Response to Comments for CMS-10280

Comments Received on Home Health Change of Care Notice (HHCCN), Form CMS 10280

DEC 2012 – FEB 2013

Organization	Document (notice, instructions)	Page # (if applicable)	Issue/Comment	CMS Response
Concordia Visiting Nurses	Notice		Found references to Option Boxes on the Home Health Advance Beneficiary Notice (HHABN) confusing.	We have had multiple reports in the past that the Home Health Advance Beneficiary Notice (HHABN) is confusing due to its multiple formatting options and “Option Boxes”. Discontinuation of the HHABN will eliminate confusion regarding option box references.
Concordia Visiting Nurses	Notice		Concern with additional change and costs associated with implementation of a new form. Concern that replacing a single form (HHABN) with two different forms (HHCCN and ABN) will increase costs.	CMS recognizes that home health agencies (HHAs) agencies incur costs with notice issuance to Medicare beneficiaries. HHAs will be given adequate time to change from using the HHABN to the HHCCN and ABN. By allowing time for this transition, HHAs with pre-printed HHABNs will be able to deplete their stockpiles before they are required to use the HHCCN and the ABN; thus, there should be minimal to no costs associated with the change. Although the HHABN is a single form, it has 3 different formatting options for printing and issuance. Substituting the 3 different HHABN notice formats with 2 notices (the ABN and HHCCN) should not increase costs.
Illinois Homecare & Hospice Council (IHHC)
CT Association of Healthcare at Home
Home Care Association of New York State	Notice		Request burden estimates that reflect time to complete the form and explain and issue the notice.	The current burden estimate of 4 minutes per response is based on prior estimates used for completion of the HHABN Option Box 2 and Option Box 3. These time were derived in 2006 with assistance from the home health industry when the Option Boxes were added to the HHABN. These time burden estimates should not change with use of the HHCCN.
Concordia Visiting Nurses	Notice		When exactly is the ABN form to be used for home health care?	The exact date of use for the ABN and HHCCN is not known at this time. The ABN and HHCCN proposals will be published in the Federal Register for a 30 day comment and response period and must receive Office of Management and Budget approval before CMS can release the notices for use by HHAs. CMS will announce the date of approved use at the HHA link on the CMS website http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html and at Home Health Hospice Durable Medical Equipment Open Door Forums.
Living Resources Certified Home Health Agency			Form Instructions state that HHAs may begin using the HHCCN ASAP. When can we actually start using the form?
Living Resources Certified Home Health Agency	Form Instructions	2	Instructions state that the HHCCN is for covered and non-covered services on plan of care (POC). If a waivered (non-covered) type of service is being reimbursed by Medicaid, MLTCP, or a managed care entity, is the HHCCN issued?	The same rules for issuance of the Home Health Advance Beneficiary Notice (HHABN), Option Box 2 and 3 will apply to the HHCCN. HHCCN issuance is only required when an Original Medicare beneficiary is receiving covered Medicare services. If a beneficiary is receiving covered Medicare home health services and the plan of care includes a service that is never covered by Medicare (e.g. telehealth monitoring), the HHCCN must be issued for a reduction or termination of this non-covered service. If an Original Medicare beneficiary is receiving items and services that are not covered by Medicare, the HHCCN shouldn’t be issued for reductions or terminations of ongoing items or services. So, if a beneficiary receives home care that is not covered by Medicare but is covered by Medicaid, HHCCN issuance is not required for care changes. Like the HHABN, HHCCNs are never issued to Medicare managed care enrollees. This information will be provided in our revision to the Medicare Claims Processing Manual, Chapter 30, Section 60 that will be released when the HHCCN is approved for use.
Home Care Association of New York State	Form Instructions		Need clarification on HHCCN issuance for non-covered services.
Living Resources Certified Home Health Agency	Form Instructions	2	Unsure of notice issuance with care terminations. Requesting clinical examples of terminations and issuance of Notice of Medicare Noncoverage (NOMNC) vs. Advance Beneficiary Notice of Noncoverage (ABN) vs. HHCCN.	CMS will soon publish a manual section on the NOMNC in the Medicare Claims Processing Manual, Chapter 30, Section 260. This publication will help providers comply with proper notice issuance. Examples of notice issuance at termination: A homebound beneficiary is receiving Medicare covered skilled nursing wound care services and physical therapy (PT). o Scenario 1 – NOMNC issuance The wound is healing, and the physician orders discontinuation of wound care. PT goals are met, and he will be discharged from home health care at the end of this week. The NOMNC must be issued prior to being discharged from home health care. o Scenario 2 – HHCCN issuance The wound is healing, and the physician orders discontinuation of wound care. PT continues per existing orders. The HHCCN is issued to notify the beneficiary of the physician’s orders for termination of wound care. o Scenario 3 – ABN issuance The wound is healing, PT goals are met, and the physician orders discontinuation of wound care and PT and discharge from home care. A NOMNC was issued, and the beneficiary did not request a Quality Improvement Organization (QIO) review of his discharge. The beneficiary has requested continued home care PT services that are not medically necessary, and his physician orders PT that will not be covered because they are no longer medically reasonable and necessary services. An ABN must be issued prior to delivering these services in order to shift financial liability to the beneficiary.
Home Care Association of New York State	Form Instructions		Request clarification on NOMNC issuance
National Association for Home Care & Hospice	Notice		Support for HHCCN	Thank you for supporting this change.
Home Care Association of New York State	Notice		When prior changes were made to the HHABN, this association advocated for a simplified form to make completion by home health staff easier and facilitate beneficiary and family understanding of the notice. HHCCN is an improvement over current HHABN Option Box 2 and 3 formats.
Illinois Homecare & Hospice Council (IHHC)	Notice		Members find the proposed HHCCN more straightforward and potentially easier than the existing HHABN. Members are not convinced that there is a compelling reason to support form revision.	Thank you for identifying positive aspects of this change. This change supports CMS’s efforts to streamline and simplify beneficiary notification processes. We have received many comments over the past 5 years from home health providers expressing confusion with the HHABN. These changes are supported by the majority of the industry including support from the largest national trade association for home health agencies. In addition, since the ABN is currently used for hospice care, home health agencies providing hospice services already have the notice in place and are familiar with it. Currently, 11,941 HHAs are enrolled in Medicare, and 1,297 of these HHAs also provide hospice care. So, 10.86% of HHAs are already using the ABN for beneficiaries enrolled in hospice.
CT Association for Healthcare at Home	Notice		Medicare HH Notice process definitely needs to be “streamlined, reduced, and simplified” but these proposed changes don’t accomplish the goal.
Illinois Homecare & Hospice Council (IHHC)	Notice		Recommend that optional language be included on the HHCCN citing issues related to the face-to-face encounter requirement and cite “some frequency” of discharges related to the face-to- face encounter. Proposed HHCCN options don’t appear to address discharge under these circumstances	Since the HHCCN replaces HHABN Option Box 2, we expect HHAs to use the HHCCN for these types of notifications. The HHABN Option Box 2 does not include language specific to the face-to-face requirements; however, the Medicare Claims Processing Manual (IOM 100-04), Chapter 30, Section 60.3.C gives an example of HHABN Option Box 2 use for terminations related to failure to meet face-to-face requirements. As with issuance of HHABN Option Box 2, HHAs may enter their own language on the HHCCN to indicate that care is ending because the HHA believes that face-to-face requirements may not be met in the required timeframe.
Home Care Association of New York State	Form Instructions		Request clarification of representative signature requirements.	The HHCCN form instructions should be used along with the manual instructions for notice issuance that are found in the Medicare Claims Processing Manual, Chapter 30. Details on representatives are published in this chapter.
National Association for Home Care & Hospice	Notice		Replace the single “Items/services and Reason for Change” box with 2 separate “Items/services and Reason for Change” boxes below each check box.	We considered this option in drafting the notice; however, the 10-12 point font requirements and language that must be included on the notice prevent this from being a feasible option for a one-page notice.
National Association for Home Care & Hospice	Notice		Remove the word “provider” from all places where it appears on the form since only physicians may order home health.	We agree with your comment and have made this change to the notice.
National Association for Home Care & Hospice	Notice		Amend the first sentence in the second box to “You can look for care from a different home health agency if you still need care and your doctor agrees.”	In drafting this notice, legal counsel recommended inclusion of the wording “a valid order for home care”. We do not plan on changing this language since even if a doctor agrees that care is needed, there must be a valid order for home care in order for another HHA to provide care.
National Association for Home Care & Hospice/ Home Care Association of New York State	Notice		Remove the statement regarding billing and appeals rights since this notice is not related to Medicare coverage.	We consulted our legal counsel regarding making these specific changes to the notice. We were advised against making these modifications in accordance with the U.S. Court of Appeals (2nd Circuit) decision in Lutwin vs. Thompson, 361 F. 3d 146; 2004 U.S. App. LEXIS 3774 which is the basis for implementation and requirements of the HHABN Option Box 2 and 3, and therefore, the HHCCN.
National Association for Home Care & Hospice	Notice		Remove the statement “If you have questions about these changes, you can contact your home health agency and/or the doctor/provider who orders your home care” as it is repetitive of advice already given on the notice.
National Association for Home Care & Hospice	Notice		Remove the statement about Medicare appeals since this notice is not related to coverage.
Home Care Association of New York State	Notice		Change language at top of second box from “Your home health agency has decided to stop giving you the home care listed above,” to “Your home health agency is unable to continue giving you the items/services listed above.”

2