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Category: Rights, Responsibilities and Ethics Number: 3.010.1

Subject: Home Health Advance Beneficiary Notice (HHABN)

Applies: All Staff Page: 1 of 4

Purpose: To ensure that Medicare beneficiaries receive timely, accurate, complete, and useful notices which will enable them to make informed consumer decisions, with a proper understanding of their rights to a Medicare initial determination, their appeals rights in the case of payment denial and how these rights are waived if they refuse to allow their medical information to be sent to Medicare.

Policy: This policy applies when the Agency reduces or terminates Medicare benefits without advanced notice and/or believes Medicare will not pay for care related to any one of the statutory bases: 1. Not medically necessary and reasonable; 2. Custodial care exclusion; 3. Failure to meet homebound and intermittent care requirements.

When the HHA expects payment for the home health services will be denied by Medicare or covered services are reduced or terminated without advanced notice, the beneficiary must be advised before home health care is initiated, continued, reduced or terminated. These notices must be issued by the HHA each time a trigger event occurs as described below. (Failure to do so is a violation of the Medicare HHA Conditions of Participation in the Medicare Program and may result in the HHA being held liable under the Limitation on Liability Provision.)

Trigger Events for the HHABN:

Initiation of Care for each episode: HHABN (CMS-R-296) Option 1 is required when any of the following situations exist and the beneficiary wishes to receive services regardless.  Services not ordered by physician  No beneficiary need for intermittent skilled nursing care, PT, SLP or continuing OT  Beneficiary not homebound  Services not reasonable and necessary  Services custodial in nature (housekeeping)  Item or service not a Medicare benefit under Title XVIII  A noncovered item or service delivered one time  Beneficiary charged for assessment, but no admission to home care YOUR COMPANY NAME HERE

Reduction of Care: HHABN (CMS-R-296) Option 1 is required when any of the following situations exist.  Some noncovered services discontinued (unless reasonable notice was given in advance)  Some previously covered services reduced because beneficiary no longer meets coverage criteria  Reduction of services (includes duration of visits) not planned/anticipated in POC; not communicated in advance with beneficiary  Reduction of services (not the beneficiary’s choice)

HHABN (CMS-R-296) Option 2 is required when the following situation exist.  Covered/noncovered services reduced for HHA financial or other HHA reasons

Termination of Care: HHABN (CMS-R-296) Option 1 is required when any of the following situations exist.  All noncovered services ending  All covered services ending, but noncovered services continue (Generic Expedited Review must also be issued)  All services ending, but patient goals not met/physician’s orders not complete  Termination of all services (not the beneficiary’s choice)

Termination of Care: HHABN (CMS-R-296) Option 2 is required when the following situation exist.  All covered/noncovered services ending for HHA financial or other HHA reasons (Generic Expedited Review must also be issued) YOUR COMPANY NAME HERE

Procedure for Notifying Beneficiary of suspected non Medicare coverage: 1. Advise the beneficiary or appropriate caregiver that it will not accept the beneficiary as a Medicare patient or will reduce or terminate services because it expects that Medicare will not pay for services and document this in the medical record.

2. Provide HHABN (CMS-R-296) Option 1 and retain a signed copy for the medical record. The HHABN should be hand delivered to the beneficiary or person acting on behalf of the beneficiary. When this is not possible, contact by telephone, followed immediately by a personal visit, this must be done before it can furnish services, reduce or terminate services.

3. Instruct the beneficiary or person acting on his or her behalf on the HHABN process patient options, and answer inquiries for additional information and/or assistance in understanding and completing the HHABN process.

4. Document patient understanding of the HHABN.

5. Notify the physician that it is expected that Medicare will not pay for services ordered and of the patient’s decision once options have been explained.

6. The HHABN shall be provided to the beneficiary no later than the end of the business day following the day on which the assessment of non-covered services was determined unless there is circumstance for a delay. In this case, those circumstances must be clearly documented in the medical record.

7. If the beneficiary refuses to sign the HHABN, the Agency may reduce, terminate or not initiate services on the date specified in the notice, which was provided to the beneficiary. This action is limited to those services specified in the notice.

YOUR COMPANY NAME HERE Category: Rights, Responsibilities and Ethics Number: 3.010.1

Procedure for HHABN Option 1, Selection #3 1. If the home health Agency does provide services to the beneficiary even though the Agency expects Medicare to deny payment or at the patient’s request, to continue home care services and submit a claim to Medicare to determine coverage, the Agency must:

a. Receive a signed and dated HHABN from the beneficiary ensuring that if Medicare does not pay for services, the beneficiary agrees to incur financial liability for payment.

b. Submit the claim to Medicare with a copy of the signed and dated HHABN including any additional information from the beneficiary or person acting on his or behalf, or from a physician that supports Medicare coverage of the subject of home care services.

c. Document patient understanding of the HHABN, beneficiary right to a Medicare initial determination and their appeals rights in the case of payment denial.

2. If the Agency continues services after the effective date of the HHABN and the beneficiary later chooses not to receive home care services, termination or reduction of services may be effectuated immediately.