evekhm/cms_iom_500 huggingface dataset:
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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.
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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.
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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;
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 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
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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.
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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
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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   If the beneficiary is physically unable to sign the HHCCN and is fully capable of understanding the notice a representative is not required for signature. The beneficiary may allow the HHA to annotate the HHCCN on his/her behalf regarding this circumstance. For example, a fully cognizant beneficiary with two broken hands may allow an HH A staff person to sign and date the notice in the presence of and under the direction of the beneficiary, inserting the beneficiarys name along with his/her own name, i.e., John Smith, Shiny HHA, signing for Jane Doe. Such signatures should be witnessed  by a second person whenever possible. Further, the medical record should support the beneficiarys inability to write in the applicable time period.   2.  Timely Notice
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2.  Timely Notice   There are no exact time frames for HHCCN delivery.  Delivery timing of the notice may sometimes occur immediately upon the HHA finding that a change in care is warranted. However, in general, HHCCN should be delivered far enough in advance of the care chan ge so that the beneficiary may pursue alternatives to continue receiving the care noted on the HHCCN. When plans for issuance of the notice are known in advance, the HHCCN should not be issued so far in advance as to cause confusion regarding the information it conveys.  Some allowance is made for immediate delivery prior to furnishing the care at issue when unforeseen circumstances arise such as an impending, unforeseen agency staffing shortage or a dangerous home situation.  This should be avoided whenever possible, but is permissible when a situation occurs prompting an immediate determination to reduce or end services that could not have been made in advance.   70 - Skilled Nursing Facility Advance Beneficiary Notice of Non- (Rev.: 4198; Issued: 01-11-19; Effective: 04 -30-18; Implementation: 04- 30-18)   The following are the standards for use by Skilled Nursing Facilities (SNFs) in implementing the SNF ABN (CMS -Approved Model Form CMS -10055) requirements. This section provides instructions, consistent with the SNF prospective payment system (SNF PPS), reg arding the SNF ABN.   SNF ABN -  Quick Glance Guide3  3  This is an abbreviated reference tool and is not meant to replace or supersede any of the directives contained in Section 7 0.   Notice Name:  SNF ABN  Notice Number:  CMS -Approved Model, Form CMS -10055  Issued by:  SNFs for non- covered SNF PPS extended care items or  services.  Recipient:  Original Medicare fee- for-service (FFS) beneficiary   Additional Information:    The ABN, Form CMS -R-131 should be used for Part B non -covered items or services.  SNFs should no longer use the 5 SNF Notices of Non- coverage (Denial Letters) or the NEMB -SNF (CMS -20014) as these have been discontinued with the 2018 SNF ABN revision.
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Type of Notice:  Must be issued in order to transfer liability to the beneficiary:  Timing of notice:  Optional/Voluntary use: Financial liability notice  Before SNF PPS extended care items or services are furnished, reduced, or terminated when the SNF, the UR entity, the QIO, or the Medicare contractor believes that Medicare may not pay for, or will not continue to pay for, those extended care services on the basis of one of the following statutory exclusions:    Not reasonable and necessary (medical necessity) for the diagnosis or treatment of illness, injury, or to improve the functioning of a malformed body member (1862(a)(1) of the Act); or   Custodial care (not a covered level of care) (1862(a)(9) of the Act).  Prior to delivery of the care item or service in question. Provide enough time for the beneficiary to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability.   Yes.  It is recommended, but not necessary to transfer liability, for SNFs to issue prior to furnishing a care item or service that is never covered by Medicare (i.e. not a Medicare benefit).    70.1 - SNF ABN Standards  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)  Step by step instructions for notice completion are posted along with the online replicable copies of the CMS -Approved Model, Form CMS -10055 on the CMS website. SNFs must not add any customizations to the notice beyond what is permitted by the accompanying SNF ABN form instructions and the guidelines published in this section. SNFs should follow the same standards when completing the SNF ABN as the ABN, Form CMS -R-131 in 50.6 of this chapter, as applicable.        70.2 - Situations in Which a SNF ABN Should Be Given  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   A.  Triggering Events
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A.  Triggering Events   A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay.  If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in 70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary.  The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events. The following describe the three triggering events for a SNF ABN:   EVENT  DESCRIPTION  Initiation  In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non- covered extended care items or services to the beneficiary.  Reduction   In the situation in which a SNF proposes to reduce a beneficiarys extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequ ency of care that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it reduces items or services to the beneficiary.  Termination   In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services.   B.  Effect of Other Insurers/Payers
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B.  Effect of Other Insurers/Payers    Some States have specific rules established regarding completion of liability notices in situations where dual -eligibles need to accept liability for Medicare non -covered care that will be covered by Medicaid.  Medicaid has the authority to make this asser tion under Title XIX of the Act, where Medicaid is recognized as the payer of last resort, meaning other Federal programs like Medicare (Title XVIII) must pay in accordance with their own policies before Medicaid picks up any remaining charges.  If the patient is a Medicare- Medicaid dual -eligible and a triggering event occurs, the SNF needs to give the beneficiary a SNF ABN.   On a practical basis, physician -prescribed items or services continue without interruption or reduction when a patient changes payer eligibility from Medicare to Medicaid.  From the Medicare coverage vantage- point, however, there is a reduction or termination when Medicare, which has been paying, stops paying.  In other words, there is a triggering event, which underlies the change in payer eligibility.  In these instances, a SNF ABN must be issued to transfer financial liability to the beneficiary.        70.3 - Situations in Which a SNF ABN Is Not Needed to Transfer Financial Liability to the Beneficiary  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   SNFs need not issue a SNF ABN to transfer financial liability to the beneficiary:    If the extended care item or service is not a Medicare benefit (e.g., personal comfort items excluded under 1862(a)(6)).    If a beneficiary is being furnished post -hospital extended care services while a resident in a SNF and payment is expected to be denied for an otherwise Medicare covered benefit because it does not meet a technical benefit requirement (e.g., SNF stay not preceded by the required prior three -day hospital stay or the beneficiary is exhausting his/her 100 benefit days).
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 If Medicare is expected to deny payment for Part B covered medical and other health services which the SNF furnishes, either directly or under arrangements with others, to an inpatient of the SNF, where payment for these services cannot be made under Part A ( e.g., the beneficiary has exhausted his/her allowed days of inpatient SNF coverage under Part A in his/her current spell of illness or was determined to be receiving a non -covered level of care).    If the SNF will not furnish the extended care items or services.  A SNF must not give a beneficiary a SNF ABN and then refuse to furnish extended care items or services even though the beneficiary elects to receive these items or services by selecting Opti on 1, as this is equivalent to the prohibited practice of the SNF pre -selecting Option 2 (not to receive items or services) on a SNF ABN.  This rule also applies when the beneficiary agrees with the triggering event (i.e., terminating therapy) and the bene ficiary will not be receiving the extended care items or services.   NOTE:   This rule is not applicable in the situation where the beneficiary elects to receive extended care items or services but refuses to sign the SNF ABN attesting to being personally and fully responsible for payment, in which case, the SNF may then consider  not furnishing the specified items or services.   For Medicare Advantage (Part C) enrollees nor for non- Medicare patients because it is to be used solely for individuals enrolled in the Medicare FFS program (Parts A and B).    When extended care items or services are reduced or terminated in accordance with a physicians order, where a physician does not order the items or services at issue, or where the physician agrees in writing with the SNFs, the UR entitys, the QIOs, or the Medicare contractors assessment that the extended care items or services are not necessary.    For swing- bed determinations.  The Preadmission/Admission HINN (HINN 1) should be given.