Home Health Advance Beneficiary Notice (HHABN) - PowerPoint by lrx91376

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									  Home Health Advance
Beneficiary Notice (HHABN)




  Centers for Medicare and Medicaid Services (CMS)
   U.S. Department of Health and Human Services
                    August 2006                      1
            HHABN Background
• Litigation going back into
  the 1990’s

• Initial multi-page
  HHABNs withdrawn

• First 1-page HHABN
  effective in June 2002

• HHABN the vehicle for
  compliance with the
  Lutwin Decision in 2004
  2006 Final HHABN Instructions   2
   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
 2006 Final HHABN Instructions   3
          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

2006 Final HHABN Instructions - Sections 60.4 A-E      4
                          HHABNs
HHABN Statutory
  Authority

• SSA, §1891-Beyond Original
  Medicare

• SSA, §1879-Original Medicare




  2006 Final HHABN Instructions – Section 60.2A   5
                        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
2006 Final HHABN Instructions – Section 60.2B-C              6
          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

 2006 HHABN Instructions – Section 60.2D   7
      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
                                                8
2006 Final HHABN Instructions – Section 60.2E
              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

2006 Final HHABN Instructions - Section 60.2F and 60.2G                 9
      Limitation on Liability (LOL)
• Outside the HH Benefit

     – “Reasonable and
       Necessary”

• Home Health Benefit

     – 4 Reasons




2006 Final HHABN Instructions – Section 60.2H
                                                10
                   Limitation of Liability –
                         Continued
Statutory        Scenario                 Explanation
Citation


§1862(a)(1)(A)   Care is not reasonable   Medicare does not pay for such care
                 and necessary

§1862(a)(9)      Custodial care is the    Medicare does not usually pay for such
                 only care delivered      care, except for some hospice services


§1879(g)(1)(A)   Beneficiary is not       Medicare requires that a beneficiary cannot
                 homebound                leave home in order to cover services
                                          under the HH benefit
§1879(g)(1)(B)   Beneficiary does not     Medicare requires an intermittent need in
                 need part-time skilled   order to cover such services under the HH
                 nursing care             benefit



2006 Final HHABN Instructions – 60.2H                                                 11
               HHABN Triggering Events
                    Definitions
Event               Description


Initiation          When an HHA expects that Medicare will not cover
                    item(s) and/or service(s) delivered under a planned
                    course of treatment from the start of a spell of illness
                    OR before the delivery of one-time item(s) and/or
                    service(s) that Medicare is not expected to cover.
Reduction           When an HHA reduces or stops some item(s) and/or
                    service(s) during a spell of illness, while continuing
                    others, including when one home health discipline
                    ends but others continue, independent of Medicare
                    coverage.
Termination         When an HHA ends delivery of either all Medicare-
                    covered care or all care in total.

2006 Final HHABN Instructions – Section 60.3                               12
       Triggering Events for the HH Benefit:
              §1879 or §1891 Applies
Application:                Medicare COVERD CARE

Population                  All Beneficiaries

Initiations                 Not Required


Reductions                  HHABN

Terminations -              Generic Expedited Determination Notice
Coverage Reasons
Terminations -              HHABN
No Coverage Reason


2006 Final HHABN Instructions – Section 60.3                         13
         Triggering Events for the HH Benefit:
                §1879 or §1891 Applies
Application:       Medicare Noncovered Care

Population:        Beneficiaries With Other    Beneficiaries With No
                   Coverage                    Other Coverage
                   (i.e., Medicaid)

Initiations        HHABN                       HHABN


Reductions         Not Required                HHABN


Terminations       Not Required                HHABN



2006 Final HHABN Instructions – Section 60.3
                                                                       14
   Triggering Events Outside the HH Benefit:
                §1879 Applies
Application:                Medicare COVERD CARE


Population                  All Beneficiaries

Initiations                 Not Required

Reductions                  HHABN

Terminations -              Generic Expedited Determination Notice
Coverage Reasons            And/Or HHABN
Terminations –              Not Required
No Coverage Reason

                                                                     15
2006 Final HHABN Instructions – Section 60.3
   Triggering Events Outside the HH Benefit:
                §1879 Applies

Application:        Medicare Noncovered Care

Population:         Beneficiaries With         Beneficiaries With No
                    Other Coverage             Other Coverage
                    (i.e., Medicaid)

Initiations         HHABN                      HHABN


Reductions          Not Required               Not Required


Terminations        Not Required               Not Required


                                                                       16
2006 Final HHABN Instructions – Section 60.3
                           Initiations
 • Assessments prior to admissions

 • Admissions for noncovered care

 • One-time services




2006 Final HHABN Instructions – Section 60.3A   17
                        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

2006 Final HHABN Instructions – Section 60.3B                      18
                     Terminations
• Cessation of all care

• Expedited determination
  notices more likely to be
  required

• HHABN required when
  Expedited determinations
  do not apply




  2006 Final HHABN Instructions – Section 60.3B   19
    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

                                                 20
 2006 Final HHABN Instructions – Section 60.3D
            HHABN Exceptions
         Initiations                            Reductions

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



2006 Final HHABN Instructions – Section 60.3D                21
               HHABN Exceptions
Reduction or Termination:                   Termination:
• Beneficiary choice                        • Patient goals met
• Exclusive other coverage




 2006 Final HHABN Instructions – Section 60.3D
                                                                  22
                      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



                                                        23
    2006 Final HHABN Instructions – Section 60.4F
                  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




                                                                        24
2006 Final HHABN Instructions – Section 60.4F
                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



2006 Final HHABN Instructions – Section 60.4.F
                                                             25
                  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


 2006 Final HHABN Instructions - Section 60.4F    26
                      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




                                                                   27
2006 Final HHABN Instructions – Sections 60.4.F
               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




                                       28
   2006 Final HHABN Instructions
               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



2006 Final HHABN Instructions – Section 60.4.G.2   29
       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)


2006 Final HHABN Instructions – Section 60.4.G.2                      30
                  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




2006 Final HHABN Instructions – Section 60.4.G.2   31
            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”)”


                                                     32
  2006 Final HHABN Instructions – Section 60.4.G.2
                         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)



    2006 Final HHABN Instructions – Section 60.4.G.2
                                                       33
               Statutory Authority Supporting
                    HHABN Option Boxes
Application                                          HH      Outside HH
                                                     Benefit Benefit
§1879 Liability Notice given prior to care to        HHABN-       HHABN-Option
alert the beneficiary of potential liability for     Option       Box 1
Medicare benefit                                     Box1
§1891 COP-Required Notice alerting                   HHABN-       None Required
beneficiaries to changes in care, specifically       Option
occurring because the HHA will no longer             Box 2
provide services for their own financial reasons
§1891 COP-Required Notice alerting                   HHABN-       None Required
beneficiaries of changes in the POC based on         Option
physician orders                                     Box 3
Voluntary Notice alerting beneficiaries of           Not          Voluntary use of
potential financial liability for care that is not   Applicable   HHABN-Option
part of a defined Medicare benefit or when not                    1
otherwise required by LOL policy

                                                                                34
2006 Final HHABN Instructions
    General Summary of HHABN Option Box Use

Option   Possible      Assessmen Home      Other      Care Not    Contains
Box      Beneficiary   t Without Health    Medicare   A           Billing
         Liability     Admission Benefit   Benefit    Medicare    Info
                                 Use       Use        Benefit
1        Must use      Use if        Yes   Yes        Voluntary   Yes
                       charging                       use
                       beneficiary

2        Can’t use     Voluntary     Yes   No         No          No
                       use if not
                       charging

3        Can’t use     Can’t use     Yes   No         No          No




2006 Final HHABN Instructions – Section 60.4.G.2b                        35
    Which Option Box Should I Use?
The following chart summarizes the circumstances in which each option box
should be used:

Triggering Event –                     Option        Option Option
Initiations                            Box 1         Box 2 Box 3
Initiations of Entirely Noncovered     Yes           No          No
Treatment, Any Medicare Benefit,
when §1879 LOL Applies
One-time Noncovered                 Yes              No          No
Items/Services, Beneficiary Liable,
Any Medicare Benefit, §1879 LOL
Applies
One-time Noncovered                    Voluntary No              No
Items/Services, §1879 LOL Does
Not Apply and/or Not a Medicare
Benefit

                                                                            36
2006 Final HHABN Instructions – Section 60.4.G.2.b
     Which Option Box Should I Use?
 The following chart summarizes the circumstances in which each option box
 should be used:
Triggering Event –                       Option         Option Option
Reductions                               Box 1          Box 2 Box 3
Any Reduction for HHA Reasons            No             Yes         No
(Unrelated to Coverage), No
Beneficiary Liability, HH Benefit
Any Reduction by Physician Order,        No             No          Yes
No Beneficiary Liability, HH Benefit
Any Other Reductions, HH Benefit         Yes            No          No
Other Covered Care Reductions,           Yes            No          No
Other Medicare Benefits, §1879 LOL
Applies
Any Other Reductions (Outside HH         Voluntary No               No
Benefit)
                                                                             37
 2006 Final HHABN Instructions – Section 60.4. G.2.b
      Which Option Box Should I Use?
The following chart summarizes the circumstances in which each option box
should be used:

Triggering Event –                        Option        Option Option
Terminations                              Box 1         Box 2 Box 3
Any Termination for HHA Reasons           No            Yes         No
(Unrelated to Coverage), No
Beneficiary Liability, HH Benefit
Covered Care Termination for              Yes           No          No
Coverage Reasons (Including
Physician Orders), HH Benefit




                                                                            38
2006 Final HHABN Instructions – Section 60.4. G.2.b
      Which Option Box Should I Use?
The following chart summarizes the circumstances in which each option box
should be used:


Triggering Event –                        Option         Option Option
Terminations                              Box 1          Box 2 Box 3
Covered Care Termination for              Yes            No          No
Coverage Reasons (Including
Physician Orders), Any Medicare
Benefit Subject to Expedited
Determinations (i.e., therapy
delivered by HHAs under a therapy
plan of care)
Any Other Terminations (services not Not
subject to Expedited Determinations
or §1879 LOL)                        Required            No          No


                                                                            39
 2006 Final HHABN Instructions – Section 60.4. G.2.b
               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


2006 Final HHABN Instructions – Section 60.4G.2.b              40
    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”




2006 Final HHABN Instructions – Section 60.4G.2.b
                                                                  41
              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


                                                    42
2006 Final HHABN Instructions – Section 60.4G.2.b
              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




                                                                43
2006 Final HHABN Instructions – Section 60.4.6.2b
              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

                                                     44
2006 Final HHABN Instructions – Section 60.4.G.2.b
 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”




                                                               45
2006 Final HHABN Instructions – Section 60.4.G.2.b
  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)
                                                      46
 2006 Final HHABN Instructions – Section 60.4.G.2.b
    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



                                                                  47
2006 Final HHABN Instructions – Section 60.4G.2.b
    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)

                                                      48
2006 Final HHABN Instructions – Section 60.4 G.2. b
                                 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

    2006 Final HHA Instructions – Section 60.4.G.2.b   49
           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

  2006 Final HHABN Instructions – Section 60.4.G.3   50
        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”
  2006 Final HHABN Instructions - Section 60.5 A   51
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

2006 Final HHABN Instructions - Section 60.5 B and 60.7 D   52
               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



2006 Final HHABN Instructions - Section 60.6
                                               53
               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”

                                                 54
2006 Final HHABN Instructions - Section 60.6.1
Defective HHABNs - Exceptions
• Care that is always
  denied for medical
  necessity – national
  or local policy



• Experimental Items
  and Services


2006 Final HHABN Instructions - Section 60.6.1 A   55
Defective HHABNs - Exceptions

• Frequency Limited
  Items and Services



• Extended Courses of
  Treatment – HHABN
  must describe all care


2006 Final HHABN Instructions - Section 60.6.1 A   56
      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

2006 Final HHABN Instructions - Section 60.7 A   57
         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
2006 Final HHABN Instructions - Section 60.7 B&C       58
      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


2006 Final HHABN Instructions - Section 60.8   59
   HHABN




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