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The Health Care Financing Administration (HCFA) last week issued instructions to its fiscal intermediaries that clarify the definition of "homebound" under the Medicare home health benefit. But the revision, which is effective immediately, threatens to trip up home health agencies (HHAs) that don’t carefully study the new changes, warns Bill Dombi, vice president of law at the National Association for Home Care in Washington, DC.
Under the revised policy, "an absence from the home related 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 program that is licensed or certified by the state or otherwise accredited" will not automatically disqualify a patient from being considered "confined to his home" and eligible for Medicare reimbursement.
Dombi says the policy requires further clarification from HCFA. "There are a number of issues HHAs and patients in adult day centers want to see addressed before they step into this area."
He notes that this policy revision changes only the portion of the homebound requirement that deals with absences from the home. "The patient still must demonstrate that it is a considerable and taxing effort to leave the home," he cautions.
From a compliance perspective, if HHAs have patients that have been referred to them who are going to an adult day center, they must first be careful not to deny Medicare coverage in the home setting, warns Dombi.
In addition, if HHAs try to use this change in policy as a method of expanding their market, they must be certain that the activities of the adult day center are part of the plan of care prescribed by the physician. There also must be a reasonable basis for claiming that those activities are either psychosocial or therapeutic.
Dombi says therapeutic and psychosocial necessity often are more difficult to qualify than medical necessity. That means HHAs must be certain they have some supporting documentation. "If they have that, their chances of having it covered are extremely high," he says.