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CARES Act provides hospitals with emergency funding and policy wins

03.31.20

CARES Act update:

As anticipated, the House of Representatives approved the CARES Act on March 27, 2020, and the President has signed the measure. The provisions highlighted in our prior summary remain intact in the final measure. 

So…how are the emergency relief funds in the legislation accessed by healthcare providers?

  • Public Health & Social Services Emergency Fund (PHSSEF): The guidance on how hospitals will access the $100 billion in PHSSEF funds to offset “COVID-19 related expenses and lost revenue” is expected to be released shortly. Keep an eye on this space for further updates as information becomes available.
  • Medicare Advanced Lump Sum or Periodic Interim Payments: Application is made through the Fiscal Intermediary (FI). It should be noted that healthcare organizations do not qualify if they are in bankruptcy, under active medical review or program integrity investigation, or have outstanding, delinquent Medicare overpayments.
  • SBA Paycheck Protection Program (PPP): This application process begins with your local lender. Do not hesitate—contact your lender immediately as it is anticipated that application volume will be tremendous. For more specifics on this program compiled by BerryDunn experts, visit our blog.

We will continue to provide updates as more information becomes available. In the meantime, please feel free to contact the hospital consulting team. Despite the current circumstances we remain available to support your needs. 


On March 25, 2020 the US Senate unanimously approved the $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act (The “Act”). The White House has signaled that it will sign the measure as approved by the Senate. 

Major provisions of the proposed legislation include:

  • $100 billion for hospital “COVID-19 related expenses and lost revenue”
  • $275 million for rural hospitals, telehealth, poison control centers, and HIV/AIDS programs
  • $250 million for hospital capacity expansion and response
  • $150 million for modifications of existing hospital, nursing home, and “domiciliary facilities” undertaken as part of COVID-19 response

The CARES Act also includes the following targeted relief and payment modifications under the Medicare and Medicaid programs:

  • The Medicare 2% sequester will be suspended from May 1, 2020 through December 31, 2020. 
  • “Through the duration of the COVID-19 emergency period”, the Act will increase by 20% hospital payments for the treatment of patients admitted with COVID-19. The add-on applies to hospitals paid through the Inpatient Prospective Payment System.
  • $4 billion in scheduled cuts to Medicaid Disproportionate Share Hospital payments will be further delayed from May 22, 2020 to November 30, 2020.
  • Certain hospitals, including those designated as rural or frontier, have the option to request up to a six month advanced lump sum or periodic interim payments from Medicare. The payments will:
    1. Be based upon net payments represented by unbilled discharges or unpaid bills,
    2. Equal up to 100% of prior period payments, 125% for Critical Access Hospitals
    3. In terms of paying down the “no interest loans”, hospitals will be given a four month grace period to begin making payments and at least 12 months to fully liquidate the obligation.

Non-financing provisions contained in the Act that will impact hospital operations include:

  • Providing acute care hospitals the option to transfer patients out of their facilities and into alternative care settings to "prioritize resources needed to treat COVID-19 cases." That flexibility will come through the waiver of the Inpatient Rehabilitation Facility (IRF) three-hour rule, which requires patients to need at least three hours of intensive rehabilitation at least five days per week to be admitted to an IRF.
  • Allowing Long-Term Care Hospitals (LTCH) to maintain their designation even if more than 50% of their cases are less intensive and would temporarily pause LTCH site-neutral payments.
  • Suspending scheduled Medicare payment cuts for durable medical equipment during the length of the COVID-19 emergency period, to help patients transition from hospital to home.
  • Disallow Medicare beneficiary cost-sharing payments for any COVID-19 vaccine.
  • Ensuring that uninsured individuals could receive free COVID-19 tests "and related service" through any state Medicaid program that elects to enroll them.

Other emergency-period provisions that directly affect other entities but have implications for hospitals:

  • Affording $150 billion to states, territories, and tribal governments to cover their costs for responding to the coronavirus public health emergency.
  • Physician assistants, nurse practitioners, and other professionals will be allowed to order home health services for Medicare beneficiaries, to increase "beneficiary access to care in the safety of their home."
  • Requiring HHS to clarify guidance encouraging the use of telecommunications systems, including remote patient monitoring, for home health services.
  • Allowing qualified providers to use telehealth technologies to fulfill the hospice face-to-face recertification requirement.
  • Eliminating the requirement that a nephrologist conduct some of the required periodic evaluations of a home-dialysis patient face-to-face.
  • Allowing federally qualified health centers and rural health clinics to serve as a distant site for telehealth consultations.
  • Eliminating the telehealth requirement that physicians or other professionals have treated a patient in the past three years.
  • Allowing high-deductible health plans with a health savings account (HSA) to cover telehealth services before a patient reaches the deductible.
  • Allowing patients to use HSA and flexible spending accounts to buy over-the-counter medical products without a prescription.

For more information
If you have questions or need more information about your specific situation, please contact the hospital consulting team. We’re here to help. 
 

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Read this if you are at a rural health clinic or are considering developing one.

Section 130 of H.R. 133, the Consolidated Appropriations Act of 2021 (Covid Relief Package) has become law. The law includes the most comprehensive reforms of the Medicare RHC payment methodology since the mid-1990s. Aimed at providing a payment increase to capped RHCs (freestanding and provider-based RHCs attached to hospitals greater than 50 beds), the provisions will simultaneously narrow the payment gap between capped and non-capped RHCs.

This will not obtain full “site neutrality” in payment, a goal of CMS and the Trump administration, but the new provisions will help maintain budget neutrality with savings derived from previously uncapped RHCs funding the increase to capped providers and other Medicare payment mechanisms.

Highlights of the Section 130 provision:

  • The limit paid to freestanding RHCs and those attached to hospitals greater than 50 beds will increase to $100 beginning April 1, 2021 and escalate to $190 by 2028.
  • Any RHC, both freestanding and provider-based, will be deemed “new” if certified after 12/31/19 and subject to the new per-visit cap.
  • Grandfathering would be in place for uncapped provider-based RHCs in existence as of 12/31/19. These providers would receive their current All-Inclusive Rate (AIR) adjusted annually for MEI (Medicare Economic Index) or their actual costs for the year.

If you have any questions about your specific situation, please contact us. We’re here to help.

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Section 130 Rural Health Clinic (RHC) modernization: Highlights

Read this if you are a plan sponsor of employee benefit plans.

This article is the eleventh in a series to help employee benefit plan fiduciaries better understand their responsibilities and manage the risks of non-compliance with Employee Retirement Income Security Act (ERISA) requirements. You can read the previous articles here.

Most employee benefit plans have outsourced a significant portion of the internal controls to a service organization, such as a third-party administrator. The plan administrator has a fiduciary responsibility to monitor the internal controls of the service organization and to determine if the outsourced controls are suitably designed and effective.

SOC 1 reports: Internal controls and financial reporting

Generally, the most efficient way to obtain an understanding of the outsourced controls is to obtain a report on controls issued by the service organization’s auditor. Commonly referred to as a System and Organization Controls (SOC) report, the SOC report should be based on the American Institute of Certified Public Accountants’ (AICPA) attestation standards and should cover internal controls relevant to financial reporting, also known as a SOC 1 report (the “1” indicating it covers internal controls over financial reporting).

Plan sponsors should perform a documented review of the SOC 1 report for each of the plan’s significant service organizations. The documented review should include the plan sponsor’s assessment of the complementary user entity controls outlined in the SOC 1 report. The complementary user entity controls are internal control activities that should be in place at the plan sponsor to provide reasonable assurance that the controls tested at the service organization are operating effectively at your plan. If a service organization’s internal controls are operating effectively, but complementary user entity controls are not in place at your organization, the effectiveness of the service organization’s internal controls may not transfer to your plan’s operations.

Creditability and CPA firms: Considerations

Creditability of the CPA firm completing the SOC 1 report examination may impact the reliability of the CPA firm’s opinion and thus your reliability on the service organization’s internal controls. Unfamiliarity with the service auditor’s qualifications may be mitigated through additional research. Items to consider are: 

  • The firm’s expertise in SOC 1 reporting
    • Are they familiar with the service organization’s industry?
    • How many professionals do they have that perform SOC 1 examination services?
  • The evaluation of AICPA peer reviews 
    Audit firms are required to have a periodic peer review conducted. The results of the peer review are public knowledge and can be found on the AICPA’s website.
    • Did the service auditor receive a “pass” rating during their most recent peer review?
    • Did the peer review cover SOC 1 examination services?
  • Evaluation of the service organization’s due diligence procedures surrounding the selection of an auditor

Some of this information may be readily available via the service auditor’s website, while other information may need to be gathered through direct communication with the service organization. A qualified service auditor should be able to provide a SOC 1 report that contains sufficient detail, relevant transactional activity, relevant control objectives, and a timely reporting period.

SOC 1 reports may contain an unqualified, qualified, adverse, or disclaimer of opinion. The report determines if the controls in place are adequate for complete and accurate financial reporting. Report qualifications may affect the risk of relying on the service organization and may result in the need for additional procedures or safeguards to help ensure the plan’s financial statements are presented fairly. Even if the SOC 1 report received an unqualified opinion, you should review the controls tested by the service auditor and the results of such testing for any exceptions. Exceptions, even if they don’t result in a qualified opinion, may have an impact on the plan’s control environment. 

You should also review the scope of the audit to check that all significant transaction cycles, processes, and IT applications were properly assessed for their impact on the plan’s financial statements. Areas outside the scope of the SOC 1 report may require additional consideration, including the possibility of obtaining more than one SOC 1 report for subservice organizations whose functions were carved out from the service organization’s SOC 1 report.

Subservice organizations

Subservice organizations are frequently utilized to process certain transactions or perform certain functions at the service organization. Management of the service organization may identify certain transaction cycles and processes that are performed by a subservice organization and choose to exclude relevant control objectives and related controls from the SOC 1 report description and the scope of the auditor’s engagement. In such cases, multiple SOC 1 reports may need to be acquired to gain adequate coverage of all controls and objectives relevant to your plan. 

Furthermore, you need to consider the time period the SOC 1 report covers. Coverage should be obtained for your plan’s full fiscal year. For SOC 1 reports that lack coverage of your plan’s full fiscal year, a bridge letter should be obtained to help ensure that no significant changes in controls occurred between the SOC 1 report examination period and the end of your plan’s fiscal year.

Although plans commonly outsource a significant portion of their day-to-day operations to service organizations, plan fiduciaries cannot outsource their responsibilities surrounding the maintenance of a sound control environment. SOC 1 reports are a great resource to assess the control environments of service organizations. However, such reports can be lengthy and daunting to review. We hope this article provides some best practices in reviewing SOC 1 reports. If you have any questions, or would like to receive a copy of our SOC 1 report review template, please don’t hesitate to reach out to our Employee Benefits Audit team.

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Service organizations and review of SOC 1 reports: Considerations and recommendations

Read this if you are involved with financial statement audits or use audited financial statements. 

Almost as exciting as the look of a new outfit or (completion of) a renovation project, SAS 134 brings a new design to the auditor’s report accompanying your audited financials for periods ending on or after December 31, 2021. Why the new look, you ask? 

Users spoke and the AICPA Auditing Standards Board listened. The new standard significantly changes the layout and content of the report (including management’s responsibilities) and permits communication of key audit matters (areas of higher assessed risk of material misstatement, areas involving significant judgment, or significant events or transactions during the period). Implemented changes include: 

  • The auditor’s opinion is now at the beginning of the audit report and otherwise strengthens the transparency for the auditor’s opinion.
  • The standard clarifies the responsibilities of both management and the auditors, strengthening the financial audit. 

Sample auditor’s report

The simplest way to relay the changes is with an example. The following report is a basic illustration in which an unmodified opinion was issued and the auditor was not engaged to communicate key audit matters. 

If you have questions or would like to speak to us about your specific situation, please contact us. We’re here to help.

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Auditor's report redesigned for better communication

Read this if you have not yet reported for Phase 1.

Phase 1 provider relief reporting portal

HRSA opened the Provider Relief Funds (PRF) reporting portal on July 1, 2021, for Phase 1 PRF reporting. In Phase 1, providers will be reporting on the use of PRF received prior to June 30, 2020. While Phase 1 reporting was originally due September 30, 2021, HRSA has provided a 60-day grace period for the reporting period. Providers will be considered out of compliance with the reporting requirements if they do not submit reporting by November 30, 2021. Providers can submit their reporting on the Provider Relief Fund portal. Please note:

  1. Providers must register for the reporting portal, as this is not the same portal as the application and attestation portal. The portal registration must be completed in one session. Follow the link to the Portal Registration User guide
  2. Providers can only report on eligible lost revenues and expenditures related to payments received before June 30, 2020. Providers are not yet allowed to report on payments received subsequent to June 30, 2020. See the June 11, 2021 Reporting Requirements Notice for more detail on reporting requirements.
  3. The period of availability for Phase 1 lost revenues and eligible expenditures is January 1, 2020 through June 30, 2021.
  4. It is extremely helpful to complete the HRSA provider portal worksheets prior to beginning the portal data entry. 
  5. Providers should return unused funds as soon as possible after submitting their report. All unused funds must be returned no later than 30 days after the end of the grace period. (December 31, 2021)
  6. Provider Relief Funds are considered federal awards under Assistance Listing Number (ALN) 93.948. Providers, both for-profit and not-for-profit, may be subject to a Uniform Guidance Audit if they expend more than $750,000 of federal awards during the provider’s fiscal year. 
  7. Providers are able to retrieve their data submission from the portal if a copy was not retained during the submission process.

Your BerryDunn Hospital team is here to help you navigate the Provider Relief Fund reporting and compliance requirements. Please contact us if you have any questions or would like to talk about your specific situation. 

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Provider Relief Funds: Highlights

Read this if you are a renewable energy developer, installer, or investor.

After months of back-and-forth negotiations, renewable energy incentives remain in the November 3, 2021 version of the Build Back Better Act (Act). For renewable energy companies, that’s good news. In summary, Subtitle F – Green Energy of the Act, includes the proposal to extend and expand existing clean energy tax incentives included in Section 45 and Section 48 for renewable energy facilities that begin construction between 2021 and 2027. Here are current regulations and proposed changes:

Renewable Energy Investment Credit (IRC SEC 48)

  • Under current regulations the Investment Tax Credit (ITC) program, set to expire in 2024, offers a 26% tax credit for systems installed between 2020 and 2022 and a 22% credit for those installed in 2023.
  • The proposed regulation is to reinstate the 30% credit through year 2026 for the majority of the current green energy sources covered AND expand credit to include energy storage technology.
  • The rate phase down in 2027 & 2028 is a 2% base rate or a bonus rate of 10% thereafter.
  • Additionally, Section 48 is amended to include interconnection property in connection with the installation of energy property which has a maximum net output of not greater than 5 megawatts.

Renewable Energy Production Credit (IRC SEC 45)

  • Under the current regulations the Production Tax Credit (PTC) for wind facilities is 2.5 cents per kilowatt-hour and is due to expire on January 1, 2022. 
  • The proposed regulation for facilities with a maximum output of less than one megawatt of electricity, extends the section 45 credit for electricity produced from certain renewable resources, through December 31, 2026, phasing down to 80% of the applicable rate in 2027, & 60% of the applicable rate in 2028.

Details on the rates for projects placed in service after December 31, 2021 through the end of 2026.  

For the ITC, the provision provides a base credit rate of 6% of the basis of energy property or a bonus credit rate of 30% of the basis of energy property. Regarding the PTC, for most facilities the Act provides a base credit rate of 0.5 cents/kilowatt hour, or a bonus credit rate of 2.5 cents/kilowatt hour. In order to claim the credit at the bonus credit rate, taxpayers must satisfy:

  1. prevailing wage requirements for the duration of the construction of the project and for five years after the project is placed into service, and
  2. apprenticeship requirements during the construction of the project.

It is important to note that the prevailing wage rate must remain in effect throughout the construction period and for five years after the project is placed in service. The apprenticeship requirement only applies during the construction period.

Failure to satisfy requirements: Penalties

There are significant penalties in the event the taxpayer uses the bonus rate and fails to satisfy the prevailing wage and apprenticeship requirements. The taxpayer must make a payment to each laborer for the difference between the wages paid and the prevailing wage plus 3% interest. Additionally the taxpayer must pay the Secretary of Agriculture (Secretary) a penalty of $5,000 for each laborer paid below the prevailing wage rate. If it is found that the taxpayer intentionally used a wage rate below the prevailing rate the penalty increases to $10,000 per laborer paid below the prevailing rate.

The Act also provides for a 10% increase in the energy credit for solar and wind facilities placed in service in a low-income community (as defined in the New Markets Tax Credit program under section 45D). The 10% increase is subject to an annual capacity limitation of 1.8 gigawatts for each calendar year 2022 through 2026. 

An additional 20% credit for the solar ITC for a solar facility placed in service in as part of a low-income economic benefit project installed on a residential rental building, if at least 50% of the financial benefits of the electricity produced by such facility are provided to households with income of less than 200% of the poverty line.

Each credit would include a direct pay option, allowing the credit to be treated as equivalent to a payment of a tax refundable if it exceeds taxes otherwise payable. This ensures that the taxpayer does not need a tax liability to benefit from the credit currently.

The taxpayer must elect to treat the applicable credit as tax payments for the taxable year in which the qualified facility is originally placed in service after December 31, 2021. The election must be made by the taxpayer no later than the due date of the return, including properly filed extensions, but not earlier than 270 days after enactment. Once the election is made it is irrevocable. 

However, it remains unclear whether the direct pay amount would be equal to the full amount of the credit otherwise claimable or whether it would be “hair cut” in a way similar to the proposed Growing Renewable Energy and Efficiency Now Act (GREEN Act), H.R. 848. Ideally, if the direct pay is “hair cut,” the direct payment due would be 85% of the total credit otherwise claimable. Certain developers would be able to forego tax equity investments and instead settle on self-funding or debt financing, including short-term bridge financing secured by the future tax refund and/or long-term project financing.

Should the direct pay option include a “haircut,” the more practical choice would be tax equity, especially if the developer cannot otherwise currently utilize depreciation deductions from the project or interest deductions from the debt.

If you have any questions, please contact the Renewable Energy team. We’re here to help.

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Current Build Back Better Act and incentives for renewable energy