HHABN H ome H ealth A dvance B eneficiary N otice

1. HHABNHome Health Advance Beneficiary Notice WellCare Home Health 2010

2. Background • Home Health Advanced Beneficiary Notice (HHABN) has been required since 2002. • HHABN informs beneficiaries in Original Medicare about possible noncovered charges when limitation of liability applies. • CMS was directed, however, by a Federal court decision to revise this notice and its instructions to encompass broader notification requirements codified under the Conditions of Participation (COPs) for Home Health Agencies (HHAs). WellCare Home Health 2010

3. Examples • HHABNs are required more frequently for changes in noncovered home care; • HHABNs are now required in some situations where qualifying requirements for Medicare benefits are not being met, such as when there is a lack of physician orders for further home care; and • HHABNs are required in a larger number of circumstances where covered care is reduced or terminated. WellCare Home Health 2010

4. Who Issues HHABN? • Only HHAs issue HHABNs. No other types of Medicare providers issue the HHABN. • HHAs issue HHABNs only for services that they bill or furnish, not for items or services that beneficiaries under their care may permissibly obtain from other sources (Note: this policy generally applies to all financial liability protection notices that are used to meet the requirements of §1879 of the Act). WellCare Home Health 2010

5. Who must I give the HHABN to? • Note the term “Beneficiary” includes either the beneficiary or an authorized representative of the beneficiary, as applicable. • Therefore, these instructions apply whether the HHA gives the HHABN to a beneficiary or an authorized representative. WellCare Home Health 2010

6. Dual Eligible Patients • For example, when a beneficiary is a dual eligible, and is receiving services that are covered only under Medicaid, so that from Medicare’s perspective, all care is noncovered, an HHABN has to be issued only at the initiation of this noncovered care. • Therefore, there would be no need for delivery of other HHABNs at subsequent triggering events, such as reductions in care, as long as coverage remained the same and the HHABN given at initiation was still effective. No additional HHABN would need to be given, unless: • (1) the beneficiary again became eligible for Medicare coverage and a triggering event occurred, or • (2) continuous treatment lasted for more than a year. WellCare Home Health 2010

7. Special Note • When Medicare beneficiaries have no coverage in addition to Medicare, HHAs must provide HHABNs at all triggering even, regardless of care being covered or noncovered. WellCare Home Health 2010

8. Triggering Events • Generally, HHAs are required to issue HHABNs whenever they believe they are about to deliver noncovered item(s) and/or service(s) at three points in time, called “triggering events”: WellCare Home Health 2010

9. HHABN Triggering Events WellCare Home Health 2010

10. HHABN Triggering Events WellCare Home Health 2010

11. HHABN Triggering Events WellCare Home Health 2010

12. Keep In Mind…… • Triggering reductions and terminations under the home health benefit may apply for purposes of either covered or noncovered care. Outside the home health benefit, triggering reductions and terminations continue to apply only to covered care that • is a Medicare benefit, e.g., durable medical equipment, • conforms to LOL requirements, i.e., is assumed to be medically, • unreasonable/unnecessary, and • is believed to involve beneficiary liability. • Finally, in keeping with standing Medicare liability notice practices, another HHABN must be furnished whenever ongoing continuous noncovered care exceeds a year in duration. WellCare Home Health 2010

13. How to use the HHABN • Number of copies • A minimum of two copies, including the original, must be made so the beneficiary and HHA each have one. • Reproduction • HHAs may reproduce the HHABN by using self-carbonizing paper, photocopying the HHABN, or other appropriate methods. • HHA staff should have HHABNs without pre-printed information on hand to allow for unusual cases that do not conform to pre-printed language for items or services or reasons for non-coverage. WellCare Home Health 2010

14. Two Notices • These HHABN instructions also take into account expedited determination notice requirements, which were implemented in 2005. • As detailed on the next slide (see 60.2 B), the HHABN and expedited determination notices are now the only two types of notices an HHA will need to use to convey liability to beneficiaries. WellCare Home Health 2010

15. Requirements • The requirement to give an HHABN is based on §1879 of the Act with its financial liability protections, and §1891, the COPs for HHAs (the COPs are further implemented through Title 42 of the Code of Federal Regulations (CFR), Part 484.) In particular, relative to written notification, §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 -- • (i) all items and services furnished by (or under arrangement with) the agency for which payment may be made under this title, • (ii) 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, • (iii) 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 • (iv) any changes in the charges or items and services described in clause (i), (ii) or (iii). WellCare Home Health 2010

16. Expedited Determination Notices • Along with the HHABN, HHAs must use expedited determinations notices when required. • [In short, expedited determination notices are given to beneficiaries before the termination of all Medicare covered services, so they are alerted to their right to obtain an independent, immediate review by a Quality Improvement Organization (QIO) of the decision to end coverage. For Original (Fee-For-Service, (FFS)) Medicare, the first or Generic Expedited Determination Notice is entitled, “Notice of Medicare Provider Non-Coverage,” Form Number CMS-10123, and the second or detailed notice is called the “Detailed Explanation of Non-Coverage,” Form Number CMS-1024.] WellCare Home Health 2010

17. The FORM…Option Box “1”Use when item(s) and/or service(s) may be provided that will not be paid for by MEDICARE • Selection 1 • “I don’t want the items and/or services listed above. I understand that I won’t be billed and that I have no appeal rights since I will not receive those items and/or services.” • Check one of the following boxes: • “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” • Must provide an estimate of the total cost of the items and/or services listed in the body section of the first blank. e.g., $400.00 for 4 weekly nursing visits in 01/06 or • $210 for 3 physical therapy visits 1/3-17/06, $50 for medical equipment (Specific pieces of durable medical equipment [DME] should be identified as space allows.) WellCare Home Health 2010

18. Option Box 1 • Use when item(s) and/or service(s) may be provided that will not be paid for by Medicare • Option Box 1 is used in any of the following situations (see the charts earlier in this section for guidance on when to use this option box for different triggering events): • A beneficiary faces potential liability/will be receiving noncovered care/will be charged. • A beneficiary wants a claim filed for potentially noncovered care the HHA provides. • The care at issue is outside the Medicare home health benefit. • A 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. WellCare Home Health 2010

19. The FORM…Option Box “2”Use when item(s) and/or service(s) will no longer be provided for financial and/or other reasons. • There is no information to complete in Option Box 2 itself. WellCare Home Health 2010

20. Option Box 2 • Use when item (s) and/or service (s) will no longer be provided for financial and/or other reasons. • 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. Examples of such reasons include: the lack of availability of staffing, closure of the HHA, or safety concerns in a beneficiary home. (See the charts earlier in this section for guidance on when to use this option box for different triggering events.) Generally, this language can be used only when: • There is no beneficiary liability. • There is no further delivery of the care described in the body of the HHA (that is, a reduction or termination with no ensuing care of the type described, not a change from covered to noncovered care, such as when Medicare stops paying but care continues). • There is no related claim (that is, there is no ensuing care described that could be billed later). • Option Box 2 could seem appropriate in similar cases when benefits other than home health are involved. However, notification is not required in these cases; additionally, the wording of this option box references home care. Note that a HHA may issue HHABNs with Option Box 2 language voluntarily to provide notice that it will not charge nor admit a beneficiary after an assessment is done. WellCare Home Health 2010

21. The FORM…Option Box “3”Used when the HHA stops providing certain items and/or services due to lack of a physician order, but other care continues. • 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 (it is a reduction, not a change in coverage from covered to noncovered for ongoing care), and • There is no related claim (i.e., nothing is being provided to bill). WellCare Home Health 2010

22. Option Box 3 • Use when physician’s orders reduce certain item(s) and/or services • 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. (See 60.3 regarding definition of triggering events, and clarification of the difference between a reduction and termination of all care; note the charts earlier in this section provide guidance on which option box to use with different triggering events.) Thus, 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 (that is, the reduction entails no ensuing care of the type described, as opposed to a reduction in coverage where particular items/services change from Medicare covered to noncovered, and delivery of care continues thereafter). • There is no related claim (there is no ensuing care described that could be billed later). • Option Box 3 could seem appropriate in cases when benefits other than home health are involved and affected by similar changes in physician orders. However, notification is not required in these cases, and additionally the wording of this option box references home care. WellCare Home Health 2010

23. Rare Circumstances • There may be rare cases where, even though orders do not clearly indicate the need for additional services, the HHA feels delivery of the service is medically justified by Medicare’s standard, and should be covered. In such situations, when doubt exists, anHHA should still give the beneficiary anHHABN if a triggering event has occurred, explaining Medicare may not cover the service, and then demand bill the service in question. WellCare Home Health 2010

24. Selecting the Options • Providers can never pre-select HHABN options for beneficiaries, in accordance with existing liability notice policy. In each case, the beneficiary must be consulted as to the option they want to select. The HHABN options presented relative to specific billing scenarios above, and in the rest of the document, are only illustrations and in no way authorization for pre-empting a beneficiaries right to choose a specific option. WellCare Home Health 2010