Aging Options

New CMS policy change may impact individuals currently considered homebound

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Under Medicare Part A and Part B, certain medical services and supplies are covered if they are provided in hospitals, doctors’ offices or other health care settings.  For homebound individuals, those services may include medically necessary part-time or intermittent skilled nursing care and/or physical therapy, speech-language pathology service and/or services for people with a continuing need for occupational therapy.  Home health services may also include medical social services, part-time or intermittent home health aide services and medical supplies for use at home.  Those services however are only covered if the beneficiary meets the criteria for being homebound.

Here’s what homebound essentially means…a beneficiary is considered homebound if he or she is confined to the home when an illness or injury restricts the individual from leaving the home except with the aid of supportive devices, the assistance of another individual or the medical condition is such that leaving the home is medically contraindicated (inadvisable).  The condition of the individual does not require an inability to leave the home but rather a degree of effort that would be considered taxing.

This is the actual language of the policy.

An individual does not have to be bedridden to be considered 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.

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 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 health care provided outside rather than in the home.

Generally speaking, a patient will be considered to be homebound if they have a condition due to an illness or injury that restricts their ability to leave their 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.

That’s the law today up until Nov. 19.  On Nov. 19, CMS will change the definition to eliminate some of the generalities and vague phrases in the language of the old definition such as “generally speaking” and “should be such.”  The new policy requires that Medicare beneficiaries meet two sets of criteria before their home health agency even considers whether or not they are confined to the home.

Here are the criteria:

1st Criteria:

The individual 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


  • Have a condition such that leaving his or her home is medically contraindicated (should be avoided).

2 nd Criteria: Then, if one of those criteria is met, the individual must meet two additional requirements.

  • There must exist a normal inability to leave home;


  • Leaving home must require a considerable and taxing effort.

Some advocates for the elderly feel that the newer restrictive language is likely to harm individuals who don’t meet the criteria but are nevertheless still homebound.  For instance, a frail individual whose frailty is brought on by advanced age would not be considered homebound.  You can read one such argument here.  You can read the actual policy change from CMS here.

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