(Medicare Claims Processing Manual)

Subcontractors may deliver HHCCNs under the direction of a primary HHA; however, notification responsibility, including effective delivery, always rests with the primary HHA. HHAs are always responsible for providing HHCCNs associated with the care that they provide. In the form instructions and instructions in this section, the term beneficiary is used to mean the beneficiary or the beneficiary's representative, as applicable.  For more inf ormation on representatives, see 40.3.5 and 40.3.4.3 of this chapter.   HHAs should contact their CMS Regional Office if they have questions on the HHCCN or related instructions. Beneficiaries who need assistance may be directed to call 1 -800-MEDICARE.   60.3 - Triggering Events for HHCCN/Written Notice  (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  HHAs may be required to provide an HHCCN to an Original Medicare beneficiary at two points in time, for reasons not related to Medicare coverage called triggering events:   Table 2  Triggering Events for HHCCN Issuance EVENT  DESCRIPTION  Reduction  of a service   When an HHA reduces or stops an item and/or service during a spell of illness while continuing others, including when one home health discipline ends but others continue.  Termination  of all services  When an HHA ends delivery of all services.   A.  Reductions   Reductions involve any decrease in items and/or services, such as frequency, amount, or level of care, provided by the HHA. When care that is listed on the POC or provided by the HHA is reduced, the beneficiary must receive the HHCCN listing the items/serv ices being reduced and the reason for the reduction, regardless of who is responsible for paying for that service.   When a reduction occurs because the HHA decides to stop providing the service for administrative reasons or because of a physicians order, the HHCCN must be issued.  Example 1  Reduction for HHA reasons:   Because of a temporary staffing shortage, an HHA reduces daily physical therapy (PT) to PT 3 times weekly for 2 weeks.   The HHCCN must be issued to the beneficiary prior to this care reduction that is due to an agency administration issue.   Example 2 Reduction based on physicians orders:   The beneficiary met PT goals sooner than expected, and the attending physician writes an order to discontinue home PT. Physical therapy services are discontinued with no change in existing skilled nursing orders.   The HHCCN must be issued to the beneficiary prior to this care reduction that is a change to the existing POC because of a physicians order. Reductions include cases, such as this, where one type of care ends, but the beneficiary continues to receive anot her type of home health service.   An ABN is issued (and not the HHCCN) if a reduction occurs for an item or service that will no longer be covered by Medicare but the beneficiary wants to continue to receive the care and assume the financial charges.  See Section 50.15.4.  B.  Terminations   A termination is the cessation of all services provided by the HHA and can include Medicare covered and noncovered care. When all home health care is ending for reasons not related to Medicare coverage, the HHA issues the HHCCN with information appropriate  to the specific situation.   Example 1  care termination due to agency reasons (such as staffing, closure of the HHA, concerns for staff safety), not related to Medicare coverage.   An HHA decides to stop providing care because guard dogs at the home where the care is being furnished have posed safety issues for staff.   Because termination is due to an HHA administrative decision, the HHCCN must be given to the beneficiary prior to discontinuation of services.   Example 2  care termination due to agency reasons (failure to meet face to face encounter requirement)   An HHA has initiated care for a beneficiary, and the beneficiary has not yet had the required face to face encounter with the certifying physician or an allowed non-physician practitioner (NPP). The HHA believes that the face to face encounter requirement will not be met in the allowed time frame and decides to stop providing care.   This termination is due to an HHA administrative decision; thus, the HHCCN must be given to the beneficiary prior to discontinuation of services. Issuing the HHCCN does not affect financial liability but serves as a written change of care notice as required by the HHA COPs.   Example 3  care termination due to a physicians orders to discontinue care or a lack of orders to continue care   A physician orders discontinuation of all home health services or fails to order continued home health services.   The Notice of Medicare Provider Non- Coverage (NOMNC), CMS -10123 must be issued to the beneficiary when all Medicare covered services are ending based on the physicians orders. Since the NOMNC provides written notification of the forthcoming termination of  all home health care, it satisfies the regulatory requirement for change of care advisement (HHCCN issuance). Thus, when the NOMNC is issued as required, the HHA doesnt have to issue a separate HHCCN. When home health services end because of physicians orders, HHAs have the option of issuing the NOMNC alone or both the NOMNC and the HHCCN.   Detailed information and instructions for issuing the NOMNC can be found on the CMS website at:  http://www.cms.gov/Medicare/Medicare -General -Information/BNI/FFSEDNotices.html  C.  Effect of Other Insurers/Payers   HHCCN requirements apply only when home health services are expected to be partially or fully covered by Medicare. When a beneficiary is not receiving any services that are expected to be covered under the Medicare home health benefit, the HHCCN is not required. For example, if a dual eligible beneficiary (having both Medicare and Medicaid) is not receiving any Medicare covered home health services, HHCCN issuance wouldnt be  required when changes of care occur. ( NOTE:  HHAs are required to issue the ABN to dual eligible beneficiaries when applicable. See Section 50.15.4 C)   D.  Exceptions to HHCCN Notification Requirements   The HHCCN is NOT required when changes in care involve:    increase in care;    changes in HHA caregivers or personnel as decided by the HHA;    changes in expected arrival or departure time for HHA staff as determined by the HHA;    changes in brand of product, ( i.e., the same item produced by a different manufacturer) as determined by the HHA;    change in the duration of services that has been included in the POC and communicated to the beneficiary by the HHA, ( i.e., shorter therapy sessions as health status improves, such as a reduction from an hour to 45 minutes);    lessening the number of items or services in cases where a range of services is included in the POC;    Example:  The POC order states:  PT 3 -5x per week as needed for gait training. The therapist begins therapy at 5 times per week, and as the patient progresses, therapy is reduced to 3 times per week. No HHCCN would be needed in this case.    changes in the mix of services delivered in a specific discipline (e.g., skilled nursing) with no decrease in frequency with which that discipline is delivered;   Example:  A beneficiary is receiving several skilled nursing services during visits that are scheduled 3 times a week.  One service within that discipline, a blood draw 1 time a week, is discontinued.  Other skilled nursing services (wound care and education) conti nue, such that skilled nursing visits continue to occur 3 times per week.  No HHCCN is required when the blood draws are discontinued, only when skilled nursing is reduced in frequency.    changes in the modality affecting supplies employed as part of specific treatment (e.g., wound care) with no decrease in the frequency with which those supplies are provided; or   Example:   A specific wound care product like Alldress is stopped, and a Hydrogel pad is started.  Since this represents a change in the modality (or intervention) and not a reduction, no HHCCN is necessary.    changes in care that are the beneficiarys decision and are documented in the medical record.   60.4 - Completing the HHCCN  (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  A.  Notices and General Notice Requirements   The HHCCN and the general instructions for preparing the HHCCN are available for download at the home health notice link found at http://www.cms.gov/Medicare/Medicare -General -Information/BNI/index.html .  The notice is available in English and Spanish, and in PDF and Word formats.  The HHCCN is the Office of Management and Budget (OMB) approved standard notice for use by Medicare HHAs to inform beneficiaries of changes in the POC when required by the COPs f or HHAs.  HHAs must use the OMB approved standard notice. HHAs must not add any customizations to the notice beyond what is permitted by the accompanying HHCCN form instructions and the guidelines published in this section.   B.  Choosing the Correct Language Version   HHAs should choose the appropriate version of the HHCCN based on the language the beneficiary best understands.  When a Spanish- language HHCCN is used, the HHA should make insertions on the notice in Spanish.  If this is impossible, the HHA must take addit ional steps needed to assure beneficiary comprehension and document this on the HHCCN.   If needed, HHAs must provide verbal assistance in other languages to assist beneficiaries in understanding the document. HHAs should document any types of translation assistance used in the Additional Information section of the notice.   C.  Compliance with Paperwork Reduction Act of 1995  Consistent with the Paperwork Reduction Act of 1995, the valid OMB control number for this information collection appearing on the HHCCN is 0938- 1196.  The estimated time required to complete this information collection is 4 minutes for a single notice. This includes the time to prepare the notice, review it with the beneficiary, and obtain the beneficiarys signature.   D.  Effective Dates   HHCCNs are effective for HHA use per the OMB assigned date given at the bottom of each notice unless CMS instructs HHAs otherwise.  The routine approval is for 3- year use. HHAs are expected to exclusively use the effective version of the HHCCN per CMS directives.   60.5 - HHCCN Delivery  (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  HHAs must make every effort to ensure beneficiaries understand the entire HHCCN prior to signing it. When delivering HHCCNs, HHAs are required to explain the notice and its content, and answer beneficiary questions to the best of their ability.  If abbreviations are used, the HHA should explain their meaning to the beneficiary.  If the beneficiary requests additional information while completing the HHCCN, the HHA must respond timely, accurately, and completely to the information request.   While in -person delivery of the HHCCN is preferable, it is not required consistent with general ABN requirements, see Medicare Claims Processing Manual, Chapter 30, 40.3.4.1.  If a mode other than in person delivery is used, the HHA must adhere to the requirements under the Health Insurance Portability and Accountability Act (HIPAA). Instructions on ABN telephone notice found in 40.3.4.2 of this chapter are also applicable to H HCCNs.   Delivery when change of care is due to agency administrative reasons   The HHA should review the text associated with the box that was checked on the HHCCN by the HHA and verbally explain to the beneficiary that he/she may be able to obtain the same or similar care from another HHA, since coverage through Medicare is not affe cted. HHAs are encouraged to do as much as possible to offer ideas to beneficiaries for contacting other HHAs and must inform ordering physicians of reductions/terminations consistent with the COPs for HHAs.   Delivery when change of care is due to physician orders   The HHA should review the text associated with the box that was checked on the HHCCN by the HHA, and inform the beneficiary that the HHA will no longer provide certain care because the physicians order has changed.  When requested, the HHA may facilitate contact and understanding between the physician and beneficiary. The beneficiary may also seek to contact the physician directly.  Retention of the HHCCN   The HHA keeps a copy of the completed, signed or annotated HHCCN in the beneficiarys record, and the beneficiary receives a copy. HHAs may retain a scanned copy of the paper copy document in an electronic medical record if desired.  The primary HHA must retain the HHCCN if a subcontractor is used.  Applicable retention periods are discussed in Chapter 1 of this manual, 110.  In general, this is 5 years from discharge when there are no other applicable requirements under State law.   Other Considerations During Completion   1.  Beneficiary Unable to Sign