Home Health Advance Beneficiary Notice HHABN

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
HHABN Background

• Litigation going back into the 1990s
• Initial multi-page HHABNs withdrawn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
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

2006 Final HHABN Instructions
4
HHABN Where When

• Notice under FFS HHABN
• http//www.cms.hhs.gov/BNI/
• Final Instructions - Pub. 100-04, Chapter 30,
  Section 60
• httpww.cms.hhs.gov/Transmittals/2006Trans/list.as
  p
• 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
5
HHABNs

• HHABN Statutory Authority
• SSA, 1891-Beyond Original Medicare
• SSA, 1879-Original Medicare

2006 Final HHABN Instructions Section 60.2A
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

2006 Final HHABN Instructions Section 60.2B-C
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

2006 HHABN Instructions Section 60.2D
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

2006 Final HHABN Instructions Section 60.2E
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 RN)
• Bundled Payments
• The bundle is always seen as a whole

2006 Final HHABN Instructions - Section 60.2F
and 60.2G
10
Limitation on Liability (LOL)

• Outside the HH Benefit
• Reasonable and Necessary
• Home Health Benefit
• 4 Reasons

2006 Final HHABN Instructions Section 60.2H
11
Limitation of Liability Continued
2006 Final HHABN Instructions 60.2H
12
HHABN Triggering Events Definitions
2006 Final HHABN Instructions Section 60.3
13
Triggering Events for the HH Benefit1879 or
1891 Applies
2006 Final HHABN Instructions Section 60.3
14
Triggering Events for the HH Benefit1879 or
1891 Applies
2006 Final HHABN Instructions Section 60.3
15
Triggering Events Outside the HH Benefit1879
Applies
2006 Final HHABN Instructions Section 60.3
16
Triggering Events Outside the HH Benefit1879
Applies
2006 Final HHABN Instructions Section 60.3
17
Initiations

• Assessments prior to admissions
• Admissions for noncovered care
• One-time services

2006 Final HHABN Instructions Section 60.3A
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

2006 Final HHABN Instructions Section 60.3B
19
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
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

2006 Final HHABN Instructions Section 60.3D
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

2006 Final HHABN Instructions Section 60.3D
22
HHABN Exceptions

• Reduction or Termination
• Beneficiary choice
• Exclusive other coverage

• Termination
• Patient goals met

2006 Final HHABN Instructions Section 60.3D
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

2006 Final HHABN Instructions Section 60.4F
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

2006 Final HHABN Instructions Section 60.4F
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

2006 Final HHABN Instructions Section 60.4.F
26
Completing the HHABN

• General Notice Requirements Continued
• Customization
• Information - Information in blanks that is
  constant can be pre-printed HHAs 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
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

2006 Final HHABN Instructions Sections 60.4.F
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

2006 Final HHABN Instructions
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

2006 Final HHABN Instructions Section 60.4.G.2
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)

2006 Final HHABN Instructions Section 60.4.G.2
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

2006 Final HHABN Instructions Section 60.4.G.2
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)

2006 Final HHABN Instructions Section 60.4.G.2
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)

2006 Final HHABN Instructions Section 60.4.G.2
34
Statutory Authority Supporting HHABN Option Boxes
2006 Final HHABN Instructions
35
General Summary of HHABN Option Box Use
2006 Final HHABN Instructions Section 60.4.G.2b
36
Which Option Box Should I Use?
The following chart summarizes the circumstances
in which each option box should be used
2006 Final HHABN Instructions Section 60.4.G.2.b
37
Which Option Box Should I Use?
The following chart summarizes the circumstances
in which each option box should be used
2006 Final HHABN Instructions Section 60.4.
G.2.b
38
Which Option Box Should I Use?
The following chart summarizes the circumstances
in which each option box should be used
2006 Final HHABN Instructions Section 60.4.
G.2.b
39
Which Option Box Should I Use?
The following chart summarizes the circumstances
in which each option box should be used
2006 Final HHABN Instructions Section 60.4.
G.2.b
40
Instructions for HHABNOption 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

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

2006 Final HHABN Instructions Section
60.4G.2.b
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

2006 Final HHABN Instructions Section 60.4G.2.b
43
HHABN Option Box 1 Step 1Continued

• 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

2006 Final HHABN Instructions Section
60.4.6.2b
44
HHABN Option Box 1 Step 1Continued

• 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

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

2006 Final HHABN Instructions Section
60.4.G.2.b
46
Instructions for HHABB Option Box 2Continued

• 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)

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

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

2006 Final HHABN Instructions Section 60.4 G.2.
b
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

2006 Final HHA Instructions Section 60.4.G.2.b
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 Beneficiarys Full Name
• Medicare (HICN) - On Medicare card
• Medicare Beneficiarys Signature
• Date
• HHAs can complete the first 2 blanks to help
  beneficiaries

2006 Final HHABN Instructions Section 60.4.G.3
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

2006 Final HHABN Instructions - Section 60.5 A
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

2006 Final HHABN Instructions - Section 60.5 B
and 60.7 D
53
Effective HHABNs

• Delivery inperson 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
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

2006 Final HHABN Instructions - Section 60.6.1
55
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
56
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
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

2006 Final HHABN Instructions - Section 60.7 A
58
HHABN Provider Liability

• Failure to give HHABN when required
• Gives defective HHABN
• Cant collect/must refund any beneficiary
  collections
• Cant collect for a part of a covered bundled
  payment

2006 Final HHABN Instructions - Section 60.7 BC
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

2006 Final HHABN Instructions - Section 60.8
60
HHABN

• THE END