Medicare Attempting to Prevent Wrongful Termination of Home Health Care Benefits

by Christina Medvescek

Medicare has made some "common sense"changes in language defining its policy that requires chronically ill people to stay at home in order to receive Medicare home health services. The new language doesn't change Medicare policy, but clarifies the stipulation that services shouldn't be terminated simply because a beneficiary leaves home occasionally for nonmedical or nonreligious reasons.

"These changes are all consistent with long-standing policies but we are adding them now to assure that the language in the manual is explicitly sensitive to these issues that are so important to our beneficiaries,"said Tom Scully, administrator of the Centers for Medicare and Medicaid Services (CMS).

The new policy language was added after activist David Jayne of Atlanta, who has amyotrophic lateral sclerosis (ALS), met with Scully in early July. "Mr. Jayne pointed out several common sense changes" that could be made in current policy language, said Jennie McGihon, a CMS public affairs specialist.

In the new instructions, CMS directs home health agencies and the contractors that pay home health claims to be more flexible in determining whether a potential beneficiary is qualified as homebound.

The new language in the program manual for home health agencies:

• Expands the list of "infrequent and unique events" that are acceptable absences from the home to include "an occasional trip to the barber, a walk around the block, a drive, attendance at a family reunion, funeral, [or] graduation," and notes that the list still isn't all-inclusive;
• Adds "patients in the late stages of ALS or a neurodegenerative disability" to the list of examples of conditions that may indicate that a beneficiary may be eligible for home health services; and
• Makes it clear that the determination of whether a person is homebound must be made over a period of time, not on a daily or weekly basis, so that several absences from the home in a short period (i.e., outings with visiting relatives) wouldn't be used to disqualify a patient who has a "normal inability to leave the home."

The instructions, dated July 26, make it clear that people with chronic disabilities who otherwise qualify as homebound shouldn't lose home health services for infrequent, short absences for special occasions.

"I have heard numerous anecdotes concerning specific chronically disabled beneficiaries who were disqualified from receiving home care because they went to a funeral or a class reunion or some other event not specifically mentioned in our instructions,"said Scully's letter to regional home health intermediaries. "I am resolved to make sure that the instructions containing our policy are written clearly enough to avoid such misunderstandings."

The $13 billion Medicare home health care program originally was intended to provide a short-term benefit for people who had been recently released from the hospital but still required skilled nursing care. However, with better medical care and technological help, people with severe disabilities caused by chronic conditions now live longer and can participate more actively in their communities, while still requiring assistance with daily care.

An estimated 2.5 million Medicare beneficiaries will receive home health services this year, the agency says.

Jayne has been trying for two years to get Legislation passed by Congress to remove or considerably amend Medicare's homebound restriction. He founded the National Coalition to Amend the Homebound Restriction, an online coalition of about 13,000 people and 46 organizations, including MDA.

"It's a start," Jayne said of Scully's clarifications. "It will provide some relief for the severely disabled. But we need legislation that's more specific and cannot be arbitrarily applied."Jayne hopes Sen. Susan Collins (R-Maine) will introduce legislation before the Senate breaks for summer recess.