| Emergency Medical Treatment & Labor Act (EMTALA). CMS has been partially waiving the enforcement of section 1867(a) of the Social Security Act (the Emergency Medical Treatment and Active Labor Act, or EMTALA). This has allowed hospitals, psychiatric hospitals, and critical access hospitals (CAHs) to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, while remaining consistent with the state emergency preparedness or pandemic plan. |
Will expire at the end of the federal PHE |
| "Stark Law" Waivers: On March 30, 2020, CMS issued blanket waivers of certain provisions of the Stark Law. These blanket waivers applied to financial relationships and referrals that are related to the COVID-19 emergency. During the PHE, CMS permitted certain referrals and the submission of related claims that would otherwise violate the Stark Law, if all requirements of the waivers were met. |
Will expire at the end of the federal PHE; physicians and entities must immediately comply with all provisions of the Stark Law. |
| Increased IPPS Payments for COVID Patients: Hospitals have received a 20% increase in Medicare payments through the IPPS for patients diagnosed with COVID-19 |
Will expire at the end of the federal PHE |
Verbal Orders. CMS has been waiving the requirements of 42 CFR §482.23, §482.24 and §485.635(d)(3) to allow for additional flexibilities related to verbal orders where readback verification is still required but authentication may occur later than 48 hours. This has allowed for more efficient treatment of patients in a surge situation. Specifically, the following requirements are waived:
- §482.23(c)(3)(i) -If verbal orders are used for the use of drugs and biologicals (except immunizations), they are to be used infrequently.
- §482.24(c)(2) -All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient.
- §482.24(c)(3) -Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders. This would include all subparts at §482.24(c)(3).
- )§485.635(d)(3) -Although the regulation requires that medication administration be based on a written, signed order, this does not preclude the CAH from using verbal orders. A practitioner responsible for the care of the patient must authenticate the order in writing as soon as possible after the fact.
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Will expire at the end of the federal PHE |
| Signature Requirements: CMS is not enforcing signature and proof of delivery requirements for Part B drugs and Durable Medical Equipment when a signature cannot be obtained because of the inability to collect signatures. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19. |
Pending CMS Confirmation of Status |
| Reporting Requirements. CMS has been waiving reporting requirements at §482.13(g) (1)(i)-(ii), which require hospitals to report patients in an intensive care unit whose death is caused by their disease process but who required soft wrist restraints to prevent pulling tubes/IVs, may be reported later than close of business next business day, provided any death where the restraint may have contributed is continued to be reported within standard time limits. Due to current hospital surge, we are waiving this requirement to ensure that hospitals are focusing on increased care demands and patient care. |
Will expire at the end of the federal PHE |
Patient Rights. CMS is waiving requirements under 42 CFR §482.13 only for hospitals that are considered to be impacted by a widespread outbreak of COVID-19. Hospitals that are located in a state which has widespread confirmed cases (i.e., 51 or more confirmed cases*) as updated on the CDC website, CDC States Reporting Cases of COVID-19, at ttps://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html, would not be required to meet the following requirements:
- §482.13(d)(2) -With respect to timeframes in providing a copy of a medical record.
- §482.13(h) -Related to patient visitation, including the requirement to have written policies and procedures on visitation of patients who are in COVID-19 isolation and quarantine processes.
- §482.13(e)(1)(ii) -Regarding seclusion.
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Will expire at the end of the federal PHE |
Telehealth
Hospital Outpatient Services Accompanying Professional Services Furnished Via Telehealth:When a physician or nonphysician practitioner, who typically furnishes professional services in the hospital outpatient department, furnishes telehealth services to the patient’s home during the COVID-19 PHE as a “distant site” practitioner, they bill with a hospital outpatient place of service, since that is likely where the services would have been furnished if not for the COVID19 PHE. The physician or practitioner is paid for the service under the PFS at the facility rate, which does not include payment for resources, such as clinical staff, supplies, or office overhead, since those things are usually supplied by the hospital outpatient department. The hospital may bill under the OPPS for the originating site facility fee associated with the telehealth service. |
After the PHE ends, this flexibility, to bill the telehealth service provided in the patient’s home as if it was provided at the hospital, will end.
Note: The Calendar Year 2023 OPPS/ASC proposed rule includes a proposal considering OPPS payment after the PHE ends for behavioral health services furnished remotely by clinical staff of hospital outpatient departments. The rule will be finalized this Fall. |
| Other Telehealth Medicare Flexibilities The Consolidated Appropriations Act of 2022 extended certain telehealth flexibilities for Medicare patients for 151 days after the official end of the federal PHE. If there are no permanent changes made to Medicare coverage, most Medicare beneficiaries will lost access to coverage of nearly all telehealth services, unless they reside in a rural area or are enrolled in Medicare Advantage. |
Will expire on the 152nd day after the end of the PHE. |
| Hospitals Able to Provide Care in Temporary Expansion Sites: As part of the CMS Hospital Without Walls initiative during the PHE, hospitals could provide hospital services in other hospitals and sites that otherwise would not have been considered part of a healthcare facility, or could set up temporary expansion sites to help address the urgent need to increase capacity to care for patients. During the PHE, CMS provided additional flexibilities for hospitals to create surge capacity by allowing them to provide room and board, nursing, and other hospital services at remote locations, such as hotels or community facilities. During the PHE, hospitals are expected to control and oversee the services provided at an alternative location. |
When the PHE ends, hospitals will be required to provide services to patients within their hospital departments, pursuant to hospital conditions of participation. |
| Ambulatory Surgical Centers Temporary Enrollment as Hospitals. CMS permitted ambulatory surgical centers (ASCs) to temporarily reenroll as hospitals and to provide hospital services to help address the urgent need to increase hospital capacity to take care of patients. Other interested entities, such as independent, freestanding, emergency departments (IFEDs), could pursue temporarily enrolling as a hospital during the PHE. |
When the federal PHE ends, ASCs must decide either to meet the certification standards for hospitals at 42 C.F.R. part 482, or return to ASC status. If they choose to return to ASC status, they can only be paid under the ASC payment system for services on the ASC Covered Procedures List. When the PHE ends, IFEDs cannot bill Medicare for services as their temporary Medicare certification would end. |
| Sterile Compounding. CMS has been waiving hospital sterile compounding requirements at 42CFR §482.25(b)(1) and §485.635(a)(3) to allow used face masks to be removed and retained in the compounding area to be re-donned and reused during the same work shift in the compounding area only. This conserves scarce face mask supplies. CMS has not been reviewing the use and storage of facemasks under these requirements. |
Will expire at the end of the federal PHE |
| Modify Discharge Planning for Hospitals: Patients must continue to be discharged to an appropriate setting with the necessary medical information and goals of care. To address the COVID-19 pandemic, CMS has been waiving certain, more detailed, requirements related to hospital discharge planning for post-acute care services at 42 CFR §482.43(c), so as to expedite the safe discharge and movement of patients among care settings, and to be responsive to fluid situations in various areas of the country. CMS has been waiving certain requirements for those patients discharged home and referred for HHA services, or for those patients transferred to a SNF for post-hospital extended care services, or transferred to an IRF or LTCH for specialized hospital services. |
Will expire at the end of the federal PHE |
Patient Rights Paperwork Requirements: CMS has been waiving certain specific paperwork requirements that are considered to be impacted by a widespread outbreak of COVID-19. Hospitals that are located in a state that has widespread confirmed cases have not been required to meet the following requirements.
- 42 CFR §482.13(d)(2) with respect to timeframes in providing a copy of a medical record.
- 42 CFR §482.13(h) related to patient visitation, including the requirement to have written policies and procedures on visitation of patients who are in COVID-19 isolation and quarantine processes.
- 42 CFR §482.13(e)(1)(ii) regarding seclusion.
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Will expire at the end of the federal PHE |
| Physical Environment: CMS has been waiving certain physical environment requirements at 42 CFR §482.41 and 42 CFR §485.623 to allow for increased flexibilities for surge capacity and patient quarantine at hospitals and psychiatric hospitals. CMS will permit facility and non-facility space that is not normally used for patient care to be utilized for patient care or quarantine, provided the location is approved by the state and is consistent with the state’s emergency preparedness or pandemic plan. States are still subject to obligations under the integration mandate of the Americans with Disabilities Act, to avoid subjecting persons with disabilities to unjustified institutionalization or segregation |
Pending CMS Confirmation of Status |
Specific Life Safety Code (LSC) for Hospitals: CMS has been modifying these requirements as follows:
- Alcohol-based Hand-Rub (ABHR) Dispensers: We are waiving the prescriptive requirements for the placement of alcohol-based hand rub (ABHR) dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident population to prevent accidental ingestion. Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area. Refer to: 2012 LSC, sections 18/19.3.2.6. In addition, facilities should continue to protect ABHR dispensers against inappropriate use as required by 42 CFR §482.41(b)(7) for hospitals and §485.623(c)(5) for CAHs.
- Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, we will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. Refer to: 2012 LSC, sections 18/19.7.1.6.
- Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients. Refer to: 2012 LSC, sections18/19.3.3.2.
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The ABHR waiver will end at the end of the federal PHE.
Pending CMS Confirmation of Status
Pending CMS Confirmation of Status |
| Hospital Outpatient: Use of Provider-Based Departments as Temporary Expansion Sites: : For the duration of the PHE related to COVID-19, CMS has been waiving certain requirements under the Medicare conditions of participation at 42 CFR §482.41 and §485.623 and the provider-based department requirements at 42 CFR §413.65 to allow hospitals to expand capacity by creating new, or relocating existing, provider-based departments. These waivers were intended to enable hospitals to meet the needs of Medicare beneficiaries in alignment with the state or local pandemic plan. |
Pending CMS Confirmation of Status |
| Hospital-Only Remote Outpatient Therapy and Education Services: Consistent with the CMS Hospitals without Walls Initiative, during the PHE, hospitals may provide behavioral health and education services furnished by hospital-employed counselors or other professionals who cannot bill Medicare directly for their professional services. This includes partial hospitalization services. These services may be furnished to a beneficiary in their home when the beneficiary is registered as an outpatient of the hospital and the hospital considers the beneficiary’s home to be a provider-based department of the hospital. |
After the PHE, these services would no longer be able to be paid when provided in the patient’s home. Note: The Calendar Year 2023 OPPS/ASC proposed rule includes a proposal considering OPPS payment after the PHE ends for behavioral health services furnished remotely by clinical staff of hospital outpatient departments. |
| Medical Staff Requirements: CMS has been waiving the Medical Staff requirements at 42 CFR §482.22(a)(1)-(4) to allow for physicians, whose privileges would have expired, to continue practicing at the hospital and for new physicians to be able to practice in the hospital before full medical staff/governing body review and approval to address workforce concerns related to COVID-19. CMS has been waiving §482.22(a) (1)-(4) regarding details of the credentialing and privileging process. |
Will expire at the end of the federal PHE |
| Physician Services: CMS has been waiving 482.12(c)(1)–(2) and §482.12(c)(4), which requires that Medicare patients be under the care of a physician. This allows hospitals to use other practitioners, such as physician’s assistant and nurse practitioners to the fullest extent possible. This waiver has been implemented while remaining consistent with a state’s emergency preparedness or pandemic plan. |
Will expire at the end of the federal PHE |
| Anesthesia Services: CMS has been waiving the requirements, at 42 CFR 482.52(a)(5),42 CFR 485.639(c)(2) and 42 CFR 416.42 (b)(2), that a certified registered nurse anesthetist (CRNA) is under the supervision of a physician. CRNA supervision has been at the discretion of the hospital or Ambulatory Surgical Center (ASC) and state law. This waiver applies to hospitals, CAHs, and ASCs. These waivers allow CRNAs to function to the fullest extent of their licensure and has been implemented while remaining consistent with a state or pandemic/emergency plan. |
Will expire at the end of the federal PHE |
| Respiratory Care Services: CMS has been waiving the requirement at 42 CFR 482.57(b)(1) that hospitals designate, in writing, the personnel qualified to perform specific respiratory care procedures and the amount of supervision required for personnel to carry out specific procedures. Not being required to designate these professionals in writing allows qualified professionals to operate to the fullest extent of their licensure and training in providing patient care for respiratory illnesses. |
Will expire at the end of the federal PHE |
| Nursing Services: CMS has been waiving the provision at 42 CFR 482.23(b)(4), 42 CFR 482.23(b)(7), and 485.635(d)(4), which requires the nursing staff to develop and keep current a nursing care plan for each patient, and the provision that requires the hospital to have policies and procedures in place establishing which outpatient departments are not required to have a registered nurse present. |
Will expire at the end of the federal PHE |
| Food and Dietetic Service: CMS has been waiving the requirement at 42 CFR 482.28(b)(3) to have a current therapeutic diet manual approved by the dietitian and medical staff readily available to all medical, nursing, and food service personnel. |
Will expire at the end of the federal PHE |
| Emergency Preparedness Policies and Procedures: CMS has been waiving 482.15(b), which requires the hospital to develop and implement emergency preparedness policies and procedures, and 482.15(c)(1)-(5) which require that the emergency preparedness communication plans for hospitals to contain specified elements with respect to the surge site. |
Will expire at the end of the federal PHE |
| Medical Records: CCMS has been waiving 42 CFR §482.24(a) through (c), which cover the subjects of the organization and staffing of the medical records department, requirements for the form and content of the medical record, and record retention requirements. CMS has been waiving requirements under 42 CFR §482.24(c)(4)(viii) related to medical records to allow flexibility in completion of medical records within 30 days following discharge. |
Will expire at the end of the federal PHE |
| Flexibility in Patient Self Determination Act Requirements (Advance Directives). CMS has been waiving the requirements at section 1902(a)(58) and 1902(w)(1)(A) for Medicaid, 1852(i) (for Medicare Advantage), and 1866(f) and 42 CFR 489.102 for Medicare, which require hospitals to provide information about its advance directive policies to patients. |
Will expire at the end of the federal PHE |
| Utilization Review: CMS has been waiving the requirements at 42 CFR §482.1(a)(3) and 42 C.F.R §482.30, that require that hospitals participating in Medicare and Medicaid to have a utilization review plan that meets specified requirements. CMS has been waiving the entire Utilization Review CoP at §482.30, which requires that a hospital must have a utilization review (UR) plan with a UR committee that provides for review of services furnished to Medicare and Medicaid beneficiaries to evaluate the medical necessity of the admission, duration of stay, and services provided. |
Will expire at the end of the federal PHE |
| Quality Assessment and Performance Improvement Program: CMS has been waiving 482.21(a)-(d) and (f), and 485.641(a), (b), and (d), which provide details on the scope of the program, the incorporation, and setting priorities for the program’s performance improvement activities, and integrated QAPI programs (for hospitals that are a part of a hospital system). While this waiver decreases burden associated with the development of a hospital QAPI program, the requirement that hospitals maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program remains. |
Will expire at the end of the federal PHE |
| State Licensure: During the PHE, CMS allowed licensed physicians and other practitioners to bill Medicare for services provided outside of their state of enrollment. |
CMS has determined that, when the PHE ends, CMS regulations will continue to allow for a total deferral to state law. There is no CMS-based requirement that a provider must be licensed in its state of enrollment. |
| Requirement for Hospitals and CAHs to Report Data for COVID-19 and Acute Respiratory Illness, including Seasonal Influenza Virus, Influenza-like Illness, and Severe Acute Respiratory Infection: Hospitals are required to report information in accordance with a frequency, and in a standardized format, as specified by the Secretary during the PHE for COVID-19. More information is available at https://www.hhs.gov/sites/default/files/covid-19-faqs-hospitals-hospital-laboratory-acute-care-facility-data-reporting.pdf |
Beginning after the PHE ends and continuing until April 30, 2024, unless the Secretary determines an earlier end date, hospitals are required to report data for COVID-19 and seasonal influenza in a standardized format and frequency as specified by the Secretary. CMS will notify regulated entities, stakeholders, and the public of the start date of necessary reporting, reporting frequency, and other requirements via subregulatory guidance, following a model similar to that which we used to inform regulated entities at the beginning of the COVID-19 PHE. https://www.hhs.gov/sites/default/files/covid-19-faqs-hospitals-hospital-laboratory-acute-care-facility-data-reporting.pdf |
Application of Teaching Physician Regulations: Under current rules, Medicare payment is made for services furnished by a teaching physician involving residents only if the physician is physically present for the key portion of the service or procedure, and immediately available to furnish services during the entire procedure, where applicable. During the COVID-19 PHE, teaching physicians may use audio/video real time communications technology to interact with the resident through virtual means, which would meet the requirement that they be present for the key portion of the service, including when the teaching physician involves the resident in furnishing Medicare Telehealth services. These flexibilities do not apply in the case of surgical, high risk, interventional, or other complex procedures, services performed through an endoscope, and anesthesia services.
Teaching physicians involving residents in providing care at certain primary care centers can provide the necessary direction, management and review for services furnished by up to four residents at a time using audio/video real time communications technology.
During the PHE, teaching physicians can oversee and bill for an expanded scope of care furnished by up to four residents at a time in certain primary care centers, including all levels of an office/outpatient evaluation and management (E/M) visit, telephone E/M, care management, and communication technology-based services |
After the PHE, only teaching physicians in residency training sites located outside of a metropolitan statistical area may meet the presence for the key portion requirement through audio/video real-time communications technology.
After the PHE, only teaching physicians in residency training sites located outside of a metropolitan statistical area may direct, manage, and review care furnished by residents through audio/video real-time communications technology.
After the PHE, teaching physicians can bill for levels 4-5 of an office/outpatient evaluation and management (E/M) visit furnished by residents in these primary care centers only when the teaching physician is physically present for the key portion of the service. |
| Resident Moonlighting: Under permanent policy, Medicare considers the services of residents that are not related to their approved graduate medical education programs and performed in the outpatient department or the emergency department of a hospital as the resident’s separately billable physicians’ services. Medicare also considers the services of residents that are not related to their approved GME programs and furnished to inpatients of a hospital in which they have their training program as separately billable physicians’ services. |
This is unchanged and will continue after the PHE. |
| Counting of Resident Time at Alternate Locations: Existing regulations have specific rules on when a hospital may count a resident for purposes of Medicare direct graduate medical education (DGME) payments or indirect medical education (IME) payments. Normally, if the resident is performing activities within the scope of his/her approved program in his/her own home, or a patient’s home, the hospital may not count the resident. During the COVID-19 PHE, a hospital that is paying the resident’s salary and fringe benefits for the time that the resident is at home or in a patient’s home, but performing duties within the scope of the approved residency program and meets appropriate physician supervision requirements could claim that resident for IME and DGME purposes. |
When the COVID-19 PHE ends, a hospital may not count a resident for purposes of Medicare DGME payments or IME payments if the resident is performing activities with the scope of his/her approved program in his/her own home, or a patient’s home. |
| Graduate Medical Education (GME) Residents Training in Other Hospitals: During the COVID-19 PHE, a teaching hospital that sends residents to other hospitals has been able to continue to claim those residents in the teaching hospital’s IME and DGME FTE resident counts, if certain requirements are met. Those requirements include that 1) the teaching hospital sends the resident to the other hospital in response to the COVID-19 pandemic; 2) the time spent by the resident training at the other hospital is in lieu of time that would have been spent training at the sending hospital; and 3) the time that the resident spent training immediately prior to and/or subsequent to the time frame that the COVID-19 PHE has been in effect has been included in the FTE count for the sending hospital. Moreover, the presence of residents in non-teaching hospitals has not triggered establishment of IME and/or DGME FTE resident caps at those non-teaching hospitals. Specifically, for DGME, the presence of residents in non-teaching hospitals has not triggered establishment of PRAs at those non-teaching hospitals. |
When the COVID-19 PHE ends, a teaching hospital that sends residents to other hospitals cannot claim those residents in its IME and DGME FTE resident counts. Also, when the COVID-19 PHE ends, the presence of residents in non-teaching hospitals will trigger establishment of IME and/or DGME FTE resident caps at those non-teaching hospitals (and for DGME will trigger establishment of PRAs at those non-teaching hospitals). |
| IME Payments Held Harmless for Temporary Increase in Beds: During the COVID-19 PHE, CMS has held teaching hospitals harmless from a reduction in IME payments due to beds temporarily added during the COVID-19 PHE, by not considering such beds when determining IME payments. |
When the COVID-19 PHE ends, any added beds will be considered in determining the hospital’s IME payments. |
| Price Transparency for COVID-19 Testing: CMS implemented the CARES Act requirement that providers of a diagnostic test for COVID-19 are to make public the cash price for such tests on their websites. Providers without websites have been required to provide price information in writing, within two business days upon request, and on a sign posted prominently at the location where the provider performs the COVID-19 diagnostic test, if such location is accessible to the public. Noncompliance may result in civil monetary penalties up to $300 per day. |
After the PHE, this special price transparency requirement will terminate.Price transparency requirements under other laws and regulations will continue to apply. |
| Enhanced Medicare Payments for New COVID-19 Treatments: Hospital Inpatient Stays: Effective for discharges occurring on or after November 2, 2020, and through the end of the FY in which the COVID-19 PHE ends, the Medicare program has provided an enhanced payment for eligible inpatient cases that involve use of certain new products authorized or approved to treat COVID-19 (86 FR 45162). The enhanced payment is equal to the lesser of: 1) 65% of the operating outlier threshold for the claim; or 2) 65% of the costs of the case beyond the operating Medicare payment (including the 20% add-on payment under section 3710 of the CARES Act) for eligible cases. |
Will remain in place through the end of the fiscal year in which the COVID-19 PHE ends. |
| Separate Medicare Payment for New COVID-19 Treatments: Hospital Outpatient Departments: CMS has excluded FDA-authorized or approved drugs and biologicals (including blood products) authorized or approved to treat COVID-19 (and for which the FDA authorization or approval does not limit use to the inpatient setting) from being packaged into the Comprehensive Ambulatory Payment Classification (C-APC) payment when these treatments are billed on the same claim as a primary C-APC service. Instead, Medicare has been paying for these drugs and biologicals separately for the duration of the PHE. |
After the PHE, payment for these treatments will be packaged into the payment for a C-APC when these services are billed on the same outpatient claim. |
| Expanded Ability for Hospitals to Offer Long-term Care Services (Swing Beds) for Patients Who do not Require Acute Care but do Meet the Skilled Nursing Facility (SNF) Level of Care Criteria as Set Forth at 42 CFR 409.31: CMS has been waiving the requirements at 42 CFR 482.58, special requirements for hospital providers of long-term care services (swing beds), subsections (a)(1)-(4) Eligibility, to allow hospitals to establish SNF swing beds, payable under the SNF prospective payment system (PPS), to provide additional options for hospitals with patients who no longer require acute care, but are unable to find placement in a SNF. |
Will expire at the end of the federal PHE |
| Housing Acute Care Patients in Excluded Distinct Part Units: During the PHE, CMS has been waiving requirements to allow acute care hospitals to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatients. The Inpatient Prospective Payment System (IPPS) hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the disaster or emergency. |
When the federal PHE ends, acute care hospitals under the IPPS cannot bill for acute care inpatients housed in excluded distinct part units. This waiver will terminate at the end of the COVID-19 PHE. |
| Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital: During the PHE, CMS has been waiving requirements to allow acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed, because of capacity or other exigent circumstances related to the COVID-19 PHE. This waiver could be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for. |
When the PHE ends, inpatients receiving psychiatric services paid under the IPF PPS and furnished by the excluded distinct part psychiatric unit of an acute care hospital cannot be housed in an acute care bed and unit. This waiver will terminate at the end of the COVID-19 PHE. |
| Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital: CMS has been waiving requirements to allow acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the Inpatient Rehabilitation Facility Prospective Payment System for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed, because of capacity or other exigent circumstances related to the disaster or emergency. This waiver could be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients and such patients continue to receive intensive rehabilitation services. When the COVID-19 PHE ends, inpatients receiving rehabilitation services, paid under the IRF PPS and furnished by the excluded distinct part rehabilitation unit of an acute care hospital, cannot be housed in an acute care bed and unit. |
Will expire at the end of the federal PHE |
| Flexibility for Inpatient Rehabilitation Facilities Regarding the 60% Rule: During the PHE, CMS has been allowing IRFs to exclude patients from the freestanding hospital’s, or excluded distinct part unit’s, inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the 60% rule), if an IRF admits a patient solely to respond to the emergency and the patient’s medical record properly identifies the patient as such. In addition, during the applicable waiver time period, this exception has also applied to facilities not yet classified as IRFs, but have attempted to obtain classification as an IRF. |
When the PHE ends, all inpatients will again be included in the freestanding hospital’s, or excluded distinct part unit’s, inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (the 60% rule). This waiver will terminate at the end of the COVID-19 PHE. |
| Intensity of Therapy Requirement (“Three-Hour Rule”): The Coronavirus Aid, Relief, and Economic Security (CARES) Act requires the Secretary to waive § 412.622(a)(3)(ii) (commonly referred to as the “three-hour rule”), the criterion that patients treated in inpatient rehabilitation facilities generally receive at least 15 hours of therapy per week. The waiver of this requirement for all beneficiaries treated in a hospital-based or freestanding IRF provides flexibility for IRFs to provide care for patients during the PHE for the COVID-19 pandemic. |
Will expire at the end of the federal PHE |
Standards to Rehabilitate Patients: Medicare payment regulations require IRFs to meet certain standards to rehabilitate patients, including providing interdisciplinary care, ensuring that admitted patients are stable enough for rehabilitation therapy and need at least two types of therapy, and providing close medical supervision by a rehabilitation physician. During the PHE, these standards do not have to apply to patients who are admitted to freestanding IRFs solely for surge capacity reasons in a state that currently satisfies all of the following, as determined by applicable state and local officials:
- All vulnerable individuals continue to shelter in place.
- Individuals continue social distancing.
- Individuals avoid socializing in groups of more than 10.
- Non-essential travel is minimized.
- Visits to senior living facilities and hospitals are prohibited.
- Schools and organized youth activities remain closed.
The standard IRF requirements would continue to apply to patients who are admitted for the IRFs’ standard rehabilitative services. During the PHE, freestanding IRFs have taken advantage of these flexibilities for some of their beneficiaries (those who are surge patients from inpatient hospitals), while continuing to provide standard IRF-level care for those beneficiaries who would benefit from IRF-level care and would otherwise receive such care in the absence of the PHE. |
Will expire at the end of the federal PHE |
LTCH Site Neutral Payment Rate Provisions: As required by section 3711(b) of the CARES Act, during the Public Health Emergency (PHE) due to COVID-19, certain provisions of section 1886(m)(6) of the Social Security Act were waived relating to certain site neutral payment rate provisions for long-term care hospitals (LTCHs).
- Section 3711(b)(1) of the CARES Act waived the payment adjustment under section 1886(m)(6)(C)(ii) of the Act for LTCHs that do not have a discharge payment percentage (DPP) for the period that is at least 50% during the COVID-19 PHE period. For the purposes of calculating an LTCH’s DPP, all admissions during the COVID-19 PHE period were counted in the numerator of the calculation. In other words, LTCH cases that were admitted during the COVID-19 PHE period were counted as discharges paid the LTCH PPS standard Federal payment rate. At the end of the COVID-19 PHE, the payment adjustment under section 1886(m)(6)(C)(ii) of the Act is applied for LTCHs that do not have a DPP for the period that is at least 50%.
- Section 3711(b)(2) of the CARES Act provides a waiver of the application of the site neutral payment rate under section 1886(m)(6)(A)(i) of the Act for those LTCH admissions that are in response to the public health emergency and occur during the COVID-19 public health emergency (PHE) period. Under this provision, all LTCH cases admitted during the COVID-19 public health emergency period (that is, admissions occurring on or after January 27, 2020 through the duration of the COVID-19 PHE) were paid the relatively higher LTCH PPS standard Federal rate.
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When the COVID-19 PHE ends, all LTCH admissions, except those that meet the requirements for exclusion from the site neutral rate, are subject to the site neutral payment rate under section 1886(m)(6)(A)(i) of the Act. |
| Long-Term Care Acute Hospitals (LTCHs) 25-day ALOS: CMS issued a blanket waiver to long-term care hospitals where an LTCH admits or discharges patients in order to meet the demands of the emergency from the 25-day average length of stay requirement at § 412.23(e)(2), which allows these hospitals to participate in the LTCH PPS. Hospitals should add the “DR” condition code to applicable claims. |
Will expire at the end of the federal PHE |
| Inpatient Psychiatric Facilities (IPFs) and Inpatient Rehabilitation Facilities (IRFs) Teaching Status Adjustment Payments: To ensure that teaching IPFs and IRFs can alleviate bed capacity issues by taking patients from the inpatient acute care hospitals without being penalized by lower teaching status adjustments, we have been freezing the IPFs’ and IRFs’ teaching status adjustment payments at their values prior to the PHE. For duration of the COVID-19 PHE, a teaching IPF’s and a teaching IRF’s teaching status adjustment payments have been the same as they were on the day before the COVID-19 PHE was declared. |
When the COVID-19 PHE ends, any change to a teaching IPF’s or a teaching IRF’s average daily census will be considered in determining its teaching status adjustment payments. |
