Clarification on
Non-applicability of Certain Provisions of the Discharge Planning Process
to Medicare+Choice Plans
PDF Version of BQA 00-067
(PDF, 14 KB)
Date: September 8, 2000 -- DSL-BQA-00-067
To: Hospitals HOSP - 28,
Home Health Agencies HHA - 26 From: Otis Woods, Chief, Health Services Section
Via: Susan Schroeder, Director, Bureau of Quality Assurance
The Bureau of Quality Assurance (BQA) received the following clarification as
Electronic Regional Program Letter #2000-25 from the federal Health Care Financing
Administration, Division of Survey and Certification, Chicago
Regional Office. The enclosed letter explains the position of the federal Health Care
Finance Administration on hospital discharge planning as it applies to home health
referrals for patients who are enrolled in Medicare+ Choice managed care.
Questions may be directed to Jane Walters, Supervisor, at (608)
243-2028 (replaced by Cremear Mims), or to Juan
Flores, Supervisor, (608) 261-7824 (replaced by Jan Heimbruch -
(608) 243-2086).
HEALTH CARE FINANCING ADMINISTRATION
Chicago Regional Office, Midwest Consortium
Electronic Regional Program Letter #2000-25
DATE: September 1, 2000
FROM: HCFA, Chicago Regional Office, Division of Survey and Certification
SUBJECT: Clarification on Non-applicability of Certain Provisions of the
Discharge Planning Process to Medicare + Choice Plans - INFORMATION
TO: State Survey Agency Directors
The purpose of this memorandum is to inform you of the statutory changes set forth by
Section 521 of the BBRA of 1999, P.L. 106-113, which clarifies the non-discrimination in
post-hospital referrals to home health agencies (HHAs) and other entities, as enacted by
Section 4321(a) of the Balanced Budget Act (BBA) of 1997, an amendment of section 1861(ee)
of the Social Security Act (the Act).
Section 521 of the BBRA clarifies post-hospital referrals for patients in Managed Care
plans by specifying that hospitals are required to provide information to managed care
patients on the availability of home health services or other post hospital services only
to the extent that the individual providers or entities have a contract with the
managed care organizations.
The amendment reads as follows:
(3) With respect to a discharge plan for an individual who
is enrolled with a Medicare+Choice organization under a Medicare +Choice plan and is
furnished inpatient hospital services by a hospital under a contract with the
organization--
(A) the discharge planning evaluation under paragraph (2)(D) is not
required to include information on the availability of home health services through
individuals and entities which do not have a contract with the organization; and (B)
notwithstanding subparagraph (H)(I), the plan may specify or limit the provider (or
providers) of post-hospital home health services or other post-hospital services under the
plan. This provision was effective upon enactment, meaning it applies to all
discharges occurring on or after November 29, 1999.
This does not mean that Medicare managed care organization (MCO) members in particular
are denied the freedom of choice to which they are entitled under section 1802 of the Act.
Medicare beneficiaries exercise their freedom of choice when they voluntarily enroll in
the MCO and agree to adhere to the plan provisions on coverage.
To alleviate confusion, hospitals can provide MCO patients with a list of available and
accessible HHAs approved by the MCO. Another option is, when discussing discharge planning
with patients, hospitals can determine whether the beneficiary has made any prior
commitments through enrollment in a MCO. Where this is the case, the patient should be
informed of the potential consequences of going outside the plan for services.
HCFA proposed changes to the hospital conditions of participation (CoPs) on December
19, 1997. The proposed rule included language to incorporate the BBA changes. Within the
final hospital CoP, which HCFA expects to publish by the end of the year, HCFA will
incorporate both the BBA and BBRA provisions regarding post-hospital referrals to home
health agencies.
/s/ Charles Bennett, Branch Manager, Survey and Certification Program Coordination and
Improvement
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