Crosswalk Document for Changes to HHABN422

Crosswalk Document for Changes to CMS-R-196

Home Health Advance Beneficiary Notice (HHABN)

Submitted for Collection April 2009

Summary of Changes to CMS-R-296

Historically, Home Health Agencies (HHAs) have used the Home Health Advance Beneficiary Notice (HHABN) as a liability and change of care notice delivered to beneficiaries when required.

This package incorporates minor formatting revisions to the form and the instructions to better comply with 508 accessibility requirements. Tables and excerpts of the form itself that were embedded within the instructions have been removed and replaced with plain text when appropriate. In addition, the requirement for beneficiaries to list their health insurance claim number (HICN) on the form has been removed and telephone contact information for Medicare is now pre-printed within the form text rather than left as blanks for HHAs to complete. Text has been added in the instructions to clarify that HHAs may complete the patient name and identification number blanks if desired rather than always directing beneficiaries to fill in these sections. No further substantive changes have been made.

The following nonsubstantive changes have been made to the form:

• Parentheses within the words “items” and “services” have been removed to facilitate accessibility access with reading options.

• Minimal changes in line spacing and line formatting were made to comply with 508 accessibility reading options.

• Identifying labels for the sample form and option boxes have been moved from the right lower corner of each sample page and placed under the header of the corresponding document to ease recognition of the different documents.

• The Office of Management and Budget (OMB) approval number was moved from the left upper corner of the form to the right lower footer area. Many of our Medicare liability notices already have the OMB number placed in this area; so, this change was made in our efforts to maintain certain elements of consistency among our forms.

• Required Paperwork Reduction Act (PRA) Disclosure Statement information has been inserted at the bottom of the form.

The following substantive change has been made to the form:

• The health care insurance claim number (HICN) is no longer included on the form. An optional patient identification number area replaces the HICN blank on the form.

• Option Box 1 text now includes Medicare telephone and TTY numbers rather than blanks for HHAs to insert this information. Since these numbers are constant, pre-printing them within the text will reduce this small amount of burden on HHAs and assure that beneficiaries are readily provided these contact numbers.

The following nonsubstantive changes have been made to the instructions:

• Outline formatting was removed to comply with 508 accessibility reading options.

• Table content was converted into plain text and the tables were removed to comply with 508 accessibility reading options.

• Form excerpts and blank lines were removed to comply with 508 accessibility reading options.

• Repetitive wording was removed to simplify understanding of the instructions.

The following substantive changes have been made to the instructions:

• Dates and information regarding implementation of the notice were updated to reflect this collection.

• Under “Instructions for Option Box 1”, directives for the HHA to fill in Medicare telephone and TTY numbers have been removed since these numbers are now pre-filled within the Option Box 1 text.

• “The Signature and Date Section” instructions now clarify that the HHA may complete the blanks for the patient name and identification number. Prior instructions directed the HHA to instruct the beneficiary to complete these two blanks; however, our revised instructions confirm that HHAs have the option of filling in these areas. This clarification may decrease burden for HHAs by facilitating more legible or pre-printed notices and by decreasing the need for HHAs to instruct beneficiaries regarding these blanks. HHA completion of these blanks may decrease energy and time expenditure needed by the beneficiary to complete the HHABN.

• Under “Patient Identification”, HHAs are instructed against entering a beneficiary’s HICN or social security number on the form and are given the option to insert a patient identification number of the agency’s choice.

The HHABN is an existing collection and is in use. It is our expectation that the substantive and nonsubstantive changes to the form and instructions will have little effect on burden for all users.

Burden is expected to decrease for the HHAs based on the following:

• The availability of a 508 compliant form for accessibility will prevent HHAs from having to invest their own work and financial resources to create an accessible document.

• Changing label placement of the sample Option Boxes should facilitate quick and easy recognition of the available formats.

• Insertion of the Medicare telephone numbers in Option Box 1 omits a task in form preparation.

• Allowing HHAs the option of filling in the blanks for the patient name and identification number may simplify issuance of the HHABN for both the beneficiary and the HHA as well as assist in legibility of documentation.