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Home Health Advance Beneficiary Notice HHABN

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Home Health Advance Beneficiary Notice HHABN

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    1. 1 Home Health Advance Beneficiary Notice (HHABN) Centers for Medicare and Medicaid Services (CMS) U.S. Department of Health and Human Services August 2006

    2. 2

    3. 3 HHABN Background – “PRA” Paperwork Reduction Act (PRA) of 1995 Approval to post first draft in February 2006 Two steps of public comment in clearance process ending in May and July 2006 Routine 3-year approval until 8/31/2009

    4. 4 HHABN – Where & When Notice – under “FFS HHABN”: http://www.cms.hhs.gov/BNI/ Final Instructions - Pub. 100-04, Chapter 30, Section 60: http:ww.cms.hhs.gov/Transmittals/2006Trans/list.asp EFFECTIVE: 09/01/2006 Use the version effective when the “triggering event” occurs; do not re-notify just for version changes

    5. 5 HHABNs HHABN Statutory Authority SSA, §1891-Beyond Original Medicare SSA, §1879-Original Medicare

    6. 6 HHABNs HHA Original Medicare Liability Notices: HHABN No More NEMB or General ABN Only HHAs give and only Original Medicare Beneficiaries receive “Beneficiary” includes representative(s) Expedited determination notices

    7. 7 Other Payers/Insurers Generally, when there is other coverage: HHABN only has to be issued at initiation Annual “update” only needed for services exceeding a year More HHABNs required for beneficiaries with no coverage other than Medicare

    8. 8 Benefit Scope For HHABN HH Benefit Meeting Social Security Act (SSA) §1861(m) Definition Bill types 32x or 33x “Outside the HH Benefit” Other Medicare Benefits Care Never Covered By Medicare Note: Any Medicare benefit can be covered or noncovered

    9. 9 Noncovered Services Never Covered Care New Policy: No charge, no notification requirement True even when related to the HH benefit or plan of care Usually Covered Care No mandatory notice unless §1879 applies (i.e., a Medicare benefit is not R&N) Bundled Payments The bundle is always seen as a whole

    10. 10 Limitation on Liability (LOL) Outside the HH Benefit “Reasonable and Necessary” Home Health Benefit 4 Reasons

    11. 11 Limitation of Liability – Continued

    12. 12 HHABN Triggering Events Definitions

    13. 13 Triggering Events for the HH Benefit: §1879 or §1891 Applies

    14. 14 Triggering Events for the HH Benefit: §1879 or §1891 Applies

    15. 15 Triggering Events Outside the HH Benefit: §1879 Applies

    16. 16 Triggering Events Outside the HH Benefit: §1879 Applies

    17. 17 Initiations Assessments prior to admissions Admissions for noncovered care One-time services

    18. 18 Reductions Some covered care must continue Can require notification whether care is covered or not Outside the HH benefit, notification is only required when LOL applies

    19. 19 Terminations Cessation of all care Expedited determination notices more likely to be required HHABN required when Expedited determinations do not apply

    20. 20 HHABN Exceptions: General Increase in care Transfers Emergency or unplanned situations Changes in care giver or personnel Changes in arrival or departure time Changes in brand Free care never covered by Medicare

    21. 21 HHABN Exceptions Initiations Free Initial Assessments Noncovered part of a a bundled payment (if any) Reductions Length of visit/care Lessening the number of items or services Changes within a HH discipline Change in modality

    22. 22 HHABN Exceptions Reduction or Termination: Beneficiary choice Exclusive other coverage Termination: Patient goals met

    23. 23 Completing the HHABN General Notice Requirements: Number of Copies – Two copies. HHA keeps original file; copy must be given to the beneficiary Reproduction – HHAs may reproduce the HHABN by using: self-carbonizing paper, photocopying, or other appropriate method Length and Page Size – Must NOT exceed 1- page in length. HHABN may be expanded to legal size paper Contrast of Paper and Print – Must have a high-contrast combination of dark ink on a pale background Modification – HHABN may not be modified, except as specifically allowed by instructions

    24. 24 Completing the HHABN General Notice Requirements: Font Font Type: Fonts should appear as they do in HHABN downloaded from either RHHI or CMS web site Font Effect/Style: Changes to the font, such as italics, embossing, bold, etc., should not be used Font Size: Font size should be 12 point. Titles should be 18 pt, and insertions can be as small as 10 point Insertions in Blanks: Information may be typed or legibly hand-written

    25. 25 Completing the HHABN General Notice Requirements: Continued Customization: May have multiple versions specialized to the common treatment scenarios, with preprinted language in blanks Different versions may be printed on different color paper May also be differentiated by adding letters or numbers in the header Maintaining underlining in the blank spaces is not required

    26. 26 Completing the HHABN General Notice Requirements: Continued Customization: Information - Information in blanks that is constant can be pre-printed: HHA’s name, 1-800-MEDICARE or 1-800-633-4227 and/or TTY 1-877-486-2048 numbers. Note the TTY phone number only needed when appropriate and based on the needs of beneficiaries Preprinted options - Beneficiary should only see information applicable to his/her case clearly indicated in each blank or checked off in a checkbox Checkboxes - Checkboxes for disciplines, if used, must still allow for explanation of what is changing

    27. 27 Completing the HHABN General Notice Requirements: Continued Customization: Note: Keep HHABNs on hand without pre-printed information to use in unusual cases Note: HHAs must exercise caution before adding any customizations beyond these guidelines. Medicare does not validate individual adaptations of HHABNs. Validity judgments are generally RHHIs, based on: Effective delivery Beneficiary comprehension

    28. 28 Sections of the HHABN The new HHABN is a 1-page notice, composed of 4 parts: Header Body Option Boxes Signature/Date The HHABN file contains four pages Available in English, Spanish, and in PDF and Word formats

    29. 29 HHABN Header and Body Header HHAs are permitted to customize the header section of the HHABN Body Step 1: HHA Name Step 2: Action (pre-formatted language) See Instructions for each option box

    30. 30 Step 3: Items and Services Describe items or services that: Medicare will no longer cover but may still be provided by the HHA Are reduced Are terminated care General descriptions of multi-faceted services or supplies are permitted. (wound care supplies) The HHABN must be used to describe reductions in either supplies or services Items are objects (i.e., supplies, DME) and services are treatment by a professional (i.e., a nursing or therapy visit)

    31. 31 Step 3: Continued When a reduction occurs, enough additional information must be included so that the beneficiary understands the nature of the reduction Changes in the modality or interventions that are part of a service like wound care are not considered reductions when the frequency of delivery remains the same This is also true for changes in the mix of services within a home health discipline Dates can be used

    32. 32 Step 4: Reason For Change The reasons provided must be in plain language that allows the beneficiary to understand why the notice is being given and make an informed choice about financial liability (when applicable) The level of detail of the reason given should be similar to that found in a Medicare Summary Notice (MSN) message (“you are no longer homebound”)”

    33. 33 Steps 4 and 5 Step 4 (Continued): If multiple item(s) and/or service(s) are listed in Step 3, the beneficiary must understand each reason specifically associated with each item or service listed Step 5: HHA Telephone number and/or TTY or similar number (when applicable)

    34. 34 Statutory Authority Supporting HHABN Option Boxes

    35. 35 General Summary of HHABN Option Box Use

    36. 36 Which Option Box Should I Use?

    37. 37 Which Option Box Should I Use?

    38. 38 Which Option Box Should I Use?

    39. 39 Which Option Box Should I Use?

    40. 40 Instructions for HHABN Option Box 1 Option Box 1 is used in any of the following situations: Beneficiary faces potential liability/will be receiving noncovered care/will be charged Beneficiary wants a claim filed for potentially noncovered care the HHA provides The care at issue is outside the Medicare home health benefit Beneficiary will be charged for an assessment although not admitted to care Any circumstance that may arise for which neither Option Box 2 nor 3 is appropriate

    41. 41 Instructions for HHABN Option Box 1 : Continued If Option Box 1 is being used, HHAs should insert the most appropriate of the following phrases: “will not provide you (if choosing Box 1 below)” “will no longer provide you (if choosing Box 1 below)” “believe Medicare will not provide you” “believe Medicare will no longer provide you”

    42. 42 HHABN Option Box 1 – Step 1 Cost Estimates: HHA must provide an estimate of the total cost of the item or service listed in the first blank Cost estimate is meant to give the beneficiary an idea of what cost would be if he/she paid out of pocket HHA must provide good faith estimate

    43. 43 HHABN Option Box 1 – Step 1: Continued Cost Estimates: The estimated cost may be $0 Since it may not be possible for HHAs to project possible costs, a proxy like average daily cost may be used

    44. 44 HHABN Option Box 1 – Step 1: Continued Cost Estimates: Cost estimates are only for services the HHA provides, not those charged or provided by other providers Updates with annotations are allowed Abbreviations can be used

    45. 45 HHABN Instructions for Option Box 2 Option Box 2 is used when an HHA decides to stop providing some or all care for its own financial and/or other reasons, regardless of Medicare policy or coverage Wording used in Step 2 of the Body: “Will no longer provide you”

    46. 46 Instructions for HHABB Option Box 2: Continued Option Box 2 is used in any of the following situations : There is no beneficiary liability There is no further delivery of the care described in the body of the HHA There is no related claim (that is, there is no ensuing care described that could be billed later)

    47. 47 Instructions for HHABN Option Box 3 Option Box 3 is used when the HHA stops providing, or reduces the frequency of, certain items and/or services due to lack of a physician order, but other care continues. That is, this option box is only used with reductions

    48. 48 Instructions for HHABN Option Box 3 Option Box 3 is appropriate when: There is no beneficiary liability There is no further delivery of the care described in the body of the HHA There is no related claim (there is no ensuing care described that could be billed later)

    49. 49 Step 2 Steps for Completion. If Option Box 3 is used, HHAs should insert the following phrase in the Step 2 blank in the body of the HHABN: “will no longer provide you” OR An HHA may substitute the phrase “will reduce” or “will stop” for this language-- and delete the following word “with” from the notice-- if it believes this phrasing will lead to clearer communications with beneficiaries

    50. 50 HHABN - Signature and Date Section All four blanks in the boxed Signature and Date Section at the bottom of the HHABN must be completed: Medicare Beneficiary’s Full Name Medicare # (HICN) - On Medicare card Medicare Beneficiary’s Signature Date HHAs can complete the first 2 blanks to help beneficiaries

    51. 51 HHABN - Special Issues Some State Medicaid programs have HHABN requirements for “dual eligibles” States also may have billing requirements related to the HHABN Nonetheless, beneficiaries always have a right to “self pay”

    52. 52 HHABN – Other Determinations An expedited determination or reconsideration decision can make an HHABN moot An initial (payment) determination on a claim may also have this effect HHABNs may need to be annotated and refunds made

    53. 53 Effective HHABNs Delivery in–person preferred HHABN must be explained Delivery must occur prior to the care at issue The reason why the HHABN is given must be clear [60.4 G.2.a on Step 4, “because”] Beneficiary signature is required Subcontractors can deliver HHABNs, but primary HHAs remain responsible

    54. 54 Defective HHABNs No use of HHABN form Unintelligible HHABN Forced HHABN Meaningless HHABN Rushed or dated HHABN HHABN that is pre-signed or with pre-selected options Incomplete HHABN Beneficiary lack of comprehension – “best effort”

    55. 55 Defective HHABNs - Exceptions Care that is always denied for medical necessity – national or local policy Experimental Items and Services

    56. 56 Defective HHABNs - Exceptions Frequency Limited Items and Services Extended Courses of Treatment – HHABN must describe all care

    57. 57 HHABN Beneficiary Liability Effective HHABNs allow funds to be collected from beneficiaries Medicare has no policy on the timing of collections for the home health benefit If Medicare ultimately pays, refunds must be prompt Refunds would also be appropriate if subsequent insurer provided payment

    58. 58 HHABN Provider Liability Failure to give HHABN when required Gives defective HHABN Can’t collect/must refund any beneficiary collections Can’t collect for a part of a covered bundled payment

    59. 59 HHABN Copies & Retention Beneficiaries must receive a copy – “subrogees” may require one RHHIs, CMS and other Federal agencies may require a copy be provided HHAs retain the original (unmodified) HHABN-- generally for 5 years The primary HHA is responsible for retention if a subcontractor is used

    60. 60 HHABN *** THE END ***

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