The Health Care Financing Administration (HCFA) issued a set of Questions and Answers (Q&As) designed to clarify HCFA's implementation of recent changes in Medicare law expanding access to home health care while attending an adult day care program. 

The BIPA amendment, Section 507, effective December 21, 2000, provides that absences attributable to the need to receive health care treatment, including regular absences to participate in therapeutic, psychosocial, or medical treatment at a licensed or accredited adult day-care program, will not disqualify a beneficiary from being considered homebound. (See, the Medicare, Medicaid and SHIP Benefits Improvement and Protection Act of 2000 (BIPA), Pub. Law 106-544, signed into law on December 21, 2000, Section 507. See also, Section 1814(a); and 1835(a) of the Social Security Act, 42 U.S.C. 1395n(a).)

The HCFA Q&As should be viewed together with HCFA's Program Memorandum: Clarification of the Homebound Definition Under the Medicare Home Health Benefit: Program Memorandum (PM), Transmittal A-01-21, Dated February 6, 2001.

The Q&As address the following questions:

(1) Whether a Home Health Agency (HHA) can provide services in a licensed/certified adult day care center;

(2) Whether it is permissible for HHA staff to go to an adult day care center to see a patient who is under a home health care plan if the visit is not considered to be billable;

(3) Whether a HHA providing skilled therapy services (physical therapy; speech language pathology; occupational therapy) to a beneficiary under a home health plan of care, can also provide those services to the patient in a day care center;

(4) How to ascertain whether the day care center the patient is attending is providing psychosocial treatment to the patient; and

(5) How to define psychosocial treatment; what is considered to be "therapeutic" - is giving medications and checking blood pressure sufficient; what constitutes a licensed or certified adult day care facility - does certification to receive Medicaid funds or other state monies satisfy the licensure or certification requirement.

Unfortunately, the Q&As do not address the equally difficult area of absences from the home for the purpose of attending a religious service of infrequent or short duration. Advocates have raised a number of questions about such absences, particularly where the activity of attending such services includes going to dinner before or after the service, or attending related functions associated with the religious event.

In other developments, a bill to make additional changes to the homebound definition has been introduced in the House of Representatives in the form of H.R. 1490. This bill would eliminate the requirement that absences from the home be infrequent and of sort durations. Beneficiaries would be considered homebound if they could not leave home without considerable and taxing effort, which already is a statutory standard. 

[HCFA's Clarification - May 2001

Frequently asked Questions and Answers: Program Memorandum:
Clarification of the Homebound Definition Under the Medicare Home Health Benefit:
Transmittal A-01-21, Dated February 6, 2001

Q: Can a home health agency (HHA) provide covered Medicare home health services to a beneficiary within the day care center if the beneficiary is attending a licensed/certified day care center?

A: The law does not permit a HHA to furnish a Medicare covered billable visit to a patient under a home health plan of care outside his or her home, except in those limited circumstances where the patient needs to use medical equipment too cumbersome to bring to the home. The only statutory change to the home health eligibility requirement is to sections 1814(a) and 1835(a) of the Social Security Act (the Act), which was amended by the Beneficiary Improvement and Protection Act (BIPA). BIPA did not amend section 1861(m) of the Act which stipulates that home health services provided to a patient be provided to the patient on a visiting basis in a place of residence used as the individual's home. A licensed/certified day care center does not meet the definition of a place of residence.

Q: May a HHA allow its staff to go to the day care center to see a patient who is under a home health plan of care if it is not considered a billable visit?

A: Although, as indicated above, a HHA generally may not furnish a Medicare covered billable visit in the adult day care center, this does not preclude home health agency staff from providing a non-covered service to a beneficiary. Such visit would not affect payment. HHAs must remain cognizant of relevant state and local laws governing health care practice to assure that they are furnishing services consistent with their legally authorized activities.

Q: If a HHA is providing skilled therapy services (physical therapy; speech language pathology; occupational therapy) to a beneficiary who is under a home health plan of care, can the patient also receive therapy in a day care center?

A: As mentioned above, an HHA generally may not furnish a Medicare covered billable visit in the adult day care center. BIPA did not amend section 1861(m) of the Social Security Act which stipulates that home health services be provided to the patient on a visiting basis in the individual's home or in an outpatient setting (like a SNF, a rehabilitation center, or a hospital) when the patient needs to use medical equipment to cumbersome to bring to the home. A licensed/certified day care center does not meet the definition of a place of residence or the listed outpatient settings.

In responding to this question, we must assume that the HHA is aware of the requirement that they furnish directly or under arrangement all the medically necessary skilled therapy services required under the plan of care, including physical therapy, speech language pathology, and occupational therapy. Consolidated billing rules require the HHA to bill for the episode and reimburse the entity providing therapy. The entity providing therapy cannot bill Medicare for their services while the beneficiary is under a home health plan of care. If therapy services are provided at the adult day care center then those services may not be services required under the plan of care or billed to Medicare; consolidated billing rules would apply in that situation.

Q: How can a HHA be sure that the day care center the patient is attending is providing psychosocial treatment to the patient? What does the law mean by psychosocial?

A: We do not believe it is the obligation of the HHA to determine whether the adult day care center is providing psychosocial treatment, but only to assure that the adult day care center is licensed/certified by the state or accrediting body. We believe that Congress, in extending a homebound exception status to attendance at such adult day care centers, recognized that they ordinarily furnish psychosocial services.

Q: What is considered to be "therapeutic"? Does giving medications and checking blood pressure count or must it be more complex procedures like wound care?

A: As you know, BIPA amended the statute to allow for absences of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State. Absences for such purpose shall not disqualify an individual from being considered confined to his home. We believe that Congress intended "health care treatment" to encompass the types of services typically furnished by a licensed/certified adult day care center. However, please be aware that the home health agency is still responsible for the provision, either directly or under arrangement, of the covered services required under the plan of care.

Q: What constitutes a licensed or certified adult day care facility? Does certification to receive Medicaid funds or other state monies satisfy the licensure or certification requirement?

A: In order to meet the requirements of BIPA, an adult day care center must be either licensed or certified by the State or accredited by a private accrediting body. State licensure or certification as an adult day care facility must be based on state interpretations of its process. For example, we understand that several states do not license adult day care centers as a whole but do certify some entities as Medicaid certified centers for the purposes of providing adult day care under the Medicaid home and community based waiver program. We believe that it is the responsibility of the state to determine the necessary criteria for "state certification" in such a situation. A state could determine that Medicaid certification is an acceptable standard and consider its Medicaid certified adult day care centers to be "state certified". On the other hand, a state could determine Medicaid certification to be insufficient and require other conditions to be met before the adult day-care center is considered to be "state certified."