Eligibility:
UNCLE SAM WANTS YOU - FOR HOMEBOUND DEMONSTRATION
Published on Thu Jul 15, 2004
Demo results could change the homebound definition forever. More details about the upcoming homebound demonstration project are emerging as the October implementation date approaches -- and some of them may surprise you. The Centers forMedicare & Medicaid Services wants all home health agencies in the three demo states -- Colorado, Massachusetts and Missouri -- to have a hand in the project that will loosen homebound requirements for disabled Medicare beneficiaries. "All home health agencies in the three states will be asked for their cooperation to participate in identifying Medicare beneficiaries who are eligible for this demonstration," a CMS official said in a special Open Door Forum held June 25. CMS stopped short of saying agencies had to take on the patients, however. Eligibility for the project hinges on a physician certifying that the patient has a permanent, disabling condition and a daily need for help with at least three activities of daily living (see Eli's HCW, Vol. XIII, No. 18). But HHAs won't necessarily have to furnish daily aide services, CMS said in the forum. For example, a patient whose family furnishes her ADL help will still qualify, an official said in response to a caller question. The demo criteria focus on what a patient needs, not what is furnished, an official noted. More good news is that beneficiaries who leave the home to attend school won't be excluded, CMS clarified. The law requiring the demo does bar beneficiaries who work outside the home from participating, however. HHAs Make the Call on Who Qualifies HHAs were happy to hear that CMS won't be looking over their shoulder on whom they identify as demonstration participants. Here's how it works: The referring physician and agency together will decide whether the patient meets the six criteria set out in the project. If they think the patient qualifies, the HHA merely sends in a request for anticipated payment (RAP) or final claim as usual, except with "HHDEMO" in the remarks field. The regional home health intermediary then will treat the claim normally, except to refrain from disqualifying the patient as non-homebound if she leaves the home, CMS explained. The data from HHDEMO claims will be sent to a contractor running the demonstration, and the contractor will contact the patient and explain the demonstration to them in detail, CMS said. The feds ask the agency merely to give a brief overview of the program when it admits the patient. In other words, it is entirely up to HHAs and referring physicians to determine who gets admitted to the homebound demonstration. "We will not be second-guessing the home health agency," a CMS staffer stressed in the forum. "We're not going to go out and say we [...]
