CMS issued important guidance ensuring that America’s clinical laboratories are prepared to respond to the threat of the 2019 Novel Coronavirus (COVID-19.) CMS is committed to taking critical steps to ensure America’s clinical laboratories are prepared to respond to the COVID-19 threat and other respiratory illnesses by implementing flexibilities around requirements for a Clinical Laboratory Improvement Amendments (CLIA) certificate during public health emergencies.

While there is no formal waiver authority under CLIA, CMS continue to exercise flexibilities under current regulations and through enforcement discretion to address temporary and remote testing sites, use of alternate specimen collection devices, and implementation of laboratory developed tests.  Our hope is that this guidance provides the steps needed for all U.S. Labs wanting to apply for a CLIA certificate to test for COVID-19.

Guidance – https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/clinical-laboratory-improvement-amendments-clia-laboratory-guidance-during-covid-19-public-health

FAQ – https://www.cms.gov/files/document/clia-laboratory-covid-19-emergency-frequently-asked-questions.pdf

On March 22, 2020, CMS announced relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to the 2019 Novel Coronavirus (COVID-19). This memorandum and factsheet supplements and provides additional guidance to health care providers with regard to the announcement. CMS has extended the 2019 Merit-based Incentive Payment System (MIPS) data submission deadline from March 31 by 30 days to April 30, 2020. This and other efforts are to provide relief to clinicians responding to the COVID-19 pandemic. In addition, the MIPS automatic extreme and uncontrollable circumstances policy will apply to MIPS eligible clinicians who do not submit their MIPS data by the April 30, 2020 deadline.

You can find a copy of the memo here:  https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf

You can find a copy of the fact sheet here: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/966/QPP%20COVID-19%20Response%20Fact%20Sheet.pdf

March 26, 2020

Early this Wednesday morning, Senate leaders announced a deal on “phase 3” of the COVID-19 legislation, and it includes a key provision expanding the Medicare telehealth services to rural health clinics as the distant site.

UPDATE: The Senate passed the legislation on Wednesday evening by a vote of 96-0. The legislation now moves to the House for an expedited vote on Friday. CMS is holding internal discussions on how to operationalize the telehealth provisions and may be able to release guidance shortly after the President’s signature. 

This victory for rural health clinics comes after weeks of pressure on Congress and the Trump Administration from NARHC and the RHC community. It means that as of the date of enactment, RHCs can confidently provide telehealth visits to Medicare patients and know that they will be paid for those telehealth visits.

However, the details of what the exact telehealth payment will be are still to-be-determined. We do know that the payment for the telehealth visit will not be the all-inclusive rate. Instead, CMS will create a specific payment mechanism for RHCs and FQHCs that is based on the average payments under the physician fee schedule. Keep a close eye on NARHC.org for updates, we will be planning a webinar as soon as those specifics are finalized.

Due to the Coronavirus, CMS and Congress have greatly expanded the Medicare telehealth benefit to allow Medicare beneficiaries to safely seek care through a video-conference style system.

Before this pandemic, telehealth was only available for rural Medicare beneficiaries, and was typically used to get specialty care from specialists in larger towns and cities. Medicare patients still had to physically go to an “originating site” and thus the convenience was limited. Now however, both of these requirements have been eliminated and all Medicare patients can receive a telehealth visit from the comfort of their home.

Congress and the Administration have also waived the requirement that telehealth visits only be with established patients and Medicare is allowing providers and patients to use popular video chat applications such as Facetime, Facebook Messenger video chat, Google Hangouts video, or Skype.

March 26, 2020

 Full Bill Text Here

The Senate has passed the third in a series of bills in response to COVID-19. The House is expected to take action on the legislation later this week. In the language, there is $127 billion to the Assistant Secretary for Preparedness and Response to include $100 billion in grants to hospitals and other Medicare and Medicaid suppliers to cover unreimbursed health care related expenses or lost revenue related to COVID-19. Additional funding includes $275 million to HRSA to support rural hospitals and critical access hospitals and telehealth, $200 million to CMS to assist nursing homes and $955 million to the Administration for Community Living to support nutrition programs and home and community-based services. Here are the Appropriations Sections in full and a Appropriations Summary. Note: This list is not exhaustive, as NRHA’s full analysis of the bill continues. Please see a list of important provisions below:

Public Health and Social Services Emergency Fund

• The legislation would make available $100 billion to reimburse eligible health care providers for health care-related expenses or lost revenues not otherwise reimbursed that are directly attributable to COVID-19. Eligible providers are defined as public entities, Medicare- or Medicaid enrolled suppliers and providers, and other for-profit and non-profit entities as specified by the Health and Human Services (HHS) Secretary. Funding would be on a rolling basis through “the most efficient payment systems practicable to provide emergency payment.”

Hospital Payments

• Sec. 3719. Expansion of the Medicare Hospital Accelerated Payment Program During The COVID-19 Public Health Emergency: This section would expand, for the duration of the COVID-19 emergency period, an existing Medicare accelerated payment program. Hospitals, especially those facilities in rural and frontier areas, need reliable and stable cash flow to help them maintain an adequate workforce, buy essential supplies, create additional infrastructure, and keep their doors open to care for patients. Specifically, qualified facilities would be able to request up to a six-month advanced lump sum or periodic payment. This advanced payment would be based on net reimbursement represented by unbilled discharges or unpaid bills. Most hospital types could elect to receive up to 100 percent of the prior period payments, with Critical Access Hospitals able to receive up to 125 percent. Finally, a qualifying hospital would not be required to start paying down the loan for four months and would also have at least 12 months to complete repayment without a requirement to pay interest.

Support for Health Care Providers

• Sec. 3211. Supplemental awards for health centers: Provides $1.32 billion in supplemental funding to community health centers on the front lines of testing and treating patients for COVID-19.
• Sec. 3212. Telehealth network and telehealth resource centers grant programs: Reauthorizes HRSA grant programs that promote the use of telehealth technologies for health care delivery, education and health information services. Telehealth offers flexibility for patients with, or at risk of contracting, COVID-19 to access screening or monitoring care while avoiding exposure to others.
• Sec. 3213. Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Grant Programs: Reauthorizes HRSA grant programs to strengthen rural community health by focusing on quality improvement, increasing health care access, coordination of care, and integration of services. Rural residents are disproportionately older and more likely to have a chronic disease, which could increase their risk for more severe illness if they contract COVID-19.
• Sec. 3216. Flexibility for members of National Health Service Corps during emergency period: Allows the Secretary of HHS to reassign members of the NHSC to sites close to the one which they were originally assigned, with the member’s agreement, in order to respond to the COVID-19 public health emergency.

Small Business Loans:

• Sec. 1102. Title I – Small Business Administration loan program provides a maximum of $10 million loans. Defines eligibility as small business, 501(c) (3) non-profit, 501(c)19, or certain tribal groups with not more than 500 employees (unless there is a higher industry standard). Sec. 1106 includes loan forgiveness provisions. Borrower shall be eligible for loan forgiveness equal to the amount spent by the borrower during an 8-week period of payroll costs, interest payment on mortgage, rent or lease. Amounts forgiven may not exceed the principal amount of the loan. Eligible payroll costs do not include salaries that exceed $100,000.
• Also waives borrower and lender fees, waives “credit elsewhere” test, and waives collateral and personal guaranteed requirements. Maximum interest rate of 4% and no pre-payment penalties Complete deferment of loan repayment is deferred by 6 months.

Telehealth:

• Sec. 3701. Health Savings Accounts for Telehealth Services: This section would allow a high-deductible health plan (HDHP) with a health savings account (HSA) to cover telehealth services prior to a patient reaching the deductible, increasing access for patients who may have the COVID-19 virus and protecting other patients from potential exposure.
• Sec. 3703. Expanding Medicare Telehealth Flexibilities: This section would eliminate the requirement in Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020 (Public Law 116-123) that limits the Medicare telehealth expansion authority during the COVID-19 emergency period to situations where the physician or other professional has treated the patient in the past three years. This would enable beneficiaries to access telehealth, including in their home, from a broader range of providers, reducing COVID-19 exposure.
• Sec. 3704. Allowing Federally Qualified Health Centers and Rural Health Clinics to Furnish Telehealth in Medicare: This section would allow, during the COVID-19 emergency period, Federally Qualified Health Centers and Rural Health Clinics to serve as a distant site for telehealth consultations. A distant site is where the practitioner is located during the time of the telehealth service. This section would allow FQHCs and RHCs to furnish telehealth services to beneficiaries in their home. Medicare would reimburse for these telehealth services based on payment rates similar to the national average payment rates for comparable telehealth services under the Medicare Physician Fee Schedule. It would also exclude the costs associated with these services from both the FQHC prospective payment system and the RHC all-inclusive rate calculation.
• Sec. 3706. Allowing for the Use of Telehealth during the Hospice Care Recertification Process in Medicare: Under current law, hospice physicians and nurse practitioners cannot conduct recertification encounters using telehealth. This section would allow, during the COVID-19 emergency period, qualified providers to use telehealth technologies in order to fulfill the hospice face-to face recertification requirement.

Other Medicare Provisions:

• Sec. 3709. Increasing Provider Funding through Immediate Medicare Sequester Relief: This section would provide prompt economic assistance to health care providers on the front lines fighting the COVID-19 virus, helping them to furnish needed care to affected patients. Specifically, this section would temporarily lift the Medicare sequester, which reduces payments to providers by 2 percent, from May 1 through December 31, 2020, boosting payments for hospital, physician, nursing home, home health, and other care. The Medicare sequester would be extended by one-year beyond current law to provide immediate relief without worsening Medicare’s long-term financial outlook.
• Sec. 3710. Medicare Add-on for Inpatient Hospital COVID-19 Patients: This section would increase the payment that would otherwise be made to a hospital for treating a patient admitted with COVID-19 by 20 percent. It would build on the Centers for Disease Control and Prevention (CDC) decision to expedite use of a COVID-19 diagnosis to enable better surveillance as well as trigger appropriate payment for these complex patients. This addon payment would be available through the duration of the COVID-19 emergency period.
• Sec. 3713. Eliminating Medicare Part B Cost-Sharing for the COVID-19: Vaccine This section would enable beneficiaries to receive a COVID-19 vaccine in Medicare Part B with no cost-sharing.
• Sec. 3718. Preventing Medicare Clinical Laboratory Test Payment Reduction: This section would prevent scheduled reductions in Medicare payments for clinical diagnostic laboratory tests furnished to beneficiaries in 2021. It would also delay by one year the upcoming reporting period during which laboratories are required to report private payer data

Community Health Centers

• Sec. 3831. Extension for Community Health Centers, the National Health Service Corps, and Teaching Health Centers that Operate GME Programs: This section extends funding for the three programs until November 20^th, 2020.

Indian Health Services

• Includes an additional $1 billion for the Indian Health Services to remain available until September 30, 2021, to prevent, prepare for, and respond to coronavirus, domestically or internationally, including for public health support, electronic health record modernization, telehealth and other information technology upgrades, Purchased/Referred Care, Catastrophic Health Emergency Fund, Urban Indian Organizations, Tribal Epidemiology Centers, Community Health Representatives, and other activities to protect the safety of patients and staff (pg. 718).

Medicaid

• Sec. 3720. Providing State Access to Enhanced Medicaid FMAP: This section would amend a section of the Families First Coronavirus Response Act of 2020 (Public Law 116-127) to ensure that states are able to receive the Medicaid 6.2 percent FMAP increase.
• Sec. 3801. Extension of Physician Work Geographic Index Floor: This section would increase payments for the work component of physician fees in areas where labor cost is determined to be lower than the national average through December 1, 2020.
• Sec. 3811. Extension of Money Follows the Person Demonstration Program: This section would extend the Medicaid Money Follows the Person demonstration that helps patients transition from the nursing home to the home setting through November 30, 2020.
• Sec. 3813. Delay of Disproportionate Share Hospital Reductions: This section would delay scheduled reductions in Medicaid disproportionate share hospital payments through November 30, 2020.
• Sec. 3715. Providing Home and Community-based Support Services during Hospital Stays: This section would allow state Medicaid programs to pay for direct support professionals, caregivers trained to help with activities of daily living, to assist disabled individuals in the hospital to reduce length of stay and free up bed
• Sec. 3813. A 6-month delay in Medicaid DSH cuts. The last delay would have expired May 23^rd, 2020 but is delayed through November 30^th, 2020.

Rural Development

• $20.5 million in new money in rural business loans and grants through the USDA to “prevent, prepare, and respond to COVID-19”
• $25 million to support the Distance, Learning, and Telemedicine program for rural communities for COVID-19 related care. This increase will help improve distance learning and telemedicine in rural areas of America.
• $100 million is provided to the ReConnect program to help ensure rural Americans have access to broadband, the need for which is increasingly apparent as millions of Americans work from home across the country.

Other Public Health and Social Services Emergency Fund

• Increasing the National Stockpile: Provides $16 billion for medical supplies to be deposited in the Strategic National Stockpile.
• Hospital Preparedness Program: Provides $250 million available for grants to or cooperative agreements with entities that are either grantees or sub-grantees of the Hospital Preparedness Program authorized in section 7 319C–2 of the Public Health Service Act or that meet such other criteria as the Secretary may prescribe, with such awards issued under such section or section 311 of the act.

March 25, 2020

Occupancy Rates in Rural and Urban Hospitals: Value and Limitations in Use as a Measure of Surge Capacity

As policymakers deal with the effects of the novel coronavirus pandemic on the hospital infrastructure, understanding the differences in occupancy rates between rural and urban hospitals may help state and local officials in their planning for dealing with surge demand. Historically, rural hospitals have reported lower occupancy rates than urban hospitals and more licensed than staffed beds. This may represent surge capacity for state and local officials to consider in responding to this crisis. The purpose of this brief is to describe variations in hospital occupancy rates nationally and by state, provide additional data for state and local officials, and highlight challenges in identifying surge capacity.

Key findings are:

1. In almost every state, rural hospitals have lower acute care and intensive care unit occupancy rates compared to their urban counterparts;
2. However, historical average occupancy rates may not reflect care patterns in the short run.

Contact Information:

Additional Resources of Interest:

• More information about the North Carolina Rural Health Research and Policy Analysis Center
• More information from the Rural Health Information Hub’s topic guides: Critical Access Hospitals, Rural Health Policy

March 26, 2020

What’s New

FCC Expands Broadband Access in Response to COVID-19.  The Federal Communications Commission (FCC) announced waivers to its Rural Health Care and E-Rate programs to allow for improved internet capacity, Wi-Fi hotspots, networking gear, or other equipment or services during the coronavirus outbreak.  Other actions by the FCC related to COVID-19 include more funding for the Rural Health Care program and efforts to keep low-income consumers connected.

SAMHSA Lists Online Resources for Treatment and Recovery.  The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a list of help lines, websites, and virtual meeting options to support substance use treatment, as well as resources and information for mental health response to COVID-19.

COVID-19 Toolkit from the National Telehealth Resource Centers.  The toolkit explains how telehealth can be used to provide care remotely, as well as what’s covered through public and private insurance.

COVID-19 Resources for Emergency Medical Personnel.  The National Highway Traffic Safety Administration has a website with resources for Emergency Medical Services (EMS) personnel.  Separately, the Interstate Commission for EMS Personnel Practice updated the Interstate Licensing Compact to allow EMS operations to cross state borders in response to the crisis.

Rural Response to Coronavirus Disease 2019.  The Rural Health Information Hub has created a guide to help you learn about activities underway to address COVID-19.

CDC Updates on the Coronavirus.  The Centers for Disease Control and Prevention (CDC) provides daily updates on the Coronavirus with guidance for health providers and local public health officials.

March 25, 2020.

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