The Five W’s of the HHABN’s WHAT..WHY..WHERE..WHO…WHEN Presented by Sheila Gunter and Sonya Baker

Hiding under the covers won’t make this go away.

What? HHABN stands for Home Health Advance Beneficiary Notice. It is a written notice given by an HHA to a Medicare beneficiary before home health care is furnished, reduced or terminated when the HHA believes that Medicare will not pay for some or all of the home health care that it furnishes and that a physician ordered on the basis of one of the following statutory exclusions:

Statutory Exclusions The patient does not need intermittent skilled nursing care The patient is not confined to the home The service may be denied as “not reasonable or necessary” (“medical necessity”) The service may be denied as “custodial care”

Why? Lawsuit Lutwin vs Thompson (HHS) HHA’s must provide to home health beneficiaries in advance of furnishing what HHA’s believe to be noncovered care or of reducing or terminating ongoing care. Effective Date June 1, 2006

Where? Federal Conditions of Participation (COP’s) Patient Rights: The patient has the right to be informed in advance about the care to be furnished and of any changes in the care to be furnished. The HHA must advise the patient in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished. The HHA must advise the patient in advance of any change in the plan of care before the change is made.

Patient Rights (cont’d) The patient has the right to be advised, before care is initiated, of the extent to which payment for the HHA services may be expected from Medicare or other sources, and the extent to which payment may be required from the patient. Before the care is initiated, the HHA must inform the patient, orally and in writing, of the extent to which payment may be expected from Medicare, Medicaid or any other federally funded or aided program known to the HHA;

Patient rights (cont’d) The charges for services that will not be covered by Medicare; and The charges that the individual may have to pay.

Who? Medicare Beneficiaries – Primary Payer Medicare Beneficiaries – Secondary Payer Dual Eligible Beneficiaries – Medicare and Medicaid

When? The HHA must notify the beneficiary well enough in advance before terminating or reducing home health services. “Well enough in advance” means the beneficiary has time to make other arrangements. If the HHA denies services to a beneficiary, the HHA must notify the beneficiary immediately after making the decision. Last moment delivery of an HHABN will be considered to be untimely, regardless of the HHA’s intentions.

Three Trigger Points Initiation of Services Reduction of Services Termination of Services

Initiation of Services In the situation in which an HHA advises a beneficiary that it will not accept the beneficiary as a Medicare patient because it expects that Medicare will not pay for the services that a physician has ordered, the HHA must provide an HHABN to the beneficiary before it furnishes home health services to the beneficiary.

Reduction of Services Reduction of Services In the situation in which an HHA proposes to reduce a beneficiary’s home health services because it expects that Medicare will not pay for a subset of home health services, or for any services at the current level and/or frequency of care that a physician has ordered, the HHA must provide an HHABN to the beneficiary before it reduces services to the beneficiary.

Termination of Services In the situation in which an HHA proposes to stop furnishing all home health services to a beneficiary, because it expects that Medicare will not continue to pay for the services that a physician has ordered, the HHA must provide an HHABN to the beneficiary before it terminates all such home health services.

Delivery of HHABN’s Delivery of an HHABN occurs when the beneficiary or authorized representative both has received the notice and can comprehend its contents. The HHA must issue the HHABN each time, and as soon as possible as, the HHA makes the assessment that it believes that Medicare payment will not be made.

Exceptions HHABN’s are not required in the following situations: Increase in care Transfer to other covered care (i.e. hospital, home health agency.) Shortened visit duration (from 1 hr to 45 min.) Services reduced or terminated based on the initial POC.

Exceptions (cont’d) Services reduced or terminated as previously communicated to the beneficiary via an HHABN that was issued at time of a change in the original POC All care ending because goals met Beneficiary choice Situations beyond agency control (disasters, transportation disruption) Personnel changes Change in visit arrival/and or departure time Change in supply product brand Services not initiated as a result of an assessment visit, provided the assessment is not charged to the patient

HHABN form Standardized form mandated by CMS. Two separate HHABN’s Option Box 1 Option Box 1 will be used a much higher frequency Option Box 1 contains three option boxes from which the patient is to choose. Standardized language: “will not provide you” “will no longer provide you” “unless you choose Option 2 or 3 below”

HHABN form (cont’d) Option Box 2 Option Box 2 is only appropriate when care is being reduced or terminated for a HHA’s own financial reasons and/or any other reason unrelated to the beneficiary’s Medicare coverage. (Option Box 1 is to be used in all other cases.)

Home Health Advance Beneficiary Notice Option Box 1

We, VNA of Cordele, Inc., your home health agency, are letting you know that we _(will not provide you) (will no longer provide you) with the following items and/or services: ________________________________________________________________

Because: ___________________________________ ___________________________________ (unless you choose Option 2 or 3 below).

The estimated cost of the items and/or services listed above is $ ______________. We think you have_______________ insurance that may cover these items and/or services. However, you may have other insurance that we are not aware of. You have three options available to you. You must choose only one of these options by checking the box next to the option and then signing below: 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. I want the items and/or services listed above, and I agree to pay myself since I don’t want a claim submitted to Medicare or any other insurance I have. I understand that I have no appeal rights since a claim won’t be submitted to Medicare. I want the items and/or services listed above, and I agree to pay for the items and/or services myself if Medicare or my other insurance doesn’t pay. Send the claim to (Please check one or both boxes): __ Medicare __ my other insurance:__________________________________________ Please note: If you select option 3 and a claim is submitted to Medicare, you will get a Medicare Summary Notice (MSN) showing Medicare’s official payment decision. If the MSN indicates that Medicare won’t pay all or part of your claim, you may appeal Medicare’s decision by following the appeal procedures in the MSN. If you don’t receive a MSN for your claim, you can call Medicare at: 1-800-633-4227. TTY: (877) 486-2048. You may have to pay the full cost at the time you get the items and/or services. If Medicare or your other insurance decides to pay for all or part of the items and/or services that you have already paid for, you should receive a refund for the appropriate amount.

Home Health Advance Beneficiary Notice Option Box 2

We, VNA of Cordele, Inc., your home health agency, are letting you know that we _(will not provide you) (will no longer provide you) with the following items and/or services: ________________________________________________________________

Because: ___________________________________ ___________________________________

By signing below, I understand that I received this notice because this Home Health Agency decided to stop providing the items and/or services listed above. The Agency’s decision doesn’t change my Medicare coverage or other health insurance coverage. I can’t appeal to Medicare since this Home Health Agency won’t provide me with any more items and/or services; however, I can try to get the items and/or services from another Home Health Agency. Please note that there are many different ways to find another Home Health Agency, including by contacting your doctor who originally ordered home care. You may then ask the new Home Health Agency to bill Medicare or your other insurance for items and/or services you receive from them.

Examples of Which HHABN To Use for Medicare PPS Patients Only SN ordered with order for PT eval. PT eval. revealed no need for further PT services. No HHABN Needed Rationale: PT ordered 1 wk 1 for evaluation on POC

EXAMPLE 2 Existing PPS patient with HH aides 3 x/week for personal care and PSA 2 x/week for respite and chore services primarily. HHABN Option 1 Rationale: Medicare does not pay for respite and chore services

EXAMPLE 3 PT ordered 3 wk 4. D/C’d after 3 weeks with goals met, SN and HHA continue HHABN OPTION 1 Rationale: PT to complete – reduction of service

EXAMPLE 4 Pt receiving skilled care under Medicare and PSAs for personal care under CCSP program instead of home health aide services under Medicare. HHABN OPTION 1 Rationale: Medicare will not pay for PSA services since patient chooses these services to be provided under CCSP. * *VNA option to provide HHABN in this instance. HHABN not required by regulation when patient refuses home health aide services and opts for aide services under Medicaid waiver (CCSP).

EXAMPLE 5 Pt receiving homemaker/chore services under CCSP program HHABN OPTION 1 Rationale: Medicare does not pay for chore services

EXAMPLE 6 Care will be initiated, but NOT covered by Medicare, i.e. PSA services only HHABN OPTION 1 Rationale: Medicare will not pay for personal care when skilled care not needed

EXAMPLE 7 Medicare patient discharged due to unsafe environment for staff HHABN OPTION 2 Rationale: Agency made determination not related to Medicare coverage

EXAMPLE 8 Visits missed due to natural disaster, inclement weather, flooding, etc. or other patient related reasons No HHABN Needed Rationale: Missed visit only, no change in POC.

EXAMPLE 9 Active Medicare patient is no longer homebound but wants care to continue HHABN OPTION 1 Rationale: Medicare will not pay for services to a non-homebound beneficiary.

EXAMPLE 10 Patient admitted to services for SN, PT added later, but we are unable to staff HHABN OPTION 2 Rationale: Decision is unrelated to Medicare coverage. Patient has option of seeking services from another agency

EXAMPLE 11 Medicare is discharged due to goals met No HHABN Needed Rationale: Not required.

EXAMPLE 12 Active Medicare patient wants PT, but his physician will not order it HHABN OPTION 1 Rationale: Medicare will not pay for services which are not ordered by MD.

EXAMPLE 13 Frequencies were reduced and an HHABN was given. Now frequencies are being reduced again. HHABN OPTION 1 Rationale: Change in frequency requires another HHABN.

EXAMPLE 14 Initial episode of care SN 3 wk 4, 2 wk 4. SN plans to recert at 1 wk 4. HHABN OPTION 1 Rationale: Reduction in services from original POC.

EXAMPLE 15 Initial episode of care SN 2 wk 8. SN will recert at 2 wk 8. No HHABN Needed Rationale: No reduction in services

Example 16 Initial episode of care 2 wk 7, 1 wk 1. Recert calls for 1 wk 1, 2 wk 7. No HHABN needed Rationale: No change to original POC at recert. No HHABN needed for increases in frequencies.

EXAMPLE 17 PT ordered 3 wk 4, 1 wk 1. Visits are made at that frequency and stopped. SN remains on the care as planned. No HHABN Needed Rationale: Initial POC frequencies are being followed

EXAMPLE 18 Active patient is non-compliant with care and instructions and we decide to D/C. HHABN OPTION 2 Rationale: Decision made by agency which is unrelated to Medicare coverage.

Example 19 Initial evaluation indicates no need for skilled services and patient inappropriate for Medicare home health. Visit will not be billed. No HHABN needed Rationale: Since service will not be billed, HHABN not required. (HHABN required if agency bills for visit.)

Example 20 Pt’s wound has healed, no further orders for wound care. No further need for wound care supplies. HHABN OPTION 1 Rationale: Medicare will not pay for supplies when there is no need for wound care supplies.

Example 21 Pt. requests more supplies than medically necessary. HHABN OPTION 1 Rationale: Medicare will not pay for supplies that are not medically necessary.

Example 22 Pt. receiving SN and PT. MD discontinues PT under home health and orders outpatient PT. HHABN OPTION 1 Rationale: Medicare will not pay for SN under home health and outpatient PT services while pt. under home health POC. Agency does not contract with OP therapy centers.

We’re all in this together!

Bottom Line… There should be no surprises for the patient.