Telemonitoring and HHABNs a clarification
Posted by: Robert Markette
August 22, 2006

Well, I have to change the answer I posted here yesterday about Telemonitoring.  Some of you may have read the e-mail NAHC sent out regarding Telemonitoring services and the use of an HHABN.  Under the original instructions and guidance, the telemonitoring service required an HHABN.  My discussion yesterday was based upon that original guidance.

However, after I received a copy of an e-mail from the National Association for Home Care (NAHC) I called Elizabeth Carmody to clarify the point.  (I must say thank you to Ms. Carmody, for taking a few minutes out of her busy day to call me back with some clarification.)  

CMS has changed its position on the use of HHABNs for telemonitoring in some circumstances.  For those of you who provide telemonitoring as a free service, there is no longer a need to provide the HHABN.  Under section 60.2 D of the new transmittal, if a service is never covered under Medicare and you are not going to charge the beneficiary for the service, no HHABN is necessary.  This means for telemonitoring, even if it is on the plan of care and integrated with the Medicare covered care, you do not need to issue an HHABN if you do not charge the beneficiary.   

However, that does not mean that all non-covered care does not require an HHABN.  If you serve dually eligible clients and the client will receive care reimbursed by Medicaid, you still need to issue an HHABN upon initiation of the care.  This is made clear in Section 60.2 D of the transmittal.  The point is that for dually eligible patients receiving Medicaid covered care or other care that is covered by insurance, but not by Medicare, the beneficiary must receive an HHABN upon initiation of care, but not for any other triggering events, until Medicare coverage again becomes an issue..

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Another thought on HHABNs
Posted by: Robert Markette
August 21, 2006

I could not help but start the week with one more HHABN post.  During a teleconference last week, I was asked about telehealth and HHABNs.  I have posted on this topic previously, but the questioner raised a point that I found interesting.  The question had to do with the use of option box one to notify the patient that the telehealth service is not covered by Medicare upon initiation of the non-covered care.

The issue in this case is that most providers do not charge for telehealth monitoring of home health patients.  The service is provided as a free service, because it can lead to improved outcomes.  (Or at least that is how it was explained to me.)  Of course, this leads to a potentially confusing situation, because the HHABN using option box one is designed to explain the beneficiary?s potential liability and then allow the beneficiary to either choose to pay for the care, refuse the care, or direct the agency to another insurance coverage.  

The first think to keep in mind in this case is that if you do not intend to charge the beneficiary, you may estimate the beneficiary?s cost at $0.  CMS made that point clear in the question and answer documents they published this year.

However, the HHABN does not provide a spaces to for the beneficiary to say, ?Yes, I choose to receive these free services.?  Instead, they are left with the option of saying they choose to receive the services and will pay for them. The obvious concern is that the beneficiary will wonder why they have to complete any paperwork stating they will agree to pay for a service that they have just been told is free.

The key in this situation is explaining to the beneficiary that they will not have any costs from receiving this service. If you have estimated the charges at $0, you can point out to the beneficiary, that they are agreeing to pay $0.00 for the service.  (You could then jokingly offer to send them a bill each month.)  When the beneficiary asks why you are explaining to them the details of a free service and asking them to agree to pay for it, you can explain to them that CMS requires the form.  You can then explain that CMS did not design the form to account for free services.  If you carefully explain to the beneficiary that you do not charge for this service, but that CMS requires you to use the form, the beneficiary might better understand why you are doing this.

You will run into other situations where the HHABN does not seem to ?fit? the circumstances.  CMS limited the number of options boxes and specified what had to be included and you will have to live with that.  That is why it is important that you train your staff to carefully and thoroughly explain the HHABN to the beneficiaries.  When you run into situations where the HHABN does not quite ?fit?, you will rely upon your field staff to explain the situation in a way that the beneficiary understands.  Frankly, even in ?simple? HHABN situations, your field staff will need to be able to clearly explain HHABNs, otherwise you may find yourself with a large number of unsigned HHABNs.

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A few thoughts on the HHABN program transmittal
Posted by: Robert Markette
August 17, 2006

Well, after a great deal of waiting, we finally saw the Program Transmittal relating to the HHABN.  It appears to include everything from both Q&As as well as additional details.  Having just participated in two seperate HHABN seminars, I wish CMS would have issued this transmittal a week or two ago.  The transmittal tries very hard to calrify when an HHABN is appropriate, and even contains a number of charts that break down the need for an HHABN by whether the care is covered, if it is in the home health benefit, and which notification provisions apply.  This is far more detail than any of the previous documents CMS has issued.  This illustrates the problematic nature of this whole process.  More than five months into this "process" and with only a couple of weeks until the compliance deadline, we get the detailed instructions.

A couple of things jumped out at me as I read through the transmittal.  (Yes, I actually read it.)  First, CMS says you cannot use ranges in an HHABN. This is a major change, because all previous indications were that reasonable ranges would be acceptable.  CMS cautiioned providers on the use of broad ranges, but there was never any indication that ranges were not acceptable.  Apparently, CMS has decided they are.  Therefore, the use of ranges to avoid issuing HHABNs is not an option.  The HHABN will need to state specific frequencies and when reductions occur, HHABNs may be necessary.

Also, preplanned reductions, an exception in the original instructions, are clarified in this transmittal.  The preplanned reductions exception now requires the reduction be part of the initial POC and communicated to the beneficiary.  Reading further into the transmittal leads to the conclusion that CMS intends for this communication with the beneficiary to be through an HHABN.  CMS says that if an agency is comfortable with it, the agency may provide advance notice of all triggering events to the beneficiary. (Be sure not to use ranges when doing this, even if ther are in the POC.)

 This advance notice would then eliminate the need for HHABN's upon the occurrence of the triggering events as outlined in the original HHABN.  However, if any triggering events occurred during the period that were not outlined in the original HHABN, a new HHABN would need to be issued.  In my opinion, this means if you want to rely upon the "preplanned reductions" exception, you would have to issue an HHABN upon initation of covered care.  Of course, this eliminates the need to issue HHABNs for preplanned reductions, but does undermine the "no HHABN upon initiation of covered care" rule.

 Once again, I think the transmittal answers some questions, but I beleive it will leave beneficiaries with more questions.  That is not unusual with any new regulatory requirement, as every provider is afraid of doing something wrong and with anything new like this, that fear is greater.  But like every other new regulatory requirement, the new HHABN shall become familiar to you in no time at all.

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HHABN Program transmittal is out.
Posted by: Robert Markette
August 16, 2006

I have not read it yet, but the HHABN program transmittal has been issued by CMS. I will comment after I have had a chance to review it. You can download it from the link below.

Attachments:
R1025CP.pdf

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Revised HHABN Instructions.
Posted by: Robert Markette
August 10, 2006

Well, the revised HHABN instructions were posted on Friday.  I do not think they added anything that was not added in the two previous questions and answers.  The new instructions do include a more detailed chart that lists a number of situations and which HHABN option box should be used in the situation.  Beyond that, CMS tried to do as they indicated in previous Q&A responses ? clarify the instructions to reflect the Q&A.

Reading through the revised instructions and the two questions and answers still leaves the new HHABN unclear.  For example, in my opinion, the April Q&A and the revised instructions indicate that providers do not need to provide HHABNs for reductions or terminations of non-covered care.  The new chart on the revised instructions lists a series of situations and which Option box is appropriate in each case.  For one type of reduction, the use of an option box is listed as ?voluntary?.  My reading of this is that the HHABN is voluntary in that context.  The context is services which are not Medicare benefits.  In my opinion that means if you are reducing non-covered care you no longer need to issue an HHABN.

However, for something that is potentially that big, I have not seen anything really discussing this change.  This is most likely because the instructions are not clear and the safest approach in the face of an unclear regulatory burden is ?overcompliance.?   What I mean is, when in doubt ? give HHABNs.

In a bulletin that went out shortly after the revised instructions were released, NAHC commented on the need for greater clarity from CMS.  NAHC is absolutely correct.  Specifically, CMS needs to make it clear when do non-covered services require an HHABN, if at all.  They could also clarify a few issues regarding reductions vs. terminations.

One area that seems to confuse a lot of providers is that you must give an HHABN upon initiation of non-covered care, but if you add non-covered services, say private pay companion care, you do not provide an HHABN upon ?initiation? of that care.  The difference in these two cases is that CMS considers initiations differently from increasing services during the plan of care.  A simple set of definitions (not what they put in the revised instructions, but definitions that make these distinctions clear), would help providers, because a lot of providers are using the terms, but are not clear on what they mean.

This lack of clarity reinforces the need for the promised update to the program manuals and, in my opinion, regulations.  Because CMS has been reacting to a law suit, the HHABN ?update? has been moving forward in an unusual fashion.  This has resulted in a very confusing implementation effort and lots of questions by providers.  Furthermore, even as September 1 approaches, everybody expects that we will hear more from CMS regarding the new HHABN.  The potential for more clarification has some providers waiting until the last minute to implement the new HHABN.  This makes some sense, because you may better understand what CMS requires, if the manual revisions are issued before September 1.

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