(Medicare Claims Processing Manual)

1879(g)(1)(A) Beneficiary is not homebound Medicare requires that a beneficiary cannot leave home (with certain exceptions) in order to cover services      1879(g)(1)(B) Beneficiary does not need skilled nursing care on an intermittent basis  Medicare requires part-time or intermittent need for skilled nursing care in order to cover        Triggering Events for ABN issuance by HHAs*   HHAs may be required to provide an ABN to an Original Medicare beneficiary when a triggering event occurs.   EVENT  DESCRIPTION  EXAMPLE  Initiation  An ABN must be issued to the beneficiary prior to receiving care that is usually covered by A beneficiary requires skilled nursing Medicare, but in this particular instance, it is not covered or may not be covered by Medicare because the care is not medically reasonable and  necessary, the beneficiary is not confined to his/her home (considered  homebound), or the beneficiary does not need skilled nursing care on an intermittent basis,  or the beneficiary is receiving custodial care  only.  wound care 3 times weekly; however, she is not confined to the home.  She wants the care done at her home by the HHA.   Reduction  Reductions involve any decrease in services or supplies, such as frequency, amount, or level of care, provided by the HHA and/or care that is part of the POC.  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, the HHA must issue the ABN prior to providing the non- covered items or servi ces. The beneficiary requires physical therapy (PT) for gait retraining 5 times per week for 2 weeks, then reduce to 3 times weekly for 2 weeks.  After 2 weeks of PT, the beneficiary wants to continue therapy 5 times a week even though this amount of therapy is  no longer medically reasonable and necessary.  The HHA would issue an ABN to the beneficiary so that he understands the situation and can consent to financial responsibility for the PT not covered by Medicare.  Termination  When an HHA expects that Medicare coverage will end for all items and services in total.   *If the beneficiary does not want the item or service that is being initiated, reduced, or terminated, no ABN is  required.  When an HHA performs an initial assessment of a beneficiary prior to admission but does not admit the beneficiary, an ABN is not required if there is no charge for the assessment.  However, if an HHA charges for an assessment, the HHA must provide notice to the beneficiary before perform ing and charging for this service.   Since Medicare has specific requirements for payment of home health services, there may be occasions where a payment requirement is not met, and therefore, the HHA expects that Medicare will not pay for the services.  The HHA cannot use the ABN to transfer  liability to the beneficiary when there is concern that a billing requirement may not be met.  For example, a home health agency cant issue an ABN at initiation of home care services in order to charge the beneficiary if the healthcare provider face to f ace encounter requirement is not met. When all Medicare covered home health care is terminated, HHAs may sometimes be required to deliver the NOMNC, CMS - 10123.  The NOMNC informs beneficiaries of the right to an expedited determination by a Quality Improvement Organization (QIO) if they feel that termination of home health services is not appropriate.  If a beneficiary requests a QIO review upon receiving a NOMNC, the QIO will make a fast decision on whether covered services should end.  If the QIO decides that Medicare covered care should end and the patient wishes to continue receiving care from the HHA even though Medicare will not pay, an ABN must be issued to the beneficiary since this would be an initiation of non- covered care.   HHA Exceptions to ABN Notification  Requirements   ABN issuance is NOT required in the following HHA situations:    initial assessments (in cases where beneficiaries are not admitted) for which HHAs do not charge;    care that is never covered by Medicare under any circumstances (i.e., an HHA offers complimentary hearing aid cleaning and maintenance);    telehealth monitoring used as an adjunct to regular covered HH care;  or    non-covered items/services that are part of care covered in total under a Medicare bundled payment (e.g., HH prospective payment system (PPS) episode  payment).   60 - Home Health Change of Care Notice (HHCCN), Form CMS -10280 (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  This section provides the standards for use by home health agencies (HHAs) in implementing the Home Health Change of Care Notice (HHCCN), Form CMS -10280, requirements.  The HHCCN is issued to Original Medicare beneficiaries before reducing or terminating most ongoing care provided by the HHA.   HHCCN Quick Glance Guide  This is an abbreviated reference tool and is not meant to replace or supersede any of the directives contained in Section 60.  Notice Name  Home Health Change of Care Notice (HHCCN)  Notice Number  Form CMS -10280  Issued by  Home Health Agency (HHA) provider  Recipient  Original Medicare (fee for service) beneficiary receiving home health care  Pertinent Information  The HHCN replaces HHABN Option Box 2 and Option Box 3.  The Advance Beneficiary Notice of Noncoverage (ABN), CMS -R-131, replaces HHABN Option Box 1.  See section 50 for ABN information and instructions.  Change of care notice   Prior to the HHA reducing or discontinuing care listed in the beneficiarys plan of care (POC) for administrative reasons specific to the HHA on that occasion  Immediately on determination,   or if possible, provide enough time for the beneficiary to arrange to obtain the reduced or discontinued home health care service(s) from a different HHA.  No.  Prior to the HHA reducing or discontinuing Medicare covered care listed in the POC because of a physician ordered change in the plan of care or a lack of orders to continue the care  Notify the beneficiary before the actual reduction or discontinuation, if possible.  No.  The HHCCN replaces the Home Health Advance Beneficiary Notice (HHABN), CMS -R-296, Option Box 2 and Option Box 3. Option Box 1 of the HHABN is replaced by the existing  Advance Beneficiary Notice of Noncoverage (ABN),CMS -R-131, which is detailed in Section 50 of this chapter.  HHAs should begin using the ABN and HHCCN in place of the HHABN as soon as possible since the HHABN will be discontinued.  The date for mandatory use of the HHCCN and ABN in place of the HHABN will be posted on the web link for home he alth notices at http://www.cms.gov/Medicare/Medicare -General -Information/BNI/index.html .   Table 1 HHA Notice Changes  Instead of:  Use:  HHABN Option Box 1  ABN (CMS -R-131) HHABN Option Box 2  HHCCN  HHABN Option Box 3  HHCCN   60.1 - Background on the HHCCN (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  HHAs have issued HHABNs related to the absence or cessation of Medicare coverage when a beneficiary had liability protection under 1879 of the Social Security Act (the Act) since 2002.  The HHABN gained additional notification capabilities in 2006 followi ng the U.S. Court of Appeals (2nd Circuit) decision in Lutwin v. Thompson, 361 F.3d 146; 2004 U.S. App. LEXIS 3774.   Following Lutwin , the HHABN was modified so that it could also be used by HHAs to notify beneficiaries receiving home health services of any care changes in accordance with the HHA conditions of participation (COPs) in 1891 of the Act.   To account for this expanded use, the HHABN was revised to contain three interchangeable Option Boxes within the body of the notice designated as Option Box 1, Option Box 2, and Option Box 3.  Option Box 1 language was applicable to situations involving potential beneficiary liability for HHA services as directed by 1879 of the Act.  Option Box 2 or Option Box 3 was inserted into the HHABN form to notify beneficiaries of changes in a home health plan of care that are subject to the requirements of  1891 of the Act.   In order to streamline, reduce, and simplify notices issued to Medicare beneficiaries, the HHABN is being discontinued.  HHABN, Option Box 1, which is the liability portion of the notice, is replaced by the existing Advance Beneficiary Notice of Noncoverage (ABN), CMS -R-131.  The change of care notification portions of the HHABN, Option Box 2 and Option Box 3, is replaced by the newly approved HHCCN.  60.2 - Scope of the HHCCN  (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  A.  Statutory Authorization for HHCCN   The requirement to give an HHCCN is based on the HHA COPs in 1891 of the Act. The COPs are further implemented through Title 42 of the Code of Federal Regulations (CFR), Part 484.   1891(a)(1)(E) stipulates that beneficiaries have:   The right to be fully informed orally and in writing (in advance of coming under the care of the [home health] agency) of    all items and services furnished by (or under arrangement with) the agency for which payment may be made under this title,   the coverage available for such items and services under this title, title XIX or any other Federal program of which the agency is reasonably aware,   any charges for items and services not covered under this title and any charges the individual may have to pay with respect to items and services furnished by (or under arrangement with) the agency, and   any changes in the charges or items and services described in clause (i), (ii) or (iii).   HHAs are required to use the HHCCN to notify the beneficiary of reductions and terminations in health care in accordance with Medicare COPs.   B.  HHAs and Other CMS Notices   HHAs will now use the Advanced Beneficiary Notice (ABN), Form CMS -R-131 for liability notification instead of the HHABN Option Box 1. The ABN and form instructions can be downloaded from the CMS website at: http://www.cms.gov/Medicare/Medicare -General -Information/BNI/ABN.html   HHAs must continue to issue an expedited determination notice called the Notice of Medicare Provider Non -Coverage, (NOMNC), CMS -10123, if applicable, when all covered services are being terminated. Please see the FFS ED Notices link at:  http://www.cms.g ov/Medicare/Medicare- General -Information/BNI/FFSEDNotices.html for information on the delivery of expedited determination notices.  C.  HHCCN Issuers and Recipients   HHAs are the only type of Medicare provider that issues the HHCCN to notify the beneficiary of care changes involving reductions or terminations of items and/or services. The recipients of the HHCCN are beneficiaries enrolled in Original Medicare only. HHC CNs are not used in Medicare managed care.  When a beneficiary transitions to Medicare managed care from Original Medicare during a home health episode, HHCCN issuance is required only if there is a specific need to provide notification of changes in care as the transfer occurs.   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