Referring to Home Health

How to refer to home health and the benefits for both patient and referring physician.

Improvement Standard Update: New Medicare Policy Manuals Released

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Regulations under Affordable Care Act has led to 130,000 fewer 30-day Medicare hospital readmissions in the first 8 months of 2013.

Regulations under Affordable Care Act has led to 130,000 fewer 30-day Medicare hospital readmissions in the first 8 months of 2013.

CMS has revised its Medicare policy manuals to ensure coverage for skilled maintenance care, reflecting the “Jimmo vs. Sebelius” settlement, reports the Center for Medicare Advocacy.

The Jimmo settlement ends a longstanding practice denying Medicare coverage to people who had “plateaued,” or were “chronic,” or “stable,” or “not likely to improve.” The Manual revisions, which clarify that improvement is not required to obtain Medicare coverage, were published by the Centers for Medicare & Medicaid Services (CMS) on Friday December 6, 2013. They pertain to care in Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), Home Health care (HH), and Outpatient Therapies (OPT).

As CMS states in the transmittal announcing the Jimmo Manual revisions:

“No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an ‘Improvement Standard’ rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly.”

Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care – not on the ability of an individual to improve. For IRF patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning.

“As with components of all settlement agreements, the Jimmo revisions are not perfect,” says Judith Stein, Executive Director of the Center for Medicare Advocacy. “But they do make it absolutely clear that skilled care is covered by Medicare for therapy and nursing to maintain a patient’s condition or slow decline – not just for improvement.”

Read revisions and “MLN Matters” article.


CMS Clarifies Homebound Criteria

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Homebound Criteria

New homebound definition designed to prevent confusion and foster compliance among health care providers.

The Centers for Medicare and Medicaid Services (CMS) released a clearer definition of homebound to be used when deciding if patients are eligible for home health services under Medicare.

Patients are considered “confined to the home” or “homebound” if they meet these two criteria:

  1. Patients either need supportive devices such as crutches, canes, wheelchairs, and walkers; special transportation; or help from someone else in order to leave their home because of illness or injury, OR have a condition that makes leaving the home medically inadvisable.

2. “There must exist a normal inability to leave home; and leaving home must require a considerable and taxing effort.”

The new definition, which goes into effect November 19, 2013, will prevent confusion, promote a clearer enforcement of the statute, and provide more definitive guidance to home health agencies in order to foster compliance, CMS says.

View Change Request 8444.

Tips to Remember:

*The designation of homebound is contingent upon a patient’s individual ability – not caregiver support. [Patients may be highly functioning due to caregiver assistance.]

*Homebound does not mean bedbound.

Homebound criteria applied to psychiatric patients:

*Illness is manifested by a refusal to leave the home (e.g., severe depression, paranoia, agoraphobia).

*Due to illness it would be unsafe for the patient to leave the home (e.g., hallucinations, violent outbursts).

NOTE: Psychiatric patients may have no physical limitations.


Does Your Patient Meet the Criteria for Homebound?

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Medicare Homebound PatientsTo qualify under Medicare for home health nursing and therapy services, Medicare requires that a patient be homebound (not necessarily bedbound). Your patients meet the Medicare requirements for homebound if:

  • They cannot leave home without “considerable and taxing effort.” Most patients have an injury or illness that makes it difficult to leave home.
  • They cannot leave home without help, such as the aid of supportive devices, special transportation, or the assistance of another person.
  • They leave home primarily for medical treatment that cannot be provided in the home (such as dialysis). They may also receive therapeutic, psychosocial, and medical treatment at a certified adult day care program.
  • They occasionally leave home for non-medical purposes with the absence being “infrequent and short in duration.” Some examples include attending a religious service or a special family event, taking a walk around the block, and getting a haircut.

Remember, a patient does not need to be bedridden to be considered confined to the home.

Homebound criteria applied to psychiatric patients:

  • Illness is manifested by a refusal to leave the home (e.g., severe depression, paranoia, agoraphobia).
  • Due to illness it would be unsafe for the patient to leave the home (e.g., hallucinations, violent outbursts).

NOTE: Psychiatric patients may have no physical limitations.