03/31/2020

Today's COVID-19 Report: Waiver Assistance Arrives for NF, Home Health, and Hospice

Today's COVID-19 Report:

Waiver Assistance Arrives for NF, Home Health, and Hospice

Here are the latest need-to-know updates for Tuesday, March 31 regarding the COVID-19 pandemic.

Nursing Facilities Expand Capacity Statewide

Across the state, LeadingAge Ohio members have been fielding calls from their regional healthcare coalitions related to their bed capacity and their ability to scale-up operations. The calls come in response to Governor DeWine’s weekend announcement that the health system is moving “from planning to action,” and noting that he’d asked each of the eight regional coalitions to deliver their plan for scaling up capacity by noon on Monday.

Many nursing homes have considered how they might re-purpose spaces, such as closing off hallways, moving single-occupancy spaces to double-occupancy, or using therapy gyms and other common areas as larger wards to expand regional capacity. LeadingAge Ohio has encouraged members that haven’t yet heard from their regional coalitions to reach out, and that in addition to sharing their potential capacity, to use it as an opportunity to advocate for the equipment and workforce that will make the capacity build-up possible, such as furnishings like beds and other equipment, workforce, and of course, PPE.

General John Harris of the Ohio National Guard is coordinating the eight regional healthcare coalitions and is planning strategy for patient care.

CMS Blanket Waivers Include Nurse Aide Training, Advance Payments

Yesterday evening, the Centers for Medicare & Medicaid Services (CMS), announced a large number of blanket waivers, granted to allow flexibility for health systems racing to prepare for the surge of COVID-19 patients.

The waivers for nursing homes include:

• Accelerated/Advance Payments: In order to increase cash flow to providers impacted by COVID-19, CMS has expanded the current Accelerated and Advance Payment Program.
• Training and Certification of Nurse Aids: CMS is waiving the requirements at 42 CFR §483.35(d), (except for 42 CFR §483.35(d)(1)(i)), which require that a SNF and NF may not employ anyone for longer than four months unless they met the training and certification requirements under §483.35(d). This waiver does NOT include competency and training requirements.
• CMS Facility without Walls (Temporary Expansion Sites): A long-term care (LTC) facility can temporarily transfer its COVID-19 positive resident(s) to another facility, such as a COVID-19 isolation and treatment location, with the provision of services “under arrangements.” The transferring LTC facility is then responsible for reimbursing the other provider that accepted its resident(s) during the emergency period.
• Physician visits in skilled nursing facilities/nursing facilities: CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options.
• MDS and PBJ Reporting Requirements: CMS is waiving timeframe requirements for Minimum Data Set assessments and transmission, as well as Payroll-based Journaling (PBJ) requirements.
• PAS/RR Requirements: CMS is allowing states and nursing homes to suspend Pre-admission Screening and Resident Review (PAS/RR) assessments for new residents for 30 days. After 30 days, new patients admitted to nursing homes with a mental illness (MI) or intellectual disability (ID) should receive the assessment as soon as resources become available.

The comprehensive list of waivers for nursing homes are included on the CMS  coronavirus waiver website.

CMS Waivers for Home Health, Hospice Include F2F, Volunteers

CMS also issued significant rule changes, waivers of certain conditions of participations, and a series of interpretations of hospice and home health requirements designed to relieve pressures and increase flexibilities during the COVID-19 pandemic. 

Regarding home health providers:

Medicare Telehealth

• Home Health Agencies (HHAs) can provide more services to beneficiaries using telehealth within the 30 day episode of care, so long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. We acknowledge that the use of such technology may result in changes to the frequency or types of in-persons visits outlined on existing or new plans of care.
• Face-to-face encounters for purposes of patient certification for the Medicare home health services can now be conducted via telehealth.

Patients Over Paperwork

• Homebound Definition: A beneficiary is considered homebound when their physician advises them not to leave the home because of a confirmed or suspected COVID-19 diagnosis or if the patient has a condition that makes them more susceptible to contract COVID-19. As a result, if a beneficiary is homebound due to COVID-19 and needs skilled services, an HHA can provide those services under the Medicare Home Health benefit.
• Plans of Care and Certifying/Recertifying Patient Eligibility: HHS is utilizing enforcement discretion with regards to the requirements at §§ 409.43 and 424.22 in order to allow a patient to be under the care of a nurse practitioner or clinical nurse specialist (as such terms are defined in section 1861(aa) (5)) who is working in accordance with State law, or a physician assistant (as defined in section 1861(aa)(5)) who is working in accordance with State law, and for such physician/practitioner:
  
  
  • (1) order home health services;
  • (2) establish and periodically review a plan of care for home health services (e.g., sign the plan of care),
  • (3) certify and re-certify that the patient is eligible for Medicare home health services.
  • This will provide the flexibility needed for more timely initiation of services for home health patients, while allowing providers and patients to practice social distancing. HHS will not conduct audits to ensure that only physicians provided orders, signed and dated the plans of care, and certified/recertified patient eligibility for claims submitted during this public health emergency.

• Reporting: CMS is providing relief to HHAs on the timeframes related to OASIS Transmission. This waiver includes extending of the 5-day completion requirement for the comprehensive assessment and waiving the 30-day OASIS submission requirement. HHAs are expected to complete the comprehensive assessment within 30 days and delayed submission is permitted. CMS continues to require that patients still have an assessment to determine and be able to appropriate meet their care needs.
• Initial Assessments: By waiving 42 CFR § 484.55(a), home health agencies can perform initial assessments and determine patients’ homebound status remotely or by record review. This will allow patients to be cared for in the best environment for them while supporting infection control and reducing impact on acute care and long-term care facilities. This will allow for maximizing coverage if there are limited physician and advanced practice clinicians and will allow those clinicians to focus on caring for patients with the greatest acuity.
• Requests for Anticipated Payments (RAPs): MACs can extend the auto-cancellation date of RAPs during emergencies. RAPs are a pre-payment for home health services.
• Review Choice Demonstration for Home Health Services: CMS is offering home health agencies in the Review Choice Demonstration for Home Health Services the option of pausing their participation for the duration of the Public Health Emergency. Home Health agencies do not have to do anything for the pause to go into effect.

COVID-19 Diagnostic Testing

If a patient is already receiving Medicare home health services, the home health nurse, during an otherwise covered visit, could obtain the sample to send to the laboratory for COVID-19 diagnostic testing.

Workforce

• Ordering Medicaid Home Health Services and Equipment: Medicaid home health regulations now allow non-physician practitioners to order medical equipment, supplies and appliances, home health nursing and aide services, and physical therapy, occupational therapy or speech pathology and audiology services, in accordance with state scope of practice laws.
• Waived onsite visits for both HHA Aide Supervision: CMS is waiving the requirements at 484.80(h), which require a nurse to conduct an onsite visit every two weeks. This would include waiving the requirements for a nurse or other professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan, as this may not be physically possible for a period of time. This waiver is also temporarily suspending 2-week aide supervision requirement at 42 CFR §484.80(h)(1) by a registered nurse for home health agencies, but virtual supervision is encouraged during the period of the waiver.

Regarding hospice providers:

Medicare Telehealth

• Hospice providers can provide services to a Medicare patient receiving routine home care through telehealth, if it is feasible and appropriate to do so.
• Face-to-face encounters for purposes of patient recertification for the Medicare hospice benefit can now be conducted via telehealth.

Workforce

• Waive requirement for hospices to use volunteers. CMS is waiving the requirement at 42 CFR §418.78(e) that hospices are required to use volunteers (including at least 5% of patient care hours). It is anticipated that hospice volunteer availability and use will be reduced related to COVID-19 surge and anticipated quarantine.
• Waived onsite visits for Hospice Aide Supervision: CMS is waiving the requirements at 42 CFR 418.76(h), which require a nurse to conduct an onsite visit every two weeks. This would include waiving the requirements for a nurse or other professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan, as this may not be physically possible for a period of time.

Patients Over Paperwork

• Comprehensive Assessments: CMS is waiving certain requirements for Hospice 42 CFR §418.54 related to update of the comprehensive assessments of patients. This waiver applies the timeframes for updates to the comprehensive assessment (§418.54(d)). Hospices must continue to complete the required assessments and updates, however, the timeframes for updating the assessment may be extended from 15 to 21 days. Waive Non-Core Services: CMS is waiving the requirement for hospices to provide certain non-core hospice services during the national emergency, including the requirements at 42 CFR §418.72 for physical therapy, occupational therapy, and speech-language pathology.

Regarding both home health and hospice:

Cost Reporting

• CMS is delaying the filing deadline of certain cost report due dates due to the COVID-19 outbreak and is currently authorizing delay for the following fiscal year end (FYE) dates. CMS will delay the filing deadline of FYE 10/31/2019 cost reports due by March 31, 2020 and FYE 11/30/2019 cost reports due by April 30, 2020. The extended cost report due dates for these October and November FYEs will be June 30, 2020. CMS will also delay the filing deadline of the FYE 12/31/2019 cost reports due by May 31, 2020. The extended cost report due date for FYE 12/31/2019 will be July 31, 2020.

Medicare appeals in Fee for Service, Medicare Advantage (MA) and Part D

• CMS is allowing Medicare Administrative Contractors (MACs) and Qualified Independent Contractor (QICs) in the FFS program 42 CFR 405.942 and 42 CFR 405.962 and MA and Part D plans, as well as the Part C and Part D Independent Review Entity (IREs), 42 CFR 562, 42 CFR 423.562, 42 CFR 422.582 and 42 CFR 423.582 to allow extensions to file an appeal;
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and the Part C and Part D IREs to waive requirements for timeliness for requests for additional information to adjudicate appeals; MA plans may extend the timeframe to adjudicate organization determinations and reconsiderations for medical items and services (but not Part B drugs) by up to 14 calendar days if: the enrollee requests the extension; the extension is justified and in the enrollee’s interest due to the need for additional medical evidence from a noncontract provider that may change an MA organization’s decision to deny an item or service; or, the extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the enrollee’s interest 42 CFR § 422.568(b)(1) (i), § 422.572(b)(1) and § 422.590(f)(1);
• CMS is allowing MACs and QICs in the FFS program 42 C.F.R 405.910 and MA and Part D plans, as well as the Part C and Part D IREs to process an appeal even with incomplete Appointment of Representation forms 42 CFR § 422.561, 42 CFR § 423.560. However, any communications will only be sent to the beneficiary;
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and MA and Part D plans, as well as the Part C and Part D IREs to process requests for appeal that don’t meet the required elements using information that is available 42 CFR § 422.562, 42 CFR § 423.562.
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and MA and Part D plans, as well as the Part C and Part D IREs, 42 CFR 422.562, 42 CFR 423.562 to utilize all flexibilities available in the appeal process as if good cause requirements are satisfied.
• Accelerated/Advance Payments: In order to increase cash flow to providers impacted by COVID-19, CMS has expanded our current Accelerated and Advance Payment Program. An accelerated/advance payment is a payment intended to provide necessary funds when there is a disruption in claims submission and/or claims processing. CMS is authorized to provide accelerated or advance payments during the period of the public health emergency to any Medicare provider/supplier who submits a request to the appropriate Medicare Administrative Contractor (MAC) and meets the required qualifications. Each MAC will work to review requests and issue payments within seven calendar days of receiving the request. Traditionally repayment of these advance/accelerated payments begins at 90 days, however for the purposes of the COVID-19 pandemic, CMS has extended the repayment of these accelerated/advance payments to begin 120 days after the date of issuance of the payment.

CMS issued an emergency interim final rule that addresses the industry-wide priority of increasing flexibility in the use of telehealth. The goal was to gain opportunities to provide telehealth as a means to maximize the availability of staff for in person visits when no alternative was possible, reduce demand on PPE, increase discharges from inpatient hospitals to free up needed beds, reduce exposures of patients and caregivers, and mitigate concerns or virus transmissions that have led to patients refusing needed care.  However, CMS determined that the law did not allow it to pay home health agencies for telehealth.

LeadingAge Ohio along with other state and national associations will continue to advocate for telehealth services for home health agencies. If you have any questions regarding the new CMS flexibilities for home health or hospice please contact Anne Shelley at ashelley@leadingageohio.org, or see the detail of these changes at the links below.

• Coronavirus Waivers and Flexibilities (CMS)

• Trump Administration Makes Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge (CMS)

• 2019-Novel Coronavirus (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs) (CMS)

LeadingAge Ohio, OHCA Request 1135 Waivers

Yesterday, LeadingAge Ohio joined the Ohio Health Care Association (OHCA) in submitting an 1135 waiver request to the Centers for Medicare & Medicaid Services on behalf of Ohio’s long-term care, home health and hospice providers. The requests included critical requirements like nurse aide training requirements, as well as other regulatory hurdles that members have found nearly impossible to comply with, such as face-to-face requirements for home health and hospice.

Many of the waivers were granted as part of the blanket waivers announced by CMS yesterday evening.

Sandata, ODM Send Coronavirus Survey via EVV

The Ohio Department of Medicaid (ODM) and Sandata Technologies, provider of Ohio’s Electronic Visit Verification (EVV) system, will be sending the following notice to all providers to let them know of the new EVV based COVID-19 survey to help agencies screen caregivers and client for potential COVID-19 exposure and symptoms.  By knowing who might have been exposed to COVID-19, providers will better know where to focus their attention and follow up with their patients/caregivers.

Please note that this survey is an optional tool provided by Sandata and not a mandatory process for EVV users. If you have questions regarding this new EVV based COVID-19 survey tool, please contact Anne Shelley at ashelley@leadingageohio.org.

ODM Shares PASSPORT FAQ

The Ohio Department of Medicaid (ODM) has provided a FAQ sheet for PASSPORT Administrative Agencies (PAAs) which includes answers to questions like background checks, provider enrollment and payment rates, and questions related to access.

AAAs Use OAA Funds for Seniors’ Needs

The Family First relief fund and the CARES Act passed by Congress included additional funds for meals and other social services through Title III of the Older Americans Act. If you have needs for your members/clients, contact your regional Area Agency on Aging (AAA) to see if funding may be made available.

The appropriated funds have not arrived yet at the AAAs, but requests will help them in planning for distribution of funds. For example, older adults who may not have qualified in the past for meals may now be eligible as a result of the stay at home order. Find your local Area Agency on Aging online or calling 1-866-243-5678 to be connected to the AAA serving your community.  AAAs are coordinating local efforts to ensure that older adults in need are being served.

Battelle Can Now Sterilize, School Closures Extended

As a result of efforts by Governor DeWine in appealing to the President and the federal government, the Food and Drug Administration (FDA) has granted Battelle permission to clean as many as 160,000 of the much-needed N95 protective face masks each day. Governor DeWine stated that Battelle would be sending sterilization machines to New York, Washington D.C., and Washington state in addition to supporting Ohio's efforts. Battelle will continue to distribute to areas needing assistance.

In his daily press conference, Governor DeWine asked hospitals to either send COVD-19 tests to neighboring hospitals or to the Ohio Department of Health (ODH), not to outside labs, which are experiencing significant delays. These tests are being processed in 8-10 hours, almost always within 24 hours.

The Governor also announced that school closures will be continued until May 1, at which point they will reassess whether schools may reopen again safely, or whether the school year will end without resumption of classes.                                 

DeWine Addresses Homelessness in Daily Press Conference

In regards to homelessness, the Governor announced they are working to reduce the number of individuals in homeless shelters, and that many communities are leading this charge with support from the Coalition on Homelessness and Housing in Ohio (COHHIO). He encouraged anyone with housing questions or ideas to reach out to Covid19housing@ohio.mha.gov.

Ohio Statistics: 1,933 Cases; 39 Deaths

In DeWine’s Daily press conference, Director of Health Dr. Amy Acton provided an update on Ohio's current statistics related to COVID-19. Ohio now has 1,933 cases, with 475 hospitalizations, 163 of which required the ICU and 39 deaths. Cases have been confirmed in over 70 counties. Ohio has tested over 27,000 people statewide. For quick turnaround on testing, Dr. Acton encouraged hospitals work with neighboring hospitals doing in-house testing, as well as the ODH lab. Modeling is still saying the peak will occur in mid- to late-April.

Dr. Acton stated that the state is tracking different types of PPE, monitoring what hospitals have, and noting where there are already shortages compared to what would be needed at 100 percent occupancy. She once again provided words of encouragement for healthcare workers, especially those who are becoming ill while working on the frontlines of this criss. 

Medicaid, MyCare Plans Share Contacts for LTC Questions

In a joint letter to Ohio long-term care providers, Ohio’s Medicaid and MyCare Ohio Health Plans have provided members contact information so that providers can reach out to with questions or needs during the ongoing pandemic. The goal of this outreach is to obtain updates about members and to provide support and assistance from the Health Plan.

Questions/All-member Call

Please send all questions to COVID19@leadingageohio.org. Additionally, members are encouraged to visit the LeadingAge Ohio COVID-19 Working Group Facebook Group to pose questions to peers and share best practices.

LeadingAge Ohio will be holding another all-member call this Thursday, April 2 at 10:30am. Call in information will be distributed tomorrow.