Some States Improperly Restrict Eligibility for Medicaid Mandatory Home Health Services

HHS Office of Inspector General
U.S. Dept. of Health & Human Services · 
200 Independence Avenue SW · Washington DC 20201


(OEI‑07‑13‑00060)http://go.usa.gov/bJz9

WHY WE DID THIS STUDY

Federal regulations prohibit the arbitrary denial or reduction of the amount, duration, and scope of a required service on the basis of a beneficiary’s diagnosis, type of illness, or condition.  In a 2000 policy letter, CMS notified State Medicaid agencies that restricting eligibility for mandatory home health services to homebound individuals violates these regulations.  In July 2011, CMS published a Notice of Proposed Rulemaking that would revise Medicaid regulations to clarify that home health services cannot be restricted to individuals who are homebound or to services furnished in the home; the rule had not yet been finalized at the time of this report.  At least one State was known to have improper homebound restrictions on its mandatory home health benefit from 2005 to 2010.  We determined how many States nationwide had such improper restrictions in their policy documents in January 2013.

HOW WE DID THIS STUDY

From each State, we requested copies of the policies that define eligibility for mandatory home health services.  These policies included State administrative codes, provider manuals, and other policy documents.  From each of the 10 CMS regional offices, we requested copies of the sections of the current State plans that define eligibility for mandatory home health services for the States in the appropriate region.  We reviewed all of these documents to determine whether any State had improperly restricted eligibility for mandatory home health services.

WHAT WE FOUND

Eleven States have language—one in its State plan and 10 in other State policy documents—that restricts eligibility for the mandatory home health benefit to homebound individuals in violation of CMS’s interpretation of the applicable statute and regulation.  These 11 States are:  Alabama, Arkansas, Indiana, Montana, Nebraska, New Mexico, North Dakota, Pennsylvania, South Dakota, Utah, and West Virginia.  Two of the eleven States, New Mexico and Utah, stated in their responses to our request that although their policies restricted eligibility for home health services to homebound individuals, those policies were incorrect and the restrictions were not being enforced.    

WHAT WE CONCLUDE

The 11 States with improper restrictions violate CMS’s interpretation of § 1902(a)(10)(B) of the Social Security Act and Federal regulation at 42 CFR §440.230(c) because the scope of the medical assistance made available to non-homebound individuals is reduced.  Such restrictions further violate CMS’s interpretation of Federal requirements at 42 CFR § 440.240(b) because they deny services on the basis of a beneficiary’s condition (i.e., not being homebound).  We encourage CMS to finalize its proposed rule clarifying that home health services cannot be restricted to individuals who are homebound or to services furnished in the home.