In the world of Medicare benefits, and many commercial health insurance plans, homebound status works like a magic key that opens a world of home health services. Would you like to go home from the hospital, rehab facility, or nursing home as soon as possible? Think home health. Do you wish a nurse could check on your elderly parent for a while because a disease is trying to flare up? Again, that’s home health. What if you could conveniently receive your rehab in the comfort of home with Medicare paying 100% – no deductibles and no copays? That’s home health, and Medicare requires patients to be “homebound” before they will pay for home health.
Homebound Status: Less Restrictive Than the Term Implies
Unfortunately, the term Medicare chose many years ago, “homebound,” seems to imply something much more restrictive than what’s in the actual rules. Confusion around this term likely leads to thousands of people missing out on home health services every year. In some regards, enforcement of the homebound rule can be subjective. Therefore, families need to know how to stick up for themselves and get the benefits for which they qualify. When people need home health, skipping it increases costs to Medicare by thousands of dollars due to worsened health outcomes. People who need home health but don’t get it prove 25% more likely to die. That’s why advocating for your home health benefits when you qualify is so important.
Homebound Status: What the Rules Say
Let’s start with the basic rule. To meet Medicare’s definition of homebound, patients have two sets of criteria.
Homebound Criterion One:
A patient must need some sort of help when leaving the home. This may be the help of another person. It could be the help of a device such as a cane, a walker, or a wheelchair. It could be the help of special transportation. This need for help must be due to illness or injury.
Alternatively, a person could have a condition such that leaving his or her home is against medical advice. In this case, technically needing help to leave home is not required. For instance, a great-grandparent may live at home with dementia. He or she may be perfectly capable of walking out of the house and driving away, but the dementia makes doing this ill-advised.
Homebound Criterion Two:
If a patient needs the help described or leaving the home is medically contraindicated, then we can move on to criterion two. In the rules, a patient must meet one of the conditions from criterion one and both conditions from criterion two. First, a patient must have a normal inability to leave the home. The inability can’t just be for a day, for instance. Second, trips away from the home should be infrequent and of short duration because leaving the home requires a “considerable” and “taxing” effort.
To read the full Medicare rules, check out Chapter 7 of the Medicare Benefit Policy Manual.
Homebound Status: Allowed Outings
Notice that the definition above talks about trips away from the home. People receiving home health may indeed leave the home from time to time, and they can still be considered homebound. Over the years, Medicare publications such as the Healthcare Manual 11 (or Pub 11) have name specific outings that would not necessarily disqualify a patient from being homebound. Here are a few:
- Religious Services: Under Medicare rules, no attendance of religious services can be used to deny a person home health.
- Healthcare: Any absence for medically necessary healthcare from a state-licensed or certified provider would not disqualify a patient.
- Adult daycare: any absence to attend an accredited adult day care should not interfere with homebound status.
- Occasional trips to the barber
- A walk around the block
- A drive
- A family reunion
- A funeral
- A graduation
Medicare’s publications have also noted that temporary improvements in the ability to travel may not necessarily disqualify a patient. An example would be out-of-town family visiting a grandparent. While visiting, they may take the grandparent on multiple outings in just a few days. Medicare publications have specifically stated this should be allowed.
Examples of People Who are Homebound
Here are some examples of people Medicare would typically consider to be homebound.
- Someone who needs the help of another person because a weakness in the hand, arm, or shoulder prevents the safe use of handrails.
- A patient who has been weakened by illness, surgery, or an extended inpatient stay. Note that elderly people lose strength much faster and gain it back much more slowly.
- A stroke survivor who now needs crutches or is confined to a wheelchair.
- A blind person who needs help leaving home.
- A senile person.
- A patient with heart disease so serious that he or she must avoid stress and physical activity.
- A person with a psychiatric illness that causes a refusal to leave the home.
These are just examples. A virtually limitless number of situations could cause a senior to meet the homebound criteria.
What if You are Declared Not Homebound?
A person who recovers to be no longer homebound can continue to receive normal medical care by traveling to facilities and offices. Normal deductibles and co-pays apply, and the taxing effort required for these trips often leads elderly patients to skip needed healthcare. If there is question about the homebound status, families need not simply go along with the first person who told them “no.” Homebound criteria contains a fair amount of subjectivity.
Know the rules. If you think you or a family member meets the definition of homebound, get a second opinion. Call other home health agencies. Some will visit your home for a no-obligation consult. Some may tell you over the phone if they would admit you to their home health services. Various home health agencies interpret homebound status differently, so you may get a better result by getting a second opinion.
Medicaid Does Not Require Homebound Status
Here’s an often-under-appreciated nuance to insurance qualifications. Medicaid, government-based insurance for low-income families, does not have homebound criteria in their home health rules. They quietly removed those criteria in the early 21st century because the homebound requirement conflicted with certain guarantees in the Medicaid benefit. Medicaid simply looks for care to be delivered in the optimal setting. In practice, this often leads to home health being for the homebound, but there is no explicit homebound requirement.