What are the criteria for a housebound patient? A Comprehensive Guide

According to the Centers for Medicare & Medicaid Services (CMS), a patient does not have to be bedridden to qualify as homebound. So, what are the criteria for a housebound patient? The determination is based on a medical condition that makes leaving home a considerable and taxing effort, often requiring assistance from another person or a supportive device.

Quick Summary

This guide explains the primary medical and physical requirements for a patient to be considered housebound for insurance purposes. It details the criteria used by Medicare and the Department of Veterans Affairs (VA) to determine eligibility for in-home care and financial allowances.

Key Points

• Two-Part Medicare Test: To be considered homebound by Medicare, a patient must meet a two-part test: requiring assistance or having a medical contraindication to leave home, and finding leaving to be a considerable and taxing effort.

• Bedridden is Not Required: A common myth is that a patient must be bedridden to qualify as homebound. Many individuals with significant mobility issues who are not confined to a bed can meet the criteria.

• Medical and Infrequent Absences Allowed: Brief and infrequent absences from the home are permitted for reasons like medical appointments, religious services, and occasional family events, without jeopardizing homebound status.

• VA Criteria Differs: The VA uses a different set of housebound criteria, typically tied to a veteran's disability ratings, to provide an increased pension allowance rather than covering home health services.

• Clinical Factors are Crucial: A physician's determination of homebound status is based on a range of clinical factors, including mobility limitations, respiratory issues, cognitive impairment, and severe pain, all documented in the patient's medical records.

• Physician Certification is Necessary: For both Medicare and VA benefits, a physician must certify the patient's eligibility and provide documentation that supports the homebound designation.

The designation of a patient as "housebound" or "confined to the home" is crucial for accessing benefits under programs like Medicare and the Department of Veterans Affairs (VA). It's a misconception that a patient must be bedridden; eligibility is based on the significant effort required to leave home due to a medical condition.

Medicare’s Homebound Criteria

To be certified as homebound for Medicare home health services, a patient must meet a two-part test, with physician documentation supporting the status after a face-to-face encounter. Part one involves requiring assistance from supportive devices, special transportation, or another person to leave home, or having a condition where leaving home is medically inadvisable. Part two requires a normal inability to leave the home, where leaving necessitates a considerable and taxing effort. Infrequent, short absences for reasons like medical treatments, religious services, or brief errands are allowed.

Department of Veterans Affairs (VA) Housebound Allowance

The VA has different criteria for a housebound allowance, an additional monetary benefit for qualifying veterans receiving a VA pension. Eligibility is typically for veterans with a 100% service-connected disability and another separate service-connected disability rated at 60% or higher, who are permanently housebound as a result. This is distinct from Aid and Attendance benefits; a veteran cannot receive both.

Comparison of Homebound Criteria: Medicare vs. VA

Feature	Medicare Homebound	VA Housebound Allowance
Primary Purpose	Eligibility for home health services (skilled nursing, therapy).	Additional financial compensation for permanently disabled veterans with a pension.
Requires Assistance	Yes, either from a person or a device, OR leaving is medically contraindicated.	Yes, confined to home most of the time due to a permanent disability.
Effort to Leave	Must require a "considerable and taxing effort".	Explicitly stated that leaving is rare and usually limited to medical reasons.
Service-Connection	Not required; based on any illness or injury.	Required; based on service-connected disabilities.
Allowed Absences	Permitted for medical treatment, religious services, infrequent social events.	Infrequent, with emphasis on medical necessity.
Qualifying Condition	Can be temporary, related to recovery from surgery, or chronic illness.	Must be permanent.

Clinical Factors for Homebound Status

Physicians evaluating homebound status consider factors like mobility issues, respiratory or cardiac conditions, cognitive/psychiatric impairments (such as dementia or severe anxiety), severe pain, and being immunocompromised.

Conclusion

Determining housebound criteria depends on the program. Medicare requires physician certification that leaving home is a considerable effort due to illness or injury requiring assistance. The VA uses criteria based on permanent, service-connected disabilities for financial aid. The assessment considers physical, cognitive, psychiatric, and environmental factors limiting a person's ability to leave home safely and independently. Consulting healthcare providers and relevant agencies is essential to document medical need and confirm eligibility for these services and benefits.

Frequently Asked Questions

Can a patient be considered housebound if they still leave the house sometimes?

Yes, a patient can be considered homebound even if they leave the house for short, infrequent, or medically necessary reasons. Examples include attending religious services, receiving outpatient medical treatments like dialysis, or going to a licensed adult day care.

Who determines if a patient is housebound?

A patient's attending physician or authorized provider is the one who ultimately determines and certifies that a patient meets the homebound criteria. This is based on their clinical findings and a face-to-face encounter with the patient.

Does being homebound for Medicare also qualify a patient for VA benefits?

No, the criteria are different. While both programs deal with confinement to the home, Medicare's rules are for home health service eligibility, whereas the VA's rules are for a special financial allowance based on permanent, service-connected disabilities.

Are psychiatric conditions, like severe anxiety, a valid reason for being housebound?

Yes, a psychiatric condition can qualify a patient as housebound. If the illness, such as severe depression or agoraphobia, makes it unsafe or impossible for the patient to leave home, they can meet the criteria.

What is the difference between a housebound patient and one needing 'Aid and Attendance'?

The distinction is the level of assistance required. A housebound patient is largely confined to their home due to a disability but may be able to manage daily tasks. A patient needing Aid and Attendance requires the help of another person for activities of daily living, like bathing or dressing.

Can I qualify as homebound if I only have weakness due to old age?

No, Medicare specifies that a patient must be confined to the home due to a specific illness or injury, not simply general weakness or feebleness associated with advanced age.

What kind of assistance devices or help can be considered when determining housebound status?

Assistance can come from another person, the use of special transportation, or supportive devices such as a cane, walker, crutches, or wheelchair. The inability to leave home without this help is a key part of the assessment.