Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 43

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SECTION 12: SPECIAL REQUIREMENTS FOR HOME HEALTH AGENCIES (HHAS)
INSTRUCTIONS
All HHAs and HHA sub-units enrolling in the Medicare program must complete this section.
HHAs and HHA sub-units initially enrolling in Medicare, Medicaid, or both programs on or after
January 1, 1998 are required to provide documentation supporting that they have sufficient initial reserve
operating funds (capitalization) to operate for the first three months in the Medicare and/or Medicaid
program(s). The capitalization requirement applies to all HHAs and HHA sub-units enrolling in the
Medicare program, including HHAs or HHA sub-units currently participating in the Medicare program
that, as a result of a change of ownership, will be issued a new provider number. The capitalization
requirement does not apply to a branch of an HHA. Regulations found at 42 C.F.R. 489.28 require that
the fee-for-service contractor determine the required amount of reserve operating funds needed for the
enrolling HHA or HHA sub-unit by comparing the enrolling HHA or HHA sub-unit to at least three other
new HHAs that it serves which are comparable to the enrolling HHA or HHA sub-unit. Factors to be
considered are geographic location, number of visits, type of HHA or HHA sub-unit and business structure
of the HHA or HHA sub-unit. The fee-for-service contractor then verifies that the enrolling HHA or HHA
sub-unit has the required funds. To assist the fee-for-service contractor in determining the amount of funds
necessary, the enrolling HHA or HHA sub-unit should complete this section.
Check here
if this section does not apply and skip to Section 13.
A. Type of Home Health Agency
1. CHECk ONE:
Non-Profit Agency Proprietary Agency
2. PROJECTED NUMBER OF VISITS BY THIS HOME HEALTH AGENCY
How many visits does this HHA project it will make in the first:
three months of operation?_____________
twelve months of operation? _______________
3. FINANCIAL DOCUMENTATION
A) In order to expedite the enrollment process, the HHA may attach a copy of its most current
savings, checking, or other financial statement(s) that verifies the initial reserve operating funds,
accompanied by:
1) An attestation from an officer of the bank or other financial institution stating that the funds are in
the account(s) and are immediately available for the HHA’s use, and
2) Certification from the HHA attesting that at least 50% of the reserve operating funds are non-
borrowed funds.
B) Will the HHA be submitting the above documentation with this application?
YES
NO
The fee-for-service contractor may require a subsequent attestation that the funds are still
NOTE:
available.
If the fee-for-service contractor determines that the HHA requires funds in addition to those
indicated on the originally submitted account statement(s), it will require verification of the additional
amount as well as a new attestation statement.
CMS-855A (07/11)
42

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