New Blanket Waivers Released by CMS

CMS Releases New Blanket Waivers & Interim Final Rule for Providers Countering the COVID-19 Public Health Emergency

On April 30, 2020, CMS released its Interim Final Rule, with comment, which contained revisions to its blanket waivers. The revisions added new flexibilities for healthcare providers who service Medicare, Medicaid, and the Basic Health Program, as well as Exchange beneficiaries needing increased flexibility to respond effectively to the spread of COVID-19. Among these changes included is tremendous access to COVID-19 diagnostic testing, accessibility to expanded Telehealth services and application, and removal of barriers for physicians and other clinicians. The changes are meant to ensure that local health systems have adequate capacity to handle patients through the implementation of the CMS Hospital Without Walls Initiative, which involves temporary site expansions.

As such, we have highlighted some of the principal points of the new Interim Final Rule and accompanying blanket waivers.

Billing for Telehealth Services in the Home:

• CMS facilitated a broad expansion of Telehealth services to enable health care providers to deliver a broader range of services to Medicare beneficiaries in their homes, which prevents patients from further exposure risk to COVID-19.
• CMS announced that hospitals may now bill for services furnished remotely by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is at home where the home is serving as a temporary provider based department of the hospital.
  • Examples of these services include counseling and educational service as well as therapy services.
• CMS also allows hospitals to bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is located at home.

Audio-Only Telehealth for Certain Services:

• To address the concern that some Medicare beneficiaries do not have access to both audio and video technology for Medicare telehealth services, CMS is waiving the video requirement for certain telephone evaluation and management services and adding them to the list of Medicare telehealth services.
• As a result, CMS waived the requirement for the use of interactive telecommunications systems to furnish certain Telehealth services to the extent they require use of video technology for certain services, including Audio-only telephone evaluation and management services, and behavioral health counseling and educational services.
• CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would effectively increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.

Broader Telehealth Services.

• CMS broadened its eligible services process and will add new telehealth services on a sub-regulatory basis, considering requests by practitioners now learning to use telehealth as broadly as possible.
• CMS broadened the types of clinical practitioners that may furnish Medicare telehealth services that were otherwise unauthorized, practitioners including physical therapists, occupational therapists, and speech language pathologists.

Rural Health Clinics and Federally Qualified Health Centers.

• Through the CARES Act, CMS is now paying for Medicare telehealth services provided by rural health clinics and federally qualified health clinics. Medicare beneficiaries located in rural and other medically underserved areas will have greater access to care in their homes.

In furtherance of its Hospitals Without Walls Initiative, CMS has created further flexibility for providers by now allowing hospitals to provide services in other healthcare facilities through temporary site expansions.

Increased Quantity of Beds.

• CMS is facilitating flexibility for healthcare practitioners by increasing the quantity of beds allowable to treat COVID-19 patients while maintaining steady Medicare payments.
• To illustrate, inpatient rehabilitation facilities and inpatient psychiatric facilities now can take in more patients to relieve the strain on acute-care hospital bed capacity without having an impact on direct teaching status payments.

Payments for Outpatient Hospital Services.

• CMS emphasized flexibilities to allow payments for outpatient hospital services that are provided in temporary expansion locations. CMS now permits certain provider-based hospital outpatient departments that relocate off-campus to obtain a temporary exception and continue to be paid under the OPPS as temporary expansion locations.
• CMS is allowing payment for outpatient hospital services delivered in temporary expansion locations such as parking lot tents, converted hotels, or patient’s homes that are temporarily designated as part of a hospital to provide outpatient services such as wound care, drug administration, and behavioral health services.

Long Term Acute-Care Hospitals:

• Under the CARES Act, CMS now permits long-term acute-care hospitals to accept any acute-care patient and still be paid at a higher Medicare payment rate.

Certain Excepted Requirements.

• Attempting to make better use of available beds for COVID-19 patients in freestanding inpatient rehabilitation facilities, CMS is now excepting certain requirements to enable these facilities to accept patients from acute-care hospitals facing an influx of patients, even if those patients do not require rehabilitative treatment.

In an effort to combat the unique challenges created by the COVID-19 Public Health Emergency, CMS has authorized new flexibilities designed to reduce administrative burdens on healthcare providers and create greater access to care.

Physical and Occupational Therapists:

• CMS will now permit physical and occupational therapists to delegate maintenance therapy services in outpatient settings to physical and occupational therapy assistants. This effectively provides both physical and occupational therapists more time to focus on more patients, creating greater access for beneficiaries to these practitioners.

Non-Physician Practitioners and Home Health Services:

• Due to the influx of beneficiaries requiring in-home services during the public health emergency, CMS authorized nurse practitioners, clinical nurse specialists, and physician assistants to provide home health services through the CARES Act.
• Whereas previously, only physicians could certify home health services for Medicare and Medicaid Home Health beneficiaries, these non-physician practitioners may now:
  • Order home health services;
  • Establish and periodically review a plan of care for home health patients; and
  • Certify and re-certify that the patient is eligible for home health services.

Ambulatory Surgical Centers:

• CMS is waiving the requirement for ambulatory surgical centers to periodically reappraise medical staff privileges for the duration of the COVID-19 emergency, allowing health care providers whose privileges are set to expire to continue treating patients.

Teaching Hospitals:

• CMS will neither reduce Medicare payments for teaching hospitals that shift their residents to other hospitals to meet COVID-related needs, nor penalize hospitals that accept these residents.
• Effective March 31, 2020, CMS expanded flexibility to allow teaching physicians to review services provided with a resident physician during or immediately after the visit using telecommunications technology; it also expanded the types of services that Medicare will compensate the teaching practitioner for when furnished by a resident physician under the primary care exception.

Community Mental Health Centers:

• In an effort to combat the physical and mental health crises influenced by the COVID-19 Public Health Emergency, CMS has authorized new flexibilities designed to reduce administrative burdens on healthcare providers, with emphasis on healthcare services able to be provided at home through Telehealth. For example, CMS now permits CMHCs to provide partial hospitalization services and other CMHC services in an individual’s home, including through telehealth, to create greater access to care while allowing patients to safely shelter-in-place.

Flexibilities for Non-physician practitioners.

• To increase access to COVID-19 related testing, the new waivers remove the requirement that a treating physician, or other health care practitioner, must order a COVID-19 diagnostic test and certain affiliated laboratory tests in order for Medicare beneficiaries to be covered for said tests.
• For the duration of the Public Health Emergency, diagnostic COVID-19 tests ordered by any healthcare professional authorized to do so under state law will be covered by Medicare.
• CMS removed the requirement necessitating that a written health care provider’s order be provided for a COVID-19 test in order for it to be covered under Medicare.
• For the duration of the Public Health Emergency, CMS will allow COVID-19 diagnostic tests to be ordered, furnished directly, and supervised by, non-physician practitioners, including nurse practitioners, clinical nurse specialists, physician assistants, and/or certified nurse midwives.

Pharmacists.

• Pharmacists can now perform certain COVID-19 tests, if enrolled in Medicare as a laboratory, as well as work with a physician or other practitioners to provide assessment and specimen collection services. The physician or other practitioner can then bill Medicare for their services.
• Pharmacists also can perform certain COVID-19 tests if they are enrolled in Medicare as a laboratory, in accordance with a pharmacist’s scope of practice and state law.

Compensable Covid-19 Testing.

• CMS will now compensate hospitals and health care practitioners who collect laboratory samples for COVID-19 testing from beneficiaries; CMS will provide a separate payment if that is the only service the beneficiary receives.
• In further efforts to facilitate expanded testing, Medicaid and Medicare will now cover certain serology tests which assist in analyzing whether a patient has established an immune response to COVID-19 and whether they may not be at high risk for reinfection.

• In order to provide greater financial stability to the 517 accountable care organizations (ACOs) serving more than 11 million beneficiaries, CMS authorized changes to the Medicare Shared Savings Program to give greater financial stability and predictability to these ACOs during the COVID-19 pandemic.
• ACOs are comprised of doctors, hospitals, and other healthcare providers, that collaborate to provide coordinated high-quality care to Medicare patients while avoiding unnecessary duplication of services and preventing medical errors.
• Importantly, CMS is forgoing the annual application cycle for 2021 and giving ACOs whose participation is set to end this year the option to extend for an additional year.
• ACOs that are required to increase their financial risk over the course of their current agreement period in the program will have the option to maintain their current risk level for next year.
• CMS is now allowing states that operate a Basic Health Program to submit retroactively effective revised BHP Blueprints for temporary changes tied to the COVID-19 public health emergency that are not restrictive, where previously revised BHP Blueprints could only be prospectively submitted.

Advis will continue to track these developments and provide guidance if in subsequent legislation the CMS IFC and waivers are further updated. Please refer to the Advis COVID-19 Information Repository for previous updates and recommendations to ensure program compliance throughout the pandemic. If you need assistance preparing data requests, or if you would like to discuss emerging issues regarding these regulations and waivers as they develop, Advis is available seven days  a week. Please contact us directly, or email one of our experts, and we will respond as soon as possible. And don’t forget to subscribe to our digital mailing list to receive all our regulatory updates.

Published: May 5, 2020