The Centers for Medicare and Medicaid Services (CMS) has issued its initial plan for medical review of the home health face-to-face (F2F) encounter requirement.  

CMS will conduct prepayment reviews of home health claims using a "Probe and Educate Review" process beginning Oct. 1, 2015. These reviews will impact claims with a "from" date beginning Aug. 1, 2015.  

The purpose of this Probe and Educate process is to ensure that home health agencies understand the new patient certification requirements.  

Because home health episodes have a 60-day certification, CMS anticipates the first documentation requests will be sent on or about October 1, 2015. 

CMS plans to provide additional details and information on the Probe and Educate process in the near future. 

Two LeadingAge members -- Presbyterian Villages of Michigan and Williamsburg Landing -- are relying on help from partners to expand their offering of in-home services.

Presbyterian Villages: Home Health Joint Venture

Presbyterian Villages of Michigan (PVM), a LeadingAge member in Southfield, MI, has formed a joint venture with Homestead Home Health Care, Inc. 

The joint venture company will serve PVM residents as well as the older adults living in their own homes in an 8-county area. For the past 5 years, Homestead has been providing services to residents of The Village at Westland, a PVM community in Westland, MI.

The for-profit Homestead will be the new company’s general manager. A representative of PVM will chair the new venture’s governing board, according to Crain’s Detroit Business.

PVM operates 25 senior living communities across Michigan. In addition, it provides community-based health care and other services to older adults living near two PACE (Program of All-Inclusive Care for the Elderly) programs that PVM operates in partnership with Henry Ford Health System.

"We see this as an area of tremendous unmet needs," said PVM President and Chief Executive Officer (CEO) Roger Myers. "We know seniors by and large want to remain in their homes. We think through this joint venture we can meet part of that demand."

Williamsburg Landing: Home Health and Hospice

Williamsburg Landing, a LeadingAge member in Williamsburg, VA, will soon be operating its own home health and hospice program for Williamsburg Landing residents and older consumers living in the Williamsburg area.

The continuing care retirement community (CCRC) has chosen Senior Options, LLC to guide it through the expansion. Senior Options provides advisory services and operational support to senior living organizations. It is a subsidiary of Westminster-Canterbury on Chesapeake Bay, a LeadingAge member in Virginia Beach, VA.

“This is a great opportunity for our independently run retirement communities to work together to serve older adults at home,” said Steve Montgomery, president and CEO of Williamsburg Landing. “Williamsburg Landing’s strategy is to improve the continuum of care that our residents have access to and strengthen their ability to remain in their homes for as long as possible.”

Partnerships are not new to Williamsburg Landing, according to The Virginia Gazette. The CCRC is currently collaborating with Riverside Health System to launch a home-based continuing care program called “ChooseHome.”

Current federal law protects the financial interests of spouses of certain Medicaid beneficiaries by allowing the spouse of a nursing facility resident to keep a minimum share of the couple’s combined income and assets.

Section 2404 of the Patient Protection and Affordable Care Act (PPACA) addresses the institutional bias that applies these spousal protections only to nursing home residents by extending the protections to spouses of Medicaid beneficiaries who receive home and community-based services. 

On May 4, the National Council on Disability (NCD) released "Transportation Update: Where We’ve Gone and What We’ve Learned," a new report offering a comprehensive assessment of surface transportation for people with disabilities. 

The report is a follow-up to the NCD’s 2005 publication, “The Current State of Transportation for People with Disabilities in the United States,” which led, in part, to major improvements in accessible transportation.

The new report outlines both the progress made in the last decade and details the persistent barriers that remain. 

More people with disabilities are riding public transit than ever before and yet in many areas, significant barriers to ground transportation for Americans with disabilities remain pervasive.  

NCD’s report also makes recommendations to policymakers to address these barriers.

Key Transportation Findings 


  • Taxi Alternatives: Emerging transportation models like Uber, SideCar, and Lyft have vigorously resisted regulations typically imposed on the taxicab sector, harming the taxi industry and evading requirements that serve the public interest, including deficits in service to people with disabilities. Uber openly claims it is not covered by the ADA.

  • Fixed Route Buses: Ridership of fixed route bus transit and rail systems by people with disabilities has grown far faster than ridership on ADA para-transit.

  • Para-transit: There have been great gains in best practices in the areas of eligibility, telephone hold time, on-time performance, no-show policies, and origin-to-destination service, but they are often not implemented.

  • Rural Transportation: Minimal or non-existent transit service in rural and remote areas still creates serious barriers to employment, accessible health care, and full participation in society.

  • Rail Transit: Amtrak has lagged behind in meeting ADA requirements for its stations, platforms, train cars, reservations practices, and communications access.


The report noted that the states of Oregon, Iowa, and Maine provide examples of positive coordination of transportation programs for people with disabilities.  

Many cities still lack adequate wheelchair accessible taxi programs, despite progress in some locations, including Chicago, New York, and Rhode Island.

The National PACE Association and the National Cooperative Bank (NCB) have announced a lending program to help finance a nationwide expansion of Programs of All Inclusive Care for the Elderly (PACE). 

This new PACE-lending program will address the financing gaps providers face as they work to implement new or to expand existing PACE programs.

Under the program, PACE providers will work with a dedicated NCB team that understands and is comfortable with the regulatory structures that support the PACE model. 

“PACE is a model of care that has always faced hurdles in accessing sufficient and affordable financing,” said NPA president and CEO Shawn Bloom. “Because PACE is not easily understood, attracting adequate financing can be a challenge. For this reason, we were delighted to work with NCB to explore a PACE lending program. The new program will be a great benefit to the missions of both organizations.” 

Through the related LeverAge program, a partnership among LeadingAge, Grantmakers In Aging and NCB, NPA members who are also LeadingAge members may benefit from interest rate discounts, extended terms and credit support features.

For questions regarding the NCB PACE program, please contact Robert Jenkens, director of social impact initiatives at National Cooperative Bank, via phone: 202-552-9632 or via email:


Marketing is a key ingredient for operating a successful Adult Day Services program. Budget and time constraints, the negative stigma of adult day services, and finding ways to market the uniqueness of individual centers are among the biggest obstacles faced by those in charge of marketing adult day programs. 

Answering these twenty questions will help you move forward with developing your marketing plan.

Adult Day: Questions to Ask

  1. Who are the people who would benefit from attending the Adult Day Services program?
  2. What is your catchment area?
  3. Who are your potential referrals?
  4. What services are important for each potential referral source?
  5. What services are provided by your competitors? Do you also offer these services?
  6. Are there services identified by referral sources that your Center or your competition do not offer?
  7. What is your average census?
  8. How has your census changed over the last 5 years?
  9. Do you have a marketing plan?
  10. What are your top 5 referral sources? 
  11. Which referral sources have increased their referrals to your program? Why?
  12. Which referral sources decreased their referrals to your program? Why?
  13. Where are caregivers and potential participants hearing about your Center?
  14. Do you have an individual in charge of marketing?
  15. How much time is spent each week on marketing?
  16. Do you have a website? 
  17. Is your Center active in social media?
  18. How often does your Adult Day Program mentioned in local media?
  19. If your Center is part of a larger organization, such as a hospital, CCRC, Nursing Home, are you receiving referrals from the staff of the other provider types within the parent organization? If not, why?
  20. What percentage of the potential participants that contact you about the program, eventually are enrolled? 

Who are the people who would benefit from attending the Adult Day Services program?  

The answer to this question will help you formulate the answers to the other 19 questions. Are you serving older adults with skilled care needs, older adults who are physically well, but may have dementia and/or depression? 

Are you serving younger individuals with physical or intellectual disabilities? Are you serving individuals from a particular ethnic group? 

Are you serving individuals with a particular disease, such as Parkinsons, MS, Alzheimers and Traumatic brain injury? 

Each of these types of potential participants may have a different entrance point to learn about your adult day center.

What is your catchment area and who are your potential referral sources?  

Where your potential clients reside in relation to the location of your center is important factor concerning transportation reliability and costs. 

Your catchment area helps you determine where you may conduct your outreach campaign. 

You may present on aging and caregiving topics at senior centers, senior housing properties, town halls, places of worship, social club meetings like Rotary and Lions club, hospital discharge planner meetings, physician practices and clinics, Area Agency on Aging, Aging and Disability Resource Centers, Centers for Independent Living, support group meetings, large businesses, local chapter of the Alzheimer’s Association, departments of Social Services and Adult Protective Services, Congregate Meal programs, United Way and 211 and Eldercare Lawyers.

What services are important for each potential referral source?  

It is helpful to have a different brochure, flyer and talking points for different referral sources. Primary care physicians, Psychiatrists, Geriatricians and other health professionals want your help with ensuring that that patients are compliant with medications and overall plan of care, that they have no re-admissions to the hospital or the emergency room and that the caregiver has less stress. 

It is important to make it easy for a physician and their staff to refer. Have brochures available in their waiting rooms. Print a Adult Day referral pad that could be available for the physician in the office or exam room. 

Caregivers want days and hours of operation and services that will reduce their responsibilities and stress, and enable them to have time for what is important to them. If a caregiver works on the weekend, a center with Saturday hours is a must.

What services are provided by your competitors?  

Your competitors may become your referral source, if they are not caring for a certain population, for example individuals with developmental disabilities or a person that only speaks Korean, and you have no staff or participants that speak Korean, or that the other adult day program is too far away from the participant’s home. 

You may offer a service that your competitor does not offer. 

Your competition may also have services that are more appropriate for a particular potential participant.

What should you monitor throughout the year to have a successful marketing program?  

You should be tracking attendance for the month and compare it to the same month last year, number of referrals each month from each referral source. 

This information will help you know what months of the year you should increase your time marketing, and prioritize which referral sources you need to contact. You should be giving follow-up calls with referral sources. With the consent of the participant, you should highlight any improvements in the participant’s condition that stem from their involvement in your program. 

This follow-up should also occur with the caregiver. They should know that their loved one who is depressed and withdrawn was engaged in a recreational activity, and has developed friendships with other participants. This feedback can result in increases in the number of days the individual attends.

Do you have an individual in charge of marketing and how much time is spent each week on marketing? 

The answer to this question depends on your budget, and if you are part of a larger organization. Everyone in your organization should be involved in your marketing plan, but it is important for one individual to be responsible for the overall implementation of the plan. 

Marketing should be discussed at each staff meeting. If you cannot afford a part time or full time marketing director, perhaps a retired business professional may be interested in volunteering their time to assist you in implementing the marketing plan.

Your website is the face of your program! 

There are so many times that websites for adult day programs don’t include the location of the program, the special services offered in the program and who would benefit from services in the adult day program. Many times the adult day program that is part of a larger organization is difficult to find on the parent organization website and they don’t have their own website. 

The new generation of older adult and caregivers use the internet as their main source of information. A poorly designed website will impact the success of your marketing. 

A video of your program that is on the website, as well as on YouTube can also help you show the value of your program. 

Media as a marketing tool for your program  

Paid advertisement many times is not an effective way to market your adult day program. The article in the local paper about your new Memory Enhancement Program for individuals with dementia may result in more referrals, and it is FREE! 

Perhaps you can recruit college journalism students to write articles to submit to the local newspaper. 

Also, holding support group meetings and health fairs in the adult day center are effective ways of having potential participants and their caregivers see your center. 

One LeadingAge Adult Day member has a radio show on caregiving. Social media today is an important driver for marketing services. 

Marketing firm GlynnDevins  has a useful article on 15 Tips for Social Media that will help you develop an effective social media plan. 

Also, it is important to have a Facebook page. A volunteer could be recruited to help you increase your Centers online activity. 

If a caregiver “Googles” adult day centers in a particular area, you should be on the top of the search list. Have a monthly or quarterly Adult Day Center newsletter that could be a source for newspaper articles, and could be given out at community events.

LeadingAge adult day members should join the marketing listserv and participate in the adult day listserv to obtain additional information from other adult day members on improving their marketing efforts.

The National Quality Forum (NQF), with funding from the U.S. Department of Health and Human Services (HHS), is launching a new initiative to create a framework for quality measurement for persons living in the community who receive home and community-based services (HCBS).

The National Quality Forum will:

  • Develop a conceptual framework for measurement.
  • Perform an environmental scan.
  • Identify gaps in HCBS measures.
  • Make recommendations for measure development

NQF will collaborate with a multi-stakeholder committee to implement this two-year project. 

There will be 3 commenting periods available for stakeholder to contribute to this process. 

States, Managed Care Organizations and home and community-based services providers are interested in having an evidence based standard of measuring quality that they can use to help them improve outcomes, and reduce costs. 

Some states are establishing pay for performance programs for the Medicaid home and community-based services providers.

The Centers for Medicare and Medicaid Services (CMS) released Change Request CR8877, which provides instruction to hospices and Medicare administrative contractors on processing the Notice of Election (NOE) and Notice of Termination or Revocation (NOTR).

In the FY2015 Hospice Final Rule, the Notice of Election (NOE) must be filed by the hospice and accepted by the Medicare administrative contractor (MAC) within 5 calendar days after the hospice admission date.  

A timely-filed Notice of Termination or Revocation (NOTR) shall be filed by the hospice and accepted by the MAC within 5 calendar days after the hospice discharge/revocation date unless a final hospice claim has been filed. An NOTR does not need to be completed in cases where the patient is discharged due to death.

In cases when the NOE is not timely filed, a hospice is responsible to provide care and not charge the beneficiary for any days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor. Hospices will report these non-covered days on the claim with an occurrence span code 77, and charges related to the level of care for these days will be reported as non-covered, or the claim will be returned to the provider (RTP).  

There is currently no consequence to a hospice for not timely filing the NOTR.

There are four possible exceptions to the timely filing of an NOE:

  1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate.
  2. An event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice.
  3. A newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor.
  4. Other circumstances determined by the Medicare contractor or CMS to be beyond the control of the hospice.

Regardless of the reason a hospice is requesting an exception, the hospice shall file the associated claim with occurrence span code 77 used to identify the non-covered, provider liable days. The hospice shall also report a KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim. 

The KX modifier shall prompt the Medicare contractor to request the documentation supporting the request for an exception. Based on that documentation, the Medicare contractor shall determine if a circumstance encountered by a hospice qualifies for an exception.

If the request for an exception is approved by the Medicare contractor, the Medicare contractor will process the claim with the CWF override code and remove the submitted provider liable days, which will allow payment for the days associated with the late-filed NOE. 

If the Medicare contractor finds that the documentation does not support allowing an exceptional circumstance, the Medicare contractor will process the claim as submitted. It is important to note that CMS has identified that due to a systems limitation, remittance advice remark code N211 (you may not appeal this decision) will be applied to the provider liable days in error. These days are appealable and CMS plans to release a correcting change request in the future.

LeadingAge submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the CY 2015 home health proposed rule that address:

  • Changes to the Face to Face Documentation Requirements.
  • Implementation of the Pay-for- Reporting performance requirement for the Home Health Quality Reporting Program.
  • Updates to HH QRP Measures Which Are Made as a Result of Review by the NQF Process.
  • Medicare Coverage of Insulin Injections Under the HH PPS.
  • Change to the Therapy Reassessment Timeframes.
  • Value-based purchasing model for Home Health Agencies that CMS plans to test in certain states beginning in CY 2016.

Changes to the Face-to-Face Encounter Documentation Requirements

LeadingAge recommends that CMS:

  • Allow the home health record or care plan to be integrated with the medical record to facilitate the ability of the Medicare contractor to accurately determine if the documentation shows that the individual was eligible for home health services.
  • Use the form CMS-485, Home Health Certification and Plan of Care  as the standardized form that is used by all Medicare home health providers to document the face to face encounter.
  • Include a checklist in the standardized form to document homebound status.
  • Develop a standardized face to face encounter electronic template based on the CMS-485, Home Health Certification and Plan of Care that includes a drop down for homebound status. 
  • Eliminate the need for the physician to include a brief narrative that describes the clinical justification of ordering skilled nursing visits for management and evaluation of the patient's care plan as part of the certification/recertification of eligibility as outlined in §424.22(a)(1)(i) and §424.22(b)(2).

Implementation of the Pay-for- Reporting performance requirement for the Home Health Quality Reporting Program

LeadingAge agrees with the timeframes and the minimum scores proposed by CMS, but we believe that there should be an exceptional circumstance policy to address situations beyond the control of the home health agency that would result in not submitting Home Health Quality Report in a timely manner. 

Updates to HH QRP Measures Which Are Made as a Result of Review by the NQF Process

LeadingAge recommends that CMS:

  • Notify home health providers when NQF in their Consensus Development Process is asking for input on NQF measures that are being used by HHA in order to give home health providers an opportunity to comment on a change in the measure. 
  • Develop a more comprehensive list and definition of what changes constitute a substantive and non- substantive change in a measure, and stakeholders should be given the opportunity to submit comments on the list for CMS to consider. 

Medicare Coverage of Insulin Injections Under the HH PPS

LeadingAge recommends the following codes for conditions that would indicate the patient is unable to self- inject insulin be added to TABLE 28:

  • DM with peripheral polyneuropathy (numbness) – this numbness can be in the hands and makes for self-injection difficult (357.2). 
  • DM with autonomic neuropathy (their blood pressure drops when standing and they are at high risk for complications related to hypoglycemia) (337.1).
  • Psychiatric disorders that would precipitate the inability of the patient to understand and comply with the regiment for self-injection of insulin. 
  • Neurodegenerative diseases (332.0), such as ALS (335.2), MS (340.0) and Essential tremor (333.1).

Change to the Therapy Reassessment Timeframes

LeadingAge proposes that CMS monitor therapy utilization, changes in hospital re-admission and admission rates for home health patients receiving therapy under the proposed reassessment regulation that requires a reassessment at least every 14 calendar days per discipline.

Value-based purchasing model for Home Health Agencies in the pilot program

LeadingAge recommends that CMS:

  • Provide a large enough incentive to encourage home health agencies to invest in technology, staff training and improved clinical and operational systems.
  • Ensure that the risk adjustment is both at the home health agency level, and at the beneficiary level.
  • Consider choosing two states from each of the four Medicare Administrative Contractor (MAC) Jurisdictions, and at least one rural state and one frontier state should be included.
  • Not include states where CMS has imposed a moratorium on certain regions for new home health agencies.
  • Not use the home health five star rating system as a determinant of payment.
  • Use measures that relate to the quality of the care for the treatment of the condition that required skilled intermittent care and /or rehabilitation under the Medicare benefit.

On July 18, the Center for Medicare and Medicaid Services (CMS) released Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice, a notice that encourages sponsors to place beneficiary-level prior-authorization requirements on only 4 categories of prescription drugs identified in a June 2012 Office of Inspector General (OIG) Report


  1. Analgesics.
  2. Anti-nauseants (antiemetics).
  3. Laxatives.
  4. Anti-anxiety drugs (anxiolytics) 

According to CMS and the OIG, these drugs are “nearly always” considered hospice-related.


Medicare Part D prescription drug plans will continue to pay for drugs for diabetes, heart disease or other chronic conditions still used by hospice patients, but not directly related to their terminal illness. 

Unlike medications covered by hospice, the beneficiary may have a copay for drugs unrelated to the terminal illness and/or related conditions.

Under this revised guidance, hospice providers are encouraged to report a beneficiary’s Medicare hospice election to the Part D sponsor and identify any drugs in the 4 categories determined to be eligible for coverage under Part D because the drugs are unrelated to the terminal illness and/or related conditions prior to the submission of a claim. 

This communication, however, is not a coverage determination or prior authorization request. Rather, the information provided by the hospice can be used by the Part D sponsor to override the beneficiary-level hospice prior authorization at point-of-sale (POS).

If a claim has been rejected by a Part D sponsor due to the beneficiary-level hospice prior approval, the pharmacy or beneficiary may contact the hospice provider for a statement that the drug is unrelated to the terminal illness and related conditions.

The hospice provider should contact the Part D sponsor to provide an oral or written statement or provide a written statement to the pharmacy or the beneficiary to transmit to the Part D sponsor. The sponsor should accept this information to override the point- of service reject without requiring that the beneficiary, or others on their behalf, request a coverage determination. 

When either the beneficiary, the beneficiary’s appointed representative, or the prescriber requests a coverage determination, the sponsor should contact either the prescriber or the hospice provider and accept and use the statement that the drug is unrelated to the terminal illness and/or related conditions provided by either the prescriber or hospice. 

A hospice provider cannot request a coverage determination on behalf of the beneficiary. CMS has authorized the use of a 2-page form to replace the list of data elements as the hospice prior approval drug form to further facilitate this process.

In those scenarios in which the drug is determined to be a hospice liability, the sponsors and hospices should negotiate repayment.

LeadingAge is pleased that CMS addressed these issues. The reduced number of medications subject to prior approval will significantly reduce the the challenges and difficulties present under the full Prior Approval policy.


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