HCFA makes revisions to beneficiary notices

How they’ll affect you

The Health Care Financing Administration (HCFA) has announced its newest requirements concerning the notification of Medicare patients for whom home health agencies believe care will be reduced or terminated.

Under Medicare rules, if a home health agency believes that Medicare will not cover a medical treatment, the agency must notify the beneficiary of such (and, accordingly, that they are responsible for payment) before reducing or terminating physician-ordered care. According to these conditions of participation, agencies must make the notice both orally and in writing, although the format of the notice is the choice of the individual agency provided it meets specified requirements.

The revised requirements state:

• Agencies may continue to develop their own notices as long as the notice is such that its design and readability are easy for the beneficiary to understand, i.e., italics and ornate typeface are discouraged.

• No body type or text heading should be less than 12-point type.

• In order for the notice to be considered as "received," the beneficiary must be able to comprehend it.

• The notice must take the patient’s special needs into account, meaning that it must be provided in the beneficiary’s language be it Spanish or Braille, etc., large print, via an interpreter, etc.

• The document must clearly state that it is the agency and not Medicare that is issuing the notice.

• The notice must clearly state a beneficiary’s options for payment, continued care services, or the submission of a demand bill. (A demand bill is the process granting a patient the right to ask that the home health agency submit a claim for an official determination from Medicare, a determination that might not otherwise be submitted because the provider believes the care won’t be covered.)

• A home health agency must, according to the National Association for Home Care, "promptly submit a claim to the intermediary and report, on the claims submitted, condition code 20, to indicate that the beneficiary believes the services are covered."

• The agency must provide the beneficiary requesting a demand bill with a copy or the claim or a written statement testifying to the fact that the claim was submitted and on what date.

(These notice requirements do not apply in instances when a physician agrees either that care is not needed or that the beneficiary’s care should be reduced or terminated.

In the event that there are changes to a beneficiary’s care, however, the requirements still hold, as well as in cases where the home health agency expects there might be a change in Medicare payment for certain care services. As a rule, it’s advised that home health agencies provide their beneficiaries with the appropriate notice even in cases where a physician terminates care.)