Home Health Agencies (HHAs)

10.2.1.6 - Home Health Agencies (HHAs) (Rev. 12393; Issued: 12-07-23; Effective: 01-01-24; Implementation: 01-02-24) A. Background 1. General Information An HHA is an entity that provides skilled nursing services and at least one of the following therapeutic services: speech therapy, physical therapy, occupational therapy, home health aide services, and medical social services. The services must be furnished in a place of residence used as the patient’s home. Like most certified providers, HHAs receive a state survey (or a survey from an approved accrediting organization) to determine compliance with federal, state, and local laws) and must sign a provider agreement. There are two potential “components” of an HHA organization: Parent – The parent HHA is the entity that maintains overall administrative control of its location(s). Branch – A branch office is a location or site from which an HHA provides services within a portion of the total geographic area served by the parent agency. The branch office is part of the HHA and is located sufficiently close to the parent agency so that it shares administration, supervision, and services with the parent agency on a daily basis. The branch office is not required to independently meet the conditions of participation as an HHA; the branch can thus be listed as practice locations on the main provider’s Form CMS-855A. Though the branch receives a 10-digit CCN identifier, it bills under the parent HHA’s CCN. See Pub. 100-07, chapter 2 for more information on branches. 2. Out-of-State HHA Operations Pub. 100-07, chapter 2, section 2184 states that when an HHA provides services across state lines: • It must be certified by the state in which its CCN is based. • The involved states must have a written reciprocal agreement permitting the HHA to provide services in this manner. In those states that have a reciprocal agreement, HHAs are not required to be separately approved in each state; consequently, they would not have to obtain a separate Medicare provider agreement/number in each state. HHAs residing in a state that does not have a written reciprocal survey agreement with a contiguous state are precluded from providing services across state lines; the HHA must establish a separate parent agency in the state in which it wishes to provide services. • A CMS approved branch office may be physically located in a neighboring state if the state agencies responsible for certification in each state approve the operation. See section 10.3.1(A)(1)(d)(iii) of this chapter for additional information regarding the enrollment of out-of-state HHA locations. B. Processing Instructions for HHA Initial Form CMS-855A Applications 1. Receipt of Application Upon receipt of an HHA initial Form CMS-855A application, the contractor shall undertake the following (in whichever order the contractor prefers unless directed otherwise in this chapter): (A) Perform all data validations otherwise required per this chapter (B) Ensure that the application(s) is complete consistent with the instructions in this chapter (C) Ensure that the HHA has submitted all documentation otherwise required per this chapter. For HHA initial enrollment, this also includes the following: • Form CMS-1561 (Health Insurance Benefit Agreement, also known as a “provider agreement”) • Evidence of successful electronic submission of the Form HHS-690 through the Office of Civil Rights (OCR) portal, as applicable. (Evidence should be either written or electronic documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more information.) (The HHA must complete, sign, date, and include the Form CMS-1561, though the HHA need not complete those sections of the form reserved for CMS. For organizational HHAs, an authorized official (as defined in § 424.502) must sign the form; for sole proprietorships, the sole proprietor must sign.) Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the form(s) or the information thereon; the contractor shall instead notify the state in its recommendation letter which document(s) was/were missing or otherwise incomplete. For all other missing or incomplete required documentation, the contractor shall follow the normal development instructions in this chapter. 2. Conclusion of Initial Contractor Review (Nothing in this section 10.2.1.6(B) prohibits the contractor from returning or rejecting the HHA application if otherwise permitted to do so per this chapter. When returning or rejecting the application, the contractor shall follow this chapter’s procedures for doing so.) (A) Approval Recommendation If, consistent with the instructions in section 10.2.1.6(B) and this chapter, the contractor believes an approval recommendation is warranted, the contractor shall send the recommendation to the state pursuant to existing practice and this chapter’s instructions. The contractor need not copy the SOG Location or PEOG on the recommendation. Unless CMS directs otherwise, the contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this chapter. The state will: (1) review the recommendation package for completeness; (2) review the contractor’s recommendation for approval; (3) perform any state-specific functions; and (4) contact the contractor with any questions. The contractor shall respond to any state inquiry in Item (4) within 5 business days. If the inquiry involves the need for the contractor to obtain additional data, documentation, or clarification from the HHA, however, the timeframe is 15 business days; if the provider fails to respond to the contractor within this timeframe, it shall notify the state thereof. The contractor may always contact its PEOG BFL should it need the latter’s assistance with a particular state inquiry. (B) Denial If the contractor determines that a denial is warranted, it shall follow the denial procedures outlined in this chapter. This includes: (1) using the appropriate denial letter format in section 10.7.8 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this chapter, referring the matter to PEOG for review prior to denying the application. 3. Completion of State Review The state will notify the contractor once it has completed its review. There are two potential outcomes: (A) Approval Not Recommended If the state does not recommend approval, it will notify the contractor thereof. (The contractor may accept any notification that is in writing (e-mail is fine).) A site visit need not be performed. No later than 5 business days after receiving this notification, therefore, the contractor shall commence the actions described in section 10.2.1.6(B)(2)(B) above. (B) Approval Recommended If the state recommends approval, it will typically (though not always) do so via a Form CMS- 1539; the contractor may accept any documentation from the state signifying that the latter recommends approval. (Note that the contractor will not receive a formal tie-in notice.) No later than 5 business days after receiving the state’s recommendation, the contractor shall commence the following activities: (i) Order a site visit (ii) Undertake the 3rd capitalization review discussed in section 10.6.1.2.2 of this chapter. (iii) Ensure that each entity and individual listed in Sections 2, 5 and 6 of the HHA’s Form CMS- 855A application is again reviewed against the Medicare Exclusion Database (MED) and the System for Award Management (SAM). (This activity applies: (1) regardless of whether the HHA is provider-based or freestanding; and (2) only to initial enrollments).) If: a. The HHA is still in compliance (e.g., no owners or managing employees are excluded/debarred; capitalization is met; site visit is passed): No later than 3 business days after all of these activities are complete (i.e., the 3-day period begins when the last of the three activities has been completed), the contractor shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following information and documents: • The Form CMS-855 application (or PECOS Application Data Report) and all applicable documents • A copy of the Form CMS-1539 or similar documentation received from the state • A copy of the provider-signed Form CMS-1561 • A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or similar documentation) included in the draft letter. (See section 10.7.5.1 for the model approval letter.) PEOG will countersign the provider agreement. Based on the information received from the contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, and (3) enter the applicable data into ASPEN, and (4) approve (with possible edits) the approval letter. Within 5 business days of receiving from PEOG the signed provider agreement, effective date, and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS-countersigned provider agreement to the HHA; (2) send a copy of both the approval letter and the provider agreement to the state and/or AO (as applicable)); and (3) switch the PECOS record from “approval recommended” to “approved” consistent with existing instructions. b. The HHA is not in compliance (e.g., the HHA does not meet one of the requirements): The contractor shall deny the application in accordance with the instructions in this chapter. C. Site Visits 1. Initial application –The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter. The NSVC will perform the site visit. The contractor shall not convey Medicare billing privileges to the provider prior to the completion of the NSVC’s site visit and the contractor’s review of the results. 2. Revalidation – If an HHA submits a revalidation application, the contractor shall order a site visit through PECOS. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter. The NSVC will perform the site visit. The contractor shall not make a final decision regarding the revalidation application prior to the completion of the NSVC’s site visit and the contractor’s review of the results. 3. New/changed location - If an HHA is (1) adding a new location or (2) changing the physical location of an existing location, the contractor shall order a site visit of the new/changed location through PECOS no later than 5 business days after the contractor receives the approval recommendation from the state but before the contractor sends to PEOG the applicable e-mail described in section 10.6.1.2(A)(3) of this chapter. (See the latter section for more information.) This is to ensure that the new/changed location complies with CMS’s enrollment requirements. The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter. The NSVC will perform the site visit. The contractor shall not make a final decision regarding the change of information application prior to the completion of the NSVC’s site visit and the contractor’s review of the results. D. Nursing Registries If the HHA checks “Yes” in Section 12B of the Form CMS-855A, the contractor shall ensure that the information furnished about the HHA nursing registry is accurate. (A nursing registry is akin to a staffing agency, whereby a private company furnishes nursing personnel to hospitals, clinics, and other medical providers.) E. Recommendation before New HHA Location Established If an HHA is adding a branch or changing the location of its main location or an existing branch, the contractor may make a recommendation for approval to the state prior to the establishment of the new/changed location (notwithstanding any other instruction in this chapter to the contrary). If the contractor opts to make such a recommendation prior to the establishment of the new/changed location, it shall note in its recommendation letter that the HHA location has not yet moved or been established. F. CHOWs and Changes of Information HHA changes of ownership shall be processed in accordance with, as applicable, section 10.6.1.1.5 or section 10.6.1.1. HHA changes of information shall be processed in accordance with section 10.6.1.2. G. Additional Information For more information on HHAs, refer to: • Sections 1861(o) and 1891 of the Social Security Act • 42 CFR Part 484 • 42 CFR § 489.28 (capitalization) • Pub. 100-07, chapter 2 • Pub. 100-04, chapter 10 • Pub. 100-02, chapter 7