Home Health Highlight: People Can Leave Home and Still Receive Medicare-Covered Home Care

The Center for Medicare Advocacy hears from Medicare beneficiaries throughout the country who are living with serious illnesses and injuries without the home care they need - and that should be covered by Medicare. There are many reasons for these access problems. Patients are told they don’t meet the qualifying criteria because they aren’t “homebound,” they don’t need skilled nursing or therapy, or they “only need maintenance care,” since they aren’t improving. Increasingly, they are told home health aides only provide bathing, for only a few days a week. None of this is accurate. All of it is harmful. 

Recently people have reported being denied access to Medicare home health care due to restrictive interpretations of the homebound standard, which must be met in order to qualify for coverage. To meet this standard,

• The individual must require assistance of another person or supportive device to leave home; or
• It is contraindicated for him/her to leave due to his or her medical, cognitive, or psychological condition; and
• There is a normal inability to leave home; and
• It requires a “considerable and taxing effort” to leave home.[1]

Unfortunately, too many Medicare providers and contractors misunderstand or distort this requirement.  For example, we received the following question from a woman who has ALS:

I cannot speak [due to my ALS] but I have a question. I was discharged a year ago from my home health agency because after the long winter of being home bound, I went to see a movie with my adult son. [The home health agency] said "You must admit, your case of ongoing care with our agency is unusual!" I didn’t fight their treatment. My question is this: living in Wisconsin with our harsh winters, making going out considerably more difficult, could I get the help I need for the winter months? My doctor has never hesitated to give me an order for needing skilled care and a plan of care. …

This kind of experience is untenable. The individual is clearly homebound, in fact, without help from another person, she would be bedbound...  She is not required to be a prisoner in her own home in order to meet the Medicare homebound requirement.

As the Centers for Medicare & Medicaid Services’ own policy manual states,

“… occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or 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.”[2]

The intent of the homebound standard is to provide Medicare-covered care at home for people who don’t ordinarily have the capacity to leave home to obtain the health care they need. We urge advocates, providers, and CMS to help ensure the standard is not restrictively interpreted to bar access to reasonable and necessary care for people who qualify under the law.

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[1] Medicare Benefit Policy Manual, Ch. 7, Sec. 30.1.1; See also, 42 USC §1395n
[2] Medicare Benefit Policy Manual, Ch. 7, Sec. 30.1.1.