Medicaid coverage gap: Tools and strategies for Medicaid agencies to help retain members

Read this if you are at a state Medicaid agency.

In early March 2021, the Biden administration passed the American Rescue Plan of 2021 (H.R.1319) with the primary goal of providing emergency supplemental funding for the ongoing response to the COVID-19 pandemic. Importantly, in addition to vaccines, unemployment, and other critical developments, the plan provided a number of Medicaid opportunities for states that expand eligibility and coverage, including the following:

• Funding increases—a new incentive to expand Medicaid eligibility through a two-year, 5% increase in the state’s base Federal Medical Assistance Percentage (FMAP).
• Coverage—the option to extend Medicaid coverage for women up to 12 months postpartum and with full Medicaid benefits.
• System transformation—a one-year, time-limited FMAP increase of 7.35% for states to make improvements and rate increases to Medicaid home-and-community-based services (HCBS).
• Waiver opportunities—a new incentive (enhanced FMAP for five years through bundled payments) for state Medicaid programs’ mobile crisis intervention services for individuals experiencing a mental health or substance use disorder crisis via a state plan amendment (SPA) or 1115 waiver demonstration.

What’s next?

It seems likely that the American Rescue Plan’s Medicaid provisions signal upcoming changes and opportunities for healthcare transformation for state Medicaid programs. The administration has consistently articulated a desire to “strengthen Medicaid” and while additional legislative actions are likely coming, there are also legislative limitations that may limit or curtail the type of broad reform we’ve seen in the past. As a result, it’s likely that the vehicle the administration will use to disseminate healthcare transformation in Medicaid are administrative actions such as executive orders, regulations, and administrative rule-making through the Centers for Medicaid and Medicare Services (CMS). This is likely to result in opportunities in two areas: waivers and the funding incentives to adopt new policies.

Waivers

The best tool the administration has is also one of its oldest: demonstration waivers. As noted above, the American Rescue Plan of 2021 includes the option for states to take advantage of waivers (as well as SPAs) to exercise new flexibilities. Unlike the Affordable Care Act (ACA) which was rolled out nationally, it’s likely the administration will seek out volunteer states that are innovative and willing to collaborate. The result will be more experimentation, more tailoring of policy, and a more gradual—even organic—approach to transformation.

In the short term for state Medicaid agencies this will mean a rebalancing of pending waivers and guidance. Prior policy priorities like work requirements and aggregate enrollment caps may be revised through the regulatory process in coming months or years. It is anticipated that CMS will execute a vision with a renewed focus on expanding services or coverage, much like those seen with the opportunities already presented under the American Rescue Plan.

Funding

Budget is a consistent challenge states have faced over the past year resulting largely from the COVID-19 pandemic. Even with recent aid to states and local governments there is likely to be uncertainty for the immediate future. The American Rescue Plan, like the ACA before it, finds mechanisms and incentives to raise the FMAP for states and potentially ease the state’s portion of Medicaid funding, particularly in the short term. Fitting with the theme of states as active partners, going forward there will likely be opportunities to maintain some type of increase to the FMAP. Beyond direct funding, opportunities like the recent CMS guidance on social determinants of heath, value-based payments, and models like the Community Health Access and Rural Transformation (CHART) hint at a continued focus on payment reform. States looking to lower costs and/or increase the quality of care will have ample opportunities to undertake projects in these areas.

State considerations

Regardless of next steps, states should expect both compliance needs and opportunities. States should begin to consider strategy, resources, and their priorities now. This process begins with knowing your agency’s strengths and potential limitations. Once states set their policy priorities and are ready to get underway with the business of transformation, time and resource constraints will likely be common barriers. Having a mature, flexible, and capable project management office, the right subject matter knowledge, and prequalified vendor lists to assist with Medicaid transformation can go a long way towards addressing time and resource constraints—making state Medicaid agencies agile in their response to the unique opportunities in the coming years.

Read this if you are in a management role at a state Medicaid agency.

States are facing unique pressure on resources and budgets due to the COVID-19 pandemic, coupled with potential uncertainty following an election year. Healthcare innovation and transformation is one route state Medicaid agencies (SMAs) may take to minimize operational costs and improve access to services. Here are some tactics, flexibilities, and practical steps to help realize innovation during this time.

US Supreme Court Justice Louis Brandeis is credited in 1932 with popularizing the phrase that states are the “laboratories of democracy”. In this case, Medicaid may be the ‘laboratory of health policy and innovation", in part as state Medicaid and Children’s Insurance Programs (CHIP) are collectively the largest US healthcare payer, covering 74 million individuals.

In 2020, states have faced the dual challenge of a public health emergency and corresponding state budget uncertainty, squeezing resources just as projected state revenues have dramatically shrunk. SMAs must be creative to meet competing priorities: administering their programs while responding to the public health emergency. Here are some tactics, flexibilities, and practical steps to help realize innovation during this time. 

Reimagining funding for state Medicaid agencies

Identifying a source of funding is often challenging. Three options to consider include:

1. Advance Planning Documents (APDs)
   While strictly for information systems, APDs can unlock 90/10 match for Development, Design, and Implementation (DDI) or a 75/25 match for operations. This funding is above most state Federal Medical Assistance Percentages (FMAPs). Realistically, program changes generally require system changes too. Consider reviewing whether you could tie the initiative to Medicaid Information Technology Architecture (MITA) business process maturity and/or outcomes-based system certification criteria. Linking personnel, training, project management, and any equipment for system needs into an APD can be an effective way to help fund the process and system changes.
2. Partnerships
   An SMA can look further afield if sister agencies have funds available. This is especially true if braiding federal payment streams is an option. For example, many developments that benefit Medicaid can also help CHIP. The federal matching rate for state CHIP programs is typically about 15 percentage points higher than the Medicaid matching rate.  
3. Certified Public Expenditures (CPE)
   Under 42 CFR § 433.51 and the Social Security Act, another governmental entity besides the SMA can contribute state matches allowing the state to draw Federal Financial Participation (FFP). One option can be another governmental entity using state dollars at the state, county, or even local level, to deliver health services (if covered under the Medicaid state plan) to Medicaid members.  

Interagency cooperation to generate savings in the health and human service (HHS) space will be the topic of a forthcoming article.

Getting help: Communications planning and the role of project management

As SMAs pursue more complex initiatives such as addressing Social Determinants of Health (SDoH)—collaborating not just with providers but with other public agencies, community organizations, vendors, federal partners, advocacy groups, and health systems—the need to coordinate such a diverse circle of stakeholders increases. Demonstration projects, system implementation efforts, and major healthcare initiatives in particular, require coordination of stakeholders throughout each project phase.

Health and human services (HHS) organizations sometimes underestimate the role of project management. For example, project management is often seen as simply “making sure things are complete” by the deadline, but there are other advantages such as establishing efficiency, improving the quality of service delivery, controlling costs, and better coordinating staff for the SMA. With stretched public workforces and more tasks in the current business environment, you want to get as much done—preferably faster, cheaper, and with less risk—and deliver the expected benefits. 

Guidance on priorities from senior leadership can help organizations establish clear and visible sponsorship to help establish success. Strategic change needs a strong champion within the SMA who has the ability to convene key stakeholders and keep projects on task.

Procuring the tools

After determining funding and before executing a project, you prepare by getting the tools you need—whether tools that involve systems, subject matter experts, or general project assistance.  If the Request for Proposal (RFP) process is not an option, consider whether a pre-qualified vendor list or cooperative contract vehicle would work for you. Cooperative contracts are increasingly popular at the federal, state, and local levels. A few cooperative options include:

• NASPO Procurement of Acquisition Support Services (PASS) contract
  Currently, 20 states participate. 
• Arizona Statewide contracts
  Arizona offers membership in its State Purchasing Cooperative to any government or non-profit entity in the US. SMAs might find the Healthcare Related Services contract particularly helpful. 
• Massachusetts Information Technology - Software & Services (ITS) contracts
  ITS contracts offer a broad range of IT services and are open for cooperative purchasing by any state government entity.
• Texas Department of Information Resources (DIR) contracts
  DIR contracts also offer a broad range of services and can be used by other states through an interstate cooperation agreement. 

The solution is strategy

Keeping Medicaid innovation moving forward requires strategic focus that combines funding, communications, project management, and procurement. The strategy you develop can help the outcome of the initiative to be greater than the sum of its parts. By using all available tools, including those discussed here, your SMA can prioritize innovation.

Next steps

• Evaluate your program and identify initiatives to prioritize in the coming year. Ask your CMS contact about the latest applicable guidance. 
• Develop APDs to help fund technology needs for initiatives, along with training your SMA team and providers. 
• Implement a communications management approach to engage stakeholders.
• Marshal project management resources and develop a realistic and achievable roadmap to success.   
• Explore agency contracting vehicles, cooperative contracts, and other procurements tools. 

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the Medicaid consulting team. 
 

Read this if you are a leader at a state Medicaid agency, Long-Term Care Hospital, Rural Health Clinic, Federally Qualified Health Center, or intermediate care facility.

The new fact sheet from CMS provides state and local governments that may be developing alternate care sites with information on how to receive payments for acute inpatient and outpatient care through federal programs, including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

CMS notes that it is easiest for an existing enrolled hospital or health system to obtain payments through CMS programs for covered health care services furnished at the ACS by treating the ACS as a short-term extension of their current ‘brick-and-mortar’ facilities. 

State and local governments that want to build a hospital ACS have three options if they wish to be paid by CMS for providing covered hospital inpatient and outpatient services:

1. Transfer operation and billing for care delivered in the ACS to a hospital or health system which is enrolled
2. Enroll the ACS as a new hospital in CMS programs
3. As an alternative, instead of making facility payments, enrolled physicians or other non-physician practitioners may bill for covered services that they furnish at the ACS

CMS guidance to states on implementing the optional COVID-19 testing group 

CMS has provided new guidance to states who may be planning to implement the Optional COVID-19 Testing Group, which was established by the Families First Coronavirus Response Act (FFCRA) for uninsured individuals in order to furnish COVID-19 testing and associated services.

• The guidance from CMS outlines the different requirements connected with implementing the uninsured group, inclusive of eligibility and enrollment, data reporting, and claims. 
• The guidance also describes flexibilities available to help states achieve implementation of the new group and strategies to meet related requirements. 
• For more information related to the eligibility requirements and the Federal Medical Assistance Percentage (FMAP) available for coverage, states can also refer to Section B of the FFCRA and Coronavirus Aid, Relief, and Economic Security (CARES) Act Frequently Asked Questions (FAQs) posted April 13, 2020.

CMS announces enhanced enforcement actions based on nursing home COVID-19 data and inspection results

Earlier in the month of June, CMS released new guidelines related to enforcement for nursing homes who may have violations of infection control practices.

• CMS intends to apportion $80 million in CARES Act funding to states in order to increase infection control surveys. With CARES Act funding, states will be required to carry out on-site surveys of nursing homes with previous COVID-19 outbreaks, in addition to nursing homes with newly confirmed cases.
• CMS will make technical assistance available in support of this effort through Quality Improvement Organizations (QIOs) for nursing homes to assist in establishing best practices for infection control.
• States are required to submit 100% of focused surveys of their nursing homes to CMS by July 31, 2020. It should be noted that submission delays may result in reductions to a state’s Cares Act allocation for FFY 2021.

HHS announces 45-day compliance deadline extension for providers

On May 22, The Department of Health and Human Service (HHS) announced a 45-day extension to the deadline for providers who are receiving payments from the Provider Relief Fund to accept the necessary terms and conditions of the payments.

• Should providers wish to keep funds—which may have been automatically dispersed—they must agree to the terms and conditions of the Provider Relief Fund.
• In order to support impacted facilities there is $50 billion in available COVID-19 relief funding for distribution to providers that bill for Medicare beneficiaries.
• The announcement from HHS gives providers 90 days from the original receipt date of a payment to accept the terms and conditions.  Alternatively, providers may choose to return the funds.

HHS announces $4.9 billion distribution to nursing facilities impacted by COVID-19

HHS has announced it has begun the distribution of additional relief funds to Skilled Nursing Facilities (SNFs) in order to address ongoing needs related to COVID-19. Such needs include labor, improving testing capacity, and obtaining personal protective equipment as well as additional expenses specifically linked to the COVID-19 pandemic.

• HHS intends to make the fund distributions to SNFs on both a fixed and variable basis. 
• Each eligible SNF will receive a fixed dissemination of $50,000 in addition to an allotment of $2,500 per bed. All certified SNFs with six or more certified beds will be eligible for this distribution.
• Recipients of these funds must attest that they will use Provider Relief Fund payments for allowed purposes under the terms and conditions as well as agree to comply with future audit and reporting requirements.

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the Medicaid consulting team. 

Read this if you are at a state Medicaid agency or CHIP agency.

CMS has posted additional Frequently Asked Questions (FAQs) to Medicaid.gov, to aid state Medicaid and Children’s Health Insurance Program (CHIP) agencies in their response to the coronavirus disease 2019 (COVID-19) pandemic.

These new FAQs have been integrated into the previously released COVID-19 FAQ document. The new FAQs cover a variety of Medicaid and CHIP topics, including:

• Emergency Preparedness and Response
• Eligibility and Enrollment Flexibilities
• Benefit Flexibilities
• Cost-Sharing Flexibilities
• Financing Flexibilities  
• Managed Care Flexibilities
• Information Technology  
• Data Reporting

Updated CMS processes for reviewing 2021 contracts between states and Medicare Dual Eligible Special Needs Plans (D-SNPs)

CMS has issued a reminder to states of the upcoming submission deadline for the Contract Year (CY) 2021 contracts with Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs). The due date for D-SNPs to submit to CMS their CY 2021 contracts with the state Medicaid agencies is July 6, 2020.

• CMS encourages state Medicaid agencies to review the November 14, 2019 Informational Bulletin that describes new requirements for CY 2021 D-SNP contracts, which CMS finalized in rulemaking to implement new statutory provisions of the Bipartisan Budget Act (BBA) of 2018.
• The Integrated Care Resource Center (ICRC) continues to provide technical assistance to states to help with the implementation of these new requirements. CMS and ICRC have a number of important resources for states regarding the new requirements for contracts with D-SNPs. Additional resources for states can be found here.
• As a result of COVID-19, CMS is extending the review and approval timelines to allow D-SNPs more time to work with states on the new CY 2021 requirements. As a result, D-SNPs will have until November 2, 2020 to resubmit revised state Medicaid agency contracts or contract amendments.

CMS announces rule changes to support healthcare workforce augmentation

CMS has taken steps to limit or remove potential barriers for hiring and retaining physicians, nurses, and other healthcare professionals in order to keep staffing levels high at healthcare facilities.

• In response to the need for in-home services during the COVID-19 crisis, nurse practitioners, clinical nurse specialists, and physician assistants can now provide home health services. These changes are effective for both Medicare and Medicaid.
• Prior to this, Medicare and Medicaid home health member were only able to receive home health services with the certification of a physician. 
• Physicians and other practitioners whose privileges are expiring will be able to continue taking care of patients. Consistent with a change made for hospitals, CMS is waiving a requirement for ambulatory surgery centers to periodically reappraise medical staff privileges during the COVID-19 emergency declaration. 

Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes 

CMS has issued a memo along with frequently asked questions which address the new requirement that nursing homes and long term care facilities report COVID-19 facility data to the Centers for Disease Control and Prevention (CDC).

• CMS will be requiring nursing homes to report COVID-19 facility data to the CDC and to residents, their representatives, and families of residents in facilities. 
• CMS has updated the COVID-19 Focused Survey for Nursing Homes, Entrance Conference Worksheet, COVID-19 Focused Survey Protocol, and Summary of the COVID-19 Focused Survey for Nursing Homes to reflect COVID-19 reporting requirements. 
• CMS will begin posting data from the CDC National Healthcare Safety Network (NHSN) for viewing by facilities, stakeholders, or the general public. The COVID-19 public use file will be available on https://data.cms.gov/.
   

Increase hospital capacity - CMS Hospitals Without Walls

On April 30, CMS announced expansions of the Hospitals Without Walls initiative, granting flexibility for services to be provided outside of traditional venues.

• CMS is encouraging the use of existing flexibilities that allow outpatient hospital services to be delivered outside of traditional settings, such as at expansion locations, converted hotels or parking lots, or patients’ homes.
• Certain outpatient departments that relocate off-site can qualify to be paid under the Outpatient Prospective Payment System (OPPS), rather than the Physician Fee Schedule.
• Hospitals may relocate outpatient departments to more than one off-campus location, or partially relocate while still furnishing care at the original site.
• As part of the CARES Act, long-term acute-care hospitals can now accept patients from any acute-care hospital and be paid at a higher Medicare rate.

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team. 

Read this if you are a leader at a state Medicaid agency.

Leveraging Medicaid to support and fund state efforts
In infectious disease control and prevention, contact tracing is the process of identifying people who may have come into contact with an infected person and tracking with whom the infected person has been in contact. The intent is to halt the chain of transmission. State Medicaid Agencies (SMAs) may be able to leverage the Medicaid program to support state efforts with systems, training, and reimbursement for contact tracing. 

What is contact tracing?
Tracing the contacts of infected individuals throughout a community, testing their contacts for infection, and treating and quarantining the disease when it is found is a long-standing practice to address infectious diseases. While contact tracing may not be a service that is reimbursable by Medicaid, it may be possible for Medicaid to cover a broader package of services designed to slow the spread of COVID-19.

Contact tracing has three major components:

1. Contact identification—Confirmation of an individual’s infection is the first step. Once identified, it is essential to identify any additional people with whom that person came into contact, including family, co-workers, community members, etc.
2. Contact tracing—After conducting a complete review of the individual's contacts, outreach begins to inform them of their contact status and discuss critical next steps, starting with testing.
3. Contact follow-up—Continued follow-up with identified contacts helps prevent the spread of infection by monitoring spread and/or additional symptoms.

Public health experts maintain that contact tracing is one of the tools needed to manage the pandemic. Medicaid can play a key role in supporting systems, training, and reimbursement for contact tracing. This is enabled through Medicaid’s unique role as a significant payer in the healthcare system, along with its role as a government partnership between federal and state governments. In addition, acting to implement contact tracing may offer an opportunity to increase employment at a time when the economy has shed countless jobs. 

Systems and training: Medicaid support for health IT system
To support contact tracing, Medicaid agencies can leverage 75% or 90% federal match or Federal Financial Participation (FFP) for the systems, training, and equipment. This match is applicable for the Medicaid population, while the remainder likely needs to be cost-allocated to other state programs. Activities that can qualify include:

• Design, development, and installation (DDI) of Medicaid solutions. The Centers for Medicare and Medicaid Services (CMS) may allow this funding to apply to data-tracking systems or changes to support new reimbursement models. 
• Provider outreach and training related to systems operation, such as training on claims submissions, claims processing, and eligibility inquiries related to case management and care coordination.
• Training of vendor or state personnel directly engaged in the operation of an approved system, including workers processing claims or determining eligibility.

To obtain this type of funding, states must submit an advanced planning document (APD). 

Reimbursement: Services and authority options for contact tracing
For Medicaid to support contact tracing, SMAs need to identify both state plan services and authority to provide the service. Defining a service and authority may be challenging, as contact tracing is historically a public health intervention and not a medical service that directly benefits a Medicaid member. CMS does not typically allow this type of service under Medicaid. Given the flexibility afforded under current disaster declarations, however, CMS may have more flexibility than usual. Some options for services include: 

Case management

• How it works 
  First, an individual tests positive and contact-tracing interviews occur. Then, a healthcare provider, such as a hospital, reaches out to the individual, facilitates testing and education, delivers results, and follows up for any care needed. This process applies to any Medicaid members or other individuals who have private insurance that is identified. The provider can discharge the member from case management once the individual recovers. Case management as a Medicaid service is unique in that a diagnosis requiring medical management is the impetus for providing the service.
• Federal approval rationale
  Hospitals may be a good partner for this service due to CMS’s Hospital Without Walls guidance. If the hospital partners with the Public Health Entity for contact tracing, then the case management piece could—in theory—be billed by the staff providing case management through the hospital. The hospital would also be able to bill for testing and lab, care, etc. Public Health could track where there is capacity through the medical community for treatment, especially hospital beds, ventilators, and alternative testing sites. The case manager providing coordination of care for COVID-19 testing and treatment would have access to the hospital medical record system, and the hospital could bill for the service.

Health home

• How it works
  A health home under the state plan could also serve as a vehicle for services for this population. To better care for Medicaid members with chronic conditions, the Affordable Care Act created an optional Medicaid state plan benefit to coordinate care. Health homes are designed to integrate all physical and behavioral healthcare. Participation in health homes is voluntary. In order for members to participate, they must possess at least one chronic condition (e.g., high blood pressure, asthma, obesity, diabetes, or any serious chronic condition) and be at risk for a second (e.g., COVID-19).
• Federal approval rationale
  The health home may be a good support model, as it is eligible for FFP of 90% for the first two years—likely long enough to respond to the pandemic—making it economically attractive. 

The most flexible potential authority for a Medicaid agency to use for contact tracing is the 1115 waiver. As part of the Medicaid Disaster Response Toolkit, CMS made expedited review available. In addition, State Medicaid Director Letter (SMDL) #20-002 provides guidance on a new section 1115 waiver available to assist states in addressing the COVID-19 public health emergency. 

Section 1115 demonstration waiver
The 1115 waiver is the most dynamic option available, and states can access it through the 1115 disaster waiver option under the Medicaid toolkit. The state may be able to show that providing contact tracing will result in savings for services billed under Medicaid. These savings may be able to be justified by decreasing the number of people who test positive for the virus, leading to budget neutrality. The budget neutrality model would need to show “with” and “without waiver” scenarios that demonstrate to Medicaid the cost of the spread of the virus with and without contact tracing. A challenge to this approach is the time necessary to develop the waiver and budget neutrality model and gain CMS approval. 

Recently, CMS approved one of these new section 1115 waivers for the state of Washington. While Washington did not request to cover contact tracing, the speed of approval and the fact that CMS has indicated for the pandemic 1115 requests states will not be required to submit budget neutrality calculations, is a positive indicator for states to consider in envisioning creative models for leveraging Medicaid to minimize the impacts of COVID-19. 

Next steps

• Check in with your CMS contacts. COVID-19 is new, and America’s response continues to evolve. Check in with your CMS contact for input on the latest guidance that may be applicable to your agency. 
• Develop an APD. Develop your state’s APD to help fund the technology needs for tracking COVID-19, along with training for your SMA team and providers. 
• Determine services. In partnership with CMS, determine if case management, a health home, or other service makes the most sense for your state to help trace contacts, reduce the spread of COVID-19, and encourage employment in this important work. 
• Submit your waiver for state plan amendment. After working with CMS to determine the service that makes sense for your state, develop and submit the request to provide this service through a 1115 waiver, 1135 waiver, or if necessary, emergency state plan amendment. 

We’re here to help
If you have more questions or want to have an in-depth conversation about your specific situation, please contact the Medicaid consulting team. 

Read this if you are a leader at a state Medicaid agency, Long-Term Care Hospital, Rural Health Clinic, Federally Qualified Health Center, or intermediate care facility.

New toolkit launches to help states navigate COVID-19 health workforce challenges 

In order to maximize workforce flexibility to help confront COVID-19, CMS and the Assistant Secretary of Preparedness and Response (ASPR) have released a new toolkit to assist state and local healthcare decision makers. The toolkits are available as a set of resource collections including:

• COVID-19 Federal Regulatory and Funding Flexibilities 
• COVID-19 Healthcare Workforce Training Resources 
• COVID-19 Licensure 
• COVID-19 Liability Protections 
• COVID-19 Matching Volunteer Workforce Needs 
• COVID-19 Pre-Hospital/Emergency Medical Services (EMS) Resources 
• COVID-19 Scope of Practice Expansions 
• COVID-19 State, Territorial, and Local Resources 
• COVID-19 Workforce Protection Resources 
• COVID-19 Workforce Resilience/Sustainability Resources 
• COVID-19 Additional Healthcare Planning Resources

Our team will be taking a closer look at these resource collections in the coming week and plan to have detailed information on the opportunities within.

Compliance flexibilities announced for implementation of interoperability final rules due to COVID-19

CMS and the Office of the National Coordinator for Health IT (ONC), in conjunction with the Health and Human Services (HHS) Office of Inspector General (OIG), have announced a policy of enforcement discretion to allow compliance flexibilities regarding the implementation of the interoperability final rules previously announced on March 9, 2020.

• Announced in March, the Interoperability and Patient Access final rule (CMS-9115-F) is focused on the pursuit of interoperability and patient access to health information.
• CMS-regulated payers, including Medicaid Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP FFS programs, and CHIP managed care entities are required to implement and maintain a secure, standards-based (HL7 FHIR Release 4.0.1) API that allows members access their claims and encounter information, as well as provider directory information available through third-party applications of their choice.
• Due to the public health emergency posed by COVID-19, CMS is exercising the “enforcement discretion” to adopt a temporary policy of relaxed enforcement for the final rule.

CMS releases additional blanket waivers for Long-Term Care Hospitals (LTCHs), Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs) and intermediate care facilities

CMS is providing additional blanket waivers related to care for patients in LTCHs, temporary expansion locations of RHCs and FQHCs, staffing and training modifications in intermediate care facilities for individuals with intellectual disabilities, and the limit for substitute billing arrangements (locum tenens).

• The new flexibilities do not require a waiver or any requests be sent to CMS electronically or any other notification to CMS regional offices.
• The guidance includes flexibilities related to provider location, staffing, reporting requirements, discharge, patient rights and other areas regulated by CMS.
• The blanket waiver authority exercised by CMS in this case applies only to federal requirements and does not apply to state requirements for licensure or conditions of participation.

State of Washington COVID-19-related section 1115(a) demonstration approval

Washington’s approval is the first section 1115(a) demonstration specifically intended to combat the effects of COVID-19 in a state.

• CMS authorized a time-limited approval for several of the requests in Washington’s March 24, 2020 section 1115(a) demonstration with a retroactive effective date of March 1, 2020 through 60 days after the public health emergency declaration.
• CMS approved two waiver authority requests, as well as six expenditure authority requests from Washington’s section 1115(a) demonstration. 
• CMS did not require the state to submit budget neutrality calculations for the Washington COVID-19 section 1115(a) demonstration. 

CMS issues guidance allowing Independent Freestanding Emergency Departments (IFEDs) to provide care to Medicare and Medicaid beneficiaries during the COVID-19 Public Health Emergency

CMS issued guidance On April 21, 2020 which allows licensed IFEDs in the states of Colorado, Delaware, Rhode Island, and Texas to temporarily provide care to Medicare and Medicaid patients to address any surge.

• IFEDs generally offer a range of services including basic imaging services, computed tomography (CT) scans, ultrasound, and basic on-site laboratory services. During this public health emergency these entities can temporarily bill Medicare and Medicaid as a certified hospital.
• CMS is waiving certain conditions of participation for hospital operations to maximize patient care capabilities during this public health emergency. IFEDs may participate in Medicare and Medicaid in one of three ways: 
   
  • Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 emergency waiver; 
  • Participating in Medicaid under the clinic benefit if permitted by the state; or
  • Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services.

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team. 

Read this if you are a leader at a state Medicaid agency.

CMS has delivered nearly  $34 billion, later updated to $51 billion, in the past week to the healthcare providers on the frontlines battling the 2019 novel coronavirus

• The process in which CMS is implementing requests has reduced times of an accelerated or advance payment to four to six days. Previously the timeframe was three to four weeks. 
• To date, CMS has received over 25,000 requests from providers and suppliers for accelerated and advance payments. Of these, CMS has approved over 17,000 requests in the past week. 
• It should be noted that this funding is separate and distinct from the $100 billion provided in the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

CMS issues new wave of infection control guidance based on CDC guidelines to protect patients and healthcare workers 

CMS has issued a series of updated guidance documents focused on infection control to prevent the spread of COVID-19 in a variety of inpatient and outpatient care settings.

• The updated guidance includes a number of updates, notably the option of providing home dialysis training and support services. These are designed to help some dialysis patients stay home during the pandemic.
• In particular, the guidance includes the establishment of Special Purpose Renal Dialysis Facilities (SPRDFs), which can allow dialysis facilities to isolate vulnerable or infected patients.
• For hospitals, psychiatric hospitals and CAHs, the updated guidance provides recommendations on screening and visitation restrictions, discharge to subsequent care locations, as well as staff screening and testing.

CMS acts to ensure US healthcare facilities can maximize frontline workforces to confront COVID-19 crisis 

CMS has temporarily suspended a number of rules in order for hospitals, clinics, and other healthcare facilities to boost their frontline medical staffs.

The CMS guidance focuses on reducing supervision and certification requirements so that practitioners can both be hired rapidly and perform work to the extent of their licensure. CMS guidance allows the following:

• Doctors can now directly care for patients in certain settings without having to be physically present.
• Nurse practitioners may now perform some medical exams on Medicare patients at skilled nursing.

CMS approves additional state Medicaid waivers and amendments to give states flexibility to address coronavirus pandemic

CMS continues to deliver regulatory relief to a number of new states in the form of waivers and state plan amendments.

• In total, CMS has now approved 49 emergency 1135 waivers, 26 state amendments, seven COVID-19 related Medicaid disaster amendments and the first CHIP COVID-related disaster amendment
• The COVID-related Children’s Health Insurance Program (CHIP) disaster amendment is for the State of Maine. 
• CMS has now approved COVID-related Medicaid disaster state plan amendments for North Dakota, Rhode Island, and Wyoming.

HHS authorizes licensed pharmacists to order and administer COVID-19 tests

On April 8, HHS released new guidance under the Public Readiness and Emergency Preparedness Act that authorizes licensed pharmacists to order and administer FDA-approved COVID-19 tests.

• The guidance allows pharmacists to order and administer COVID-19 tests to their patients will provide easier access to testing and will expand testing for healthcare workers and first responders. 

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team. 

Read this if you are a leader at a state Medicaid agency.

Here is a summary of information we have gleaned from the Center for Medicare and Medicaid Services (CMS) Administrator Verma’s recent call.

CMS is implementing new rules and waivers that increase provider flexibility and free up resources to deal with a surge in COVID-19 patients. CMS is working with the provider community to provide clarity around specific changes that impact their operations.

• The rulemaking process has been dramatically expedited to accommodate recent and forthcoming regulatory changes
• CMS is in the process of working out details to administer CARES Act provisions, including further regulatory flexibilities, expansion of accelerated payment program, and $100 billion appropriated to reimburse eligible health care providers
• CMS clarifies that the 3-Day Rule Waiver for skilled nursing facilities applies throughout the country and to all patients, regardless of their COVID-19 status

Medicaid Substance Use Disorder Treatment via Telehealth, and Rural Health Care and Medicaid Telehealth Flexibilities Guidance

This informational bulletin is composed of two parts: Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder Treatment via Telehealth.

• The informational bulletin identifies opportunities for telehealth delivery for services to increase access to Medicaid services. It is composed of two parts, Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder (SUD) Treatment Services Furnished via Telehealth
• The bulletin provides SUD guidance around Medication Assisted Treatment (MAT), counseling, high risk populations, and other areas critical to providing SUD services.

Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit

CMS is issuing an electronic toolkit regarding telehealth and telemedicine for Long Term Care Nursing Home Facilities.

• The toolkit includes electronic links to sources of information regarding telehealth and telemedicine, including the changes made by CMS over the last week in response to the national health emergency.
• Much of the toolkit’s information is intended for providers who may wish to establish a permanent telemedicine program, but there is information here that will help in the temporary deployment of a telemedicine program as well.
• There are specific documents identified that may be useful in choosing telemedicine vendors, equipment, and software, initiating a telemedicine program, monitoring patients remotely, and developing documentation tools. 

CMS makes regulatory changes to help US healthcare system address COVID-19 patient surge

CMS has issued a number of temporary regulatory waivers and new rules to assist the nation’s healthcare system with improved flexibility.

• Increased hospital capacity. CMS will allow communities to take advantage of local ambulatory surgery centers that have canceled elective surgeries, per federal recommendations.
• Healthcare workforce expansion. CMS’s temporary requirements allow hospitals and healthcare systems to increase their workforce capacity by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community as well as those licensed from other states without violating Medicare rules.
• Paperwork requirements. CMS is temporarily eliminating paperwork requirements.
• Telehealth in Medicare. CMS will now allow for more than 80 additional services to be furnished via telehealth.

Additional COVID-19 FAQs for state Medicaid and Children's Health Insurance Program (CHIP) agencies

CMS released an update to the COVID-19 FAQs posted on March 18, 2020 related to emergency preparedness and response, eligibility and enrollment flexibilities, benefit flexibilities, cost sharing flexibilities, financial flexibilities, managed care flexibilities, fair hearing flexibilities, health information exchange flexibilities, and COVID-19 T-MSIS coding guidance. Notably:

• States that have CHIP disaster provisions in their state plans can activate these provisions. CMS considers a significant outbreak of an infectious disease to be a disaster. CMS also recommends that states that do not have disaster relief provisions in their CHIP state plans include language that a federal- or governor-declared emergency is considered an event that can trigger the disaster provisions.

States may not suspend use of their AVS, however CMS reminds states that they can rely on self-attestation of assets and verify financial assets using their AVS post-enrollment in Medicaid.

• CMS can help provide technical assistance regarding approaches states can use to rapidly scale telehealth technologies.
• CMS clarified and provided COVID-19 T-MSIS coding guidance.

For more information

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team.