What Exactly Constitutes a “Normal Inability” to Leave Home?
The second criterion for being homebound consists of two requirements that must be met. The first part is having a “normal inability to leave home,” which means that leaving the house is not a routine activity due to illness or injury. While not a complete inability, it reflects a consistent pattern of confinement. Allowable absences must be infrequent and brief.
- Infrequent and Short Duration: Outings should not be lengthy or suggest the ability to leave routinely for extended periods.
- Permitted Absences: Leaving for medical treatment like dialysis, chemotherapy, or licensed adult day care for medical care is allowed. Infrequent non-medical absences for things like religious services or family events are also permissible if they require considerable effort.
The Role of “Considerable and Taxing Effort”
The second part of criterion two is that leaving home must require a “considerable and taxing effort”. This means that leaving home, even for allowed reasons, involves substantial physical or mental exertion. This effort is evaluated based on the patient's specific medical condition. Examples include significant pain from osteoarthritis or severe shortness of breath. The effort might also lead to needing frequent rest or a long recovery period. This taxing effort must stem directly from the illness or injury, not just general feebleness or a preference to stay home.
Comparing Homebound Criteria: The Two-Part Test
Both criteria are essential. Criterion 1 focuses on why a patient needs help to leave home, while Criterion 2 addresses the pattern of leaving and the required effort.
| Feature | Criterion 1: Need for Assistance | Criterion 2: Normal Inability & Taxing Effort |
|---|---|---|
| Focus | Physical or medical reasons preventing independent exit from home. | The overall pattern of leaving home and the level of effort required. |
| Requirements | Patient must need assistive devices (cane, walker, wheelchair), special transportation, or personal assistance; OR leaving home is medically contraindicated. | There must be a normal inability to leave home; AND leaving home must require a considerable and taxing effort. |
| Examples | - A stroke survivor requiring a wheelchair to mobilize. - A patient with severe heart disease advised against physical activity. - A person with severe dementia who should not leave home unattended. |
- Someone with severe arthritis finding a trip to the barbershop painful and exhausting. - A person recovering from surgery who needs to rest frequently during a short, necessary trip. - Leaving for a rare family event results in prolonged recovery time. |
| Outings | The need for aid on outings. | Outings must be infrequent, short, and strenuous. |
Examples of Meeting the Second Homebound Criterion
- Post-Surgery Recovery: A patient with weakness and pain after major surgery finds leaving home exhaustive, even with help for medical appointments. This demonstrates a pattern of confinement and significant effort for any departure.
- Severe Cardiovascular Disease: A patient whose doctor advises avoiding significant exertion due to heart risk. Any necessary trips outside are brief.
- Psychiatric Illness: Conditions like severe depression or agoraphobia can make leaving home unsafe or impossible without help. The required effort can be psychological.
What the Homebound Status is NOT
Being homebound does not apply if a person:
- Prefers to stay home due to convenience or general old-age feebleness.
- Leaves home often for social activities or shopping without much effort.
- Can drive independently for errands and appointments.
Homebound status is a medical determination that a physician must certify. The certification needs to be supported by medical records explaining how the patient's condition leads to a taxing effort and normal inability to leave home. Without this medical documentation, Medicare coverage for home health services may be denied.
The Importance of Physician Certification
A physician is crucial in documenting homebound status. They must create and sign a care plan outlining the patient's condition and how it meets the criteria. This documentation must clearly state why leaving home is a considerable and taxing effort and why there's a normal inability to do so. A face-to-face visit with the patient by the physician or a qualified practitioner (like a nurse practitioner) is needed to certify eligibility, ensuring a thorough assessment.
Conclusion
In conclusion, what is the criteria 2 for homebound is a key part of Medicare's eligibility, focusing on a patient's overall inability to leave home easily and the significant effort required for any departure. This criterion, along with Criterion 1, ensures that home health services are for those genuinely confined due to illness or injury. For patients and caregivers, understanding these rules is vital for proper certification and accessing needed care. Consulting healthcare providers and Medicare-certified home health agencies is recommended. The rules allow for necessary medical and infrequent non-medical outings, provided the patient's condition and the effort involved support the homebound classification.
