is not homebound if s/he uses such equipment or devices regularly to get out of the house.

Under the current homebound criteria, however, such beneficiaries should be considered eligible for home health services. An individual is homebound if s/he needs the assistance of another or of a supportive device to get out of the home, and if leaving home requires a considerable and taxing effort. A beneficiary who needs a hoyer lift to get out of bed and into an electric wheelchair, for example, meets this requirement and should be homebound even if s/he then is able to leave the home.

HCFA's interpretation creates a dilemma for beneficiaries. They must choose between getting the home care they need to be independent and the very independence they work hard to achieve. It also would appear to conflict with the Americans with Disabilities Act, which considers whether the individual meets the Act's definition of disability without the use of devises or technologies. Advocates should continue to appeal denials of Medicare home health benefits for individuals who are clearly homebound but for the assistive devices they utilize to ensure that these individuals get the assistance they need.

Adult day care: HCFA takes the position that consideration of adult day care programs as medical treatment is contrary to current law, a position with which many advocates do not agree. This is an important issue because a beneficiary who leaves the home to get medical treatment is still considered homebound.

Many individuals with cognitive impairments such as dementia attend adult day care programs for the psychological benefit they receive from the socialization and other services. While some advocates have successfully argued that the psycho-social benefits achieved from attending an adult day care program are medical treatment, HCFA rejects this interpretation as an expansion of the homebound definition. Even worse, HCFA attempts to restrict the eligibility of beneficiaries who attend adult day care programs for what HCFA defines as medical treatment. The report states:

[I]t is very unlikely that a genuinely homebound beneficiary would need to leave the home on a regular basis to seek necessary medical treatment from an adult day center. Because of the relative infrequency of this type of event, we would expect the individual cases to be unique and separately adjudicated by the intermediary. Additionally, a pattern of leaving to attend an adult day center, especially if the patient actually participates in the center's program, could raise questions about whether the individual has a normal ability to leave the home..... Even if specialized transportation is needed to take the beneficiary to thee day care center, if the beneficiary regularly uses the transportation, then the effort involved is very likely to be less than for regular trips.

Thus, advocates need to continue to fight for the right of individuals who attend adult day care programs for medical, psycho-social reasons to get home health benefits, despite these comments.

Implications of OASIS: The fact that HCFA recommends no change in the homebound definition now does not mean they will not recommend changes in the future. The report indicates several times that the OASIS data which plans will be required to collect and submit to HCFA may form the basis for determining a better definition of homebound status. When OASIS data collection is finally implemented, Advocates need to monitor it closely to determine its impact on the receipt of home health benefits by individual beneficiaries.

New policy initiatives: HCFA states that it is working with regional home health intermediaries to develop revised policies to implement the current homebound definition. It also states it will make these policies available to doctors, providers, and beneficiaries for their comments. These policy directives may contain changes that are adverse to our clients. Beneficiary groups, if given the opportunity to comment, will need to review any policy directives careful to ensure that they don't further restrict access to home health benefits.

CONCLUSION
For the time being, beneficiaries have won a small victory. HCFA has conceded that it will continue to utilize the current definition of the homebound criterion in determining eligibility for Medicare home health benefits. It has publicly acknowledged that its efforts to use a "bright line" test for determining homebound status based on length and duration of absences from the home is not a workable option. The report also indicates HCFA's unwillingness to expand the definition to consider the realities of beneficiaries who need home health care. HCFA still maintains that beneficiaries who attend adult day center programs are not homebound. The agency refuses to concede that beneficiaries who use assistive devices and who leave the home with considerable and taxing effort meet the statutory definition. Finally, the report indicates HCFA may still find ways to limit the home health benefit through development of revised policies to improve the administration of the homebound criteria and through analysis of OASIS data. As always, advocates need to pay close attention to these activities to ensure that Medicare beneficiaries are receiving home health benefits to the full extend defined by the statute.