Comment 1

MRY-07-2007

MAY,

15:50

2. 2007 12: 56PM

OMB DEP DIR MGMT

AHA2026264626

202

3956974

NO. 045

P.16/18

P. 2/4

Arnetican Hospital
Association
May 2,2007

Ms.Carolyn Lovett
OMB Desk Officer
OMB H ~ a Resources
n
and Housing Bfanch
New Executive Office Building, Room 10235
Washington, DC 20503
Re: CMS-10066 (OM#: 0938-New)Proposed Detuild Discharge Notice pol: 72,No. 66),
April 6,2007
Dear Ms.Lavett:

On behalf of our nearly 5,000 member hospitals,health systems and other heaIth care
organizations, and our 37,000 individual members,the .4merican Hospital Association (AHA)
appreciates this oppoRuni~to comment on the Centers for Medicare & Medicaid Services'
(CMS)proposed new 'Detailed Discharge Notice" and its related paperwork requirements,
which were submitted to the Office of Management and Budget (OMB) on April 6.
This proposed new fbnn would implement elemeats of the revised regulations on notification of
Medicare beneficiaries regarding their hospital discharge appeal rights, which were published in

the November 27,2006 Federal Register. It would replace the "Hospital Inpatient Notice of
Non-coverage" WINN) as the means of infomirig Medicare beneficiaries and Medicare
Advantage (MA) enrollees of the specific reasons why continued hospital-level care is no longer
needed or covered when beneficiaries ask a Quality Improvement Organization to review the
appropriateness of their discharge.
The AHA believes that a few items, mostly in the instructions that accompany the form, require
clarification. As indicated in our companion letter on the proposed revisions to the "Important
Message horn Medicare," we arc concerned that CMS will be unable to provide hospitals with
the final notice laurnpageand instructions early enough to allow s a c i e n t rime for hospitals to
effectively comply with the new requirements by the re@tionls July 1 implementation date.

Issms REQUIRING
CLA~ICATIO
PRIOR
N TO IMPLEMENTATION
As the AHA and state hospital associations worked with hospitals to do preimplementation

MWi-07-2007
I ~ I ~ I S1 .

LUUI

15: 50

I L .JI~IW

ONE DEP D IF! MCNT

H~HLUIOLO~O~O

Catolyn Lovett

May 2,2007
Page 2 of 3
planning, s c v m l issues &at needed clarification were identified. We recommend that 0 h
require CMS to address the issues explained below prior to ma1 approval and
implementation of the new notice.

Clam the level of detail required by the notice. The instructions tell hospitals and MA
plans to supply detailed and specific reasons why hospital services are no longer needed or
covered, in Wl sentences and in "plain English." First, all referenoes in the imtructions to
"plain English"should be changed to 'blain language" or "laymen's turns." Second, even
though this is the "detailed" notice, it r e d y is intended to be ipecific to the individual's
admission and easily understood by the bene5ciary. As such, focusing the instruction on
providing s~ecificreasons in plain language and dropping the word "detailed" would be
clearer.

Clearly distinguish betwten provider and plan responsibility regarding provision of the
detailed notice Throughout both the supporting statement and the instructions for
completing the form, the text refers to hospitals providing the detailed notice to traditional
Medicare program beneficiaries ~d MA plan enrollees. The nales published last November
clearly state that the hospital is responsible for preparing and delivering the notice only to
tmlitional Medicare program beneficiaries. The MA plan is responsible for preparing and
delivering the notice to its enrollees.
Clarify responsibility for coverage of additional care costs during appeals. The
regulations clearly stated that, for Medicare prospective paynent system admissions under
the traditional program, there is no additional payment to hospitals. However, fm MA
enrollees, the plan must pay the hospital for those additional days of care. Similarly,
clarification is needed regarding who is responsible for additional days when Medicare is a
secondary payer.
Clarify when the HMN would still be required. Page 3 of the supporting statement under
the section on "Duplication of Similar Information" sates that the HINN only would be used
in the e ~ e m e l rare
y instance where a patient decides to remain in the hospital past the
planned discharge date and chooses not to initiate a nview of the disoharge decision. CMS
has not yet proposed its planned revision of the HMN;CMS will presumably clarify when
the HINN still must be used rather than this new form in its proposal. It is unclear that this is
the only type of instance when the HDW would be used. Our members indicate that there
arc a variety of circumstances un& which the HINN is used and seek ~Iarificationas to
when this new form doe6 replace the HMN.
Provide on CMS' Web site the text of the notice translated b t o the top 15 languages
hospitals most frequently encounter. Almost one-fifth of the U.S. population speaks a
language other than English at home. Hospitals are required to provide language services for
such individuals but do not receive compensation for the cost of those savices. The size of
this population and the vast number of languages now being encountered make it very
difficult for individual hospitals to provide translated documents, Since the text of this notice
cannot be altered by the hospitzl, CMS should obtain and provide translations of the key
bmcficiay notices. The Social Security Administration bas a list of 15 frequently

MRY-07-2007
~enr. L , L U U I

15:51
ONE DEP DIR MGMT
I L : ~ I ~ I W wBwLUlblb4b2b

202

395 6974

P.18/18

NO. 045

P. 4/4

Carolyn Lovett
May 2,2007
Page 3 of 3
encountered languages that it uses for such puqores. Last year, the AHA'S research affilide2
the Health Research and Educational Trust, conducted a suwey of hospital language services
that identified 15 languages that at least 20 percent of hospitals encounter frequently. They
are: Spanish; Chinese; Vietnamese; Japanese; Korean;Russian; Gman; French; Arabic;
Mian; Laotian;Hindi; Polish; Tagalog; and Thai.

T

~ OF IMPLEME~ATION
G

It is our understanding fkom CMS M t h a t , under the best-case scenario,the OMB-approved
notice and insmcrions will not be made available to hospitals until late May or early June. With
the July 1 effective date approaching, we are concerned that hospitals will have insufficient time
prior to the effective date to print the new notices,prepare written internal policies and
insrmctions and eain s t a f f If even less time is available, we believe they will be unabIe to meet
the JuIy I date. h d , if the approved notice and instructions are not out by July 1, we do not
know what to tell our mernbm to do, since they cannot use a notice that has not been approved
by OMB. Since we do not h o w exactly when OMB will be able to act, the AFXA urges that
once O M .approves the form hospitals be given a minimum of 60 days to prepare before
tbey are required to implement the new requirements.

If you have any questions concerning our comments, please feel free to contact me or Ellen
Pryga, director for policy, at (202) 626-2267or m a h a . o r g .

~xecktiveVice President
Cc: Bonnie Harkless (CMS)