As the COVID-19 pandemic continues, home health and hospice agencies need to be aware of changes that will affect operations. Following is a brief summary of the most recent updates. Please note that these changes are in direct response to COVID-19 and may be modified at any time, so it’s recommended that you consult with CMS, your MAC, and/or HHS before taking any action. We will regularly update this post as new information is made available. For more information, you can also visit our COVID-19 Resources page for updates, tips, and best practices.
Click here to view CMS’s COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.
Updated November 3, 2020
CARES Act Provider Relief Fund
As of April 10, CMS has begun to distribute payments to Medicare providers as part of the CARES Act Provider Relief Fund. CMS intends to distribute $30 billion in grant funding between all participating programs. Payments will be proportional, based on 2019 Medicare revenue. According to NAHC, to determine your estimated payment, divide your 2019 Medicare fee-for-service reimbursement total (excluding Medicare Advantage) by $484 billion (the total amount the program paid out last year), then multiply the ratio by $30 billion.CMS states that the payment will not need to be repaid, but there are some conditions that must be met.
- Providers have to have received Medicare fee-for-service payments last year.
- Providers must agree to no ask for out-of-pocket payments from COVID-19 patients beyond what would be expected if care had been provided by an in-network provider.
- Providers must sign an attestation within 90 days of receiving the money, confirming the payment was received and they agree to the associated terms and conditions.
The Department of Health & Human Services (HHS) states that health care providers who have received relief funds from the federal government won’t need to submit a separate quarterly report to them or the Pandemic Response Accountability Committee. Instead, HHS will develop its own report to satisfy the legal transparency requirements.
Home Health Updates
Accelerated and Advance Payments Program (AAP)
Between March 28 and April 26, 2020, home health agencies were able to request full payment for three months’ worth of anticipated revenue based on reimbursement history October – December 2019. The payment amount was based on the agency’s Medicare reimbursement history and not on any other payor revenues.
AAP Repayment
HHAs who received payment through this program must be ready when repayment begins, 120 days after the date of issuance, with the balance due within 210 days. For many, this could occur as soon as the end of July 2020.
Every claim submitted will be offset from the new claims to repay the accelerated/advanced payment. Instead of receiving payment for newly submitted claims, your outstanding accelerated/advance payment balance is reduced by the claim payment amount. This process is automatic. No interest will be charged on the repayment and demand letters will not be issued for the uncollected amounts until day 210 (120 + 90 days of recoupment without interest). Only after the demand letter has been issued will interest accruals begin. Agencies may also submit a voluntary refund of the AAP at any time.
Check with your MAC for further details on AAP and additional repayment details.
- CGS Administrators – Jurisdiction 15
- National Government Services (NGS) – Jurisdictions 6 & K
- Palmetto GBA – Jurisdiction M
Requests for Anticipated Payments (RAPs)
Medicare Administrative Contractors (MAC) can extend the auto-cancellation date of RAPs. Palmetto GBA has extended the auto-cancellation timeframe by 90 days from the paid date of the RAP. No additional details from other MACs has been released at this time.
Homebound Status
Patients are considered homebound when they are advised by a MD to stay at home because of a confirmed or suspected COVID-19 diagnosis or if they have a condition that makes them more susceptible to contract COVID-19. If patients are homebound because of COVID-19 and they need skilled services, home health agencies can provide those services.
Physical, Therapists, Occupational Therapists, Speech-Language Pathologists
Physical Therapists (PT), Occupational Therapists (OT), and Speech-Language Pathologists (SLP) can now perform the initial and comprehensive assessment for all patients receiving therapy services as part of the plan of care, to the extent permitted under state law, regardless of whether therapy is the service that establishes eligibility. OTs, PTs, SLPs, and other therapists cannot perform assessments in nursing only cases.
Home Health Aides
CMS waived the requirement that a nurse or other professional conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan. It also suspended the 2-week aide supervision by a registered nurse requirement for home health agencies. CMS still encourages virtual supervision during this time.
CMS waived the requirement that requires a registered nurse or other skilled professional to make an annual onsite supervisory visit for each aide that provides services on the behalf of the agency. All onsite assessments that are postponed must be completed no later than 60 days after the expiration of the public health emergency (PHE).
Initial Assessment
Home health agencies can perform initial assessments and determine patients’ homebound status remotely or by record review. This allows patients to be cared for in the best environment while supporting infection control and reducing impact on acute care and long-term care facilities. It also allows for maximum coverage if there are a limited number of physicians and advanced practice clinicians, and it allows clinicians to focus on caring for patients with the greatest acuity.
Clinical Records
CMS will allow agencies 10 business days to provide a patient a copy of their medical record, instead of four.
OASIS Transmission
CMS extended the 5-day completion requirement for the comprehensive assessment and waived the 30-day OASIS submission requirement. Delayed submission is allowed, but home health agencies are expected to complete the comprehensive assessment within 30 days. Patients must still have an assessment to determine and appropriately meet care needs.
Home Health Quality Reporting (HH QRP)
An exception has been granted by CMS for the Home Health Quality Reporting Program. Home health agencies are not required to submit January – June 2020 OASIS data for quality reporting program purposes. However, OASIS data should be submitted for payment. Additionally, submission of HHCAHPS survey data for January – June 2020 is also not required. You can still submit this data on a voluntary basis. However, we don’t know if agencies that voluntarily submit this data will have the submissions counted in calculations used for the 2% Annual Payment Update (APU) penalty.
CMS is implementing a policy to align the HHVBP Model data submission requirements with any exceptions or extensions granted for purposes of the HH QRP during COVID-19. CMS is also implementing a policy for granting exceptions for the following New Measures data reporting requirements under the HHVBP Model during COVID-19:
- April 2020 New Measures submission period (data collection period October 1, 2019 –March 31, 2020).
- July 2020 New Measures submission period (data collection period April 1, 2020 –June 30, 2020).
CMS is also evaluating possible changes to the public reporting of CY2020 performance year data.
Quality Assurance and Performance Improvement (QAPI)
CMS is modifying QAPI requirements to narrow the scope of the program to concentrate on infection control issues, while keeping the requirement that remaining activities should continue to focus on adverse events. This decreases the burden that comes with development and maintenance of a broad-based program and allows agencies to focus on the aspects of care delivery most closely associated with COVID-19.
Plans of Care and Certifying/ Recertifying Patient Eligibility
Nurse practitioners, clinical nurse specialist, or physician assistants can order home health services, can establish and review a plan of care, and certify/re-certify for Medicare eligibility. HHS will not conduct audits to ensure that physicians provided orders, signed and dated the plans of care, and certified/recertified patient eligibility for claims submitted during this public health emergency. This provides flexibility for more timely initiation of services for home health patients, while allowing providers and patients to practice social distancing.
Discharge Planning
CMS is waiving the requirements 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 allows facilities to expedite discharge and movement of residents across care settings.
Telehealth
With the expansion of telehealth under the 1135 waiver, doctors and practitioners can use telehealth for the face-to-face encounter to satisfy Medicare’s requirement for eligibility. While home health and hospice providers may communicate with patients by telehealth, currently those communications do not qualify as reimbursable visits under Medicare. On Friday, October, 23, , the Home Health Emergency Access to Telehealth (HEAT) Act (S.4854/H.R. 8677) was introduced. It’s a bipartisan bill that would authorize reimbursement for Medicare home health services provided by telehealth during a public health emergency where telehealth can be used appropriately. Beneficiary consent would be required for such services to be included in the plan of health. As an added safeguard ensuring that the home health benefit does not become a telehealth-only benefit, telehealth services can constitute no more than half of the billable visits made during the 30-day payment period.
Home Health Value-Based Purchasing (HHVBP)
CMS is waiving enforcement of HHVBP reporting requirements for the April 2020 submission period (data collection October 2019 – March 2020) and the July 2020 submission period (data collection April – June 2020). It recognizes that changes in the HHCAHPS and HH QRP reporting requirements will impact performance measure calculations under HHVBP. It states that it will address this later.
Review Choice Demonstration
Home health agencies participating in the Review Choice Demonstration (RCD) can pause their participation for the duration of this health crisis. Home health agencies are not required to take any action for the pause to go into effect.
Cost Reporting
CMS has delayed cost reporting for the following fiscal year end (FYE) dates. CMS will delay the filing deadline of FYE 10/31/2019 cost reports due by March 31, 2020 and FYE 11/30/2019 cost reports due by April 30, 2020. The extended cost report due dates for these October and November FYEs is June 30, 2020. CMS has also delayed the filing deadline of the FYE 12/31/2019 cost reports due by May 31, 2020. The extended cost report due date for FYE 12/31/2019 is July 31, 2020.
Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)
The requirement that RHC s and FQHCs can provide visiting nurse services (RN /LPN) to homebound patients only where there is a shortage of HHAs within the center’s area has been lifted. RH s and FQHCs can now see patients in their homes in areas even where there is a sufficient number of HHAs.
RHCs and FQHCs can provide and receive reimbursement for telehealth services using real-time interactive audio-visual communications to patients in their homes.
COVID-19 Diagnostic Testing
If a patient is already receiving home health services, the home health nurse can obtain a sample during a covered visit to send to the laboratory for COVID-19 diagnostic testing.
Click here for more information about the CMS Flexibilities to fight COVID-19 for home health agencies.
OASIS-E
CMS is delaying implementation of OASIS-E which was slated to begin on January 1, 2021. Agencies will be required to use OASIS-E to begin collecting data on the two TOH Information Measures beginning with discharges and transfers on January 1st of the year that is at least one full calendar year after the end of the COVID-19 PHE. For example, if the COVID-19 PHE ends on September 20, 2020, you’ll be required to begin collecting data on those measures beginning with patients discharged or transferred on January 1, 2022.
CMS will also require agencies to begin collecting data on the SPADEs (Standardized Patient Assessment Data Elements) beginning with the start of care, resumption of care, and discharges on January 1st of the year that is at least one full calendar year after the end of COVID-19.
Hospice Updates
Accelerated and Advance Payments Program
Between March 28th and April 26th, hospices were able to request 100% payment for a three-month period. The payment amount was based on the hospice’s Medicare reimbursement history and not on any other payor revenues.
Hospices who received payment through this program will need to be prepared for repayment, which begins 120 days after the date of issuance, with the balance due within 210 days. For many, this could happen as early as the end of July 2020.
Each claim submitted will be offset from the new claims to repay the accelerated/advanced payment. Instead of receiving payment for newly submitted claims, your outstanding accelerated/advance payment balance is automatically reduced by the claim payment amount. No interest will be charged on the repayment and demand letters will not be issued for the uncollected amounts until day 210 (120 + 90 days of recoupment without interest). Only after the demand letter has been issued will interest accruals begin. Hospices can also submit a voluntary refund of the AAP at any time.
Comprehensive Assessments
While hospices must complete required assessments and updates, the time frame for updating the assessment has been extended from 15 to 21 days.
Non-Core Services
Hospices do not have to provide certain non-core hospice services at this time. This includes physical therapy, occupational therapy, and speech-language pathology.
Hospice Quality Reporting
CMS has granted an exemption to the Hospice Quality Reporting Program reporting requirements. Hospices are not required to report data on measures, HIS data, and CAHPS surveys for October – December 2019 and January – June 2020. For HIS, quarters are based on submission of HIS admission or discharge assessments. CAHPS quarters are based on patient deaths in 2019 and 2020.
Quality Assurance and Performance Improvement (QAPI)
CMS is modifying QAPI requirements to narrow the scope of the program to concentrate on infection control issues, while keeping the requirement that remaining activities should continue to focus on adverse events. This decreases the burden that comes with development and maintenance of a broad-based program and allows agencies to focus on the aspects of care delivery most closely associated with COVID-19.
Hospice Volunteer Requirement
CMS waived the requirement that hospices must use volunteers.
Hospice Aide Competency Testing
Hospices can utilize pseudo patients, instead of actual patients, in the competency testing of hospice aides for tasks that must be observed being performed on a patient.
Onsite Visits for Hospice Aide Supervision
Nurses do not need to conduct an onsite visit every two weeks. This includes waiving the requirement 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.
CMS waived the requirement that a registered nurse or other skilled professional make an annual onsite supervisory visit for each aide that provides services on behalf of the agency. All postponed onsite assessments must be completed no later than 60 days following the end of the COVID-19 emergency.
Hospice Training
CMS waived the requirement that hospice aides receive 12 hours of in-service training every 12 months to allow aides and RNs who train the aides to spend more time delivering care.
CMS has postponed the requirement that hospices annually assess the skills and competence of all individuals furnishing care and provide in-service training and education programs. The deadline for completion will be postponed until the end of the first full quarter after the declaration of the COVID-19 emergency concludes.
Telehealth
Hospices can provide services to a patient receiving routine home care through telehealth, if it’s feasible and appropriate to do so. Additionally, face-to-face encounters for hospice recertification can be conducted via telehealth.
Cost Reporting
CMS delayed cost reporting for the following fiscal year end (FYE) dates. CMS will delay the filing deadline of FYE 10/31/2019 cost reports due by March 31, 2020 and FYE 11/30/2019 cost reports due by April 30, 2020. The extended cost report due dates for these October and November FYEs is June 30, 2020. CMS has also delayed the filing deadline of the FYE 12/31/2019 cost reports due by May 31, 2020. The extended cost report due date for FYE 12/31/2019 is July 31, 2020.
Click here for more information about the CMS Flexibilities to Fight COVID-19 for hospices.
Additionally, NAHC has made several requests to CMS regarding regulatory action that would better enable home health and hospice agencies to provide care during this pandemic. Click here to view these considerations, including the status of each.
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