CMS Pub. 100-04, ch. 30, § 60.3

HHAs may be required to provide an HHCCN to an Original Medicare beneficiary at two

points in time, for reasons not related to Medicare coverage called “triggering events”:

Table 2

Triggering Events for HHCCN Issuance

EVENT DESCRIPTION

Reduction

of a service

When an HHA reduces or stops an item and/or

service during a spell of illness while continuing

others, including when one home health

discipline ends but others continue.

Termination

of all services

When an HHA ends delivery of all services.

A. Reductions

Reductions involve any decrease in items and/or services, such as frequency, amount, or

level of care, provided by the HHA. When care that is listed on the POC or provided by

the HHA is reduced, the beneficiary must receive the HHCCN listing the items/services

being reduced and the reason for the reduction, regardless of who is responsible for

paying for that service.

When a reduction occurs because the HHA decides to stop providing the service for

administrative reasons or because of a physician’s order, the HHCCN must be issued.

Example 1 – Reduction for HHA reasons:

Because of a temporary staffing shortage, an HHA reduces daily physical therapy

(PT) to PT 3 times weekly for 2 weeks.

The HHCCN must be issued to the beneficiary prior to this care reduction that is

due to an agency administration issue.

Example 2 –Reduction based on physician’s orders:

The beneficiary met PT goals sooner than expected, and the attending physician

writes an order to discontinue home PT. Physical therapy services are

discontinued with no change in existing skilled nursing orders.

The HHCCN must be issued to the beneficiary prior to this care reduction that is a

change to the existing POC because of a physician’s order. Reductions include

cases, such as this, where one type of care ends, but the beneficiary continues to

receive another type of home health service.

An ABN is issued (and not the HHCCN) 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 care and assume the financial charges. See Section 50.15.4.

B. Terminations

A termination is the cessation of all services provided by the HHA and can include

Medicare covered and noncovered care. When all home health care is ending for reasons

not related to Medicare coverage, the HHA issues the HHCCN with information

appropriate to the specific situation.

Example 1 – care termination due to agency reasons (such as staffing, closure of the

HHA, concerns for staff safety), not related to Medicare coverage.

An HHA decides to stop providing care because guard dogs at the home where

the care is being furnished have posed safety issues for staff.

Because termination is due to an HHA administrative decision, the HHCCN must be

given to the beneficiary prior to discontinuation of services.

Example 2 – care termination due to agency reasons (failure to meet face to face

encounter requirement)

An HHA has initiated care for a beneficiary, and the beneficiary has not yet had

the required face to face encounter with the certifying physician or an allowed

non-physician practitioner (NPP). The HHA believes that the face to face

encounter requirement will not be met in the allowed time frame and decides to

stop providing care.

This termination is due to an HHA administrative decision; thus, the HHCCN must be

given to the beneficiary prior to discontinuation of services. Issuing the HHCCN does not

affect financial liability but serves as a written change of care notice as required by the

HHA COPs.

Example 3 – care termination due to a physician’s orders to discontinue care or a

lack of orders to continue care

A physician orders discontinuation of all home health services or fails to order

continued home health services.

The Notice of Medicare Provider Non-Coverage (NOMNC), CMS-10123 must be issued

to the beneficiary when all Medicare covered services are ending based on the

physician’s orders. Since the NOMNC provides written notification of the forthcoming

termination of all home health care, it satisfies the regulatory requirement for change of

care advisement (HHCCN issuance). Thus, when the NOMNC is issued as required, the

HHA doesn’t have to issue a separate HHCCN. When home health services end because

of physician’s orders, HHAs have the option of issuing the NOMNC alone or both the

NOMNC and the HHCCN.

Detailed information and instructions for issuing the NOMNC can be found on the CMS

website at: http://www.cms.gov/Medicare/Medicare-General-

Information/BNI/FFSEDNotices.html

C. Effect of Other Insurers/Payers

HHCCN requirements apply only when home health services are expected to be partially

or fully covered by Medicare. When a beneficiary is not receiving any services that are

expected to be covered under the Medicare home health benefit, the HHCCN is not

required. For example, if a dual eligible beneficiary (having both Medicare and

Medicaid) is not receiving any Medicare covered home health services, HHCCN issuance

wouldn’t be required when changes of care occur. (NOTE: HHAs are required to issue

the ABN to dual eligible beneficiaries when applicable. See Section 50.15.4 C)

D. Exceptions to HHCCN Notification Requirements

The HHCCN is NOT required when changes in care involve:

• increase in care;

• changes in HHA caregivers or personnel as decided by the HHA;

• changes in expected arrival or departure time for HHA staff as determined by the

HHA;

• changes in brand of product, ( i.e., the same item produced by a different

manufacturer) as determined by the HHA;

• change in the duration of services that has been included in the POC and

communicated to the beneficiary by the HHA, ( i.e., shorter therapy sessions as

health status improves, such as a reduction from an hour to 45 minutes);

• lessening the number of items or services in cases where a range of services is

included in the POC;

Example: The POC order states: PT 3-5x per week as needed for gait

training. The therapist begins therapy at 5 times per week, and as the patient

progresses, therapy is reduced to 3 times per week. No HHCCN would be

needed in this case.

• changes in the mix of services delivered in a specific discipline (e.g., skilled

nursing) with no decrease in frequency with which that discipline is delivered;

Example: A beneficiary is receiving several skilled nursing services during

visits that are scheduled 3 times a week. One service within that discipline, a

blood draw 1 time a week, is discontinued. Other skilled nursing services

(wound care and education) continue, such that skilled nursing visits continue

to occur 3 times per week. No HHCCN is required when the blood draws are

discontinued, only when skilled nursing is reduced in frequency.

• changes in the modality affecting supplies employed as part of specific treatment

(e.g., wound care) with no decrease in the frequency with which those supplies

are provided; or

Example: A specific wound care product like Alldress is stopped, and a

Hydrogel pad is started. Since this represents a change in the modality (or

intervention) and not a reduction, no HHCCN is necessary.

• changes in care that are the beneficiary’s decision and are documented in the

medical record.