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Home Health & Hospice Week

Eligibility:

Homebound Demonstration Slated For Fall

Published on Thu May 13, 2004

But will demo patients be a financial liability for HHAs?

If your state gets chosen to participate in the Medicare homebound demonstration project, it could open up a whole new market for your home health agency. And if the project succeeds, it could mean big changes for everyone.

The Medicare Modernization Act passed last December included a provision requiring a demonstration project to test a new, looser definition of "homebound" for Medicare home care eligibility purposes (see Eli's HCW, Vol. XII, No. 43). The demo aims to test whether using a less restrictive homebound definition will increase home health utilization and Medi-care costs, and/or boost patient outcomes.

The two-year project will take place starting Oct. 4 in three states, "representing northeast, midwestern, and western regions," the Centers for Medicare & Medicaid Services says in a May 7 transmittal.

Under the demonstration, Medicare beneficiaries with permanent, severe disabilities can qualify for home care services even if they leave the home frequently or for extended duration. (For eligibility requirements, see "Wrap Your Brain Around This New Homebound Definition"). Beneficiary participation will be capped at 15,000 patients.

CMS is staying mum on which states it will choose for the project, notes Mary St. Pierre with the National Association for Home Care & Hospice.

But all agencies in the chosen states will be able to participate in the homebound demo, notes Bob Wardwell with the Visiting Nurse Associations of America. The project won't be conducted "in an isolated few agencies," cheers Wardwell.

In that way, the demonstration is meant to mirror what the Medicare home care benefit really would be like if the changes to the homebound definition were made across the board, Wardwell tells Eli. Those disability advocates "who worked for this demo wanted it to run as much as possible like the law would have worked."

CMS has a full plate with all of its MMA duties, but it is prioritizing this demonstration by getting it off the ground nearly on time, Wardwell adds. The law requires a start date of June 9, but the project will begin Oct. 4.

The Demo Rundown

Here's how it will work: Once the demo begins, all HHAs in the three chosen states can enroll patients who fit the loosened homebound criteria. The process will include:

  • Physician certification. The doc must "indicate in the open text remark section" of the plan of care "that he/she certifies that the patient has a severe and permanent condition and satisfies the requirements of the demonstration," CMS explains in the transmittal.

  • Patient education. The HHA must inform the patient that she is eligible for home care under a special, limited-time demonstration project. The agency should encourage the beneficiary to take advantage of the more liberal homebound definition, CMS instructs.

    The demonstration contractor also will later contact the patient, review the demonstration requirements, and urge the patient to utilize the relaxed homebound definition.

    But the beneficiary will have some responsibilities -- "the patient will be asked to keep a log of absences from home for the purpose of the evaluation of the demonstration and will be told that the evaluation contractor may contact him/her after home care has been completed," CMS says. Patients can call a toll-free number to have questions about the demo answered.

  • Billing. Demo billing will be relatively simple for HHAs. They must include the word "HHDEMO" in the remarks field of any request for anticipated payment (RAP) and claim they submit for a demo patient, the transmittal says.

    That term will indicate to regional home health intermediaries not to subject the claim to regular homebound medical review. Of course, the claims still will be subject to other Medicare rules.

  • HHA log. CMS will "encourage" agencies to keep a log of all beneficiaries who meet the loosened homebound criteria, and whether they enrolled or not.

  • Medical records. After an HHA discharges a demo patient, the demo contractor will request the patient's POC and medical record, CMS indicates.

    CMS appears to have done its best to limit the work HHAs and patients will have to do to participate in the project, Wardwell surmises. CMS is "trying to minimize any extra work for providers who admit patients to the demo" and curtail onerous "research-related paperwork," he says.

    Disabled beneficiary advocates hope that if the demo proves successful, the pilot project will become Medicare law. Such a change "would free folks who are truly Medicare home health patients from a homebound definition that is terribly out of date with how folks live in the 21st century," Wardwell stresses.

    For Medicare, the definition of "successful" probably will include a negligible increase in Medicare costs and home health utilization associated with the relaxed homebound definition. Wardwell believes that's a distinct possibility. "There really are not a huge number of folks who qualify under these criteria who are not already in home health," he predicts.

    If CMS Throws a Homebound Party, Will Anyone Show Up?

    Observers harbor a number of concerns about the demonstration, however. Foremost, Medicare beneficiaries, physicians and HHAs will need a lot of education. "Folks who could benefit from this may not participate unless CMS does a really good outreach effort," Wardwell worries. "That remains to be seen."

    HHAs and physicians also may scratch their heads at the requirement that the patient require "skilled nursing services" for the rest of her life. "What is skilled nursing for life?" St. Pierre asks. Confusion over this term could keep patients out of the project.

    Cause for concern: Most troubling to beneficiaries is that agencies may not want to take on the patients who will become eligible for home care under the project. "Many home health agencies may not be eager to accept such patients, at least if they are perceived as high cost, challenging patients," Wardwell forecasts.

    Such rejection may depend on how CMS defines the daily attendant care requirement, St. Pierre notes. The project may not require HHAs to actually furnish the daily attendant care that a patient must have to qualify for the demonstration.

    Many of these questions should be answered by forthcoming provider education efforts. CMS soon will issue a Medlearn education article on the matter, and the demo contractor and RHHIs also will educate HHAs on the project.

    Editor's Note: The CMS transmittal is at www.cms.hhs.gov/manuals/pm_trans/R3DEMO.pdf.

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