HHA Triggering Events
HHAs may be required to provide an ABN to an Original Medicare beneficiary when
a triggering event occurs. Table 2, below, outlines triggering events specific
to HHAs.
Event Description
Initiation When an
HHA expects that Medicare will not cover an item and/or service delivered under
a planned course of treatment from the start of a spell of illness, OR before
the delivery of a one-time item and/or service that Medicare is not expected to
cover.
Reduction When an HHA expects
that Medicare coverage of an item or service will be reduced or stopped during
a spell of illness while continuing others, including when one home health
discipline ends but others continue.
Termination When an HHA expects
that Medicare coverage will end for all items and services in total.
• HHA Initiations
The HHA must issue a beneficiary an ABN prior to delivering care that is
usually covered by Medicare,
but in this particular instance, the item or service may not be or is not
covered by Medicare because:
− The care is not medically reasonable and necessary;
− The beneficiary is not confined to his/her home (is not considered
homebound);
− The beneficiary does not need skilled nursing care on an intermittent
basis; or
− The beneficiary is receiving custodial care only.
Note: If the HHA believes that Medicare will not (or may not) pay for
care for a reason other than
ones listed directly above, issuance of the ABN is not required.
INITIATION EXAMPLE: A beneficiary requires
skilled nursing wound care 3 times weekly; however, she is not confined to the
home. She wants the care done at her home by the HHA. The HHA must issue
the ABN to this beneficiary before providing the home care that will not be
paid for by Medicare. This allows the beneficiary to make an informed decision
on whether to receive the non-covered care, and to accept the financial
obligation.
An ABN, signed at initiation of home health care for items and/or services not
covered by Medicare, is effective for up to a year; as long as the items/services
being given remain unchanged from those listed on the notice.
• HHA Reductions
Reductions involve any decrease in services or supplies, such as frequency,
amount, or level of care that an HHA provides and/or that is part of the Plan
of Care (POC). If a reduction occurs for an item or service that will no longer
be covered by Medicare, but the beneficiary wants to continue to receive the
item or service and will assume the financial charges, the HHA must issue the
ABN prior to providing the noncovered items or services. (Technically, this is
an initiation of noncovered services following a reduction of services).
REDUCTION WITH SUBSEQUENT INITIATION EXAMPLE: A beneficiary requires Physical
Therapy (PT) for gait retraining 5 times per week for 2 weeks, then reduce to 3
times weekly for 2 weeks. After 2 weeks of PT, the beneficiary wants to
continue therapy 5 times a week even though this amount of therapy is no longer
medically reasonable and necessary. The HHA would issue an ABN so that he understands
the situation and can consent to financial responsibility for the PT not
covered by Medicare.
• HHA Terminations
A termination is the cessation of all HHA-provided Medicare covered services.
If a beneficiary wants to continue receiving home health care that will not be
covered by Medicare for any of the statutory reasons listed in Table 1 and a
physician orders the services; the HHA must issue the beneficiary an ABN in
order to charge the beneficiary or a secondary insurer. If the beneficiary will
not be getting any further home care after discharge, there is no need for ABN
issuance.
When all Medicare covered home health care is terminated, HHAs may sometimes be
required to deliver the Notice of Medicare Provider Non-Coverage, (NOMNC),
CMS-10123. The NOMNC informs beneficiaries of the right to an expedited
determination by a Quality Improvement Organization (QIO) if they feel that
termination of home health services is not appropriate. Detailed information
and instructions for issuing the NOMNC can be found on the CMS website under
the link for “FFS ED Notices” at
http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html on the
CMS website.
If a beneficiary requests a QIO review upon receiving a NOMNC, the QIO will
make a fast decision on whether covered services should end. If the QIO decides
that Medicare covered care should end and the beneficiary wishes to continue
receiving care from the HHA even though Medicare will not pay, an ABN must be
issued since this would be an initiation of non-covered care.
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