"Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): Cms Flexibilities to Fight Covid-19"

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Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): Cms Flexibilities to Fight Covid-19 is a 11-page legal document that was released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services on July 9, 2020 and used nation-wide.

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Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing
Facilities): CMS Flexibilities to Fight COVID-19
** Indicates items added or revised in the most recent update
Since the beginning of the COVID-19 Public Health Emergency, the Trump Administration has
issued an unprecedented array of temporary regulatory waivers and new rules to equip the
American healthcare system with maximum flexibility to respond to the 2019 Novel
Coronavirus (COVID-19) pandemic. These temporary changes will apply immediately across the
entire U.S. healthcare system for the duration of the emergency declaration. The goals of these
actions are to 1) expand the healthcare system workforce by removing barriers for physicians,
nurses, and other clinicians to be readily hired from the community or from other states; 2)
ensure that local hospitals and health systems have the capacity to handle a potential surge of
COVID-19 patients; this includes temporary expansion sites (also known as CMS Hospital
Without Walls); 3) increase access to telehealth in Medicare to ensure patients have access to
physicians and other clinicians while keeping patients safe at home; 4) expand in-place testing
to allow for more testing at home or in community based settings and establish data reporting
vehicles that are critical to addressing the pandemic; and 5) put Patients Over Paperwork to
give temporary relief from many paperwork, reporting and audit requirements so providers,
health care facilities, Medicare Advantage and Part D plans, and States can focus on providing
needed care to Medicare and Medicaid beneficiaries affected by COVID-19.
Patients Over Paperwork
• Physical Environment: Provided that the State has approved the location as one that
sufficiently addresses safety and comfort for patients and staff, CMS is waiving
requirements under 42 CFR §483.90 to allow for a non-SNF/NF building to be
temporarily certified as and available for use by a SNF in the event there are needs for
isolation processes for COVID-19 positive residents which may not be feasible in the
existing SNF structure to ensure care and services during treatment for COVID-19 is
available while protecting other vulnerable adults. CMS believes this will also provide
another measure that will free up inpatient care beds at hospitals for the most acute
patients while providing beds for those still in need of care. CMS will waive certain
conditions of participation and certification requirements for opening a SNF/NF if the
state determines there is a need to quickly stand up a temporary COVID-19 isolation and
treatment location. To assist with isolation needs, CMS is also temporarily allowing for
rooms in a long-term care facility not normally used as a resident’s room, to be used to
accommodate beds and residents for resident care in emergencies and situations
needed to help with surge capacity. Rooms that may be used for this purpose include
activity rooms, meeting/conference rooms, dining rooms, or other rooms, as long as
residents can be kept safe, comfortable, and other applicable requirements for
participation are met. This can be done so long as it is not inconsistent with a state’s
7/9/2020
1
Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing
Facilities): CMS Flexibilities to Fight COVID-19
** Indicates items added or revised in the most recent update
Since the beginning of the COVID-19 Public Health Emergency, the Trump Administration has
issued an unprecedented array of temporary regulatory waivers and new rules to equip the
American healthcare system with maximum flexibility to respond to the 2019 Novel
Coronavirus (COVID-19) pandemic. These temporary changes will apply immediately across the
entire U.S. healthcare system for the duration of the emergency declaration. The goals of these
actions are to 1) expand the healthcare system workforce by removing barriers for physicians,
nurses, and other clinicians to be readily hired from the community or from other states; 2)
ensure that local hospitals and health systems have the capacity to handle a potential surge of
COVID-19 patients; this includes temporary expansion sites (also known as CMS Hospital
Without Walls); 3) increase access to telehealth in Medicare to ensure patients have access to
physicians and other clinicians while keeping patients safe at home; 4) expand in-place testing
to allow for more testing at home or in community based settings and establish data reporting
vehicles that are critical to addressing the pandemic; and 5) put Patients Over Paperwork to
give temporary relief from many paperwork, reporting and audit requirements so providers,
health care facilities, Medicare Advantage and Part D plans, and States can focus on providing
needed care to Medicare and Medicaid beneficiaries affected by COVID-19.
Patients Over Paperwork
• Physical Environment: Provided that the State has approved the location as one that
sufficiently addresses safety and comfort for patients and staff, CMS is waiving
requirements under 42 CFR §483.90 to allow for a non-SNF/NF building to be
temporarily certified as and available for use by a SNF in the event there are needs for
isolation processes for COVID-19 positive residents which may not be feasible in the
existing SNF structure to ensure care and services during treatment for COVID-19 is
available while protecting other vulnerable adults. CMS believes this will also provide
another measure that will free up inpatient care beds at hospitals for the most acute
patients while providing beds for those still in need of care. CMS will waive certain
conditions of participation and certification requirements for opening a SNF/NF if the
state determines there is a need to quickly stand up a temporary COVID-19 isolation and
treatment location. To assist with isolation needs, CMS is also temporarily allowing for
rooms in a long-term care facility not normally used as a resident’s room, to be used to
accommodate beds and residents for resident care in emergencies and situations
needed to help with surge capacity. Rooms that may be used for this purpose include
activity rooms, meeting/conference rooms, dining rooms, or other rooms, as long as
residents can be kept safe, comfortable, and other applicable requirements for
participation are met. This can be done so long as it is not inconsistent with a state’s
7/9/2020
1
emergency preparedness or pandemic plan, or as directed by the local or state health
department.
•
3- Day Prior Hospitalization: Using the waiver authority under Section 1812(f) of the
Social Security Act, CMS is temporarily waiving the requirement for a 3-day prior
hospitalization for coverage of a skilled nursing facility (SNF) stay. This waiver provides
temporary emergency coverage of SNF services without a qualifying hospital stay. In
addition, for certain beneficiaries who exhausted their SNF benefits, it authorizes
renewed SNF coverage without first having to start and complete a 60-day “wellness
period” (that is, the 60-day period of non-inpatient status that is normally required in
order to end the current benefit period and renew SNF benefits). This waiver will apply
only for those beneficiaries who have been delayed or prevented by the emergency
itself from commencing or completing the 60-day “wellness period” that would have
occurred under normal circumstances. By contrast, if the patient has a continued skilled
care need (such as a feeding tube) that is unrelated to the COVID-19 emergency, then
the beneficiary cannot renew his or her SNF benefits under the Section 1812(f) waiver,
as it is this continued skilled care in the SNF rather than the emergency that is
preventing the beneficiary from beginning the 60-day “wellness period.”
• Reporting Minimum Data Set: CMS is waiving 42 CFR §483.20 to provide relief to SNFs
on the timeframe requirements for Minimum Data Set assessments and transmission.
• **Staffing Data Submission: CMS is waiving 42 CFR 483.70(q) to provide relief to long
term care facilities on the requirements for submitting staffing data through the Payroll-
Based Journal system. Submission of staffing data through the Payroll Based Journal
system was reinstated on June 25, 2020.
• Waive Pre-Admission Screening and Annual Resident Review (PASRR): CMS is allowing
states and nursing homes to suspend these 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.
• Resident Groups: CMS is waiving the requirements at §483.10(f)(5) to allow for residents
to have the right to participate in-person in resident groups. This waiver would only
permit the facility to restrict having in-person meetings during the national emergency
given the recommendations of social distancing and limiting gatherings of more than ten
people. Refraining from in-person gatherings will help prevent the spread of COVID-19.
• Quality Assurance and Performance Improvement (QAPI). CMS is modifying certain
requirements in 42 CFR §483.75, which requires long-term care facilities to develop,
implement, evaluate, and maintain an effective, comprehensive, data-driven QAPI
program. Specifically, CMS is modifying §483.75(b)–(d) and (e)(3) to the extent
7/9/2020
2
necessary to narrow the scope of the QAPI program to focus on adverse events and
infection control. This will help ensure facilities focus on aspects of care delivery most
closely associated with COVID-19 during the PHE.
• In-Service Training: CMS is modifying the nurse aide training requirements at
§483.95(g)(1) for SNFs and NFs, which requires the nursing assistant to receive at least
12 hours of in-service training annually. In accordance with section 1135(b)(5) of the
Act, we are postponing the deadline for completing this requirement throughout the
COVID-19 PHE until the end of the first full quarter after the declaration of the PHE
concludes.
• Detailed Information Sharing for Discharge Planning for Long-Term Care (LTC)
Facilities. CMS is waiving the discharge planning requirement in §483.21(c)(1)(viii),
which requires LTC facilities to assist residents and their representatives in selecting a
post-acute care provider using data, such as standardized patient assessment data,
quality measures and resource use. This temporary waiver is to provide facilities the
ability to expedite discharge and movement of residents among care settings. CMS is
maintaining all other discharge planning requirements, such as but not limited to,
ensuring that the discharge needs of each resident are identified and result in the
development of a discharge plan for each resident; and involving the interdisciplinary
team, as defined at 42 CFR §483.21(b)(2)(ii), in the ongoing process of developing the
discharge plan address the resident's goals of care and treatment preferences.
• Clinical Records. Pursuant to section 1135(b)(5) of the Act, CMS is modifying the
requirement at 42 CFR §483.10(g)(2)(ii) which requires long-term care (LTC) facilities to
provide a resident a copy of their records within two working days (when requested by
the resident). Specifically, CMS is modifying the timeframe requirements to allow LTC
facilities ten working days to provide a resident’s record rather than two working days.
• Provider Enrollment: CMS has established toll-free hotlines for all providers and Part A
certified providers and suppliers establishing isolation facilities to enroll and receive
temporary Medicare billing privileges. In addition, the following flexibilities are provided
for provider enrollment:
o Waive certain screening requirements.
o Postpone all revalidation actions.
o Expedite any pending or new applications from providers.
Establish data reporting vehicle critical to addressing the pandemic
• Required Facility Reporting: Under the new §483.80(g), CMS is requiring facilities to
report COVID-19 cases in their facility to the CDC National Health Safety Network
(NHSN) on a weekly basis. CDC and CMS will use information collected through the new
7/9/2020
3
NHSN Long-term Care COVID-19 Module to strengthen COVID-19 surveillance locally
and nationally; monitor trends in infection rates; and help local, state, and federal
health authorities get help to nursing homes faster. Nursing home reporting to the CDC
is a critical component of the national COVID-19 surveillance system and to efforts to
reopen America. The information will also be posted online for the public to be aware of
how the COVID-19 pandemic is affecting nursing homes.
Facilities are also required to notify residents, their representatives, and families of
residents in facilities of the status of COVID-19 in the facility, which includes any new
cases of COVID-19 as they are identified. This action supports CMS’ commitment to
transparency so that individuals know important information about their environment,
or the environment of a loved one.
Payment
• Accelerated/Advance Payments: In order to provide additional cash flow to healthcare
providers and suppliers impacted by COVID-19, CMS expanded and streamlined the
Accelerated and Advance Payments Program, which provided conditional partial
payments to providers and suppliers to address disruptions in claims submission and/or
claims processing subject to applicable safeguards for fraud, waste and abuse. Under
this program, CMS made successful payment of over $100 billion to healthcare
providers and suppliers. As of April 26, 2020, CMS is reevaluating all pending and new
applications for the Accelerated Payment Program and has suspended the Advance
Payment Program, in light of direct payments made available through the Department
of Health & Human Services’ (HHS) Provider Relief Fund. Distributions made through the
Provider Relief Fund do not need to be repaid. For providers and suppliers who have
received accelerated or advance payments related to the COVID-19 Public Health
Emergency, CMS will not pursue recovery of these payments until 120 days after the
date of payment issuance. Providers and suppliers with questions regarding the
repayment of their accelerated or advance payment(s) should contact their appropriate
Medicare Administrative Contractor (MAC).
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
7/9/2020
4
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.
Cost Reporting
• **CMS is delaying the filing deadline of certain cost report due dates due to the COVID-
19 outbreak. We are 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
revised extended cost report due date for FYE 12/31/2019 will be August 31, 2020. For
the FYE 01/31/2020 cost report, the extended due date is August 31, 2020. For the FYE
02/29/2020 cost report, the extended due date is September 30, 2020.
CMS Facility without Walls ( Temporary Expansion Sites)
• Transfers of COVID -19 Patients: 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 need not issue a formal discharge in this situation, as it is still
considered the provider and should bill Medicare normally for each day of care. The
transferring LTC facility is then responsible for reimbursing the other provider that
accepted its resident(s) during the emergency period. This is consistent with recent CDC
guidance, and helps residents with COVID-19 by placing them into facilities that are
7/9/2020
5
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