Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Summary
Rural Crosswalk: CMS Flexibilities to Fight COVID-19, a document dated May 2021 and paid for by the U.S. Department of Health and Human Services. It says it highlights COVID-19 related provisions that CMS issued or carried out during the Public Health Emergency that affect Rural Health Clinics, Federally Qualified Health Centers, Critical Access Hospitals, Rural Acute Care Prospective Payment System Hospitals and Medicare-certified Skilled Nursing Facilities. Its table of contents lists Telehealth and Other Virtual Services, CMS Hospital Without Walls, CMS Facility Without Walls, Patients Over Paperwork, Workforce, Payment, Data Reporting and Additional Guidance. Tables mark each flexibility Yes or No by facility type, including a note that CMS added 11 new services to the Medicare telehealth services list on October 14, 2020.
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Cite this document
“Rural Crosswalk: CMS Flexibilities to Fight COVID-19.”
Original at www.cms.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/ppr-int-f7c95adddb58d7cf-rural-providers-pdf-0bece19ab8/
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May 2021
Rural Crosswalk:
CMS Flexibilities to Fight COVID-19
Paid for by the U.S. Department of Health and Human Services
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Since the beginning of the COVID-19 Public Health Emergency (PHE), CMS has issued an unprecedented array of temporary regulatory
waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-
19) pandemic. These temporary changes will apply immediately across the entire U.S. healthcare system for the duration of the emergency
declaration. The goals of these 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 (also known as CMS Hospital Without Walls);
3) increase access to telehealth in Medicare to ensure patients have access to physicians and other clinicians while keeping patients safe at
home; 1 4) expand in-place testing to allow for more testing at home or in community based settings; and 5) put Patients Over Paperwork to
give temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage and
Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.
This document highlights COVID-19 related provisions that CMS has issued and/or carried out during the Public Health Emergency (PHE)
that impact Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), Critical Access Hospitals (CAHs), Rural Acute Care
Prospective Payment System (PPS) Hospitals, and/or Medicare-certified Skilled Nursing Facilities (SNFs).
** Indicates items added or revised in the most recent update
Table of Contents
Telehealth and Other Virtual Services .................................................................................................................................................................2
CMS Hospital Without Walls (Temporary Expansion Sites) ................................................................................................................................5
CMS Facility Without Walls (Temporary Expansion Sites) ................................................................................................................................11
Patients Over Paperwork ...................................................................................................................................................................................14
Workforce ..........................................................................................................................................................................................................23
Payment .............................................................................................................................................................................................................29
Data Reporting ...................................................................................................................................................................................................36
Additional Guidance ...........................................................................................................................................................................................38
1
Telehealth and other virtual services are furnished by eligible clinicians paid under the Physician Fee Schedule. This document outlines telehealth and
other virtual service waivers that affect clinicians practicing in the types of facilities included or who may have reassigned their billing rights to these
facilities.
May 2021 1
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Telehealth and Other Virtual Services
Telehealth and Other Virtual Services
Flexibility Description RHC FQHC CAH Hospital SNF
Beneficiary Medicare can pay for many types of office, hospital, and other visits furnished via
Location for telehealth across the country and including in patient’s places of residence.
Yes Yes Yes Yes No
Telehealth Additionally, the HHS OIG is providing flexibility for healthcare providers to reduce or
Services waive cost-sharing for telehealth visits paid by federal healthcare programs. 2
Clinicians are allowed to provide more than 135 new telehealth services, including:
emergency department visits, initial and subsequent observation, initial hospital care
Additional and hospital discharge day management, initial nursing facility visits, critical care
Telehealth services, intensive care services, therapy services. 3 On October 14, 2020, using a
Services new expedited process, CMS added 11 new services to the Medicare telehealth Yes Yes Yes Yes Yes
Covered by services list. Medicare will begin paying eligible practitioners who furnish these newly
Medicare added telehealth services effective immediately and for the duration of the PHE.
These new telehealth services include certain neurostimulator analysis and
programming services, and cardiac and pulmonary rehabilitation services.
Clinicians can provide virtual check-in, remote evaluation of patient-submitted
Virtual Check- video/images, and e-visit services to both new and established patients. These
Ins, Remote services were previously limited to established patients. Licensed clinical social
workers, clinical psychologists, physical therapists, occupational therapists, and Yes Yes Yes Yes No
Evaluations, &
speech language pathologists can provide e-visits, virtual check-ins, and remote
E-Visits evaluations. A broad range of clinicians, including physicians, can now provide certain
services by telephone to their patients.
Remote Patient Clinicians can provide remote patient monitoring services to both new and established
patients. These services can be provided for both acute and chronic conditions and Yes Yes Yes Yes No
Monitoring
can now be provided for patients with only one disease. 4
2
More information on this flexibility can be found here: https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/factsheet-telehealth-2020.pdf
3
A complete list of all Medicare telehealth services can be found here: https://www.cms.gov/Medicare/Medicare-General-
information/Telehealth/Telehealth-Codes
4
More information on this flexibility can be found here: https://www.cms.gov/files/document/covid-final-ifc.pdf
May 2021 2
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Telehealth and Other Virtual Services
Flexibility Description RHC FQHC CAH Hospital SNF
The following services no longer have limitations on the number of times they can be
Removal of provided by Medicare telehealth:
Frequency • A subsequent inpatient visit can be furnished via Medicare telehealth, without the
limitation that the telehealth visit is once every three days;
Limitations on No No Yes Yes Yes
• A subsequent SNF visit can be furnished via Medicare telehealth, without the
Medicare
limitation that the telehealth visit is once every 30 days;
Telehealth
• Critical care consult codes may be furnished to a Medicare beneficiary by
telehealth beyond the once per day limitation.
CMS is waiving the requirements of section 1834(m)(4)(E) of the Social Security Act
and 42 CFR § 410.78 (b)(2) which specify the types of practitioners that may bill for
their services when furnished as Medicare telehealth services from the distant site.
Eligible The waiver of these requirements expands the types of health care professionals that
can furnish distant site telehealth services to include all those that are eligible to bill Yes Yes Yes Yes Yes
Practitioners
Medicare for their professional services. This allows health care professionals who
were previously ineligible to furnish and bill for Medicare telehealth services, including
physical therapists, occupational therapists, speech language pathologists, and
others, to receive payment for Medicare telehealth services.
CMS is waiving the Medicare requirement that a physician or non-physician
practitioner must be licensed in the State in which s/he is practicing for individuals for
whom the following four conditions are met: 1) must be enrolled as such in the
Practitioner Medicare program, 2) must possess a valid license to practice in the State which
Yes Yes Yes Yes Yes
Locations relates to his or her Medicare enrollment, 3) is furnishing services – whether in person
or via telehealth – in a State in which the emergency is occurring in order to contribute
to relief efforts in his or her professional capacity, and 4) is not affirmatively excluded
from practice in the State or any other State that is part of the 1135 emergency area.
Allowing FQHCs FQHCs and RHCs may serve as distant site practitioners to furnish telehealth
and RHCs to services. Medicare pays for these telehealth services based on payment rates similar
Serve as Distant to the national average payment rates for comparable telehealth services under the Yes Yes No No No
Sites for Medicare Physician Fee Schedule. These services are excluded from both the FQHC
Telehealth prospective payment system and the RHC all-inclusive rate calculation.
Physician Visits
in SNFs/ CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician
practitioners to perform in-person visits for nursing home residents and allow visits to No No No No Yes
Nursing
be conducted, as appropriate, via telehealth options.
Facilities
May 2021 3
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Telehealth and Other Virtual Services
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving the requirements of section 1834(m)(1) of the Social Security Act and
Audio-Only 42 CFR § 410.78(a)(3) for use of interactive telecommunications systems to furnish
telehealth services, to the extent they require use of video technology, for certain
Telehealth for Yes Yes Yes Yes Yes
services. This waiver allows the use of audio-only equipment to furnish services
Certain Services
described by the codes for audio-only telephone evaluation and management
services, and behavioral health counseling and educational services.
**Non-Physician During the COVID-19 PHE, non-physician practitioners who are eligible to bill
Medicare directly, including registered dietitians and nutrition professionals, may bill
Practitioner Yes Yes Yes Yes No
for audio-only telephone assessment and management services: CPT codes 98966-
Billing (revised)
98968 (Dates of service on or after March 1 until the end of the PHE).
When a physician or non-physician practitioner who typically furnishes professional
services in the hospital outpatient department furnishes telehealth services during the
Hospital COVID-19 PHE, they bill with a hospital outpatient place of service since that is likely
Outpatient Fees where the services would have been furnished if not for the COVID-19 PHE. The
Accompanying 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
Professional No No Yes Yes No
overhead since those things are usually supplied by the hospital outpatient
Services
department. During the COVID-19 PHE, if the beneficiary’s home or temporary
Furnished Via expansion site is considered to be a provider-based department of the hospital, and
Telehealth the beneficiary is registered as an outpatient of the hospital for purposes of receiving
telehealth services billed by the physician or practitioner, the hospital may bill under
the PFS for the originating site facility fee associated with the telehealth service.
May 2021 4
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Hospital Without Walls (Temporary Expansion Sites)
CMS Hospital Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
As part of the CMS Hospital Without Walls initiative, hospitals can provide hospital
Hospitals Able services in other healthcare facilities and sites that would not otherwise be considered
to Provide Care to be part of a healthcare facility (such facilities would be re-enrolled as hospitals); or
No No Yes Yes No
in Temporary can set up temporary expansion sites to help address the urgent need to increase
Expansion Sites capacity to care for patients. In the absence of waivers, hospitals are generally
required to provide services to patients within their hospital departments.
CMS is waiving the enforcement of section 1867(a) of the Social Security Act (the
Off Site Patient Emergency Medical Treatment and Active Labor Act, or EMTALA). This will allow
hospitals, psychiatric hospitals, and CAHs to screen patients at a location offsite from No No Yes Yes No
Screening
the hospital’s campus to prevent the spread of COVID-19, so long as it is not
inconsistent with the state emergency preparedness or pandemic plan.
CMS is waiving certain specific paperwork requirements under this section only for
hospitals which are considered to be impacted by a widespread outbreak of COVID-
19. This allows hospitals to establish COVID-19 specific areas. Hospitals that are
located in a state that has widespread confirmed cases would not be required to meet
the following requirements:
Paperwork
• 42 CFR §482.13(d)(2) with respect to timeframes in providing a copy of a medical No No No Yes No
Requirements
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.
CMS is waiving certain physical environment requirements under the Medicare
conditions of participation at 42 CFR §482.41 and 42 CFR §485.623 to allow for
increased flexibilities for surge capacity and patient quarantine at hospitals,
psychiatric hospitals, and CAHs as a result of COVID-19. CMS will permit facility and
Physical non-facility space that is not normally used for patient care to be utilized for patient
Environment care or quarantine, provided the location is approved by the state (ensuring that No No Yes Yes No
(Hospitals) safety and comfort for patients and staff are sufficiently addressed) 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.
May 2021 5
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Hospital Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
For the duration of the PHE related to COVID-19, CMS is 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 establish and operate as part of the hospital any location meeting
the conditions of participation for hospitals in operation during the PHE. This waiver
also allows hospitals to change the status of their current provider-based department
Hospital locations to the extent necessary to address the needs of hospital patients as part of
Outpatient: Use the state or local pandemic plan. CMS also is offering some additional flexibilities to
furnish inpatient services under arrangements. These changes include: 5
of Provider-
• Adopting a temporary extraordinary circumstances relocation exception policy for
Based No No Yes Yes No
on-campus PBDs and excepted off-campus PBDs that are relocating off-campus
Departments as during the COVID-19 PHE. Under our existing extraordinary relocation exception
Temporary policy, only relocating off-campus PBDs are eligible to request this exception.
Expansion Sites • Streamlining the process during the COVID-19 PHE for relocating PBDs to seek
the extraordinary circumstances exception so they can start seeing patients and
billing for services immediately in the relocated PBD.
• Allowing PBDs to relocate into more than one PBD location, and allowing PBDs to
partially relocate while still maintaining the original location. Hospitals can relocate
PBDs to the patient’s home and continue to receive the full OPPS payment
amount under the extraordinary circumstances relocation exception policy.
CAH Length of CMS is waiving the Medicare requirements that CAHs limit the number of beds to 25,
and that the length of stay be limited to 96 hours under the Medicare conditions of No No Yes No No
Stay
participation regarding number of beds and length of stay at 42 CFR §485.620.
CMS is waiving the requirement at 485.610(b) that the CAH be located in a rural area
or an area being treated as rural, allowing the CAHs flexibility in the establishment of
surge site locations. Waiving the requirement at 485.610(e) regarding off-campus and
CAH Status and co-location requirements allows the CAH flexibility in establishing off-site locations. In
No No Yes No No
Location an effort to facilitate the establishment of CAHs without walls, these waivers will
remove restrictions on CAHs regarding their rural location and their location relative to
other hospitals and CAHs. These flexibilities should be implemented so long as it is
not inconsistent with State or emergency or pandemic plan.
5
More information on this flexibility can be found here: https://www.cms.gov/files/document/covid-19-regulations-waivers-enable-health-system-
expansion.pdf
May 2021 6
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Hospital Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
Housing Acute CMS is waiving requirements to allow acute care hospitals to house acute care
Care Patients in inpatients in excluded distinct part units, where the distinct part unit’s beds are
appropriate for acute care inpatients. The Inpatient Prospective Payment System
Excluded No No No Yes No
(IPPS) hospital should bill for the care and annotate the patient’s medical record to
Distinct Part
indicate the patient is an acute care inpatient being housed in the excluded unit
Units because of capacity issues related to the disaster or emergency.
CMS is waiving the provisions related to telemedicine for hospitals and CAHs at 42
CFR 482.12(a)(8)-(9) and 42 CFR 485.616(c), making it easier for telemedicine
Telemedicine services to be furnished to the hospital’s patients through an agreement with an off- No No Yes Yes No
site hospital. This allows for increased access to necessary care for hospital and CAH
patients, including access to specialty care.
Inspection,
Testing & CMS is waiving certain physical environment requirements for Hospitals, CAHs,
Maintenance inpatient hospice, ICF/IIDs, and SNFs/NFs to reduce disruption of patient care and
(ITM) under the potential exposure/transmission of COVID-19. The physical environment regulations
No No Yes Yes Yes
Physical require that facilities and equipment be maintained to ensure an acceptable level of
Environment safety and quality. CMS will permit facilities to adjust scheduled inspection, testing
Conditions of and maintenance (ITM) frequencies and activities for facility and medical equipment.
Participation
Hospital-Only
Remote Hospitals may bill for services furnished remotely by hospital-based practitioners to
Outpatient Medicare patients registered as hospital outpatients, including when the patient is at
home when the home is serving as a temporary provider based department of the No No Yes Yes No
Therapy and
hospital. Examples of such services include counseling and educational services as
Education well as therapy services.
Services
Hospital clinical staff must furnish certain services such as infusions and wound care
in person given the nature of the services. Under interim final regulations and
Hospitals without Walls:
Hospital Only • the beneficiary’s home can be considered a provider-based department of the
hospital for purposes of receiving outpatient services and the beneficiary would be
Clinical Staff In- No No Yes Yes No
registered as a hospital outpatient.
Person Services
• the hospital may bill for these services as hospital outpatient services, provided
the PBD is an on campus or excepted off-campus PBD that relocated to the
patient’s home consistent with the extraordinary circumstances relocation
exception policy.
May 2021 7
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Hospital Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
Under section 1135(b)(1) of the Act, CMS is 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
Expanded additional options for hospitals with patients who no longer require acute care but are
Ability for unable to find placement in a SNF. This waiver applies to all Medicare enrolled
Hospitals to hospitals, except psychiatric and long term care hospitals that need to provide post-
hospital SNF level swing-bed services for nonacute care patients in hospitals, so long No No No Yes No
Offer Long-term
as the waiver is not inconsistent with the state’s emergency preparedness or
Care Services pandemic plan. The hospital shall not bill for SNF PPS payment using swing beds
(“Swing-Beds”) when patients require acute level care or continued acute care at any time while this
waiver is in effect. This waiver is permissible for swing bed admissions during the
COVID-19 PHE with an understanding that the hospital must have a plan to discharge
swing bed patients as soon as practicable, when a SNF bed becomes available, or
when the PHE ends, whichever is earlier.
Hospitals CMS is waiving certain eligibility requirements at 42 CFR § 412.92(a) for hospitals
Classified as classified as SCHs prior to the PHE. Specifically, CMS is waiving the distance
Sole Community requirements at paragraphs (a), (a)(1), (a)(2), and (a)(3) of 42 CFR § 412.92, and is No No No Yes No
Hospitals also waiving the “market share” and bed requirements (as applicable) at 42 CFR §
(SCHs) 412.92(a)(1)(i) and (ii).
Hospitals
Classified as For hospitals classified as MDHs prior to the PHE, CMS is waiving the eligibility
Medicare- requirement at 42 CFR § 412.108(a)(1)(ii) that the hospital has 100 or fewer beds
during the cost reporting period, and the eligibility requirement at 42 CFR §
Dependent, No No No Yes No
412.108(a)(1)(iv)(C) that at least 60 percent of the hospital's inpatient days or
Small Rural
discharges were attributable to individuals entitled to Medicare Part A benefits during
Hospitals the specified hospital cost reporting periods.
(MDHs)
May 2021 8
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Hospital Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving and modifying particular waivers under 42 CFR §482.41(b) for
hospitals; §485.623(c) for CAHs; §418.110(d) for inpatient hospice; §483.470(j) for
ICF/IIDs and §483.90(a) for SNF/NFs. Specifically, CMS is modifying these
Specific Life requirements as follows:
Safety Code Alcohol-based Hand-Rub (ABHR) Dispensers: We are waiving the prescriptive
(LSC) for requirements for the placement of alcohol based hand rub (ABHR) dispensers for use
Multiple by staff and others due to the need for the increased use of ABHR in infection control.
Providers: However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and No No Yes Yes Yes
Alcohol-based there are restrictions on the storage and location of the containers. This includes
Hand-Rub restricting access by certain patient/resident population to prevent accidental
(ABHR) 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
Dispensers
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; §485.623(c)(5) for CAHs; §418.110(d)(4) for inpatient hospice;
§483.470(j)(5)(ii) for ICF/IIDs and §483.90(a)(4) for SNF/NFs.
CMS is waiving and modifying particular waivers under 42 CFR §482.41(b) for
hospitals; §485.623(c) for CAHs; §418.110(d) for inpatient hospice; §483.470(j) for
Specific Life ICF/IIDs and §483.90(a) for SNF/NFs. Specifically, CMS is modifying these
Safety Code requirements as follows:
(LSC) for Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff No No Yes Yes Yes
Multiple together, we will instead permit a documented orientation training program related to
Providers: the current fire plan, which considers current facility conditions. The training will
Fire Drills 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.
May 2021 9
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Hospital Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is executing an innovative Acute Hospital Care At Home program, providing
eligible hospitals with unprecedented regulatory flexibilities to treat eligible patients in
their homes. 6 This program was developed to support models of at-home hospital
care throughout the country that have seen prior success in several leading hospital
institutions and networks, and reported in academic journals, including a major study
funded by a Healthcare Innovation Award from the Center for Medicare and Medicaid
Innovation. The program clearly differentiates the delivery of acute hospital care at
**Acute Hospital home from more traditional home health services. While home health care provides
important skilled nursing and other skilled care services, Acute Hospital Care at Home
Care at Home No No Yes No Yes
is for beneficiaries who require acute inpatient admission to a hospital and who
(added)
require at least daily rounding by a physician and a medical team monitoring their
care needs on an ongoing basis. To support these efforts, CMS has launched an
online portal to streamline the waiver request process and allow hospitals and
healthcare systems to submit the necessary information to ensure they meet the
program’s criteria to participate. 7 CMS will also closely monitor the program to
safeguard beneficiaries by requiring hospitals to report quality and safety data to CMS
on a frequency that is based on their prior experience with the Hospital At Home
model.
6
An approved list of hospitals can be found here: https://www.cms.gov/files/document/covid-acute-hospital-care-home-program-approved-list-hospitals.pdf
7
More information is available at the online portal here: https://qualitynet.cms.gov/acute-hospital-care-at-home
May 2021 10
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Facility Without Walls (Temporary Expansion Sites)
CMS Facility Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving the requirements at 42 CFR §491.5(a)(3)(iii) which require RHCs and
Temporary FQHCs be independently considered for Medicare approval if services are furnished
Expansion in more than one permanent location. Due to the current PHE, CMS is temporarily
Locations for waiving this requirement removing the location restrictions to allow flexibility for Yes Yes No No No
RHCs and existing RHCs/FQHCs to expand services locations to meet the needs of Medicare
FQHCs beneficiaries. This flexibility includes areas which may be outside of the location
requirements 42 CFR §491.5(a)(1) and (2) for the duration of the PHE.
Bed Count for RHCs that are provider-based to a hospital with fewer than 50 beds are exempt from
Provider-Based the national RHC payment limit. For the duration of the PHE, the number of beds prior
Yes No No No No
RHCs and RHC to the start of the PHE will be the official hospital bed count for application of this
Payment Limit policy so that hospitals are not discouraged from increasing bed capacity if needed.
CMS is waiving requirements related at 42 CFR 483.90, specifically the following:
• Provided that the state has approved the location as one that sufficiently
addresses safety and comfort for patients and staff, CMS is waiving requirements
under § 483.90 to allow for a non-SNF building to be temporarily certified and
available for use by a SNF in the event there are needs for isolation processes for
COVID-19 positive residents, which may not be feasible in the existing SNF
structure to ensure care and services during treatment for COVID-19 are available
while protecting other vulnerable adults.
• CMS believes this will also provide another measure that will free up inpatient care
Physical beds at hospitals for the most acute patients while providing beds for those still in
Environment need of care. CMS will waive certain conditions of participation and certification
No No No No Yes
(Long-Term requirements for opening a NF if the state determines there is a need to quickly
Care Facilities) stand up a temporary COVID-19 isolation and treatment location.
• CMS is also waiving requirements under 42 CFR 483.90 to temporarily allow for
rooms in a long-term care facility not normally used as a resident’s room, to be
used to accommodate beds and residents for resident care in emergencies and
situations needed to help with surge capacity. Rooms that may be used for this
purpose include activity rooms, meeting/conference rooms, dining rooms, or other
rooms, as long as residents can be kept safe, comfortable, and other applicable
requirements for participation are met. This can be done so long as it is not
inconsistent with a state’s emergency preparedness or pandemic plan, or as
directed by the local or state health department.
May 2021 11
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Facility Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving the requirements in 42 CFR 483.10(e) (5) and (7) solely for the
purposes of grouping or cohorting residents with respiratory illness symptoms and/or
residents with a confirmed diagnosis of COVID-19, and separating them from
**Resident residents who are asymptomatic or tested negative for COVID-19. This action waives
Roommates and a facility’s requirements, under 42 CFR 483.10, to provide for a resident to share a
No No No No Yes
Grouping room with his or her roommate of choice in certain circumstances, to provide notice
(revised) and rationale for changing a resident’s room, and to provide for a resident’s refusal a
transfer to another room in the facility.
Effective May 10, 2021, waived requirements in §483.10 (e)(6) were terminated.
CMS is waiving requirements in 42 CFR 483.10(c)(5); 483.15(c)(3), (c)(5)(i) and (iv),
(c)(9), and (d) (with some exceptions) to allow a long term care facility to transfer or
discharge residents to another LTC facility solely for the following cohorting purposes:
• Transferring residents with symptoms of a respiratory infection or confirmed
diagnosis of COVID-19 to another facility that agrees to accept each specific
resident, and is dedicated to the care of such residents;
• Transferring residents without symptoms of a respiratory infection or confirmed to
**Resident not have COVID-19 to another facility that agrees to accept each specific resident,
Transfer and and is dedicated to the care of such residents to prevent them from acquiring
No No No No Yes
Discharge COVID-19, as well as providing treatment or therapy for other conditions as
(revised) required by the resident’s plan of care; or
• Transferring residents without symptoms of a respiratory infection to another
facility that agrees to accept each specific resident to observe for any signs or
symptoms of a respiratory infection over 14 days.
Effective May 9, 2021, waived requirements in § 483.21(a)(1)(i), (a)(2)(i), and (b) (2)(i)
were terminated. Effective May 10, 2021, waived requirements in § 483.10 (c)(4)(ii)
were terminated.
May 2021 12
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
CMS Facility Without Walls (Temporary Expansion Sites)
Flexibility Description RHC FQHC CAH Hospital SNF
A long term care (LTC) facility can temporarily transfer its COVID-19 positive
resident(s) to another facility, such as a COVID-19 isolation and treatment location,
with the provision of services “under arrangements.” The transferring LTC facility
need not issue a formal discharge in this situation, as it is still considered the provider
and should bill Medicare normally for each day of care. The transferring LTC facility is
then responsible for reimbursing the other provider that accepted its resident(s) during
Transfers of the emergency period. If the LTC facility does not intend to provide services under
COVID-19 arrangement, the COVID-19 isolation and treatment facility is the responsible entity No No No No Yes
Patients for Medicare billing purposes. The SNF should follow the procedures described in
40.3.4 of the Medicare Claims Processing Manual to submit a discharge bill to
Medicare. The COVID-19 isolation and treatment facility should then bill Medicare
appropriately for the type of care it is providing for the beneficiary. If the COVID-19
isolation and treatment facility is not yet an enrolled provider, the facility should enroll
through the provider enrollment hotline for the Medicare Administrative Contractor
that services their geographic area to establish temporary Medicare billing privileges.
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Patients Over Paperwork
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving the requirements of 42 CFR §482.23, §482.24 and §485.635(d)(3) to
Verbal Orders allow for additional flexibilities related to verbal orders where read-back verification is No No Yes Yes No
still required but authentication may occur later than 48 hours.
CMS is 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
Reporting process but who required soft wrist restraints to prevent pulling tubes/IVs, may be
No No No Yes No
Requirements 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.
CMS is waiving detailed regulatory requirements to provide information regarding
discharge planning, as outlined in 42 CFR §482.43(a)(8), §482.61(e), and
485.642(a)(8). The hospital, psychiatric hospital, and CAH must assist patients, their
families, or the patient’s representative in selecting a post-acute care provider by
using and sharing data that includes, but is not limited to, home health agency (HHA),
SNF, inpatient rehabilitation facility (IRF), and long term care hospital (LTCH) data on
Limit Discharge quality measures and data on resource use measures. The hospital must ensure that
Planning for the post acute care data on quality measures and data on resource use measures is
No No Yes Yes No
Hospital and relevant and applicable to the patient’s goals of care and treatment preferences.
CAHs During this PHE, a hospital may not be able to assist patients in using quality
measures and data to select a nursing home or home health agency, but must still
work with families to ensure that the patient discharge is to a post-acute care provide
that is able to meet the patient’s care needs. CMS is maintaining the discharge
planning requirements that ensure a patient is discharged to an appropriate setting
with the necessary medical information and goals of care as described in 42 CFR
§482.43(a)(1)-(7) and (b).
May 2021 14
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Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving certain 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
Modify various areas of the country. CMS is waiving certain requirements for those patients
Discharge discharged home and referred for HHA services, or for those patients transferred to a
No No No Yes No
Planning for SNF for post-hospital extended care services, or transferred to an IRF or LTCH for
Hospitals specialized hospital services. CMS is maintaining the discharge planning
requirements that ensure a patient is discharged to an appropriate setting with the
necessary medical information and goals of care as described in 42 CFR
§482.43(a)(1)-(7) and (b).
CMS is waiving the discharge planning requirement in §483.21(c)(1)(viii), which
Detailed requires LTC facilities to assist residents and their representatives in selecting a post-
Information acute care provider using data, such as standardized patient assessment data, quality
Sharing for measures and resource use. CMS is maintaining all other discharge planning
Discharge requirements, such as but not limited to, ensuring that the discharge needs of each No No No No Yes
Planning for resident are identified and result in the development of a discharge plan for each
Long-Term Care resident; involving the interdisciplinary team, as defined at 42 CFR §483.21(b)(2)(ii),
Facilities in the ongoing process of developing the discharge plan address the resident's goals
of care and treatment preferences.
CMS is 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
Medical form and content of the medical record, and record retention requirements. CMS is
waiving requirements under 42 CFR §482.24(c)(4)(viii) and §485.638(a)(4)(iii) related No No Yes Yes No
Records
to medical records to allow flexibility in completion of medical records within 30 days
following discharge and for CAHs that all medical records must be promptly
completed.
Pursuant to section 1135(b)(5) of the Act, CMS is modifying the requirement at 42
CFR §483.10(g)(2)(ii) which requires long-term care (LTC) facilities to provide a
Clinical Records resident a copy of their records within two working days (when requested by the No No No No Yes
resident). Specifically, CMS is modifying the timeframe requirements to allow LTC
facilities ten working days to provide a resident’s record rather than two working days.
May 2021 15
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Patients Over Paperwork
Flexibility Description RHC FQHC CAH Hospital SNF
Flexibility in
Patient Self
Determination CMS is 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
Act No No Yes Yes No
Medicare, which require hospitals and CAHs to provide information about its advance
Requirements
directive policies to patients.
(Advance
Directives)
Per requirements at section 1886(d)(10)(C)(ii) of the Social Security Act (the Act) and
Postponement 42 CFR 412.256(a)(2), September 1, 2020 is the deadline to submit an application to
of Application the Medicare Geographic Classification Review Board (MGCRB) for FY 2022
Deadline to the reclassifications. These provisions require applications to be filed through OH CDMS 8
Medicare not later than the first day of the 13-month period preceding the Federal fiscal year for No No No Yes No
Geographic which reclassification is requested. Due to the COVID-19 PHE, under the authority of
Classification section 1135(b)(5) of the Act, CMS is postponing the September 1 deadline until 15
Review Board days after the public display date of the FY 2021 IPPS/LTCH final rule by the Office of
the Federal Register.
CMS is waiving these requirements at 42 CFR §482.1(a)(3) and 42 C.F.R §482.30,
that requires that hospitals participating in Medicare and Medicaid to have a utilization
review plan that meets specified requirements. CMS is waiving the entire Utilization
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 No No No Yes No
Review
Medicare and Medicaid beneficiaries to evaluate the medical necessity of the
admission, duration of stay, and services provided. These flexibilities should be
implemented so long as they are not inconsistent with a State or pandemic/
emergency plan.
CMS is waiving 482.21(a)-(d) and (f), and 485.641(a), (b), and (d), which provide
Quality details on the scope of the program, the incorporation, and setting priorities for the
Assurance and program’s performance improvement activities, and integrated QAPI programs (for
Performance hospitals that are a part of a hospital system). These flexibilities, which apply to both
hospitals and CAHs, should be implemented so long as they are not inconsistent with No No Yes Yes No
Improvement
a state’s emergency preparedness or pandemic plan. While this waiver decreases
Program burden associated with the development of a hospital or CAH QAPI program, the
(Hospitals) requirement that hospitals and CAHs maintain an effective, ongoing, hospital-wide,
data driven quality assessment and performance improvement program will remain.
8
Applications can be filed here: https://www.cms.gov/Regulations-and-Guidance/Review-Boards/MGCRB/Electronic-Filing
May 2021 16
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Patients Over Paperwork
Flexibility Description RHC FQHC CAH Hospital SNF
Quality
Assurance and CMS is modifying certain requirements in 42 CFR §483.75, which requires long-term
Performance care facilities to develop, implement, evaluate, and maintain an effective,
Improvement comprehensive, data driven QAPI program. Specifically, CMS is modifying No No No No Yes
Program §483.75(b)–(d) and (e)(3) to the extent necessary to narrow the scope of the QAPI
(Long-Term program to focus on adverse events and infection control.
Care Facilities)
CMS is 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
Nursing under to have a registered nurse present. In addition, we expect that hospitals will
No No Yes Yes No
Services need relief for the provision of inpatient services and as a result, the requirement to
establish nursing-related policies and procedures for outpatient departments is likely
unnecessary. These flexibilities apply to both hospitals and CAHs, and should be
implemented so long as they are not inconsistent with a State or
pandemic/emergency plan.
CMS is waiving the requirement at 42 CFR 482.28(b)(3) to have a current therapeutic
Food and diet manual approved by the dietitian and medical staff readily available to all medical,
nursing, and food service personnel. Such manuals would not need to be maintained No No No Yes No
Dietetic Service
at surge capacity sites. These flexibilities should be implemented so long as they are
not inconsistent with a State or pandemic/emergency plan.
Written Policies CMS is waiving 482.12(f)(3) related to Emergency services, with respect to the surge
and Procedures facility(ies) only, such that written policies and procedures for staff to use when
for Appraisal of evaluating emergencies are not required for surge facilities. This removes the burden
Emergencies at on facilities to develop and establish additional policies and procedures at their surge No No No Yes No
Off Campus facilities or surge sites related to the assessment, initial treatment and referral of
Hospital patients. These flexibilities should be implemented so long as they are not
Departments inconsistent with a state’s emergency preparedness or pandemic plan.
May 2021 17
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Patients Over Paperwork
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving 482.15(b) and 485.625(b), which requires the hospital and CAH to
develop and implement emergency preparedness policies and procedures, and
Emergency 482.15(c)(1)-(5) and 485.625(c)(1)-(5) which requires that the emergency
Preparedness preparedness communication plans for hospitals and CAHs to contain specified
elements with respect to the surge site. The requirement under the communication No No Yes Yes No
Policies and
plan requires hospitals and CAHs to have specific contact information for staff,
Procedures entities providing services under arrangement, patients’ physicians, other hospitals
and CAHs, and volunteers. This would not be an expectation for the temporary
expansion site.
CMS is delaying the filing deadline of certain cost report due dates due to the COVID-
19 outbreak. We are currently authorizing delay 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 will be June
Cost Reporting Yes Yes Yes Yes Yes
30, 2020. CMS will also delay the filing deadline of the FYE 12/31/2019 cost reports
due by May 31, 2020. The revised extended cost report due date for FYE 12/31/2019
will be August 31, 2020. For the FYE 01/31/2020 cost report, the extended due date
is August 31, 2020. For the FYE 02/29/2020 cost report, the extended due date is
September 30, 2020.
This waiver of the requirement for a 3-day prior hospitalization for coverage of a SNF
3-day Prior stay provides temporary emergency coverage of SNF services without a qualifying
Hospitalization hospital stay, for those people who are evacuated, transferred, or otherwise
No No No No Yes
for Coverage of dislocated as a result of the effect of disaster or emergency. In addition, for certain
a SNF Stay beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF
coverage without first having to start a new benefit period.
**Reporting
Minimum Data (This waiver was terminated effective May 10, 2021) CMS is waiving 42 CFR §483.20
to provide relief to SNFs on the timeframe requirements for Minimum Data Set No No No No Yes
Set for SNFs
assessments and transmission.
(revised)
May 2021 18
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Patients Over Paperwork
Flexibility Description RHC FQHC CAH Hospital SNF
Extension for CMS collects data every 3 years on the occupational mix of employees for each
Inpatient short-term, acute care hospital participating in the Medicare program. CMS originally
Prospective granted an extension for hospitals nationwide affected by COVID-19 until August 3,
Payment 2020. Due to continued COVID-19 related concerns from hospitals about meeting this
System (IPPS) deadline, CMS is further extending this deadline to September 3, 2020. Hospitals No No No Yes No
Wage Index must submit their occupational mix surveys along with complete supporting
Occupational documentation to their MACs by no later than September 3, 2020. Hospitals may then
Mix Survey submit revisions to their occupational mix surveys to their Medicare Administrative
Submission Contractors (MACs), if needed, by no later than September 10, 2020.
Waive Pre- CMS is waiving 42 CFR 483.20(k), allowing nursing homes to admit new residents
Admission who have not received Level 1 or Level 2 Preadmission Screening. Level 1
Screening and assessments may be performed postadmission. On or before the 30th day of
No No No No Yes
Annual Resident admission, new patients admitted to nursing homes with a mental illness (MI) or
Review intellectual disability (ID) should be referred promptly by the nursing home to State
(PASARR) PASARR program for Level 2 Resident Review.
CMS is waiving the requirements at 42 CFR 483.10(f)(5), which ensure residents can
Resident participate in-person in resident groups. This waiver would only permit the facility to
restrict in-person meetings during the national emergency given the No No No No Yes
Groups
recommendations of social distancing and limiting gatherings of more than ten
people.
CMS is modifying the nurse aide training requirements at §483.95(g)(1) for SNFs and
In-Service NFs, which requires the nursing assistant to receive at least 12 hours of in-service
training annually. In accordance with section 1135(b)(5) of the Act, CMS is postponing No No No No Yes
Training
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.
May 2021 19
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Patients Over Paperwork
Flexibility Description RHC FQHC CAH Hospital SNF
The Interoperability and Patient Access final rule includes policies that impact a
Relaxed variety of stakeholders. Recognizing that hospitals, including psychiatric hospitals and
Enforcement of CAHs, are on the frontlines of the COVID-19 PHE, CMS is extending the
Certain implementation timeline for the admission, discharge, and transfer notification CoPs
by an additional 6 months. In the version of the rule displayed on March 9, 2020 on
Interoperability No No Yes Yes No
the CMS website, it stated these CoPs would be effective 6 months after the
and Patient
publication of the final rule in the Federal Register. We have changed this in the final
Access Final rule now displayed on the Federal Register to state that the new CoPs at 42 CFR
Rule Policies Parts 482 and 485 will now be effective 12 months after the final rule is published in
the Federal Register.
The physician self-referral law (also known as the “Stark Law”) prohibits a physician
from making referrals for certain healthcare services payable by Medicare if the
physician (or an immediate family member) has a financial relationship with the entity
performing the service. There are statutory and regulatory exceptions, but in short, a
physician cannot refer a patient to any entity with which he or she has a financial
“Stark Law” relationship. On March 30, 2020, CMS issued blanket waivers of certain provisions of
Yes Yes Yes Yes Yes
Waivers the Stark Law regulations. These blanket waivers apply to financial relationships and
referrals that are related to the COVID-19 emergency. The remuneration and referrals
described in the blanket waivers must be solely related to COVID-19 Purposes, as
defined in the blanket waiver document. Under the waivers, CMS will permit certain
referrals and the submission of related claims that would otherwise violate the Stark
Law. 9
CMS has established toll-free hotlines for all providers as well as the following
Provider flexibilities for provider enrollment:
• Waive certain screening requirements. Yes Yes Yes Yes Yes
Enrollment
• Postpone all revalidation actions.
• Expedite any pending or new applications from providers.
Relief in Quality CMS is granting exceptions from reporting requirements and extensions for clinicians
Reporting and providers participating in Medicare quality reporting programs with respect to No No Yes Yes Yes
Programs upcoming measure reporting and data submission for those programs.
9
More information on this flexibility can be found here: https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Spotlight
May 2021 20
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
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Flexibility Description RHC FQHC CAH Hospital SNF
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued
by providers (including independent laboratories, home health agencies, and
hospices), physicians, practitioners, and suppliers to Original Medicare (fee for
Advance service - FFS) beneficiaries in situations where Medicare payment is expected to be
Beneficiary denied. The ABN is issued to transfer potential financial liability to the Medicare
Notice of beneficiary in certain instances. [Note: Skilled nursing facilities (SNFs) issue the ABN
to transfer potential financial liability for items/services expected to be denied under Yes Yes Yes Yes Yes
Noncoverage
Medicare Part B only.] The ABN, Form CMS-R-131, and instructions have been
(ABN) Use approved by the Office of Management and Budget (OMB) for renewal. Due to
Extension COVID-19 concerns, CMS has expanded the deadline for use of the renewed ABN,
Form CMS-R-131 (exp. 6/30/2023). At this time, the renewed ABN will be mandatory
for use on 1/1/2021. The renewed form may be implemented prior to the mandatory
deadline.
Volume CMS will not enforce the procedural volume requirements contained in the NCDs for
Requirements percutaneous left atrial appendage closure, transcatheter aortic valve replacement,
for Certain transcatheter mitral valve replacement, and ventricular assist devices for facilities and
National providers that, prior to the PHE for COVID-19, met the volume requirements. This No No Yes Yes No
Coverage enforcement discretion ensures that beneficiaries will continue to have access to the
Determinations services that are covered under these NCDs and applies only during the period of the
(NCDs) PHE for COVID-19.
CMS is not enforcing signature and proof of delivery requirements for Part B drugs
Signature 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 No No Yes Yes No
Requirements
appropriate date of delivery and that a signature was not able to be obtained because
of COVID-19. 10
10
More information on this flexibility can be found here: https://www.cms.gov/files/document/se20011.pdf
May 2021 21
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
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Flexibility Description RHC FQHC CAH Hospital SNF
Hospital Value-
Based
Purchasing CMS has the ability to grant exceptions to hospitals located in entire regions or
(VBP) locales, which could include the entire United States, without an ECE request form
where we determine that the extraordinary circumstance has affected the entire
Program’s No No No Yes No
region or locale. CMS is granting an exception for certain HVBP reporting
Extraordinary
requirements in light of the COVID-19 PHE as specified in the March 27, 2020
Circumstances guidance memo. 11
Exceptions
(ECE) Policy
11
The guidance memo can be found here: https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-
based-purchasing-programs.pdf
May 2021 22
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Workforce
Workforce
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving the Medical Staff requirements at 42 CFR §482.22(a)(1)-(4) to allow
for physicians whose privileges will expire to continue practicing at the hospital and
Medical Staff for new physicians to be able to practice in the hospital before full medical
No No No Yes No
Requirements staff/governing body review and approval to address workforce concerns related to
COVID-19. CMS is waiving §482.22(a) (1)-(4) regarding details of the credentialing
and privileging process.
CMS is waiving 482.12(c), which requires that Medicare patients be under the care of
Physician a physician. This allows hospitals to use other practitioners, such as physician’s
assistant and nurse practitioners to the fullest extent possible. This waiver should be No No No Yes No
Services
implemented so long as they are not inconsistent with a state’s emergency
preparedness or pandemic plan.
CMS is waiving requirements under 42 CFR §482.52(a)(5), §485.639(c) (2), and
§416.42 (b)(2) that a certified registered nurse anesthetist (CRNA) is under the
supervision of a physician in paragraphs §482.52(a)(5) and §485.639(c)(2). CRNA
Anesthesia supervision will be at the discretion of the hospital and state law. This waiver applies
No No Yes Yes No
Services to hospitals, CAHs, and Ambulatory Surgical Centers (ASCs). These waivers will
allow CRNAs to function to the fullest extent of their licensure, and may be
implemented so long as they are not inconsistent with a state’s emergency
preparedness or pandemic plan.
CMS is waiving the requirement at 42 CFR 482.57(b)(1) that hospitals designate in
Respiratory writing the personnel qualified to perform specific respiratory care procedures and the
amount of supervision required for personnel to carry out specific procedures. These No No No Yes No
Care Services
flexibilities should be implemented so long as they are not inconsistent with a State or
pandemic/emergency plan.
CMS is waiving the minimum personnel qualifications for clinical nurse specialist,
nurse practitioners, and physician assistants described at 42 CFR 485.604 (a)(2), 42
CAH Minimum CFR 485.604 (b)(1-3), and 42 C.F.R 485.604 (c)(1-3). Clinical Nurse Specialists,
Nurse Practitioners, and Physician Assistants will still have to meet state
Personnel No No Yes No No
requirements for licensure and scope of practice, but not additional Federal
Qualifications
requirements that may exceed State requirements. These flexibilities should be
implemented so long as they are not inconsistent with a State or
pandemic/emergency plan.
May 2021 23
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Workforce
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is deferring to staff licensure, certification, or registration to State law by waiving
the requirement at 42 CFR 485.608(d) that staff of the CAH be licensed, certified, or
CAH Staff registered in accordance with applicable Federal, State, and local laws and
regulations. The CAH and its staff must still be in compliance with applicable Federal,
Licensure No No Yes No No
State and Local laws and regulations, and all patient care must be furnished in
Deferral
compliance with State and local laws and regulations. These flexibilities should be
implemented so long as they are not inconsistent with a State or
pandemic/emergency plan.
For services requiring direct supervision by the physician or other practitioner, that
Medicare physician supervision can be provided virtually using real-time audio/video
Physician technology. Also, “direct” physician supervision is no longer required for non-surgical
extended duration therapeutic services provided in hospital outpatient departments Yes Yes Yes Yes No
Supervision
and CAHs. Instead, a physician can provide a general level of supervision for these
Requirements services so that a physician is no longer required to be immediately available in the
office suite.
CMS waives the Medicare requirement that a physician or non-physician practitioner
must be licensed in the State in which s/he is practicing for individuals for whom the
following four conditions are met: 1) must be enrolled as such in the Medicare
Practitioner program, 2) must possess a valid license to practice in the State which relates to his
Yes Yes Yes Yes No
Locations or her Medicare enrollment, 3) is furnishing services – whether in person or via
telehealth – in a State in which the emergency is occurring in order to contribute to
relief efforts in his or her professional capacity, and 4) is not affirmatively excluded
from practice in the State or any other State that is part of the 1135 emergency area.
CMS is waiving hospital sterile compounding requirements (also outlined in USP797)
at 42CFR §482.25(b)(1) and §485.635(a)(3) to allow used face masks to be removed
Sterile and retained in the compounding area to be re-donned and reused during the same
No No Yes Yes No
Compounding work shift in the compounding area only. This will conserve scarce face mask
supplies. CMS will not be reviewing the use and storage of facemasks under these
requirements.
Home Nursing RHCs and FQHCs can provide visiting nursing services to a beneficiary’s home with
Yes Yes No No No
Visits fewer requirements, making it easier for homebound beneficiaries to receive care.
May 2021 24
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Workforce
Flexibility Description RHC FQHC CAH Hospital SNF
42 C.F.R. § 485.631(b)(2). CMS is waiving the requirement for CAHs that a Doctor of
Medicine or osteopathy be physically present to provide medical direction,
consultation, and supervision for the services provided in the CAH at § 485.631(b)(2).
Responsibilities CMS is retaining the regulatory language in the second part of the requirement at §
485.631(b)(2) that a physician be available “through direct radio or telephone
of Physicians in No No Yes No No
communication, or electronic communication for consultation, assistance with medical
CAHs
emergencies, or patient referral.” Retaining this longstanding CMS policy and related
longstanding sub regulatory guidance that further described communication between
CAHs and physicians will assure an appropriate level of physician direction and
supervision for the services provided by the CAH.
42 CFR 491.8(a)(6). CMS is waiving the requirement in the second sentence of §
Certain Staffing 491.8(a)(6) that a nurse practitioner, physician assistant, or certified nurse-midwife be
Requirements available to furnish patient care services at least 50 percent of the time the RHC
operates. CMS is not waiving the first sentence of § 491.8(a)(6) that requires a Yes Yes No No No
for RHCs and
physician, nurse practitioner, physician assistant, certified nurse midwife, clinical
FQHCs social worker, or clinical psychologist to be available to furnish patient care services at
all times the clinic or center operates.
42 C.F.R. 491.8(b)(1). CMS is modifying the requirement that physicians must provide
medical direction for the clinic’s or center’s health care activities and consultation for,
Physician and medical supervision of, the health care staff, only with respect to medical
Supervision of supervision of nurse practitioners, and only to the extent permitted by state law. The
Yes Yes No No No
NPs in RHCs physician, either in person or through telehealth and other remote communications,
and FQHCs continues to be responsible for providing medical direction for the clinic or center’s
health care activities and consultation for the health care staff, and medical
supervision of the remaining health care staff.
May 2021 25
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Workforce
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is waiving the requirements at 42 CFR 483.35(d) (with the exception of 42 CFR
483.35(d)(1)(i)), which require that a SNF and NF may not employ anyone for longer
than four months unless they met the training and certification requirements under §
483.35(d). CMS is waiving these requirements to assist in potential staffing shortages
Training and seen with the COVID-19 pandemic. To ensure the health and safety of nursing home
residents, CMS is not waiving 42 CFR § 483.35(d)(1)(i), which requires facilities to not
Certification of No No No No Yes
use any individual working as a nurse aide for more than four months, on a full-time
Nurse Aides
basis, unless that individual is competent to provide nursing and nursing related
services. We further note that we are not waiving § 483.35(c), which requires facilities
to ensure that nurse aides are able to demonstrate competency in skills and
techniques necessary to care for residents’ needs, as identified through resident
assessments, and described in the plan of care.
42 C.F.R. 483.30(e)(4). CMS is waiving the requirement in § 483.30(e)(4) that
prevents a physician from delegating a task when the regulations specify that the
physician must perform it personally. This waiver gives physicians the ability to
delegate any tasks to a physician assistant, nurse practitioner, or clinical nurse
Physician specialist who meets the applicable definition in 42 C.F.R. 491.2 or, in the case of a
Delegation of clinical nurse specialist, is licensed as such by the State and is acting within the No No No No Yes
Tasks in SNFs scope of practice laws as defined by State law. We are temporarily modifying this
regulation to specify that any task delegated under this waiver must continue to be
under the supervision of the physician. This waiver does not include the provision of §
483.30(e)(4) that prohibits a physician from delegating a task when the delegation is
prohibited under State law or by the facility’s own policy.
42 C.F.R. 483.30(c)(3). CMS is waiving the requirement at § 483.30(c)(3) that all
required physician visits (not already exempted in § 483.30(c)(4) and (f)) must be
Physician Visits made by the physician personally. We are modifying this provision to permit
physicians to delegate any required physician visit to a nurse practitioner (NPs), No No No No Yes
in SNFs
physician assistant, or clinical nurse specialist who is not an employee of the facility,
who is working in collaboration with a physician, and who is licensed by the State and
performing within the state’s scope of practice laws.
May 2021 26
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Workforce
Flexibility Description RHC FQHC CAH Hospital SNF
Modification of CMS is modifying the 60-day limit in section 1842(b)(6)(D)(iii) of the Social Security
60-Day Limit for Act to allow a physician or physical therapist to use the same substitute for the entire
Substitute time he or she is unavailable to provide services during the COVID-19 emergency
plus an additional period of no more than 60 continuous days after the PHE expires. Yes Yes Yes Yes No
Billing
On the 61st day after the PHE ends (or earlier if desired), the regular physician or
Arrangements physical therapist must use a different substitute or return to work in his or her
(Locum Tenens) practice for at least one day in order to reset the 60-day clock.
National
Coverage
Determinations To the extent NCDs and LCDs require a specific practitioner type or physician
specialty to furnish or supervise a service, during this PHE, the Chief Medical Officer
(NCDs) and No No Yes Yes No
or equivalent of a hospital or facility will have the authority to make those staffing
Local Coverage
decisions. 12
Determinations
(LCDs)
Requirement to Under the new 483.80(h) CMS is requiring Long-Term Care (LTC) Facilities to test
Conduct Testing Staff and Residents. Specifically, facilities are required to test residents and staff,
No No No No Yes
for Staff and including individuals providing services under arrangement and volunteers, for
Residents COVID-19 based on parameters set forth by the Secretary.
CMS is working to increase the number of providers that will administer a COVID-19
vaccine to Medicare beneficiaries when it becomes available, to make it as
convenient as possible for America’s seniors. New providers are now able to enroll as
Providers who a “Medicare mass immunizers” through an expedited 24-hour process. The ability to
can Administer easily enroll as a mass immunizer is important for some pharmacies, schools, and
other entities that may be non-traditional providers or otherwise not eligible for Yes Yes Yes Yes Yes
the COVID-19
Medicare enrollment. To further increase the number of providers who can administer
Vaccine the COVID -19 vaccine, CMS will continue to share approved Medicare provider
information with states to assist with Medicaid provider enrollment efforts. CMS is also
making it easier for newly enrolled Medicare providers also to enroll in state Medicaid
programs to support state administration of vaccines for Medicaid recipients.
12
More information on this flexibility can be found here: https://www.cms.gov/files/document/covid-final-ifc.pdf
May 2021 27
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Workforce
Flexibility Description RHC FQHC CAH Hospital SNF
CMS is modifying the requirements at 42 CFR §§ 483.60(h)(1)(i) and 483.160(a)
regarding required training of paid feeding assistants. Specifically, CMS is modifying
the minimum timeframe requirements in these sections, which require this training to
be a minimum of 8 hours. CMS is modifying to allow that the training can be a
Paid Feeding minimum of 1 hour in length. CMS is not waiving any other requirements under 42
No No No No Yes
Assistants CFR §483.60(h) related to paid feeding assistants or the required training content at
42 CFR §483.160(a)(1)-(8), which contains infection control training and other
elements. Additionally, CMS is also not waiving or modifying the requirements at 42
CFR §483.60(h)(2)(i), which requires that a feeding assistant must work under the
supervision of a registered nurse (RN) or licensed practical nurse (LPN).
May 2021 28
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Payment
Payment
Flexibility Description RHC FQHC CAH Hospital SNF
In order to provide additional cash flow to healthcare providers and suppliers
impacted by COVID-19, CMS expanded and streamlined the Accelerated and
Advance Payments Program, which provided conditional partial payments to
providers and suppliers to address disruptions in claims submission and/or claims
processing subject to applicable safeguards for fraud, waste and abuse. Under this
program, CMS made successful payment of over $100 billion to healthcare providers
and suppliers. As of April 26, 2020, CMS is reevaluating all pending and new
applications for the Accelerated Payment Program and has suspended the Advance
Payment Program, in light of direct payments made available through the Department
of Health & Human Services’ (HHS) Provider Relief Fund. Distributions made through
**Accelerated/ the Provider Relief Fund do not need to be repaid. For providers and suppliers who
have received accelerated or advance payments related to the COVID-19 PHE, CMS
Advance
will not pursue recovery of these payments until 120 days after the date of payment Yes Yes Yes Yes Yes
Payments
issuance. Providers and suppliers with questions regarding the repayment of their
(revised) accelerated or advance payment(s) should contact their appropriate Medicare
Administrative Contractor (MAC). On October 8, 2020, CMS announced amended
terms for payments issued under the Accelerated and Advance Payment (AAP)
Program as required by Congress. This Medicare loan program allows CMS to make
advance payments to providers and are typically used in emergency situations. Under
the Continuing Appropriations Act, 2021 and Other Extensions Act repayment will
now begin one year from the issuance date of each provider or supplier’s accelerated
or advance payment.
Repayment of COVID-19 Accelerated and Advance Payments began on March 30,
2021.
In an Interim Final Rule with Comment Period (IFC) issued October 28, 2020, CMS
Price implemented the CARES Act requirement that providers of a diagnostic test for
Transparency COVID-19 to make public the cash price for such tests on their websites. Providers
without websites will be required to provide price information in writing within two Yes Yes Yes Yes No
for COVID-19
business days upon request and on a sign posted prominently at the location where
Testing 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.
May 2021 29
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Payment
Flexibility Description RHC FQHC CAH Hospital SNF
Enhanced In order to mitigate potential financial disincentives for hospitals to provide new
Medicare COVID-19 treatments hospital during the COVID-19 PHE, the Medicare program will
Payments for provide an enhanced payment for eligible inpatient cases that involve use of certain
new products authorized or approved to treat COVID-19. The enhanced payment will
New COVID-19 No No Yes Yes No
be equal to the lesser of: (1) 65 percent of the operating outlier threshold for the
Treatments:
claim; or (2) 65 percent of the cost of a COVID-19 stay beyond the operating
Hospital Medicare payment (including the 20 percent add-on payment under section 3710 of
Inpatient Stays the CARES Act) for eligible cases.
Enhanced CMS wants to mitigate potential financial disincentives for hospitals to provide new
Medicare COVID-19 treatments provided in a hospital outpatient setting during the COVID-19
Payments for PHE. Therefore, in this IFC, CMS has excluded FDA-authorized or approved drugs
New COVID-19 and biologicals (including blood products) authorized or approved to treat or prevent
No No Yes Yes No
Treatments: COVID-19 from being packaged into the Comprehensive Ambulatory Payment
Hospital Classification (C-APC) payment when these treatments are billed on the same claim
Outpatient as a primary C-APC service. Instead, Medicare will pay for these drugs and
Departments biologicals separately throughout the course of the PHE.
The CARES Act temporarily lifted the Medicare sequester, which reduces payments
**Temporary to providers by 2 percent, from May 1 through December 31, 2020, boosting
Suspension of payments for hospital, physician, nursing home, home health, and other care. 13 The
Medicare Consolidated Appropriations Act, 2021, signed into law on December 27, 2020, Yes Yes Yes Yes Yes
Sequestration extended the suspension period to March 31, 2021. An Act to Prevent Across-the-
(revised) Board Direct Spending Cuts, and for Other Purposes, signed into law on April 14,
2021, extends the suspension period to December 31, 2021.
Add-on The CARES Act increased the payment that would otherwise be made to a hospital
Payment for 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
Inpatient No No No Yes No
COVID-19 diagnosis to enable better surveillance as well as trigger appropriate
Hospital COVID-
payment for these complex patients. This add-on payment would be available through
19 Patients the duration of the COVID-19 emergency period.
13
More information on this flexibility can be found here: https://www.finance.senate.gov/imo/media/doc/CARES%20Act%20Section-by-
Section%20(Finance%20Health).pdf
May 2021 30
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Payment
Flexibility Description RHC FQHC CAH Hospital SNF
On February 13 and March 5, CMS announced new HCPCS codes for healthcare
providers and laboratories to test patients for SARS-CoV2. Healthcare providers
using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus
Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly
created HCPCS code (U0001). A second new HCPCS code (U0002) 2019-nCoV
COVID-19 Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or
subtypes (includes all targets), non-CDC can also be used by laboratories and
Diagnostic Yes Yes Yes Yes Yes
healthcare facilities. Both codes can be used to bill Medicare as well as by other
Codes 14
health insurers that choose to utilize and accept the code. Effective April 1, 2020, for
dates of service on or after February 4, 2020. Additionally, the AMA created CPT
code 87635 for infectious agent detection by nucleic acid tests as well as CPT codes
86769 and 86328 for serology tests. Laboratories performing these tests may bill
Medicare for services that occurred after their respective effective dates. There is no
cost-sharing for Medicare patients. 15
CMS announced Medicare will nearly double payment for certain lab tests that use
High-Production high-throughput technologies to rapidly diagnose large numbers of 2019 Novel
Coronavirus Coronavirus (COVID-19) cases. 17 CMS created the new HCPCS codes U0003 and Yes Yes Yes Yes Yes
Lab Tests 16 U0004 so that laboratories conducting testing that uses high-throughput technology
can bill at this rate for dates of service on or after April 14, 2020.
Antibody During the PHE, Medicare will cover FDA-authorized COVID-19 serology testing (a
(Serology) diagnostic test) for beneficiaries with known current or known prior COVID-19 Yes Yes Yes Yes Yes
Tests 18 infection or suspected current or suspected past COVID-19 infection. 19
14
The “COVID-19 Diagnostic Codes” flexibility applies only to Clinical Laboratory Improvement Amendments of 1988 (CLIA)-certified labs.
15
More information and test pricing can be found here: https://www.cms.gov/files/document/mac-covid-19-test-pricing.pdf
16
The “High-Production Coronavirus Lab Tests” flexibility applies only to Clinical Laboratory Improvement Amendments of 1988 (CLIA)-certified labs.
17
The CMS announcement can be found here: https://www.cms.gov/newsroom/press-releases/cms-increases-medicare-payment-high-production-
coronavirus-lab-tests-0
18
The “Antibody (Serology Tests)” flexibility applies only to Clinical Laboratory Improvement Amendments of 1988 (CLIA)-certified labs.
19
More information can be found here: https://www.medicare.gov/coverage/coronavirus-disease-2019-covid-19-antibody-test
May 2021 31
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Payment
Flexibility Description RHC FQHC CAH Hospital SNF
CMS announced that Medicare beneficiaries can receive coverage of monoclonal
antibodies to treat COVID-19 with no cost-sharing during the PHE. CMS’s coverage
of monoclonal antibody infusions applies to bamlanivimab, which received an
emergency use authorization (EUA) from the U.S. Food and Drug Administration. 20
Starting March 24, 2021, the U.S. Government, in coordination with Eli Lilly and
Company, stopped distributing bamlanivimab alone due to a sustained increase in
COVID-19 viral variants in the U.S. that are resistant to bamlanivimab when
administered alone. Instead of administering bamlanivimab alone, health care
providers should consider using the other authorized monoclonal antibody therapies
expected to retain activity against the viral variants: (1) Casirivimab and imdevimab,
administered together; (2) Bamlanivimab and etesevimab, administered together.
**COVID-19 On May 6, 2021, CMS increased the Medicare payment rate for administering
Antibody monoclonal antibodies to treat beneficiaries with COVID-19, continuing coverage
Yes Yes Yes Yes Yes
Treatment under the Medicare Part B COVID-19 vaccine benefit. Beneficiaries pay nothing out of
(revised) pocket, regardless of where the service is furnished – including in a physician’s office,
healthcare facility or at home. The national average payment rate will increase from
$310 to $450 for most health care settings. In support of providers’ efforts to prevent
the spread of COVID-19, CMS will also establish a higher national payment rate of
$750 when monoclonal antibodies are administered in the beneficiary’s home,
including the beneficiary’s permanent residence or temporary lodging (e.g.,
hotel/motel, cruise ship, hostel, or homeless shelter). The new national payment rate
for at-home administration of monoclonal antibodies accounts for increased costs
associated with the one-on-one nature of this care model. These higher national
average payment rates reflect additional information provided to CMS about the costs
of providing these services in a safe and timely manner, such as clinical staff and
personal protective equipment. This action also means Medicare payments to
providers and suppliers will be more aligned to their costs to administer these
products.
COVID-19 Medicare will pay independent laboratories that send trained technicians to a
Diagnostic beneficiary’s home, including a nursing home, to collect a sample for COVID-19 No No No No Yes
Testing diagnostic testing. Medicare will pay a collection fee and for the travel.
20
More information on this flexibility can be found here: https://www.cms.gov/files/document/covid-medicare-monoclonal-antibody-infusion-program-
instruction.pdf
May 2021 32
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Payment
Flexibility Description RHC FQHC CAH Hospital SNF
Enforcement
Discretion
Relating to CMS will allow Medicare-enrolled immunizers, including but not limited to pharmacies
working with the United States, to bill directly and receive direct reimbursement from No No No No Yes
Certain
the Medicare program for vaccinating Medicare SNF residents. 21
Pharmacy
Billing
In response to the COVID-19 PHE, CMS is implementing 12 new procedure codes to
describe the introduction or infusion of therapeutics, including remdesivir and
convalescent plasma, into the International Classification of Diseases, Tenth
Revision, Procedure Coding System (ICD-10-PCS), effective August 01, 2020. These
new codes, which go into effect August 1, will enable CMS to conduct real-time
**Procedure surveillance and obtain real-world evidence in how these drugs are working and
provide critical information on their effectiveness and how they can protect patients.
Codes for
These codes can be reported to Medicare and other insurers may also use the codes No No Yes Yes No
Therapeutics
to identify the use of COVID-19 therapies and help facilitate monitoring and data
(revised) collection on their use.
On November 30, 2020, CMS implemented 21 new procedure codes to describe the
introduction or infusion of therapeutics, including monoclonal antibodies and vaccines
for COVID-19 treatment, into the International Classification of Diseases, Tenth
Revision, Procedure Coding System (ICD-10-PCS), also effective January 01, 2021.
In general, Medicare covers reasonable and necessary laboratory tests with zero
patient cost sharing. CMS specifically instructed Medicare Administrative Contactors
Medicare and notified Medicare Advantage plans to cover COVID-19 laboratory tests in nursing
Coverage of homes. Starting on July 6, 2020, and for the duration of the PHE, consistent with
COVID-19 sections listed below of CDC guidelines titled, “Interim SARS-CoV-2 Testing
Testing for Guidelines for Nursing Home Residents and Healthcare Personnel,” Original
Medicare and Medicare Advantage plans will cover diagnostic COVID-19 lab tests No No No No Yes
Nursing Home
and non-cover tests not considered diagnostic. 22
Residents • Viral Testing of Residents for SARS-CoV-2
(Medicare • Initial Viral Testing in Response to an Outbreak
Advantage) • Recommended testing to determine resolution of infection with SARS-CoV-2
• Public health surveillance for SARS-CoV-2 Tests that are considered non-
diagnostic are not covered.
21
More information can be found here: https://www.cms.gov/files/document/snf-enforcement-discretion-letter.pdf
22
The CMS guidance can be found here: https://www.cms.gov/files/document/hpms-memo-diagnostic-testing-nursing-home-residents-and-patients-
coronavirus-disease-2019.pdf
May 2021 33
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Payment
Flexibility Description RHC FQHC CAH Hospital SNF
On October 28, 2020, CMS released an IFC establishing that any vaccine that
receives Food and Drug Administration (FDA) authorization, through an Emergency
Use Authorization (EUA) or licensed under a Biologics License Application (BLA), will
be covered under Medicare as a preventive vaccine at no cost to beneficiaries. The
IFC also implements provisions of the CARES Act that ensure swift coverage of a
COVID-19 vaccine by most private health insurance plans without cost sharing from
both in and out-of-network providers during the course of the PHE. The Medicare
payment rates for COVID-19 vaccine administration will be $28.39 to administer
single-dose vaccines. For a COVID-19 vaccine requiring a series of 2 or more doses,
the initial dose(s) administration payment rate will be $16.94, and $28.39 for the
administration of the final dose in the series. These rates will be geographically
**COVID-19 adjusted and recognize the costs involved in administering the vaccine, including the
Vaccine additional resources involved with required public health reporting, conducting
important outreach and patient education, and spending additional time with patients
Medicare Yes Yes Yes Yes Yes
answering any questions they may have about the vaccine. Medicare beneficiaries,
Payment
those in Original Medicare or enrolled in Medicare Advantage, will be able to get the
(revised) vaccine at no cost. For calendar years 2020 and 2021, Medicare will pay directly for
the COVID-19 vaccine and its administration for beneficiaries enrolled in Medicare
Advantage (MA) plans. Providers should submit COVID-19 claims to Original
Medicare for all patients enrolled in MA in 2020 and 2021. MA plans will not be
responsible for reimbursing providers to administer the vaccine during this time. MA
beneficiaries also pay nothing for COVID-19 vaccines and their
copayment/coinsurance and deductible are waived.
CMS increased the Medicare payment amount for administering the COVID-19
vaccine. Effective for COVID-19 vaccines administered on or after March 15, 2021,
the national average payment rate for physicians, hospitals, pharmacies and many
other immunizers will be $40 to administer each dose of a COVID-19 vaccine.
May 2021 34
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Payment
Flexibility Description RHC FQHC CAH Hospital SNF
Starting April 16, in addition to screening your patients, you can check Medicare
eligibility for COVID-19 vaccine administration history from Fee-for-Service (FFS)
claims paid for calendar years 2020 and 2021. This includes Medicare Advantage
patients. You can get the following eligibility information for each paid vaccine
**COVID-19 administration claim:
Vaccine: Check • CPT or HCPCS codes
Medicare • Date of service Yes Yes Yes Yes No
Eligibility • National provider identifier for who administered the vaccine
(added)
We can only provide this information if the provider billed Medicare for administering
the vaccine. If your patients got vaccinated and the provider didn’t submit a Medicare
claim (like if they got vaccinated at a free event), ask your patients about their COVID-
19 vaccination history.
May 2021 35
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Data Reporting
Data Reporting
Flexibility Description RHC FQHC CAH Hospital SNF
Requirement for Hospitals and CAHs are to report information in accordance with a frequency and in a
Hospitals and standardized format as specified by the Secretary during the PHE for COVID-19. 23
Failure to report the specified data needed to support broader surveillance of COVID- No No Yes Yes No
CAHs to Report
19 may lead to the imposition of the remedy to terminate a provider’s participation
COVID-19 Data from the Medicare and Medicaid programs.
Under §483.80(g), long-term care facilities are required to report COVID-19 cases in
their facility to the CDC National Health Safety Network (NHSN) on a weekly basis.
CDC and CMS will use information collected through the new NHSN Long-term Care
COVID-19 Module to strengthen COVID-19 surveillance locally and nationally;
monitor trends in infection rates; and help local, state, and federal health authorities
get help to nursing homes faster. Nursing home reporting to the CDC is a critical
component of the national COVID-19 surveillance system and to efforts to reopen
Required America. The information will also be posted online for the public to be aware of how
the COVID-19 pandemic is affecting nursing homes. In the August 21, 2020 Interim
Facility No No No No Yes
Final Rule with Comment Period, CMS is codifying enforcement actions for facilities
Reporting
noncompliance with this requirement. Failure to report will result in the imposition of a
civil money penalty for each occurrence of non-reporting as follows: A civil money
penalty of $1,000 for the first occurrence, followed by $500 added to the previously
imposed civil money penalty for each subsequent occurrence, not to exceed the
maximum amount set forth in § 488.408(d)(1)(iii). Facilities are also required to notify
residents, their representatives, and families of residents in facilities of the status of
COVID-19 in the facility, which includes any new cases of COVID-19 as they are
identified.
23
More information can be found here: https://www.hhs.gov/sites/default/files/covid-19-faqs-hospitals-hospital-laboratory-acute-care-facility-data-
reporting.pdf
May 2021 36
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Data Reporting
Flexibility Description RHC FQHC CAH Hospital SNF
On May 11, 2021, CMS published an interim final rule with comment period (IFC).
This rule establishes Long-Term Care (LTC) Facility Vaccine Immunization
**COVID-19 Requirements for Residents and Staff. This includes new requirements for educating
Vaccine residents or resident representatives and staff regarding the benefits and potential
Immunization side effects associated with the COVID-19 vaccine, and offering the vaccine.
Requirements Furthermore, LTC facilities must report COVID-19 vaccine and therapeutics treatment No No No No Yes
for Residents information to the Centers for Disease Control and Prevention’s (CDC) National
and Staff Healthcare Safety Network (NHSN). CMS will post the new information reported to
(added) the NHSN for viewing by facilities, stakeholders, or the general public on CMS’s
COVID-19 Nursing Home Data website. CMS has also updated tools used by
surveyors to assess compliance with these new requirements.
May 2021 37
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Additional Guidance
Additional Guidance
Resource Description RHC FQHC CAH Hospital SNF
COVID-19 FAQs CMS released a Frequently Asked Questions (FAQs) document to supplement
on Medicare previously released FAQs: 1135 Waiver FAQs and Without 1135 Waiver FAQs. The
Yes Yes Yes Yes Yes
Fee-for-Service supplemental document can be found here:
(FFS) Billing https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf
COVID-19 CMS released a Frequently Asked Questions (FAQs) document regarding provider
Provider Burden burden relief, which can be found here: https://www.cms.gov/files/document/provider- Yes Yes Yes Yes No
Relief FAQs burden-relief-faqs.pdf
Standards of CMS released a document providing guidance on infection control and prevention
Practice and related to COVID-19. The guidance was targeted towards hospitals, psychiatric
No No Yes Yes No
Flexibilities for hospitals, CAHs, nursing homes, and outpatient providers, among others, and can be
Hospitals found here: https://www.cms.gov/files/document/qso-20-13-hospitals-cahs-revised.pdf
Standards of
Practice and CMS released a document providing guidance on infection control and prevention
related to COVID-19 in outpatient settings. The document includes FAQs and other
Flexibilities for Yes Yes No No No
considerations, and can be found here: https://www.cms.gov/files/document/qso-20-
Outpatient
22-asc-corf-cmhc-opt-rhc-fqhcs.pdf
Settings
Standards of
Practice for
Infection CMS released additional guidance for nursing homes to help them improve their
infection control and prevention practices to prevent transmission of COVID-19. The
Control and No No No No Yes
guidance can be found here: https://www.cms.gov/files/document/3-13-2020-nursing-
Prevention of
home-guidance-covid-19.pdf
COVID-19 in
Nursing Homes
Hospital CMS released guidance on the Emergency Medical Treatment and Labor Act
(EMTALA) requirements for hospitals and CAHs, including screening obligations and
Flexibilities No No Yes Yes No
stabilization, transfer, and recipient hospital obligations. The guidance can be found
under EMTALA
here: https://www.cms.gov/files/document/qso-20-15-hospital-cah-emtala-revised.pdf
May 2021 38
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Additional Guidance
Resource Description RHC FQHC CAH Hospital SNF
CMS issued a set of Frequently Asked Questions (FAQs) clarifying requirements and
considerations for hospitals and other providers related to EMTALA during the
FAQs for COVID-19 pandemic. The FAQs address questions around patient presentation to the
Hospitals and Emergency Department, EMTALA applicability across facility types, qualified medical
No No Yes Yes No
CAHs regarding professionals, medical screening exams, patient transfer and stabilization, and
EMTALA telehealth, among others. The document can be found here:
https://www.cms.gov/files/document/frequently-asked-questions-and-answers-emtala-
part-ii.pdf
Requirements CMS announced new regulatory requirements that will require nursing homes to
for Notification inform residents, their families, and representatives of COVID-19 cases in their
of Confirmed facilities. In addition, CMS will now require nursing homes to report cases of COVID-
COVID-19 19 directly to the Centers for Disease Control and Prevention (CDC). This information
No No No No Yes
Among must be reported in accordance with existing privacy regulations and statute. Finally,
Resident and CMS will also require nursing homes to fully cooperate with CDC surveillance efforts
Staff in Nursing around COVID-19 spread. More information can be found here:
Homes https://www.cms.gov/files/document/qso-20-29-nh.pdf
Millions of COVID-19 vaccinations have been administered to nursing home residents
**Nursing Home and staff, and these vaccines have been shown to help prevent symptomatic SARS-
Visitation CoV-2 infection (i.e., COVID-19). Therefore, CMS, in conjunction with the Centers for
Disease Control and Prevention (CDC), is updating its visitation guidance accordingly, No No No No Yes
Guidance
but emphasizing the importance of maintaining infection prevention practices, given
(revised) the continued risk of COVID-19 transmission. The guidance can be found here:
https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf
Medicare
Payments for CMS released a presentation that summarizes Medicare payments for COVID-19 viral
COVID-19 Viral testing in skilled nursing facilities and nursing facilities. The presentation can be found
No No No No Yes
Testing in here: https://www.cms.gov/files/document/covid-medicare-payment-covid-19-viral-
SNFs/Nursing testing-flow-chart.pdf
Facilities
May 2021 39
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Additional Guidance
Resource Description RHC FQHC CAH Hospital SNF
COVID-19
Survey CMS is initiating a performance-based funding requirement tied to the CARES Act
Activities, supplemental grants for State Survey Agencies. Further, CMS is providing guidance
CARES Act for the limited resumption of routine survey activities. CMS is also enhancing the
Funding, penalties for noncompliance with infection control to provide greater accountability
Enhanced and consequence for failures to meet these basic requirements. The enhanced
Enforcement for enforcement actions are more significant for nursing homes with a history of past
infection control deficiencies, or that cause actual harm to residents or Immediate No No No No Yes
Infection
Jeopardy. Quality Improvement Organizations have been strategically refocused to
Control assist nursing homes in combating COVID-19 through such efforts as education and
deficiencies, training, creating action plans based on infection control problem areas and
and Quality recommending steps to establish a strong infection control and surveillance program.
Improvement More information can be found here: https://www.cms.gov/files/document/qso-20-31-
Activities in all.pdf
Nursing Homes
SNF Quality CMS released a tip sheet designed to assist SNF providers in understanding the
Reporting status of the SNF Quality Reporting Program during the COVID-19 PHE. The
document also provides is practical guidance to address quality data submission
Program COVID- No No No No Yes
requirements starting July 1, 2020 now that the temporary QRP exemptions from the
19 PHE Tip
COVID-19 PHE have ended. The tip sheet can be found here:
Sheet https://www.cms.gov/files/document/snfqrp-covid19phetipsheet-july2020.pdf
FAQs on
COVID-19 CMS released a Frequently Asked Questions (FAQs) document regarding COVID-19
testing at SNFs and nursing homes. The document can be found here: No No No No Yes
Testing at
https://www.cms.gov/files/document/covid-faqs-snf-testing.pdf
SNFs/NFs
CMS is encouraging clinicians who participate in the Quality Payment Program
(QPP), such as physicians, physician assistants, nurse practitioners, and others, to
contribute to scientific research and evidence to fight the COVID-19 pandemic.
Reporting of Clinicians may now earn credit in the Merit-based Incentive Payment System (MIPS),
COVID-19 a performance-based track of QPP that incentivizes quality and value, for participation
Clinical Trial in a clinical trial and reporting clinical information by attesting to the new COVID-19
Data through Clinical Trials improvement activity. This action will provide vital data to help drive Yes Yes Yes Yes No
the Quality improvement in patient care and develop innovative best practices to manage the
Payment spread of COVID-19 within communities. CMS has updated the Quality Reporting
Program Document Architecture (QRDA) Category III Implementation Guide to include
information for eligible clinicians on this new activity, which can be found here:
https://ecqi.healthit.gov/sites/default/files/2021-CMS-QRDA-III-Eligible-Clinicians-and-
EP-IG-508.pdf
May 2021 40
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Additional Guidance
Resource Description RHC FQHC CAH Hospital SNF
CMS published a memorandum, outlining changes to the Nursing Home 5 Star
Nursing Home Quality Rating System and Nursing Home Staff Counts. For CMS's Nursing Home
5 Star Quality Compare website and Nursing Home Five Start Quality Rating System, CMS is
Rating System holding the inspection domain constant temporarily due to the prioritization and
suspension of certain surveys to ensure the rating system reflects fair information for No No No No Yes
updates and
consumers. CMS is also publishing a list of the average number of nursing and total
Nursing Home staff that work onsite in each nursing home, each day, which will help direct adequate
Staff Counts PPE and testing to nursing homes. The document can be found here:
https://www.cms.gov/files/document/qso-20-34-nh.pdf
**Nursing Home
Series for Front CMS is released the first episode in a series of short podcasts for frontline nursing
home staff “CMS Beyond the Policy”. The edition is titled “Nursing Home Series for
Line Clinicians No No No No Yes
Front Line Clinicians and Staff.” The episode can be found here:
and Staff
https://www.cms.gov/podcast/nursing-home-series-front-line-clinicians-and-staff
(added)
**Coverage of
Monoclonal CMS released the Coverage of Monoclonal Antibody Products to Treat COVID-19
Antibody infographic. The infographic can be found here:
No No Yes Yes Yes
Products to https://www.cms.gov/files/document/covid-infographic-coverage-monoclonal-
Treat COVID-19 antibody-products-treat-covid-19.pdf
(added)
COVID-19 COVID-19 vaccine toolkits for providers, private health plans and state Medicaid
Yes Yes Yes Yes Yes
Vaccine Toolkits programs can be found here: www.cms.gov/covidvax
New COVID 19
Testing and CMS released a document describing new testing and reporting requirements for
nursing homes, hospitals, and CLIA-certified labs. The toolkit can be found here: Yes Yes Yes Yes Yes
Reporting
https://www.cms.gov/files/document/covid-ppt-nh-all-call.pdf
Requirements
May 2021 41
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Additional Guidance
Resource Description RHC FQHC CAH Hospital SNF
CMS regulations for Emergency Preparedness require specific testing exercises be
conducted to validate the facility’s emergency program. During or after an actual
Emergency emergency, the regulations allow for an exemption to the testing requirements based
Preparedness on real world actions taken by providers and suppliers. CMS developed a worksheet
Testing that presents guidance for surveyors, as well as providers and suppliers, with relevant
scenarios on meeting the testing requirements in light of many of the response No No Yes Yes No
Exercise
activities associated with the COVID-19 PHE. The worksheet and additional guidance
Requirements can be found here: https://www.cms.gov/medicareprovider-enrollment-and-
Guidance certificationsurveycertificationgeninfopolicy-and-memos-states-and/guidance-related-
emergency-preparedness-testing-exercise-requirements-coronavirus-disease-2019-
covid
COVID-19
Guidance and CMS compiled nursing home guidance in the form of: memos; non-memos; waivers
Updates for and flexibilities; and data releases. The guidance can be found here:
No No No No Yes
Nursing Homes https://www.cms.gov/files/document/covid-guidance-and-updates-nursing-homes-
during COVID- during-covid-19.pdf
19
CMS released tools to reduce burdensome paperwork and authorization delays for
Tools to laboratories seeking CLIA certification to test for COVID-19. CMS’s quick-start guide
Streamline helps laboratories with the application process for CLIA certification and includes
information on the expedited review process implemented at the beginning of the
Certification for Yes Yes Yes Yes No
PHE that allows labs to start COVID-19 testing before the official paper certificate
Labs Testing for
arrives by postal mail. More information can be found here:
COVID-19 https://www.cms.gov/files/document/laboratory-quick-start-guide-cms-clia-
certification.pdf
**New Platform CMS announced a new web-based tool to assist Medicare/Medicaid-participating
for Submissions providers and suppliers in submission of 1135 Waiver requests and inquiries. With
very limited exception, the new web system should be used for all 1135 waiver
of 1135 Waiver Yes Yes Yes Yes Yes
requests and/or PHE-related inquiries submitted on or after January 11, 2021. The
Requests and
platform can be found here:
Inquiries (added) https://cmsqualitysupport.servicenowservices.com/cms_1135
May 2021 42
Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Additional Guidance
Resource Description RHC FQHC CAH Hospital SNF
CMS released a toolkit developed to aid nursing homes, Governors, states,
departments of health, and other agencies who provide oversight and assistance to
Nursing Homes these facilities, with additional resources to aid in the fight against the COVID-19
Best Practices pandemic within nursing homes. The toolkit is comprised of best practices from a
variety of frontline health care providers, Governors' COVID-19 task forces,
Toolkit to No No No No Yes
associations and other organizations, and experts, and is intended to serve as a
Combat
catalogue of resources dedicated to addressing the specific challenges facing nursing
COVID-19 homes as they combat COVID-19. The toolkit can be found here:
https://www.cms.gov/files/document/covid-toolkit-states-mitigate-covid-19-nursing-
homes.pdf
CMS hosts recurring stakeholder engagement sessions to share information related
CMS COVID-19 to the agency's response to COVID-19. These sessions are open to members of the
Stakeholder healthcare community and are intended to provide updates, share best practices
among peers, and offer attendees an opportunity to ask questions of CMS and other Yes Yes Yes Yes Yes
Engagement
subject matter experts. Recordings of these sessions are publicly available for those
Calls unable to attend, and can be found here: https://www.cms.gov/Outreach-and-
Education/Outreach/OpenDoorForums/PodcastAndTranscripts
CMS Office of
Minority Health CMS OMH has compiled Federal resources on the 2019 Novel Coronavirus (COVID-
(CMS OMH): 19) to assist its partners who work with those most vulnerable--such as older adults,
those with underlying medical conditions, racial and ethnic minorities, rural
COVID-19 Yes Yes Yes Yes Yes
communities, and people with disabilities. Those resources can be found here:
Resources on
https://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/COVID-
Vulnerable 19-Resources
Populations
Interim Final CMS regularly updates a webpage that includes Interim Final Rules, waivers, and
provider-specific fact sheets related to COVID-19, which can be found here:
Rules and Yes Yes Yes Yes Yes
https://www.cms.gov/about-cms/emergency-preparedness-response-
Waivers
operations/current-emergencies/coronavirus-waivers
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Rural Crosswalk: CMS Flexibilities to Fight COVID-19
Document Last Updated: May 2021
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- www.cms.gov