Confined to the Home Definition – Clarification

Since the issuance of the Centers for Medicare & Medicaid Services’ (CMS) Change Request (CR) 8444/Transmittal 172 – Home Health – Clarification to Benefit Policy Manual Language on Confined to the Home Definition there have been varying interpretations as to its meaning. Some believe the definition is a change with fewer restrictions while others believe the definition is a change with more restrictions. Then there are those that view the homebound definition in the transmittal as without change from how it is currently applied.

CMS does not intend for the transmittal be interpreted as a change in their long- standing definition of homebound. CMS cites the reason for the need to rearrange sections of the manual is to better align the homebound definition with the Social Security Act at 1814(a)(8), which reads as follows:

“….For purposes of paragraph (2)(C), an individual shall be considered to be “confined to his home” if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home and, that leaving home requires a considerable and taxing effort by the individual.”

Therefore, Medicare contractors should not interpret the transmittal as a change in the homebound definition. Patients that have a normal inability to leave the home and therefore leaving the home is a considerable and  taxing effort most likely require some kind of assistive device, the assistance of another person, or have a condition  where leaving the home would be medically contraindicated.  Agencies have been applying these criteria all along and should be alert for any greater scrutiny by the Medicare contractor who might try to interpret the clarification as a change in the criteria for meeting the homebound definition for Medicare covered home health services.

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