Understanding the Homebound Status Framework
To qualify for Medicare-covered home health services, a beneficiary must be certified as "homebound" by a physician. CMS defines homebound status using two criteria, both of which must be met.
Dissecting the Second Criterion: A Normal Inability to Leave Home
The second criterion specifies a "normal inability to leave home" where leaving requires a "considerable and taxing effort". This does not mean completely unable to leave, but rather that it's typically very difficult.
- Normal inability: Refers to the patient's usual state, not an absolute prohibition. Occasional brief absences for specific events are permissible.
- Considerable and taxing effort: Describes the significant physical and mental strain involved in leaving home, potentially causing substantial fatigue, pain, or requiring significant recovery time.
Differentiating Between the Two Homebound Criteria
The two criteria address different aspects of a patient's limitations.
| Aspect of Mobility | Criterion One | Criterion Two |
|---|---|---|
| Focus | Requirement of assistance to leave the home. | The effort and frequency of leaving home. |
| Key Component | Needing supportive devices (cane, wheelchair), special transportation, or another person's help; OR having a medical condition where leaving is unsafe. | Having a normal inability to leave home, and finding that leaving requires a considerable and taxing effort. |
| Documentation Emphasis | Evidence of the need for an assistive device or another person's physical assistance. | The degree of physical and emotional strain, and the infrequency or brevity of permissible outings. |
| Example | A patient with a broken hip who requires a walker and family assistance to move. | A patient with severe chronic obstructive pulmonary disease (COPD) who can walk short distances inside with a walker but becomes extremely breathless and exhausted by the effort of preparing for and taking a short trip. |
How Outings Affect Homebound Status
Being homebound doesn't prohibit leaving home entirely. Certain infrequent absences are permitted:
- Permitted Outings: These include trips for medical treatment not available at home (like dialysis), attending a state-licensed adult day care for medical or therapeutic reasons, or going to religious services. Brief, occasional trips for special family events or to places like a barbershop are also generally allowed.
- Crucial Caveat: Permitted outings must not indicate the patient can routinely access healthcare outside the home without significant difficulty. Trips should be short and infrequent.
Documenting the Second Criterion for Certification
Accurate documentation by physicians and home health agencies is essential to support the patient's homebound status under both criteria. Medical records should show the patient's normal inability to leave home without considerable effort. This might include notes on fatigue, pain, fall risk, or symptom exacerbation with exertion. The home health agency's assessment also helps support the physician's certification.
Conclusion: The Combined Homebound Definition
In conclusion, what is the criteria 2 for homebound status is that there must be a normal inability for the patient to leave home, and any instance of doing so requires a considerable and taxing effort. Combined with the first criterion concerning the need for assistance or a medical contraindication to leaving, this defines a patient as "confined to the home" for Medicare eligibility. This is not about total confinement but the significant burden of leaving the residence, a key point for patients and providers to understand for proper home health coverage.
Frequently Asked Questions
What does 'taxing effort' mean for homebound status?
'Taxing effort' means that leaving home is a considerable physical and mental strain for the patient, potentially causing significant fatigue, pain, or requiring a prolonged recovery period. It goes beyond the normal exertion an individual experiences during an outing.
Can a homebound patient leave for a doctor's appointment?
Yes, a homebound patient can leave their home to receive medical treatment that cannot be provided in the home, such as a doctor's appointment. These types of outings are infrequent and do not compromise homebound status.
Does leaving for a religious service affect homebound status?
No, occasional absences for religious services are permitted and do not affect a patient's homebound status, as long as leaving home remains a considerable and taxing effort.
What documentation is needed to support the second homebound criteria?
To support the second criterion, a physician or home health agency must document the patient's condition, detailing their normal inability to leave home and the significant effort required for outings. This may include clinical notes describing fatigue, pain, or the need for frequent rest.
Does 'homebound' mean completely confined to a bed?
No, being homebound does not mean being bedridden. A patient can still be homebound while being mobile within their home, as long as leaving their residence is a considerable and taxing effort.
What is the difference between criterion one and criteria two?
Criterion one focuses on the need for assistance (like a cane, walker, or another person's help) or having a medically unsafe condition to leave home. Criteria two focuses on the overall difficulty and taxing effort of leaving, assuming the patient already meets a condition from criterion one.
Can a person with a mental health condition be homebound?
Yes, a patient can be considered homebound if a mental health condition, such as severe depression or agoraphobia, prevents them from safely or willingly leaving their home. The inability to leave must be a manifestation of the illness.
