Home Health Change of Care Notice (HHCCN)

Form Instructions
for the Home Health Change of Care Notice (HHCCN)
CMS-10280
OMB Approval Number: 0938-1196
Overview
Medicare currently requires home health agencies (HHAs) to issue HHCCNs to Medicare
beneficiaries receiving the home health care benefits for notification of plan of care changes.
Consistent with the Medicare Condition of Payment and the 2nd Circuit Court’s decision in
Lutwin v. Thompson regarding notification procedures, home health agencies must provide the
HHCCN whenever they reduce or terminate a beneficiary’s home health services due to
physician/provider orders or limitations of the HHA in providing the specific service.
Notification is required for covered and non-covered services listed in the plan of care (POC).
The Advance Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, must be used
in order to transfer potential financial liability to the beneficiary in the following situations:
•
•
•
•

providing care that Medicare usually covers but may not pay for in this instance
because the care,
is not medically reasonable and necessary,
is considered custodial care, or
is not covered because the beneficiary is not homebound.

(For information on the ABN, please see the ABN webpage:
http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html )
Triggering Events
HHAs are required to issue the HHCCN when a triggering event changes the beneficiary’s
POC. Triggering events are reductions or terminations in care.
Examples of HHCCN triggering events due to physician or provider orders:
• Reduction = The POC lists wound care every day. The provider writes a new
order to decrease wound care to every other day.
• Termination = The POC lists wound care 2x week. The provider writes a new
order to discontinue all wound care.
Examples of HHCCN triggering events due to HHA reasons:
• Reduction = PT services are ordered 4 times per week in the POC. The HHA has
an unexpected staffing shortage and can only provide PT services 2 times per
week.
• Termination = PT services are ordered 4 times per week in the POC. The HHA has
lost PT staff and can no longer provide any PT services.

If a termination involves the end of all Medicare covered care and no further care is being
delivered, the only notice issued would be a Notice of Medicare Non-coverage (NOMNC), Form
CMS-10123.
HHCCN Preparation
The following are the general instructions for HHCCN preparation:
•

Number of Copies: A minimum of two copies, including the original, must be made so
that the beneficiary and HHA each have one.

•

Electronic Issuance: Electronic issuance of HHCCNs is permitted. If a provider elects
to issue an HHCCN that is viewed on an electronic screen before signing, the beneficiary
must be given the option of requesting paper issuance over electronic if that is what the
beneficiary prefers. Also, regardless of whether a paper or electronic version is issued
and regardless of whether the signature is digitally captured or manually penned, the
beneficiary must be given a copy of the signed HHCCN to keep for his/her own records.

•

Reproduction: HHAs may reproduce the HHCCN by using self-carbonizing paper,
photocopying the HHCCN, or other methods. All reproductions must conform to CMS
instructions.

•

Length and Page Size: The HHCCN must NOT exceed one page in length. The
HHCCN is designed as a letter-sized form. If necessary, it may be expanded to a legalsized page to accommodate information HHAs insert in the notice, such as the HHA’s
contact information or a list of multiple changes to the plan of care.

•

Contrast of Paper and Print: A visually high-contrast combination of dark ink on a pale
background must be used. Do not use reversed print such as white on black or blockshaded (highlighted) text.

•

Modification: Don’t modify the HHCCN, except as specifically allowed by these
instructions.

•

Font: The lettering on the HHCCN must meet the following requirements to facilitate
beneficiary understanding:
o Font Type: Use the fonts as they appear on the documents downloaded from the
CMS website. Any changes in the font type should be based solely on software
and/or hardware limitations of the HHA. Examples of easily readable alternative
fonts include Arial, Arial Narrow, Times Roman, and Courier.
o Font Effect/Style: Don’t make style changes to the font, such as italics,
embossing, bold, etc., since this could make the HHCCN more difficult to read.

o Font Size: The font size generally should be 12 point. Titles should be 14-16
point. Words inserted in the blanks on the HHCCN can be as small as 10 point if
needed.
o Insertions in Blanks: Information inserted by HHAs in the blank spaces on the
HHCCN may be typed or legibly hand-written.
•

Customization: HHAs are permitted to do limited customization of HHCCNs, such as
pre- printing agency-specific information to promote efficiency and to ensure clarity for
beneficiaries. Guidelines for customization are:
o HHAs may pre-print descriptions of common change of care scenarios. For
example, an HHA could pre-print, “Beginning on
, we will decrease the
frequency of your wound care to
times per
.”
o HHAs may print distinct versions of their pre-printed HHCCNS on different
colored paper so that they are easily identified, but the notice must appear as a
high-contrast combination of dark-colored font on light-shaded paper.
o HHAs may label different pre-printed versions of their HHCCNs by adding letters
or numbers in the header area.
o Information in blanks that is constant can also be pre-printed, such as the HHA
name, address, and phone number.
o Pre-printed information inserted on the notice should be at least 12-point font size
if possible, and 10-point minimum. 10 point should only be used if a smaller font
is needed to include all applicable information in the blank space provided.
o HHAs may list multiple change-of-care scenarios on a pre-printed HHCCN. If
multiple scenarios are listed, the beneficiary should be able to clearly identify the
information that pertains to his/her case. HHAs may use checkboxes to indicate
information applicable to the beneficiary. Alternatively, applicable items can be
circled, or items that do not apply can be crossed out.
o The printed blank lines in the change of care description area of the notice may be
removed if needed for customization.
o The HHA may pre-print specific HHA disciplines with corresponding checkboxes
on the HHCCN. However, an explanation of what is changing must be included
on the notice. For example, if Physical Therapy is checked, text such as “reduced
to 2 times per week” must be inserted. Just checking off a discipline without an
explanation could render the notice invalid.
o HHCCNs without pre-printed information should be available for HHA staff to
use in cases that don’t conform to pre-printed language.

HHCCN Completion and Delivery
The HHCCN is a one-page notice composed of three sections:
Header
Body
Signature/Date
The Header Section
HHAs are permitted to customize the header section of the HHCCN that sits above the “Home
Health Change of Care Notice” title at the top of the page. HHAs may add identifying
information such as a logo, web address, or an email address.
The blanks in the header section are completed as follows:
•

Home Health Agency: The name of the HHA must be listed.

•

Address: The correspondence address of the HHA must be listed.

•

Phone: A phone contact must be included and a TTY number must be included when
necessary.

•

Patient’s Name: The beneficiary's full name must be inserted in the blank. (A preprinted name label is permitted.)

•

Patient Identification: Completion of this blank is optional and serves for HHA
identification purposes. A birth date or medical record number may be inserted. HHAs
must not include the beneficiary’s Medicare health insurance claim number (HICN),
Medicare Beneficiary Identifier (MBI) or Social Security number on the notice.
Electronic bar codes are permitted.

The Body Section
The body section of the HHCCN is below the header and above the signature area. The body
includes (5) components for completion by the HHA:
•

Date: Directly under the title of the notice there is a blank line for insertion of a date.
The HHA must insert the date that the changes listed on the notice will start.

•

Items/services description: When there are changes in care that require written
beneficiary notification, the HHA lists the change or changes in the blank area under
“Items/services:” The HHA must also explain whether the item/service is being reduced
or terminated.
The description should be informative, in language understandable to the beneficiary.

Common abbreviations such as “PT” for physical therapy may be used only if the
beneficiary is familiar with the term.

•

•

Example 1: “On Dec.17, 2019, we will stop all of your occupational therapy
services.”

•

Example 2: “On Dec 21, 2019, the frequency of your wound care will decrease
to 3 days per week.”

Reason for the change: In the blank area under “Reason for change”, the HHA must
insert the specific reason that the care change is occurring. For doctor’s order changes,
an example of language that can be used is: “Your doctor has changed your order for
this care.”
For agency related changes, more specific information may be provided in accordance
with the situation. For example, “Your dog has repeatedly threatened our staff, and we
are unable to safely enter your home,” could be a possible reason cited.

•

Check boxes - General reason for change: The HHA must identify the general reason
for the change or changes that are listed in the table above. The HHA must check one of
the 2 checkboxes in the section under “Read the information next to the checked box
below.”
•

“Your doctor’s or provider’s orders for your home care have changed.”
The HHA checks the first box when care will be reduced or stopped because of an
order change or the lack of an order to renew care.

•

“Your home health agency has decided to stop giving you the home care
listed.”
The HHA checks the second box when the HHA decides to stop providing some
or all care for its own financial and/or other reasons, regardless of Medicare
policy or coverage, such as the availability of staffing, closure of the HHA, or
safety concerns in a beneficiary’s home.

When multiple care changes occur due to simultaneous order changes and agency
specific reasons for change, the HHA must give the beneficiary (2) separate HHCCN’s
so that s/he can identify the reason that corresponds to each change. Only one check
box indicating the reason for change can be marked on each HHCCN.
•

Additional Information: An entry in this area is optional. HHAs should use this area
to include information that may be helpful to the beneficiary’s specific case. For
example, the ordering provider’s name and phone number could be inserted here if the
beneficiary has questions on an order change that the HHA can’t answer.

The Signature/Date Section
This section contains 2 boxed and labeled blanks for completion. The beneficiary or
representative is required to sign and date the HHCCN confirming his/her review and
understanding of the notice.
•

Signature: The beneficiary or representative must sign the HHCCN.

•

Date: The beneficiary or representative must enter the date that the HHCCN
was signed. The HHA may insert the date if the beneficiary is having
difficulty and requests assistance.

If a representative is signing on behalf of the beneficiary, this must be indicated by
either the representative or the HHA writing “(rep)” or “(representative)” next to the
representative’s signature. If the representative’s signature is not clearly legible, the
name must be printed near the signature.
If the beneficiary refuses to sign the HHCCN, the HHA must note on the
HHCCN that the beneficiary refused to sign, and provide a copy of the annotated
HHCCN to the beneficiary.
HHCCN Delivery
When delivering HHCCNs, HHAs are required to explain the entire notice and its content and
answer all beneficiary questions to the best of their ability. HHAs must make every effort to
ensure beneficiaries understand the HHCCN prior to signing it. If common abbreviations are
used, the HHA should explain their meanings to the beneficiary. While in-person delivery of
the HHCCN is preferable, it is not required.
Retention of the HHCCN
The HHA keeps one copy of the completed, signed or annotated HHCCN in the
beneficiary’s record, and the beneficiary receives a copy. Electronic retention of
electronically issued or scanned HHCCNs is permitted.