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Report recommends no major changes in the current homebound definition
By MATTHEW HAY
HHBR Washington Correspondent
BALTIMORE Late last month, the Health Care Financing Administration (HCFA; Baltimore) sent Congress its long overdue report on the homebound eligibility criteria for Medicare home healthcare services. As expected, the report recommends no major changes in the current definition, which industry executives say makes the report a dead issue.
"The analysis carried out for this study did not yield new options that are superior to current law," HCFA concluded. But the agency added that "future developments in home health may hold some promise for improvements for making homebound determinations."
The report was required by the Balanced Budget Act of 1997 and asked HCFA to submit recommendations to Congress by October 1998 to clarify the eligibility criteria concerning the definition of homebound. The home care industry, in fact, requested the report as an alternative to subsequent administration proposals to establish specific criteria for determining homebound status.
HCFA reported that it examined a wide range of options, including the establishment of a bright-line test based on the number and duration of absences from the home and a standard based on an individual’s functional capacity. But the agency determined that there is a threshold matter that constrained policy options.
"If Medicare intermediaries are responsible for administering the homebound criteria, they will need to do so within the context of the current claims process" said HCFA. "If new criteria defining homebound are to be implemented, a wide range of reviews and edits must be made to the current process.
"Although the current definition may not be specific enough for universally consistent determinations by the (regional home health intermediaries), it does express an overall expectation that the benefit offered under Medicare is one aimed at individuals who cannot ordinarily leave the home," HCFA continued.
"If this expectation continues to be the view of Congress, the current definition creates a clear separation between those individuals who can ordinarily leave the home and those who cannot.
"This option has the advantage of sending a clear signal," HCFA added. "Though the definition remains a challenge to enforce uniformly, leaving it unchanged avoids the potential unintended consequences that may occur by adopting specific criteria."
HCFA added that a change may be in order once agency starts collecting "extensive information about the medical condition of patients" through the Outcome Assessment Information Set (OASIS).
"Once OASIS data are being routinely submitted, HCFA may be able to link the data with medical necessity criterion and analyze them to determine if they provide the basis for developing stronger and more objective measures of homebound status," the agency stated. However, the OASIS regulation is currently on hold pending agency review.
The National Association for Home Care (NAHC; Washington) criticized HCFA’s findings by failing to analyze the homebound issue "from an objective health policy position" instead of a "a budgetary and political" standpoint.
"With no modification in the homebound definition, individuals who, as a practical matter, cannot receive necessary healthcare services outside the home may still be excluded from coverage," said NAHC. "Without any bright-line test, home health agencies and their patients will remain confused as to the appropriate criteria."
NAHC currently has a lawsuit pending that challenges the current application of the homebound criteria as it relates to disabled individuals who cannot receive healthcare services outside the home until they receive home health services. That case, which NAHC argues "effectively creates an institutional care setting standard for home care," is pending cross motions for summary judgment in a federal district court. NAHC’s Bill Dombi told HHBR a decision is expected this week.