Medicare homebound definition gets broader

Home health patients could benefit from change

A recent change in the definition of patients who can receive Medicare home health benefits will allow homebound patients to leave the house to receive services in adult day care centers.

The change, passed by Congress in December as part of a Medicare/Medicaid bill, is unlikely to unleash a flood of new home health patients.

Most patients who would be affected had previously been forgoing care at the day centers rather than give up home health benefits. But supporters say the new definition will provide therapeutic benefits for home health patients, ease the burden on their caregivers, and give agencies greater flexibility in providing services.

"We believe that adult day services can really complement Medicare home health and provide a lot of relief for families," says Howard Bedlin, vice president for public policy and advocacy for the National Council on the Aging.

But he and others involved in the push to change the definition say they expect use of the new homebound rules to take place slowly, as the Health Care Financing Administration (HCFA) and fiscal intermediaries work out what exactly will be allowed.

Day care provides benefits

The definition, set out by HCFA in a program memorandum in February, states:

"The absence of an individual from home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a state, or accredited to furnish adult day-care services in the state, shall not disqualify an individual from being considered to be confined to his home."

William Dombi, Esq., vice president for law at the National Association for Home Care (NAHC), says he expects home care providers to use the new definition "cautiously," but that it is expected to lead to an expansion of services.

"The Congressional Budget Office says it’s going to cost money to do this change, so that translates to an expected expansion," Dombi says. "In the early stages, I would suspect that the impact would be limited because the home care providers are going to be cautiously approaching this expansion."

NAHC joined with the National Council on the Aging in working for the change. Also lobbying for the expanded definition was the Alzheimer’s Association, which is "very pleased" with the outcome, says Bonnie Hogue, director of federal and state policy.

Hogue says under the previous definition, patients with Alzheimer’s disease who received care at adult day centers were unable to qualify for Medicare home health services. Because home care is more expensive than adult day care, most patients chose to forego the day center visits in order to continue receiving home health care.

According to the Alzheimer’s Association, adult day care can help Alzheimer’s patients with exercise and movement activities and personal interaction, and can help reduce caregiver burden.

Hogue notes that patients with Alzheimer’s disease often have comorbid conditions, such as cancer or heart disease, which require hospitalization and subsequent home health care.

She says when some of those patients have had to give up the adult day care, they began to decline more rapidly than they might have otherwise.

"For people with Alzheimer’s disease, that component of dementia treatment within adult day care can often be a very critical component of their care," she says. "We heard of cases where people who had left the hospital didn’t get back to adult day care and eventually ended up in a nursing home because of the decline."

Bedlin says he believes allowing home health patients to also receive services at adult day centers could result in patients being able to live at home longer.

Another benefit of the expanded definition could be more efficient delivery of services by home health agencies, Dombi says.

"We’re looking at it as an opportunity for both the patient and the home care provider to try to create some cost-effectiveness in delivery of services as well as convenience for the patient," he says.

For example, he says, diabetic patients could receive insulin injections at the day care center, or someone needing personal exercise assistance could receive it there. For some agencies, providing care directly at the centers would reduce costs.

However, Dombi says, those visits wouldn’t be counted by HCFA as qualifying skilled visits for coverage purposes. They couldn’t be counted when determining low-utilization payment adjustments and outlier payments.

Working out details

Dombi says NAHC representatives have been meeting with HCFA officials to determine the full scope of what will be allowed under the adult day care definition. Allowed activities would have to meet the therapeutic and psychosocial requirements in the definition.

"One question that’s come to us from Congress is, "Does psychosocial include going to a center to play bingo?" The answer is, it really depends on the patient," Dombi says. "In some cases, absolutely yes. Alzheimer’s patients will gain a lot from that kind of integrative activity with others. And many other homebound patients would as well."

Bedlin says he expects there will be concern among agencies over how the fiscal intermediaries would review claims from patients attending adult day care. As a result, claims using the new definition could start slowly.

"I do think it will take several months, but I expect by the end of this year, we’ll have some clarity, and home health agencies will be comfortable knowing that they can submit a claim for payment when a person is going to adult day services — and get it covered."

And the definition could get even looser, if various movements now under way pan out. Bedlin says a coalition of disability rights groups has asked for an even broader homebound definition and further legislation on the issue could be introduced this year.

Howard Bedlin, Vice President for Public Policy and Advocacy, National Council on the Aging, 409 Third St. S.W., Washington DC 20024. Phone: (202) 479-6685. Fax: (202) 479-0735. Web:

William Dombi, Esq., Vice President for Law, National Association for Home Care, 228 Seventh St. S.E., Washington, DC 20003. Phone: (202) 547-7424. Web:

Bonnie Hogue, Director of Federal and State Policy, Alzheimer’s Association, 1319 F St. N.W., Suite 710, Washington, DC 20004. Phone: (202) 393-7737. Fax: (202) 393-2109. E-mail: