CMS-10201.Supporting Statement and Instrument (final)

CMS-10201.Supporting Statement and Instrument (final).pdf

Evaluation of Home Health Independence Demonstration: Home Health Agency Survey

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Contract No.:
MPR Reference No.:

500-00-0033(06)
6152-542

Supporting Statement
for a Home Health
Agency Survey on the
Medicare Home Health
Independence
Demonstration
Paperwork Reduction Act
Submission Supporting
Statement
July 20, 2006

Submitted to:
Centers for Medicare & Medicaid
Office of Research, Development,
and Information
7500 Security Boulevard
Baltimore, MD 21244-1850
Project Officer:
Ann Meadow

Submitted by:
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543-2393
Telephone: (609) 799-3535
Facsimile: (609) 799-0005
Project Director:
Valerie Cheh

A. BACKGROUND
This application requests approval of a survey that will support the required evaluation of
the Home Health Independence (HHI) Demonstration mandated under Section 702 of the
Medicare Modernization Act (MMA) of 2003 (see Appendix A).
The Section 702 Demonstration, or the Home Health Independence (HHI) demonstration,
represents an effort to clarify the definition of homebound by eliminating the homebound
criterion for a defined group of Medicare beneficiaries. The demonstration allows beneficiaries
who are permanently disabled and require substantial help to receive home health services
regardless of the number, or frequency, and duration of their home absences. Specifically, the
demonstration’s clinical criteria for waiving the homebound requirement are that the patient (1)
has a permanent and severe disabling condition that is not expected to improve (and a physician
certifies this status); (2) needs permanent help with at least three of five activities of daily living
(ADL); (3) needs permanent skilled nursing care other than medication management; (4) requires
daily visits from an attendant to monitor, treat, or provide ADL assistance; (5) requires human or
technological assistance to leave home; and (6) is not working outside the home.
Under the demonstration, Medicare beneficiaries who qualify for Medicare home health
benefits and meet the demonstration criteria can leave their homes more frequently and for
longer periods without risking the loss of those benefits. The Section 702 Demonstration and its
evaluation were intended to assess the effect of removing the homebound requirement on
beneficiary outcomes and costs/savings to the Medicare program.
1. How does demand for home health services change after removal of the
homebound requirement? How many beneficiaries who would not otherwise be
eligible seek care? How many beneficiaries receive more 60-day episodes of care
than they otherwise would have?
2. What is the likely cost or savings to the Medicare program? What is the cost of
additional episodes of care provided under the waiver? Do Medicare expenditures
1

for other services increase or decrease for beneficiaries receiving home health care
under the waiver? Did the environment of the demonstration, or the way the
agencies implemented the demonstration, suggest that actual national program costs
could be higher or lower than costs predicted by the demonstration?
3. How are beneficiaries who receive care as a result of the new policy affected?
Does the health and functioning of beneficiaries who receive care under the waiver
improve relative to what it would have been otherwise? Do they leave their homes
more often than similar beneficiaries who receive home health care? For what
purpose? In what ways do their sources of care change?
4. How did the demonstration affect home health agency staff behavior and
resource use? Did agencies’ staff know about the demonstration, chose to
participate, and actively encourage their patients to participate? How did they
determine which patients met the demonstration criteria? Do demonstration
participants have a different casemix distribution than typical home health patients?
Do they use more resources, on average, then patients in the same casemix group?
The HHI demonstration, which is limited to 15,000 beneficiaries, is a 2-year demonstration
and was implemented on October 4, 2004 in three states:

Massachusetts, Missouri, and

Colorado. Contrary to the original expectations of high enrollment, the agencies have reported
that a total of only 25 participants have enrolled in the demonstration since its inception on
October 2004.1 As a result, an evaluation of the demonstration’s impact upon the enrollees is not
feasible. The focus of the demonstration evaluation has changed from examining the extent of
the homebound problem and demonstration implementation process to understanding the reasons
underlying the lack of enrollment.
B. JUSTIFICATION
1.

Need and Legal Basis
The statute authorizing the demonstration mandates a report to Congress on the effects of

the demonstration, to be submitted not later than one year after the date of completion of the
1

This number is the total number of enrollees who were enrolled using the correct
procedures. Agencies may have tried to enroll more participants, but used incorrect procedures,
and thus are not included in the demonstration records.

demonstration (see Appendix A). The expected completion date of the demonstration was to be
October 2006. In light of the low enrollment for the demonstration, the final report will instead
evaluate the implementation of the demonstration outreach and enrollment efforts, and
knowledge and perceptions of the major stakeholders towards the demonstration. With home
health agencies (HHAs) as the major mediators of enrollment in the demonstration, this survey
of HHAs is necessary to collect information on agency perceptions and recommendations
regarding the home health eligibility criteria and the impact of the homebound provision waiver.
2.

Information Users
This document seeks Office of Management and Budget (OMB) approval to collect these

primary data using the mail survey instrument described below. Mathematica Policy Research,
Inc. (MPR) will use the quantitative data collected with the home health agency survey to
supplement the qualitative data collected from other central stakeholders to understand the
reasons for the low enrollment rate for the demonstration and ways to change the home health
eligibility requirements. MPR has designed this mail questionnaire to be completed in 30
minutes (see Appendix B) and to collect information from the home health agencies in the
following domains: interpretation of the homebound rule, impact of the homebound rule upon
their admissions and discharges, understanding of the demonstration eligibility criteria and
determination of the eligibility status of their caseloads. This information will be used by
Congress to understand why the demand within the Medicare population for the homebound
waiver did not materialize as anticipated.
3.

Use of Information Technology
There will be no use of information collection technology as the HHAs will receive a mail

survey.

Duplication of Efforts
The information to be collected is uniquely related to this demonstration, and there are no

similar data available. No other agencies or organizations are conducting any similar data
collections.
5.

Small Businesses
No small businesses will be involved in this study.

Less Frequent Collection
The proposed data collection will inform CMS about the factors related to the low

enrollment of the demonstration and the role of the home health agencies in implementing the
homebound rule and demonstration. Failure to collect the survey data would seriously hinder
CMS’s ability to explain why the demonstration failed to meet its stated objectives, to make
recommendations regarding the need to modify home health requirements and to deliver a
mandated report to Congress.
7.

Special Circumstances
No special circumstances apply to this data collection. Respondents will not be required to

retain any records. The statistical survey of home health agencies is designed to produce valid
and reliable results that can be generalized to the universe of the study. The project will not use
a statistical data classification not reviewed or approved by OMB. All project staff will follow
MPR’s confidentiality procedures (see Section A.10). Respondents are not required to provide
any secrets or proprietary information.

Federal Register/Outside Consultations
The emergency notice soliciting comments on the proposed collection was published in the

Federal Register on July 28, 2006. A copy of the notice appears in Appendix C. People outside
CMS have been consulted about the availability of other data sources for this study and the data
that need to be collected; these include the staff of the evaluation contractor, MPR, and the staff
of the demonstration contractor, Abt Associates. The following people participated in the survey
design:
•

•

MPR Staff
-

Valerie Cheh (609) 275-2385

Karen CyBulski (609) 936-2797

Nancy Duda (609) 945-3340

Barbara Carlson (609) 275-2374

Daniel Kasprzyk (202) 264-3482

CMS Staff
-

Ann Meadow (410) 786-6602

In addition, MPR has pretested the survey instrument by interviewing five home health
agencies. Respondents in the pretest were asked to comment on any questions that were unclear.
There are no unresolved issues regarding this data collection.
9.

Payments/Gift to Respondents
The information that we are requesting from the home health agencies can only be provided

by a representative who is knowledgeable about the agency’s caseload and characteristics. We
expect that this representative will be either the executive director or other senior manager at the
home health agency. To compensate for the time spent filling out the questionnaire and to
increase response we are proposing that compensation of $50 be provided to respondents.

10. Confidentiality
Notification of respondents regarding confidentiality, MPR’s confidentiality procedures, and
the basis for confidentiality assurances are discussed below.
a.

Notification of Respondents
We will mail to sample members an advance letter from CMS informing them of the survey

and asking for their cooperation. It will also inform them that their participation is voluntary.
The letter will assure sample members that their responses will be treated confidentially. It will
also describe the purpose of the study, provide information regarding the monetary compensation
and an estimate of burden, give the name of the contractor conducting the survey, and provide a
toll-free telephone number that the home health agencies can call if they desire more information
about the study. A copy of the letter appears in Appendix D.
b. MPR’s Confidentiality Procedures
MPR maintains extensive, tested procedures to ensure that confidentiality is maintained. As
a condition of employment, all employees must sign a confidentiality pledge affirming that they
accept their responsibility to protect the confidentiality of survey data. This pledge informs them
that a violation may result in termination and possible legal action.
Survey data are maintained in MPR’s Survey Operations Center, access to which is limited.
During working hours, only MPR personnel have access to the Center. Visitors are required to
report to the Center managers or supervisors upon entering the building. The Center is locked
during nonworking hours, with access limited to the Center managers, supervisors, and MPR
senior systems analysts. Interviewers and other MPR personnel do not have access to the center
after working hours.

To ensure that data are protected and that the confidentiality of sample members is
maintained, access to identifying information is limited to project personnel for the period of
time it is needed. The Survey Operations Center is equipped with locked file cabinets for storing
hard-copy questionnaires and other paper documents. Access to these storage units is limited to
project managers and supervisors.
The respondents will provide patient-level medical data in a non-identifiable form. The
survey requires agencies to provide medical information for specific patients. However, prior to
the submission of the survey, the agency will remove all identifiers from the hard-copy
questionnaire. Even after the questionnaires have been received at MPR, identifying information
will neither be kept with completed survey data nor included on the data files provided to clients.
Hard-copy questionnaires and other paper documents are routinely returned to the client or
destroyed after completion of the project in accordance with contract specifications. Similarly,
as required by contract specifications, data are purged from the computer system at the
conclusion of a project or maintained for a set period of time.
c.

Basis for Confidentiality Assurance
Assurance of confidentiality is made on the basis of the Privacy Act of 1974, as amended

(45 CFR 5b), which stipulates that information may be released by the U.S. Department of
Health and Human Services (DHHS) without written consent for a purpose compatible with the
purpose for which the information was collected.
Respondent confidentiality will be ensured by adherence to Section 903(d) of the Public
Health Services Act (42 USC 299 a-1(c)), as follows:
“No information, if an establishment or person supplying the information or
described in it is identified, obtained in the course of activities undertaken or
supported under this title may be used for any purpose other than the purpose for
which it was supplied unless such establishment or person has consented (as
7

determined under regulations or the Secretary) to its use for such other purpose.
Such information may not be published or released in other form if the person
who supplied the information or who is described in it is identifiable unless such
person has consented (as determined under regulations of the Secretary) to its
publication or release in other form.”
No individually identifying information collected by the study will be released.

Only

aggregated data will be reported.
11. Sensitive Questions
The proposed survey does not contain any sensitive questions.
12. Burden Estimates
Table B.1 presents burden and cost estimates for respondents. We estimate that the total
burden associated with the survey will be 75 hours. These estimates of burden are based on a
pretest of respondents who are representative of the study population. The pretest completion
time averaged 30 minutes for the respondents who completed the mail questionnaire. We
estimate that the total cost to respondents for completion of the survey will be $17.50 per
completed response based on hourly wage estimate of $35.
TABLE B.1
BURDEN AND COST ESTIMATES

Questionnaire
Mail Survey

Number of
Respondents

Number of
Responses per
Respondent

Hours per
Response

120

0.50

Total Burden
(Hours)
60

Total Cost to
Respondents
$2,100

13. Capital Costs
Respondents will incur no monetary costs in completing the survey. The advance letter will
include a toll-free telephone number that sample members can call if they have any questions
8

about the survey or would like additional information.

The sample will be selected from

administrative files maintained by CMS. Thus, the selection of the sample will not impose any
costs on the people participating in the survey.
14. Cost to the Federal Government
The total cost to CMS of conducting this survey is $178,776. These costs were estimated by
projecting the number of hours to develop the survey instruments, as well as expected number of
hours to conduct the survey. We multiplied these hours by wage rates of staff expected to
complete the tasks, and added in equipment use costs.
15. Changes to Burden
This is the first submission for this survey; there are therefore no changes or adjustments.
16. Publication/Tabulation Dates
The demonstration began enrolling patients in October 2004. The evaluation of the HHI
demonstration began in January 2005. Data collection for the agency survey will begin on July
2006 and end on October 2006. The data collected in the survey will be tabulated and analyzed
in the Final Report due to Congress by January 2007.
The survey is designed to address the question of why the enrollment rate for the
demonstration was much lower than originally anticipated. Was the failure to enroll beneficiaries
in the demonstration due to: the stringency of eligibility criteria, the lack of knowledge and
support by home health agencies, the extent to which homebound is a problem, or some other
reason or combination of reasons? The survey data will be used for descriptive analyses,
consisting of percentages and frequencies of the key variables to determine which factors limited
enrollment. Table B.2 describes the use of the items in the agency survey.

TABLE B.2
DATA ELEMENTS
Question
1-3
4-9
10
11-14

Data Element
Implementation of Homebound criteria
Extent of homebound problem
Patient characteristics
Demonstration experience

For each state, we will tabulate agencies’ responses to the questions and compare findings
between states. Because we are not formally testing hypotheses, no power calculations or
minimum detectable differences are required.
17. Expiration Date
The proposed data collection will display the OMB number and expiration date in the
introductory letters to be sent to sample members, as well as on the mail version of the survey
instrument.
18. Certification Statement
The proposed data collection does not involve any exceptions to the certification statement
identified in Item 19 of OMB Form 83-I.
C. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS
1.

Respondent Universe and Sampling Methods
Below we describe the target population and sample frame, the sample design, the sample

size, and the selection method. We also discuss postsurvey adjustments to the sample weights
and variance estimation from survey data with a complex design.

Sample Design and Survey Implementation
Overview. The sample for the HHI is drawn in two stages: (1) agencies and (2) patients

within agencies. The goal of the HHI sample design is to select a representative sample of 50
home health agencies that have patients who are potentially eligible for the demonstration in
each of the three participating states (Colorado, Massachusetts, and Missouri), and to select a
representative sample of such patients within each selected agency. Within each of the selected
agencies, we plan to randomly select 5 patients who are potentially eligible for the
demonstration, and for whom the agency will abstract the medical record information needed for
this evaluation.
Eligibility. For sampling purposes, we have decided to include as “potentially eligible”
those patients who have been receiving Medicare home health services from these agencies for
two or more consecutive 60-day episodes, who use technical or human assistance to move, and
who have three or more Activities of Daily Living (ADLs) for which they need assistance. An
agency is considered to be eligible for this sample if it has five or more eligible patients.
Agency Sample. According to the most recent OASIS administrative data we have,2 there
are 60 eligible agencies in Colorado, 80 eligible agencies in Massachusetts, and 81 in Missouri.
If these numbers are similar when looking at updated administrative data, we will randomly
select 50 in each of the three states. Within each state, we will randomly sort the eligible
agencies by zip code, and select a sample of 50 in each, with probability proportional to the
number of potentially eligible patients. We will use a sequential sampling technique based on a

From January 2004 to June 2005.

procedure developed by Chromy.3 If an agency is so large that its probability of selection is one
or greater, we will select that agency with certainty and remove it from the random selection
process. Based on the current data, 20 to 30 agencies per state will be selected with certainty.
Patient Sample. Within each of the selected agencies, we will obtain a list of potentially
eligible patients, with information about their gender and age. We will sort each agency’s list by
gender, and then by age within gender, and select a Chromy sequential sample of 5 patients per
agency with equal probability.
b. Weighting and Precision
After data collection, we will produce agency-level and patient-level analysis weights. At
the agency level, the base weight will be the inverse of the probability of selection of the agency.
The certainty selections will have an agency-level base weight equal to 1. If there is any
ineligibility or nonresponse at the agency level, this will be accounted for in the weights. This
weight should be used for agency-level analyses.
At the patient level, the weight will be the inverse of the patient’s probability of selection
within agency. Should there be any missing medical record abstractions (for example, record not
found), this will be accounted for in the weights as well. The cumulative patient-level weight,
which should be used for patient-level analyses, will be the product of the agency and patient
weights.

For patients within non-certainty agencies, the cumulative weight should be

approximately equal to 1.

The Chromy procedure offers all the advantages of the systematic sampling approach but
eliminates the risk of bias associated with that approach. It makes independent selections within
each of the sampling intervals while controlling the selection opportunities for units crossing
interval boundaries. Chromy, J.R. “Sequential Sample Selection Methods.” Proceedings of the
Survey Research Methods Section of the American Statistical Association, 1979, pp. 401-406.

Variance Estimation
At the agency level, the variance of estimates must account for the unequal weights across

agencies, due to the probability-proportional-to-size selection methodology. Table C.1 shows
the standard errors and 95 percent confidence intervals around estimates using all 50 agencies in
a state, and around estimates from a subgroup of half these agencies. For example, if the
outcome measure of interest is the proportion of agencies that report a certain characteristic, the
in Massachusetts, if that proportion is .4, the standard error would be about .085, and the
confidence interval would be .4 ± .170.
Table C.1. Precision of Agency-Level Estimates
Outcome measure – proportion
of sample equal to:
Colorado
design effecta
Sample size=50
Sample Size=25
Massachusetts
design effect
Sample Size=50
Sample Size=25

1.089
std. error
conf. intvl.b
std. Err.
conf. intvl.

.045
.090
.064
.132

.060
.120
.085
.176

.068
.137
.098
.201

.073
.147
.104
.215

.075
.150
.107
.220

1.462
std. error
conf. intvl.
std. error
conf. intvl.

.052
.104
.074
.153

.069
.139
.099
.204

.079
.159
.113
.233

.085
.170
.121
.250

.086
.174
.123
.255

.073
.146
.104
.214

.078
.156
.111
.229

.079
.159
.113
.234

Missouri
design effect
Sample Size=50

1.233
std. error
.048
.063
conf. intvl.
.096
.128
Sample Size=25
std. error
.068
.091
conf. intvl.
.140
.187
a
Design effect due to unequal weighting.
b
This number represents the half-width of a 95% confidence interval.
N.B. These figures are based on the currently available data.

At the patient level, the variance of estimates must account for the unequal weights across
patients, as well as the clustering effect of the multi-stage design (for patients selected within
non-certainty agencies). Table C.2 shows the standard errors and 95 percent confidence intervals
around estimates using all 250 patients in a state, and around estimates from a subgroup of half

these patients. For an estimated proportion of about .2 made from all 250 patients selected in
Colorado, the standard error would be about .034, and the confidence interval would be .2 ±
.067.
Table C.2 Precision of Patient-Level Estimates
proportion= .1
or .9

.2
.8

.3
.7

Colorado
Sample
std. error
.026
.034
.039
Size=250
conf. intvl.a .050
.067
.077
Sample
std. err.
.036
.048
.055
Size=125
conf. intvl. .071
.095
.109
Massachusetts
Sample
std. error
.028
.037
.043
Size =250
conf. intvl. .055
.074
.084
Sample
std. error
.040
.053
.061
Size=125
conf. intvl. .079
.105
.120
Missouri
Sample
std. error
.026
.035
.040
Size=250
conf. intvl. .051
.068
.078
Sample
std. error
.037
.049
.056
Size=125
conf. intvl. .073
.097
.111
a
This number represents the half-width of a 95% confidence interval.
N.B. These figures are based on the currently available data.

.4
.6

.5
.5

.042
.082
.059
.117

.043
.084
.060
.119

.046
.090
.065
.129

.047
.092
.066
.131

.043
.084
.060
.119

.043
.086
.061
.121

When analyzing data resulting from a complex sample design, it is important to account for
the design when calculating the variance of an estimate. Because of the unequal weighting and
clustering, a specialized approach (such as Taylor Series or replication techniques) must be used
to properly calculate the variances. These techniques are available in statistical packages such as
SUDAAN and Stata.
2.

Procedures for the Collection of Information
There will be three mailings to the home health agencies. The first will contain an advance

letter that explains the purpose of the study and provides MPR’s toll-free telephone number for
agencies that have questions, a contact person, and information about the monetary

compensation for participation. This letter will be mailed first class and sent one week before the
first questionnaire mailing. A week later, a second mailing will be sent, containing a cover letter,
the questionnaire, and a return FedEx envelope. The cover letter will contain content similar to
that of the advance letter and will address confidentiality concerns. We will send a second
questionnaire mailing one month after the first questionnaire mailing. The cover letter will be
modified to address issues of nonresponse and will include letters, if available, from the
appropriate state and national home health associations. Both questionnaire mailings will be sent
by priority mail. Agencies that return completed questionnaires will receive $50 in compensation
for their time.
After questionnaires have been received and entered into the system, they will be quickly
routed for data entry. We will develop procedures for identifying critical items and conducting
follow-up calls to collect missing or inconsistent information. We will begin the telephone phase
two weeks after the second questionnaire mailing. This phase will consist of two major activities:
(1) locating telephone numbers for HHAs, and (2) making telephone reminder calls to the
agencies who have not return the mail instrument. We estimate that about 40 percent of the
initial sample will be referred to the telephone phase for item follow-up and reminders. When we
begin the telephone phase, we will update the telephone sample daily to eliminate, as much as
possible, calls to respondents who have completed mail instruments.
3.

Methods to Maximize Response Rates and Deal with Nonresponse
To assure the validity of the response to the survey, the survey seeks a response rate of

80 percent. To achieve the highest possible response, we will undertake the following steps for
the collection of information:
1. Pretesting. We pretested the instrument to assure that the language, questions,
pathing, and format are readily comprehensible to the targeted population.
15

Respondents are much less apt to refuse a question or, indeed, the entire
questionnaire, when they can understand the task they are being asked to accomplish.
We conducted this limited pretest of the entire questionnaire with 9 agencies
resembling the targeted population.
2. Support of home health associations. A key to achieving this response rate will be
the support of state and national home health associations. We discussed this with the
state associations and asked them to provide a letter of support. We have provided
the home health associations an opportunity to comment on the survey instrument.
3. Data collection materials. The focus of all respondent materials (advance and
refusal conversion letters) will be to secure respondent cooperation through the
clarity, simplicity, and thoroughness of the materials.
4. Data collection methods. Section C.2 described several data collection techniques
that will minimize nonresponse: sending advance letters, offering an incentive, and
calling agencies who have not returned completed questionnaires.
We will also assess and address any nonresponse in the postsurvey analysis phase. If the
agencies which fail to respond to a survey would have provided systematically different answers
from those who do respond, then the survey estimates obtained only from respondent data will be
biased. We will calculate adjustments to the sampling weights to compensate for such bias.
Finally, survey data collected for this evaluation are subject to item nonresponse. Item
nonresponse occurs when the beneficiary participates in the survey but is unable or unwilling to
answer all the questions. Upon receipt of a completed survey, project staff will check the survey
against a list of critical data elements. Any uncompleted items will trigger a call to the agency to
obtain or clarify the missing/incomplete data. Remaining item non-response will be handled by
including a missing category in the analysis.
4.

Tests of Procedure or Methods to be Undertaken
To estimate completion time and uncover problems in questionnaire wording and logic, we

conducted a pretest of the mail questionnaire with nine respondents. These respondents were
representative of the full study sample. No significant problems were uncovered.

Persons Consulted on Statistical Aspects and Persons Collecting and/or Analyzing
Data
Mathematica Policy Research, Inc. (MPR) is conducting this study, including collecting and

analyzing the survey data, under contract to CMS (contract no: CMS 500-00-0033 (06)). The
MPR person responsible for the statistical aspects of the sample design is Barbara Lepidus
Carlson (609-275-2374). Karen CyBulski of MPR (609-936-2797) will direct the data collection
effort. Valerie Cheh of MPR (609-275-2385) is the project director with overall responsibility
for the project, and will lead the analysis. Ann Meadow of CMS (410-786-6602) is the technical
Project Officer for the task order

APPENDIX A
APPLICABLE LEGISLATION

PUBLIC LAW 108–173—DEC. 8, 2003
SEC. 702. DEMONSTRATION PROJECT TO CLARIFY THE DEFINITION
OF HOMEBOUND.

(a) DEMONSTRATION PROJECT.—Not later than 180 days after
the date of the enactment of this Act, the Secretary shall conduct
a 2-year demonstration project under part B of title XVIII of the
Social Security Act under which medicare beneficiaries with chronic
conditions described in subsection (b) are deemed to be homebound
for purposes of receiving home health services under the medicare
program.
(b) MEDICARE BENEFICIARY DESCRIBED.—For purposes of subsection
(a), a medicare beneficiary is eligible to be deemed to be
homebound, without regard to the purpose, frequency, or duration
of absences from the home, if—
(1) the beneficiary has been certified by one physician
as an individual who has a permanent and severe, disabling
condition that is not expected to improve;
(2) the beneficiary is dependent upon assistance from
another individual with at least 3 out of the 5 activities of
daily living for the rest of the beneficiary’s life;
(3) the beneficiary requires skilled nursing services for
the rest of the beneficiary’s life and the skilled nursing is
more than medication management;
(4) an attendant is required to visit the beneficiary on
a daily basis to monitor and treat the beneficiary’s medical
condition or to assist the beneficiary with activities of daily
living;
(5) the beneficiary requires technological assistance or the
assistance of another person to leave the home; and
(6) the beneficiary does not regularly work in a paid position
full-time or part-time outside the home.
(c) DEMONSTRATION PROJECT SITES.—The demonstration project
established under this section shall be conducted in 3 States selected
by the Secretary to represent the Northeast, Midwest, and Western
regions of the United States.
(d) LIMITATION ON NUMBER OF PARTICIPANTS.—The aggregate
number of such beneficiaries that may participate in the project
may not exceed 15,000.
(e) DATA.—The Secretary shall collect such data on the demonstration
project with respect to the provision of home health
services to medicare beneficiaries that relates to quality of care,
patient outcomes, and additional costs, if any, to the medicare
program.
(f) REPORT TO CONGRESS.—Not later than 1 year after the
date of the completion of the demonstration project under this
section, the Secretary shall submit to Congress a report on the
project using the data collected under subsection (e). The report
shall include the following:
(1) An examination of whether the provision of home health
services to medicare beneficiaries under the project has had
any of the following effects:
(A) Has adversely affected the provision of home health
services under the medicare program.
(B) Has directly caused an increase of expenditures
under the medicare program for the provision of such services
that is directly attributable to such clarification.
Deadline.

Deadline.
42 USC 1395x
note.
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117 STAT. 2336 PUBLIC LAW 108–173—DEC. 8, 2003
(2) The specific data evidencing the amount of any increase
in expenditures that is directly attributable to the demonstration
project (expressed both in absolute dollar terms and as
a percentage) above expenditures that would otherwise have
been incurred for home health services under the medicare
program.
(3) Specific recommendations to exempt permanently and
severely disabled homebound beneficiaries from restrictions on
the length, frequency, and purpose of their absences from the
home to qualify for home health services without incurring
additional costs to the medicare program.
(g) WAIVER AUTHORITY.—The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) to such extent and for such period as
the Secretary determines is necessary to conduct demonstration
projects.
(h) CONSTRUCTION.—Nothing in this section shall be construed
as waiving any applicable civil monetary penalty, criminal penalty,
or other remedy available to the Secretary under title XI or title
XVIII of the Social Security Act for acts prohibited under such
titles, including penalties for false certifications for purposes of
receipt of items or services under the medicare program.
(i) AUTHORIZATION OF APPROPRIATIONS.—Payments for the costs
of carrying out the demonstration project under this section shall
be made from the Federal Supplementary Medical Insurance Trust
Fund under section 1841 of such Act (42 U.S.C. 1395t).
(j) DEFINITIONS.—In this section:
(1) MEDICARE BENEFICIARY.—The term ‘‘medicare beneficiary’’
means an individual who is enrolled under part B
of title XVIII of the Social Security Act.
(2) HOME HEALTH SERVICES.—The term ‘‘home health services’’
has the meaning given such term in section 1861(m)
of the Social Security Act (42 U.S.C. 1395x(m)).
(3) ACTIVITIES OF DAILY LIVING DEFINED.—The term ‘‘activities
of daily living’’ means eating, toileting, transferring,
bathing, and dressing.

APPENDIX B
SURVEY INSTRUMENT

FORM APPROVED:
OMB No.
APPROVAL EXPIRES:

Survey of Home Health Agencies
May 9, 2006

Centers for Medicare & Medicaid Services (CMS)

INSTRUCTIONS
This questionnaire should be completed by the person or persons who know the most about the
composition of the home health agency’s caseload and activities related to CMS’s Home Health
Independence Demonstration. Even if your agency did not participate in this demonstration, it is
very important that you complete this questionnaire. Please use black or blue ink to complete this
questionnaire. Most questions can be answered by simply placing a check mark in the appropriate
box. For a few questions you will be asked to write in a response. If you are unsure about how to
answer a question, please give the best answer you can rather than leaving it blank.
If you have any questions, please contact Valerie Cheh, the study director, at Mathematica Policy
Research, Inc. (609) 275-2385, Monday through Friday, between 9:00 a.m. and 5:00 p.m. (Eastern
Time). Valerie Cheh is also available to answer your questions via email at: vcheh@mathematicampr.com.
Please return the completed questionnaire in the enclosed pre-paid Federal Express mailer
by ______________________. If you need to arrange for Federal Express pick-up, you can call
the toll-free 800 number on the mailer.
As a token of our appreciation you will receive $50 for completing this questionnaire.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection will be entered after clearance. The time required to complete this
information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection.

The Home Health Independence Demonstration
The Medicare Home Health Independence Demonstration is a project being conducted by the Centers for
Medicare and Medicaid Services (CMS) that allows qualifying Medicare beneficiaries who receive Medicare
home health benefits in COLORADO, MASSACHUSETTS, and MISSOURI to leave their home more
frequently and for longer periods without risking the loss of those benefits. You may know this demonstration
as the Homebound Exemption Demonstration.
Who can participate in the Home Health Independence Demonstration?
To be eligible for the demonstration, the individual must be a Medicare beneficiary who is enrolled in Part B,
meets all of the eligibility criteria for Medicare home health, and receives home health services under the
traditional Medicare home health benefit and NOT through an HMO. In addition to these requirements, the
individual must meet six additional criteria, which are as follows:
(a) Beneficiary has a permanent and severe disabling condition that is not expected to improve;
(b) Beneficiary requires skilled nursing services for the rest of beneficiary’s life (not necessarily daily or
with any fixed frequency) and the skilled nursing is more than medication management;
(c) Beneficiary requires technological assistance or the assistance of another person to leave the
home;
(d) Beneficiary does not regularly work in a paid position full-time or part-time outside the house;
(e) Beneficiary is dependent upon assistance from another individual with at least 3 out of the 5
activities of daily living (eating, toileting, transferring, bathing and dressing) for the rest of
beneficiary’s life;
(f) An attendant is required on a daily basis to monitor and treat the beneficiary’s medical condition or
to assist the beneficiary with activities of daily living.
This ability to leave home more often, for any purpose, and for longer periods of time is the ONLY change
under the demonstration. Beneficiaries must meet ALL the other usual eligibility and coverage criteria for
Medicare home health care (including having limitations that make leaving home require a considerable and
taxing effort). The Home Health Independence Demonstration began on October 4, 2004 and runs for two
years. A maximum of 15,000 Medicare beneficiaries (across all 3 states) are allowed to participate.

Questions 1-3 are how your agency defines homebound.
1.

Please check all the specific activities for which the
“homebound” patient may leave the house without
any limits on the frequency or length of absences
without jeopardizing his or her homebound status
and still be eligible for Medicare home health.

CHECK ONE BOX ONLY
1 ! Less than 10 percent
2 ! 11-25 percent
3 ! 26-50 percent
4 ! 51-75 percent
5 ! 76-99 percent
6 ! 100 percent

CHECK ALL THAT APPLY

1
2
3
4
5
6
7

!
!
!
!
!
!
!

Have dinner with family members
Visit the doctor or medical institutions
Go to religious services
Shopping for food
Shopping for clothes
Visiting friends
None of the above

Under normal circumstances, a homebound patient
can leave the house no more than:
CHECK ONE BOX ONLY
1 ! Once a month
2 ! Once a week
3 ! Two or three times a week
4 ! Four or five times a week
5 ! More than five times a week
6 ! Can’t leave the house for any other activities

Please answer questions 4 through 9 based on your
agency’s last fiscal year. Your state annual report may be
helpful in answering these questions.
What was the total number of patients your agency
served in the last fiscal year?

Approximately what percent of these patients had
Medicare as their primary payer?
|

MEDICARE

Prepared by Mathematica Policy Research, Inc.

Of the denied Medicare referrals, approximately
what percent met all of the requirements for
Medicare home health except the patient was not
homebound?
CHECK ONE BOX ONLY
1 ! 0-2 percent
2 ! 3-10 percent
3 ! 11-25 percent
4 ! 26-50 percent
5 ! 51-75 percent
6 ! 76-100 percent
7 ! 100 percent

__________ NUMBER OF PATIENTS

In the last fiscal year, approximately how many
Medicare referrals did your agency not admit for
home health services?
CHECK ONE BOX ONLY
1 ! 0 - 10
2 ! 11 - 25
3 ! 26 - 50
4 ! 51 - 75
5 ! 76 - 100
6 ! Over 100 (Please estimate specific number)

Under normal circumstances, the maximum amount
of time a homebound patient may be away from
home is:
CHECK ONE BOX ONLY
1 ! Less than 30 minutes
2 ! 30-59 minutes
3 ! 1-2 hours
4 ! 3-4 hours
5 ! More than 5 hours
6 ! Can’t leave the house for any other activities

Of the Medicare patients who were discharged,
approximately what percent were discharged
because they were no longer homebound?
CHECK ONE BOX ONLY
1 ! 0-2 percent
2 ! 3-10 percent
3 ! 11-25 percent
4 ! 26-50 percent
5 ! 51-75 percent
6 ! 76-100 percent
7 ! 100 percent

For the next two questions, please exclude any activities that
you marked in question 1.
2.

In the last fiscal year, approximately what percent
of your total Medicare patients were discharged
from receipt of home health care services?

Eligibility Criterion
0 NO

!
0 NO

0 NO

!
0 NO

1 YES
1 YES
1 YES

3. Eating

4. Toileting

5. Transferring

Prepared by Mathematica Policy Research, Inc.

1 YES

2. Dressing

1 YES

d. Needs permanent help with
ADL:
1. Bathing
0 NO
0 NO
0 NO
0 NO
0 NO

!
!
!
!

0 NO

1 YES

0 NO

_________________________

1 YES

_________________________

1 YES

_________________________

_________________________
1 YES

_________________________

1 YES

_________________________

c. Needs permanent skilled
nursing care for medication
management only

Specify skilled nursing care

b. Needs permanent skilled
nursing care (not including
medication management)

Specify medical conditions
and ICD-9 codes

Name

Name
1 YES

HIC #

!
0 NO

1 YES

0 NO

_________________________

1 YES

_________________________

1 YES

Name

HIC #

!
0 NO

0 NO

1 YES

0 NO

_________________________

1 YES

_________________________

________________________

_________________________

1 YES

Name

HIC #

0 NO

1 YES

0 NO

_________________________

1 YES

_________________________

1 YES

Name

HIC #

The last question is about patients who have received Medicare home health services from your agency within the past two years. We have
identified 5 patients and have listed their Medicare ID number and name at the top of each column. To answer these questions, it is important to
review the patient’s medical record For each patient, please indicate whether or not the patient meets each eligibility criteria.

a. Has a permanent and
severe disabling condition

10.

Able to leave the house if
homebound requirement
is waived

1 YES

0 NO

! DON’T KNOW

WORKS FROM
HOME

1 YES

0 NO

! DON’T KNOW

1 YES

WORKS FROM
HOME

! EMPLOYED,

! EMPLOYED, ON

! EMPLOYED,
3

0 NO

! NOT EMPLOYED

SICK LEAVE

1 YES

SICK LEAVE

! EMPLOYED, ON

1 YES

0 NO

! NOT EMPLOYED

0 NO

1 YES

0 NO

! DON’T KNOW

WORKS FROM
HOME

! EMPLOYED,

SICK LEAVE

! EMPLOYED, ON

! NOT EMPLOYED

1 YES

Prepared by Mathematica Policy Research, Inc.

0 NO

1 YES

0 NO

! DON’T KNOW

WORKS FROM
HOME

! EMPLOYED,

SICK LEAVE

! EMPLOYED, ON

! NOT EMPLOYED

1 YES

Please remove the labels from the top of each column when you have completed this section.

i. Number of episodes of
home health care received
in the last 12 months

3. Hospice Benefit

2. Medicare Advantage

1. Part B

h. Medicare coverage:

(CHECK ONE ONLY)

1 YES

f. Requires human or
technological assistance
to leave the home

g. Employment status:

1 YES

e. Requires an attendant (not
necessarily paid) on a
daily basis to treat and
monitor medical condition
or provide ADL assistance
for rest of beneficiary’s life

Eligibility Criterion

0 NO

1 YES

0 NO

! DON’T KNOW

WORKS FROM
HOME

! EMPLOYED,

SICK LEAVE

! EMPLOYED, ON

! NOT EMPLOYED

1 YES

11. How many patients did your agency enroll in the demonstration?
|

| NUMBER OF PATIENTS YOUR AGENCY ENROLLED IN THE DEMONSTRATION

12. Please use the space below to describe any problems your agency encountered enrolling patients into the
demonstration or reasons why your agency decided not to participate in the demonstration?

13. Do you think the homebound criteria is still a major issue for Medicare patients?

YES !

NO !

14. Please describe the type of patients for whom you think the homebound criteria should be waived.

Thank you for completing the survey. Please fill out your name, address and telephone number on the label
below. We will use this information to send you the check for $50 for completing the survey. We will use the
telephone number to call you if we have any questions regarding your responses. All of your information is
confidential. We will remove the label from this form. Information reported to CMS will not be identified by
person or agency.

Prepared by Mathematica Policy Research, Inc.

APPENDIX C
FEDERAL REGISTER NOTICE

APPENDIX D
AGENCY INTRODUCTION
LETTER

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard
Baltimore, MD 21244-1850

July 2006
«NameNew»
«Address1»
«Address2»
«City», «State» «Zip»
Dear «Salutation»:
I am writing to ask for your help with an important study sponsored by the Centers for Medicare and
Medicaid Services (CMS) about the Home Health Independence Demonstration. Mandated under
Section 702 of the Medicare Modernization Act (MMA) of 2003, the demonstration allowed beneficiaries
meeting certain requirements to waive the homebound requirement while receiving home health services.
The demonstration was implemented in the states of Massachusetts, Missouri and Colorado on October 4,
2004. You may also know the demonstration under the name of Homebound Exemption Demonstration.
The purpose of the survey is to learn about your agency’s experiences with the homebound
requirement and the home health independence demonstration. Specifically, the survey includes questions
about the agency’s understanding of the homebound requirement and the number of people who are
affected by it, and characteristics of the agency’s caseload and whether particular demonstration
requirements kept otherwise qualified beneficiaries from participating. Results from this study are
important to the development of policy related to the homebound requirement for home health patients, so
we hope you will agree to participate.
CMS has hired Mathematica Policy Research, Inc. a private national research firm to conduct the
survey. We assure you that all information collected will be totally confidential and will not be reported
in any way that identifies you or your agency personally. We are only collecting this information for
research purposes and to improve program operations—it will not be used for payment or any other
purposes .
Please help us by completing the enclosed survey, which should take about 30 minutes to complete.
In appreciation of your time and effort, we will send a check of $50 upon receipt of your completed
survey. If you have any questions, or wish to set up an interview time, please call Mathematica and say
you are calling about the Home Health Independence Demonstration Survey. The toll-free number is
XXX-XXXX.

Thank you for your assistance.
Sincerely,
CMS Privacy Officer
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. The
time required to complete this information is 45 minutes per response. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving the questionnaire, please write to: CMS, 7500 Security Boulevard, N2-14-266,
Baltimore, Maryland 21244-1850.

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File Modified	2006-07-20
File Created	2006-06-16