CMS Releases New Flexibilities to Help Homecare Providers Fight COVID-19

On April 30th, the Centers for Medicare and Medicaid Services (CMS) released a series of new and updated regulatory waivers to allow homecare providers more flexibility in responding to the COVID-19 pandemic. These temporary changes will apply immediately across the U.S. healthcare system and will remain for the duration of the emergency declaration.

According to CMS, the goals of these new 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 through temporary expansion sites
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
5. Give temporary relief from many types of paperwork, reporting, and audit requirements so providers and health care facilities can focus on patients first and providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.

Now, let’s take a look at the new flexibilities and what they mean for homecare providers.

Medicare Telehealth & Telecommunications Technology

• Home Health Agencies (HHAs) can provide more services to beneficiaries using telecommunications technology within the 30-day period of care, so long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. CMS clarified that telecommunications technology can include, for example: remote patient monitoring; telephone calls (audio only and TTY); and 2-way audio-video technology that allows for real-time interaction between the clinician and patient. However, only in-person visits can be reported on the home health claim.
• CMS also clarified that the required face-to-face encounter for home health certification can be conducted via telehealth (i.e., 2-way audio-video telecommunications technology that allows for real-time interaction between the physician/allowed practitioner and the patient).

Patients Over Paperwork

• Homebound Definition: A beneficiary is considered homebound when their physician advises them not to leave the home because of a confirmed or suspected COVID-19 diagnosis or if the patient has a condition that makes them more susceptible to contract COVID-19. As a result, if a beneficiary is homebound due to COVID-19 and needs skilled services, an HHA can provide those services under the Medicare Home Health benefit.
• Detailed Information Sharing for Discharge Planning for Home Health Agencies: CMS is waiving the requirements of 42 CFR §484.58(a) to provide detailed information regarding discharge planning, to patients and their caregivers, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, (another) home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term care hospital (LTCH) quality measures and resource use measures. This temporary waiver provides facilities the ability to expedite discharge and movement of residents among care settings. CMS is maintaining all other discharge planning requirements.
• Clinical Records: In accordance with section 1135(b)(5) of the Act, CMS is extending the deadline for completion of the requirement at 42 CFR §484.110(e), which requires HHAs to provide a patient a copy of their medical record at no cost during the next visit or within four business days (when requested by the patient). Specifically, CMS will allow HHAs ten business days to provide a patient’s clinical record, instead of four.
• Training and Assessment of Aides: CMS is waiving the requirement at 42 CFR §484.80(h)(1)(iii) for HHAs, which require a registered nurse or other appropriate skilled professional (physical therapist/occupational therapist, speech language pathologist) to make an annual onsite supervisory visit (direct observation) for each aide that provides services on behalf of the agency. In accordance with section 1135(b)(5) of the Act, CMS is postponing completion of these visits. All postponed onsite assessments must be completed by these professionals no later than 60 days after the expiration of the PHE.
• 12-hour annual in-service training requirement for home health aides: CMS is modifying the requirement at 42 C.F.R. §484.80(d) that home health agencies must assure that each home health aide receives 12 hours of in-service training in a 12-month period. In accordance with section 1135(b)(5) of the Act, CMS is 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. This will allow aides and the registered nurses (RNs) who teach in-service training to spend more time delivering direct patient care and additional time for staff to complete this requirement.
• Quality Assurance and Performance Improvement (QAPI): CMS is modifying the requirement at §484.65 for HHAs, which requires these providers to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. Specifically, CMS is modifying the requirements at §484.65(a)–(d) to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events. This modification decreases the burden associated with the development and maintenance of a broad-based QAPI program, allowing the providers to focus efforts on aspects of care delivery most closely associated with COVID-19 and tracking adverse events during the PHE. The requirement that HHAs maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program will remain.
• Reporting: CMS is providing relief to HHAs on the timeframes related to OASIS transmission through the following 1) extending the 5-day completion requirement for the comprehensive assessment to 30 days; and 2) waiving the 30-day OASIS submission requirement. Delayed submission is permitted during the PHE. CMS is now allowing 30 days for the completion of the comprehensive assessment. HHAs must submit OASIS data prior to submitting their final claim in order to receive Medicare payment.
• Home Health Quality Reporting Program: HHAs are exempted from the Home Health Quality Reporting Program reporting requirements. The time period covered by this exemption is October 1, 2019 through June 30, 2020. HHAs that do not submit data for those quarters will not have their annual market basket percentage increase reduced by two percentage points. CMS is also delaying the compliance dates for collecting and reporting the Transfer of Health Information quality measures and certain standardized patient assessment data elements (SPADEs) adopted for the HH Quality Reporting Program. HHAs will be required to begin collecting the Transfer of Health Information quality measures and certain SPADEs on January 1st of the year that is at least one calendar year after the end of the public health emergency.
• Home Health Value Based Purchasing (HHVBP) Model: CMS is implementing a policy to align HHVBP data submission requirements with any exceptions or extensions granted for purposes of the Home Health Quality Reporting Program during the PHE for the COVID-19 pandemic, as well as a policy for granting exceptions to the New Measures data reporting requirements under the HHVBP Model during the PHE for the COVID-19 pandemic.
• Initial Assessments: By waiving 42 CFR § 484.55(a), home health agencies can perform initial assessments and determine patients’ homebound status remotely or by record review. This will allow patients to be cared for in the best environment for them while supporting infection control and reducing impact on acute care and long-term care facilities. This will allow for maximizing coverage if there are limited physician and advanced practice clinicians, and will allow those clinicians to focus on caring for patients with the greatest acuity.
• Requests for Anticipated Payments (RAPs): MACs can extend the auto-cancellation date of RAPs during emergencies. RAPs are a pre-payment for home health services.
• Review Choice Demonstration for Home Health Services: CMS is offering home health agencies in the Review Choice Demonstration for Home Health Services the option of pausing their participation for the duration of the Public Health Emergency. Home Health agencies do not have to do anything for the pause to go into effect.

Workforce

• Ordering Medicaid Home Health Services and Equipment: Medicaid home health regulations can now allow non-physician practitioners to order medical equipment, supplies and appliances, home health nursing and aide services, and physical therapy, occupational therapy or speech pathology and audiology services, in accordance with state scope of practice laws.
• Waived onsite visits for both HHA Aide Supervision: CMS is waiving the requirements at 42 CFR 484.80(h), which require a nurse to conduct an onsite visit every two weeks. This would include waiving the requirements for a nurse or other professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan, as this may not be physically possible for a period of time. This waiver is also temporarily suspending 2-week aide supervision requirement at 42 CFR §484.80(h)(1) by a registered nurse for home health agencies, but virtual supervision is encouraged during the period of the waiver.
• Certification for Payment of Medicare Home Health Services: As required under section 3708 of the CARES Act, CMS is allowing nurse practitioners, clinical nurse specialists and physician assistants to certify the need for home health services as defined under 42 CFR § 424.507(b)(1) payment requirements for covered Part A or Part B home health services.

To view the full report and additional guidance on COVID-19, visit the CMS newsroom.

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