§ 512.450 - Beneficiary choice and beneficiary notification.

§ 512.450 Beneficiary choice and beneficiary notification.

(a) Beneficiary choice. The EPMs do not restrict Medicare beneficiaries' ability to choose any Medicare enrolled provider or supplier, or any physician or practitioner who has opted out of Medicare.

(1) As part of discharge planning and referral, EPM participants must provide a complete list of HHAs, SNFs, IRFs, or LTCHs that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient.

(i) This list must be presented to EPM beneficiaries for whom home health care, SNF, IRF, or LTCH services are medically necessary.

(ii) EPM participants must specify on the list those post-acute care providers on the list with whom they have a sharing arrangement.

(iii) EPM participants may recommend preferred providers and suppliers, consistent with applicable statutes and regulations.

(iv) EPM participants may not limit beneficiary choice to any list of providers or suppliers in any manner other than that permitted under applicable statutes and regulations.

(v) EPM participants must take into account patient and family preferences when they are expressed.

(2) EPM participants may not charge any EPM collaborator a fee to be included on any list of preferred providers or suppliers, nor may the EPM participant accept such payments.

(b) Required beneficiary notification -

(1) EPM participant detailed notification. Each EPM participant must provide written notification to any Medicare beneficiary that meets the criteria in § 512.240 of his or her inclusion in the EPM. The notification must be provided upon admission to the EPM participant if the admission that initiates the EPM episode is not scheduled with the EPM participant in advance. If the admission is scheduled in advance, then the EPM participant must provide notice as soon as the admission is scheduled. In circumstances where, due to the patient's condition, it is not feasible to provide notification at such times, the notification must be provided to the beneficiary or his or her representative as soon as is reasonably practicable but no later than discharge from the EPM participant accountable for the EPM episode. The EPM participant must be able to generate a list of all beneficiaries receiving such notification, including the date on which the notification was provided to the beneficiary, to CMS upon request. The beneficiary notification must contain all of the following:

(i) A detailed explanation of the EPM and how it might be expected to affect the beneficiary's care.

(ii) Notification that the beneficiary retains freedom of choice to choose providers and services.

(iii) Explanation of how patients can access care records and claims data through an available patient portal, and how they can share access to their Blue Button® electronic health information with caregivers.

(iv) A statement that all existing Medicare beneficiary protections continue to be available to the beneficiary. These include the ability to report concerns of substandard care to Quality Improvement Organizations or the 1-800-MEDICARE helpline.

(v) A list of the providers, suppliers, and ACOs with whom the EPM participant has a sharing arrangement. This requirement may be fulfilled by the EPM participant including in the detailed notification a web address where beneficiaries may access the list.

(2) EPM collaborator notice. An EPM participant must require every EPM collaborator to provide written notice to applicable EPM beneficiaries of the structure of the EPM and the existence of its sharing arrangement with the EPM participant.

(i) An EPM participant must require every EPM collaborator that furnishes an item or service to an EPM beneficiary during an EPM episode to provide written notice to the beneficiary of the structure of the EPM and the existence of the individual's or entity's sharing arrangement. The notice must be provided no later than the time at which the beneficiary first receives an item or service from the EPM collaborator during an EPM episode. In circumstances where, due to the patient's condition, it is not feasible to provide notice at such times, the notice must be provided to the beneficiary or his or her representative as soon as is reasonably practicable. The EPM collaborator must be able to generate a list of all beneficiaries who received such a notice, including the date on which the notice was provided to the beneficiary, to CMS upon request.

(ii) An EPM participant must require every EPM collaborator that is a PGP, NPPGP, or TGP where a member of the PGP, member of the NPPGP, or member of the TGP furnishes an item or service to an EPM beneficiary during an EPM episode to provide written notice to the beneficiary of the structure of the EPM and the existence of the entity's sharing arrangement. The notice must be provided no later than the time at which the beneficiary first receives an item or service from any member of the PGP, member of the NPPGP, or member of the TGP, and the required notice may be provided by that member. In circumstances where, due to the patient's condition, it is not feasible to provide notice at such times, the notice must be provided to the beneficiary or his or her representative as soon as is reasonably practicable. The PGP, NPPGP, or TGP must be able to generate a list of all beneficiaries who received such a notice, including the date on which the notice was provided to the beneficiary, to CMS upon request.

(iii) An EPM participant must require every EPM collaborator that is an ACO where an ACO participant bills for or ACO provider/supplier furnishes an item or service to an EPM beneficiary during an EPM episode to provide written notice to the beneficiary of the structure of the EPM and the existence of the entity's sharing arrangement. The notice must be provided no later than the time at which the beneficiary first receives an item or service from any ACO participant or ACO provider/supplier and the required notice may be provided by that ACO participant or ACO provider/supplier. In circumstances where, due to the patient's condition, it is not feasible to provide notice at such times, the notice must be provided to the beneficiary or his or her representative as soon as is reasonably practicable. The ACO must be able to generate a list of all beneficiaries who received such a notice, including the date on which the notice was provided to the beneficiary, to CMS or its designee upon request.

(3) Discharge planning notice. An EPM participant must provide the beneficiary with a written notice of any potential financial liability associated with non-covered services recommended or presented as an option as part of discharge planning, no later than at the time that the beneficiary discusses a particular post-acute care option or at the time the beneficiary is discharged, whichever occurs earlier.

(i) If the EPM participant knows or should have known that the beneficiary is considering or has decided to receive a non-covered post-acute care service or other non-covered associated service or supply, the EPM participant must notify the beneficiary that the service would not be covered by Medicare.

(ii) If the EPM participant is discharging a beneficiary to a SNF prior to the occurrence of a 3-day hospital stay, and the beneficiary is being transferred to or is considering a SNF that would not qualify under the SNF 3-day waiver in § 512.610, the EPM participant must notify the beneficiary in accordance with paragraph (b)(3)(i) of this section that the beneficiary will be responsible for payment for the services furnished by the SNF during that stay, except those services that would be covered by Medicare Part B during a non-covered inpatient SNF stay.

(4) Access to records and retention. Lists of beneficiaries that receive notifications or notices must be retained and access provided to CMS, or its designees, in accordance with § 512.110.