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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