End Stage Renal Disease Facility Providers

This page provides basic information about being certified as a Medicare and/or Medicaid End Stage Renal Disease (ESRD) provider and includes links to applicable laws, regulations, and compliance information.

ESRD is that stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplant to maintain life.

Types of ESRD Facilities:

•    Renal Transplantation Center

A hospital unit which is approved to furnish, directly, transplantation and other medical and surgical specialty services required for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement.  A renal transplantation center may also be a renal dialysis center.

•    Renal Dialysis Center

A renal dialysis center is a hospital unit that is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under arrangement and outpatient dialysis).  A hospital need not provide renal transplantation to qualify as a renal dialysis center.

•    Renal Dialysis Facility

A renal dialysis facility is a unit that is approved to furnish dialysis service(s) directly to ESRD patients.

•    Self Dialysis Unit

A self-dialysis unit is a unit that is part of an approved renal transplantation center, renal dialysis center, or renal dialysis facility, and which furnishes self-dialysis services.

ESRD Application Requirement

Filing of Application

To establish eligibility to provide ESRD services under Medicare, an applicant must complete Part I of the End Stage Renal Disease Application and Survey and Certification Report, Form CMS-3427.

Advance Beneficiary Notice of Non-coverage: When Should You Sign an ABN?

Medicare has broad coverage, but there are some services that are not covered because they are considered reasonable, medically necessary, and appropriate. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.

The following are some examples of when an ABN can be used for non-covered services:

• Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.

• Services paid for by a government entity other than Medicare

• Personal comfort items

• Routine eye care

• Dental care

• Routine foot care

ABNs cannot be issued for services that the provider knows is medically necessary and is covered by Medicare. In addition, an ABN cannot be issued for emergency ambulance transportation because the patient is presumed to be under ‘great duress’. An ABN cannot be issued to a patient if they are under great duress.

An ABN must be given to you (or your representative) prior to receiving the item or service in question. The Centers for Medicare & Medicaid (CMS) mandates your provider give you the ABN far enough in advance for you to have time to consider your options and make an informed choice.

CMS has created a standardized ABN form to use; however, it does allow your health care provider to use their own form, as long as it contains the same information.

If your provider asks you to sign an ABN, the document must:

• Give the name or description of the service they are providing

• Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: 'Medicare does not pay for this test for your condition,' 'Medicare does not pay for this test as often as this (denied as too frequent)', or 'Medicare does not pay for experimental or research tests.'

• Give you the estimated cost of the service or procedure

• Provide you with three options, worded in the following ways:

Medicare ABN - If patient has other insurance - what is the procedure

Effect of Other Insurers/Payers  

If a beneficiary is eligible for both Original Medicare and Medicaid (dually eligible) or is covered by Original Medicare and another insurance program or payer (such as waiver programs, Office on Aging funds, community agencies (e.g., Easter Seals) or grants), ABN requirements still apply.   For example, when a beneficiary is a dual eligible and receives home health services that are covered only under Medicaid, but are not covered by Medicare for one of the reasons listed in Table 1; an ABN must be issued at the initiation of this care to inform the beneficiary that Medicare will likely deny the services.  

Some States have specific rules regarding HHA completion of liability notices in situations where dual eligible beneficiaries need to accept liability for Medicare noncovered care that Medicaid will cover.  Medicaid has the authority to make this assertion under Title XIX of the Act, where Medicaid is recognized as the “payer of last resort” (meaning other Federal programs like Medicare (Title XVIII) must pay in accordance with their own policies before Medicaid assumes any remaining charges)

On the ABN, the first check box under the “Options” section indicates the choice to bill Medicare and is equivalent to the third checkbox on the outgoing HHABN. HHAs serving dual eligibles should comply with existing HHABN State policy within their jurisdiction as applicable to the ABN unless the State instructs otherwise.

What are cases can HHA give ABN TO beneficiary - time period of ABN

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.

ABN notice for - Home health agency

Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 

This article is based on Change Request (CR) 8404 which provides: 1) instructions for Home Health Agency (HHA) use of the Advance Beneficiary Notice of Noncoverage (ABN) to replace the outgoing Home Health Advance Beneficiary Notice (HHABN), Form CMS-R-296, Option Box 1; 2) ABN issuance guidelines for therapy services and therapy specific examples; and 3) minor editorial changes  to clarify existing manual instructions regarding ABN issuance.

Home health agencies and therapy providers should make sure that their health care and billing staff are aware of these ABN policy changes. All other providers should note that there have been no substantive changes to the ABN form or general instructions for issuance and can reference MM7821 (available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm7821.pdf) for general ABN information. 

HHA Use of ABN – General Use

HHAs are required to issue an ABN to Original Medicare beneficiaries in specific situations where “Limitation on Liability” (LOL) protection is afforded under Section 1879 of the Act for items and/or services that the HHA believes Medicare will not cover (see Table 1 below). In these circumstances, if the beneficiary chooses to receive the items/services in question and Medicare does not cover the home care, HHAs may use the ABN to shift liability for the non-covered home care to the beneficiary.