The Sentinel
www.smpresource.org
February 2014
CMS Changes Homebound Definition
By Mike Klug
SMP Resource Center Consultant
I
t will come as no surprise to most SMPs that a patient must be homebound, or “confined to the home” before
Medicare will pay for part-time or intermittent home health care services. It is also no surprise that billing
Medicare for home health care for patients who are not homebound is one of the prime examples of Medicare
fraud. The issue has been around awhile, and Medicare recently took steps to address it by revising its homebound
policy.
CMS’s new homebound policy eliminates vague terms like “generally speaking” that appeared in the old
definition in an effort “to ensure clear and specific requirements in the definition.” But most importantly, the new
definition moves familiar language from the old policy into two criteria that must be met for a patient to be
considered homebound. The rule, which took effect on November 19, 2013, says:
Criteria-One The patient must either:
--Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and
walkers; the use of special transportation; or the assistance of another person in order to leave their place of
residence,
OR
--Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional
requirements defined in Criteria-Two below.
Criteria-Two:
--There must exist a normal inability to leave home;
AND
--Leaving home must require a considerable and taxing effort.
The policy is found in Chapter 7 of the Medicare Benefit Policy Manual at section 30.1.1 .
continued
Background on the Policy Change
In a July 1997 audit of home health services in California, Illinois, New York, and Texas (four states with grants
that were the precursor to the SMP program of today), the Office of Inspector General (OIG) estimated that nearly
40 percent of the $6.7 billion in Medicare-approved payments to home health providers during a 15-month period
were inappropriate for one reason or another. The OIG identified several factors that contributed to the high
number of problematic claims and recommended that Medicare provide “additional guidance on the standards for
defining ‘considerable and taxing effort.’”
Then, in a report titled The Physician’s Role in Medicare Home Health 2001, the OIG found that physicians are
not clear on key Medicare rules in the home health context. A survey revealed that 38 percent of physicians who
responded were unclear on the Medicare criteria for homebound. The survey also found that a large difference
exists “between the percentage of physicians that believe Medicare expects them to ensure that home health
patients are homebound, and the number that believe they are able to do this (59 versus 26 percent).”
These recommendations and findings may have motivated CMS to revise the homebound definition. But CMS
did not refer to a specific OIG report when it said that its purpose in clarifying the “confined to the home” definition
was to “address the recommended changes of the OIG to the home health benefit policy manual” (see Federal
Register, November 4, 2011).
It remains to be seen how the rule change will affect the ability of physicians and home health providers to
appropriately discern who is truly homebound and the extent to which it prevents inappropriate payments. Some
patient advocacy organizations have raised concerns. The problem with the new rule, according to the Center for
Medicare Advocacy, is that some patients may be homebound even if they do not require assistance of some sort
to leave their residences.
The group cites the example of a patient whose severe chronic obstructive pulmonary disease (COPD) makes it
difficult for her to breathe while descending or climbing stairs. If she has no need of a supportive device like a cane
or walker, special transportation, or assistance of another person, she would be ineligible under the new rule
because she cannot meet Criteria-One (assuming that leaving home with COPD is not contraindicated). Under the
prior rule, which made the “normal inability to leave home” and “considerable and taxing effort” language the main
criteria in defining homebound, her labored breathing might have been enough on its own to establish that she is
“confined to the home.”
SMPs should be aware that explanations of the homebound requirement in some older CMS beneficiary
education materials may not be entirely consistent with the recent policy change. The Medicare and You 2014
handbook appears, however, to incorporate the change. 
This newsletter was made possible by grant number 90NP0001 from the U.S. Administration for Community Living (ACL), Administration on Aging (AoA), and
was prepared by the National Consumer Protection Technical Resource Center, more commonly known as The Senior Medicare Patrol (SMP) Resource Center.