Submit an 1135 Waiver/Flexibility Request

Summary

Quick reference guide titled Submit an 1135 Waiver/Flexibility Request. It states that, with very limited exception, the new web system should be used for all 1135 waiver requests and PHE-related inquiries submitted on or after January 11, 2021, and that waiver requests related to the Physician Self-Referral (Stark Law) should not be submitted through the web portal. It walks through the form in steps: selecting the Public Health Emergency, providing contact and organization information including CMS identification numbers, describing the waiver or flexibility request type, and submitting the form. It states that submitting displays a confirmation message with a Case number and sends an email confirmation.

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Full text

                      QUICK REFERENCE GUIDE
         Submit an 1135 Waiver/Flexibility Request
With very limited exception, the new web system should be used for all 1135 waiver requests and/or
PHE-related inquiries submitted on or after January 11, 2021. Waiver requests related to the Physician
Self-Referral (Stark Law) should not be submitted via the new web portal. For these requests, please
visit: https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Spotlight for additional
information.

      Please complete all fields on the form in the order they appear, as outlined in the
      4 simple steps below. There are several optional fields. However, your form will be
      more easily processed if you complete them.
      Keyboard-only users can use the Tab key to move from field to field, the arrow keys to
      navigate to the item they wish to select, and the space bar to make a selection.
      A Submit button will appear at the bottom of the form once you have completed all the
      required fields. Required fields are marked with (required)* following the field name.

      If you need additional information about a field, hover over the question mark icon           to
      the right of the field.




Using either of the two recommended browsers (Google Chrome or Mozilla Firefox),
navigate to the web portal at:
                               CMS PHE Emergency Web Portal
Microsoft Edge and Safari are also supported browsers.
The form is also available from the CMS.gov Current Emergencies portal:
  https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities



To Begin:     Select “I want to submit a waiver/flexibility
              request.”
Step 1: Select the Public Health Emergency
        (PHE) for which you are making your
        request.
        •   Make a selection from the dropdown
            list by clicking on the down arrow. You
            can also begin typing the name of
            your emergency in the field search bar
            to find your Public Health Emergency.




Step 2: Provide your contact information and
        your organization information.
        •   You must retype your email address in
            the Confirm Email address field. The
                                                      Type. Do not copy/paste.
            copy/paste tool will not work.
        •   Your telephone number is an optional
            field, but all others are required. We
            encourage you to enter your phone
            number in the event there is a need to
            contact you directly.

        •   Complete the Organization name field
            by typing the name of your organization
            in the field.

        •   Complete the State/US Territory/
            Federal District field by selecting all
            locations covered by this request from
            the dropdown list or by typing the
            name or abbreviation for each location
            in the field search bar. Be sure to
            include them all!

        •   Select the Organization Categories
            that best describe your organization.
            Select a checkbox or checkboxes to
            describe your organization from any of
            the three tabs: General, Emergency
            Provider/Supplier Types, or Other. At
            least one checkbox is required, but
            you may select multiple checkboxes.
        •   If you can't find an appropriate
            organization category, go to the Other
            tab and select the Other checkbox.
            Type an organization category in the
            text field that appears.
        •   If your entry in the Other text field
            matches an existing Organization
            Category, a pop-up message lets you
            know that a duplicate category exists.
            -   If they are identical, select OK.
                The system will select the
                checkbox for the appropriate
                existing organization category.
            -   If not, select Cancel and the
                system accepts the text field entry.
        •   Enter ALL applicable CMS
            identification numbers in the
            Identification Number field. If you are
            entering multiple identification
            numbers, separate them with
            commas. These numbers will be
            different depending on the categories
            you have selected for your
            organization, including: CCN/Provider,
            Medicare Contract Number, or NPI.


Step 3: Describe your waiver/flexibility request.
        •   For Waiver/Flexibility Request Type,
            select from the options in the
            dropdown box by clicking on the down
            arrow to see the choices, or you can
            type in the name of the
            waiver/flexibility in the search bar to
            find your waiver/flexibility request.
•   If you can't find an appropriate
    waiver/flexibility type in the dropdown
    menu, click the checkbox for “Can’t
    find what you’re looking for? Click
    here.” The field will convert to a text
    box where you can type in the name
    of a new waiver/flexibility request type.

•   If your entry matches an existing
    waiver/flexibility request type, a pop-up
    message lets you know that a duplicate waiver
    type exists.
    -   If they are identical, select OK. The system
        will deselect the checkbox, remove the new
        waiver type you entered in the field, and
        select the existing waiver/flexibility type.
    -   If not, select Cancel and the system accepts
        the new waiver/flexibility type that you
        entered.
•   For Regulation Related to this Request, enter details of any
    regulations related to this request. The regulation citation(s)
    will help us understand for which part of the regulation you
    are requesting a waiver. This question is optional. However,
    your form will be more easily processed if this field is
    completed.
•   For Request Description, please provide a brief summary of
    why the waiver is needed and the type of relief you are
    seeking. For example, CAH is sole community provider
    without reasonable transfer options at this point during the
    specified emergent event (e.g., flooding, tornado, fires, or flu
    outbreak). CAH needs a waiver to exceed its bed limit by X
    number of beds for Y days/weeks (be specific).
•   If you have additional waiver/flexibility requests, click
    “Add another waiver request” and the system will
    display the fields to enter an additional request. You
    may add as many additional requests as needed. For
    any additional request created in error, delete the
    request by clicking the red trash can icon.
Step 4: Submit the form.
        •   The Submit button will display when all required fields are
            completed.
        •   When you click the Submit button, a confirmation
            message with your Case number will appear on the
            screen. You will also receive an email confirmation
            summarizing your request and providing you with
            additional guidance.
1135 Waiver/Flexibility Request Form




             Hover over any question mark icon to see more information about the field.


                    Select “I want to submit a waiver/flexibility request.”




                  Click on the down arrow to find your PHE selection or begin
                  typing the name of your PHE in the field search bar.




                   Retype your email address confirmation. Do not copy/paste.




                    Enter your phone number. (optional)
    Provide the name of your organization and all State(s), US Territory(ies)
    or Federal District(s) covered by this request. Click in the field and select
    from the list or begin typing the name or abbreviation for your location(s)
    in the field search bar.


Select the Organization Categories that best describe your organization from
any of the three tabs. At least one checkbox is required, but you may select
multiple checkboxes.




    Enter ALL applicable CMS identification numbers
    (e.g., CCN, NPI, Medicare Contract Number, etc.) in
    the Identification Number field. If you are entering
    multiple identification numbers, separate them with
    commas. This field is optional. However, your form
    will be more easily processed if it is completed.
        Select from the options in the dropdown box by clicking on the down
        arrow, or you can type in the name of the waiver/flexibility in the search
        bar to find your waiver/flexibility request.




     Regulation citation(s) will help us understand for which part of the regulation
     you are requesting a waiver. This question is optional. However, your form
     will be more easily processed if this question is completed.




        Provide a comprehensive description of the waiver request.



Click “Add Another Waiver Request” to display fields for entering
additional waiver requests.

*Note: The Submit button will display only after all
required fields are complete.
You will receive a system-generated email confirming that we have received your request. The
email will include the case number that has been assigned to your request, which you can
reference in any follow-up communications with CMS.


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