CMS-10280_HHCCN_Supporting_StatementOCT2012v508

Supporting Statement for the
Home Health Change of Care Notice (HHCCN) (CMS-10280)
Contained in 42 USC §1395(bbb) and 42 CFR §484.10(c)

INTRODUCTION
The Centers for Medicare and Medicaid Services (CMS) requests a new collection named
the Home Health Change of Care Notice (HHCCN) to replace, in part, the existing,
previously approved Office of Management and Budget (OMB) notice, titled the Home
Health Advance Beneficiary Notice (HHABN) (CMS-R-296), OMB 0938-0781, that
expires on October 31, 2012.
A.

BACKGROUND

Home health agencies (HHAs) are required to provide written notice to original Medicare
beneficiaries under various circumstances involving the initiation, reduction, or
termination of services. The notice used in these situations has been the Home Health
Advance Beneficiary Notice (HHABN), CMS-R-296.
The HHABN, originally a liability notice specifically for HHA issuance, was first
approved for use and implementation in 2000 with the home health prospective payment
system transition. In 2006, the notice underwent significant modifications subsequent to
the decision of the US Court of Appeals (2nd Circuit) in Lutwin v. Thompson. HHABN
content and formatting were revised so that it could be used to provide beneficiaries with
change of care notification consistent with HHA Conditions of Participation (COPs) in
addition to its liability notice function. Three interchangeable option boxes were
introduced to the HHABN to support the added notification purposes. Option Box 1
addressed liability, Option Box 2 addressed change of care for agency reasons, and
Option Box 3 addressed change of care due to provider orders. HHABN Collection 09380781 last received PRA approval in 2009 following minor notice changes such as
accessibility reformatting for compliance with Section 508 of the Rehabilitation Act of
1973, as amended in 1998, and removal of the beneficiary’s health insurance claim
number (HICN).
In an effort to streamline, reduce, and simplify notices issued to Medicare beneficiaries,
HHABN Option Box 1, the liability notice portion, will be replaced by the existing
Advanced Beneficiary Notice of Noncoverage (ABN) which is approved by OMB (09380566), consistent with the Paperwork Reduction Act of 1995 (PRA), for conveying
information on beneficiary liability. Written notices to inform beneficiaries of their
liability under specific conditions have been available since the “limitation on liability”
provisions in section 1879 of the Social Security Act were enacted in 1972 (P.L. 92-603).
The ABN (CMS-R-131) is presently used by providers and suppliers other than HHAs to
inform fee for service (FFS) Medicare beneficiaries of potential liability for certain
items/services that might be billed to Medicare. The HHABN was developed specifically
as the liability notice for HHA issuance. Since 2006, the HHABN has evolved to serve
both liability and change of care notification purposes. Pursuant to a separate PRA
package revising the use of the ABN, HHAs will now use the ABN for liability

notification, and the HHCCN will be introduced as a separate, distinct document to give
change of care notice in compliance with HHA COPs. The HHCCN will replace both
Option Box 2 and Option Box 3 formats of the HHABN. The single page format of the
HHCCN is designed to specify whether the change of care is due to agency reasons or
provider orders.
Suggestions made during the public comment period for the 2006 HHABN revision and
industry feedback received in the years following implementation of the 2006 version of
the HHABN were incorporated in developing the HHCCN and in the decision to separate
HHA COP notices from HHA liability notices.
Implementing regulations are found at 42 CFR §484.10(c). These requirements are
fulfilled by the HHCCN and subject to PRA.
B.

JUSTIFICATION

1.

NEED AND LEGAL BASIS

The home health COP requirements are set forth in §1891[42 USC 1395bbb] of the
Social Security Act (the Act). The applicable regulations under 42 CFR §484.10(c)
specify that Medicare patients receiving HHA services have the following rights:
“(c) Standard: Right to be informed and to participate in planning
care and treatment. (1) The patient has the right to be informed, in
advance about the care to be furnished, and of any changes in the care
to be furnished.
(i) The HHA must advise the patient in advance of the disciplines
that will furnish care, and the frequency of visits proposed to be
furnished.
(ii) The HHA must advise the patient in advance of any change in the plan of care
before the change is made.
These statutory requirements for written notice contain a paperwork burden. Therefore,
these requirements are subject to the general information collection guidelines in 5 CFR
1320.6.
2.

INFORMATION USERS

Based on CMS statistics for 2010, we estimate the number of HHAs potentially
delivering the HHCCN as about 10,914 (calculated from CMS Fast Facts, p. 6, Medicare
Institutional Providers Calendar Year 2010).
HHCCNs are not given every time items and services are delivered. Rather, HHCCNs
are given only when the HHA becomes aware of a change in a beneficiary’s plan of care
(POC) due to doctor/ordering provider orders or HHA specific limitations.
CMS reports 6,897,670 episodes of home health care in 2010 (Source: CMS, Chronic
Care Policy Group data). Since the HHCCN will replace HHABN Option Box 2 and

Option Box 3 and based on CMS estimates and industry comments, we believe that
HHCCN use associated with each episode of care is as follows:
•
•

HHCCN change of care for agency reasons (HHABN Option Box 2): 4.8 percent
of 6,897,670 episodes equals 331,088 HHCCNs issued annually.
HHCCN change of care due to provider orders (HHABN Option Box 3): 200
percent of 6,897,670 episodes equals 13,795,340 HHCCNs issued annually. We
estimate that an average of 2 HHCCNs are issued per 60-day episode of care due
to provider orders.

Based on the above estimates, HHAs will deliver about 14,126,428 HHCCNs annually.
331,088 HHCCNs
+ 13,795,340 HHCCNs
=
issued annually
issued annually
for agency reasons
for provider orders

3.

14,126,428 HHCCNs
issued annually

IMPROVED INFORMATION TECHNOLOGY

HHCCNs will usually be given as hard copy notices during in-person patient encounters.
In some cases, notification may be done by telephone with a follow-up notice mailed or
transmitted via secure fax. In person, electronic issuance of the notice is permitted as long
as the beneficiary consents to electronic delivery and a copy is provided to the
beneficiary. Incorporation of HHCCNs into other automated business processes is
permitted, and some limited flexibility in formatting the notice is allowed as discussed in
the form instructions. HHAs may choose to store the required signed copy of the
HHCCN electronically.
4.

DUPLICATION OF SIMILAR INFORMATION

The information we are requesting is unique and does not duplicate any other effort.
5.

SMALL BUSINESS

All HHAs will be expected to give the HHCCN in relevant situations. The requirement
does not impose any greater burden on small businesses than on large businesses since
there is no difference in the information collected.
6.

LESS FREQUENT COLLECTION

HHCCNs are given on an as-needed basis as described under 2, above.
7.

SPECIAL CIRCUMSTANCES

There are no special circumstances.
8.

FEDERAL REGISTER NOTICE/OUTSIDE CONSULTATION

The HHCCN is a new collection. A 60 day Federal Register notice published on
December 12, 2012. Interested parties will have an opportunity to comment. Public
comments will be considered carefully in making any necessary revisions to the notice
and accompanying instructions.
9.

PAYMENT/GIFT TO RESPONDENT

We do not plan to provide any payment or gifts to respondents.
10.

CONFIDENTIALITY

According to the applicable definition of confidentiality, this item does not apply.
11.

SENSITIVE QUESTIONS

There are no questions of a sensitive nature associated with this notice.
12.

BURDEN ESTIMATE

As explained in section 2. the number of affected HHAs (“respondents”) is 10,914.
CMS received industry comments in 2006 requesting increased time estimates for
HHABN delivery. Based on these comments, delivery of the HHABN with Option Box 1
was estimated to be 18 minutes and those with Option Boxes 2 or 3 was estimated to take
4 minutes each. Since the HHCCN is replacing Option Boxes 2 and 3 of the HHABN, we
estimate that it will take 4 minutes (.06664 hours) to complete the HHCCN, for a total
annual burden estimate of 941,385 hours (14,126,428 responses x .06664 hours). The
annual burden estimate per respondent is 86.3 hours (941,385 hours divided by 10,914
respondents).
We estimate the annual cost of delivering 14,126,428 HHCCNs to be $27,264,006
(14,126,428 responses x $1.93 per response). This is based on our expectation that the
HHCCN notices will be prepared by a staff person with professional skills at the GS-12Step 1 hourly salary of $28.88. See: Office of Personnel Management (OPM) website at:
www.opm.gov. Based on this hourly salary, the cost per response is $1.93 ($28.88 x
.06664 hours). We estimate that each of the 10,914 respondents will deliver
approximately 1294 HHCCNs annually for a total annual cost per respondent of
$2,492.34 (86.3 hours x $28.88).
13.

CAPITAL COSTS

Since all affected notifiers are expected to already have the capacity to reproduce
HHABNs based on CMS guidance, there are no capital costs associated with this
collection.
14.

COSTS TO FEDERAL GOVERNMENT

There is no cost to the Federal Government for this collection.
15.

PROGRAM OR BURDEN CHANGES

This is a new collection.
16.

PUBLICATION AND TABULATION DATES

These notices will be published on the Internet; however, no aggregate or individual data
will be tabulated from them.
17.

EXPIRATION DATE

We are not requesting exemption.
18.

CERTIFICATION STATEMENT

There are no exceptions to the certification statement.
C.

COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

There are no statistical methods associated with this collection.