COVID-19 Brings Big Changes to Home Health
CARES Act, Medicare interim final rule change who can order home health, homebound definition, and much more.
Congress and the Centers for Medicare & Medicaid Services (CMS) have gone into overdrive to provide home care providers with regulatory relief to fight the COVID-19 pandemic.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act, signed into law March 27, broadens home health ordering under Medicare. The law adds nurse practitioners, clinical nurse specialists, and physician assistants to the list of clinicians who can order home health. Following suit, CMS issued March 30 an interim final rule implementing a host of regulatory changes to help providers deal with the COVID-19 pandemic.
What Does the Interim Final Rule Provide?
For starters, CMS is allowing nonphysician practitioners (NPPs) to order home health services on the Medicaid side. “We recognize that increased demand on the direct care services provided by physicians during the PHE for the COVID-19 pandemic could cause a delay in the availability of physicians to order home health services in the normal timeframe,” CMS says in the interim final rule with comment period.
The interim final rule implements a host of other regulatory changes to help providers deal with the COVID-19 pandemic. “In recognition of the critical need to expand workforce capacity, we are amending 42 CFR 440.70 to allow licensed practitioners practicing within their scope of practice, such as, but not limited to, NPs and PAs, to order Medicaid home health services during the existence of the PHE for the COVID-19 pandemic.”
Definition for Homebound
The rule also includes a broadening of the definition of who counts as homebound for eligibility purposes.
“The definition of ‘confined to the home’ … allows patients to be considered ‘homebound’ if it is medically contraindicated for the patient to leave the home,” CMS says in the rule. That applies when a physician has determined that it is medically contraindicated for a beneficiary to leave the home because (1) she has a confirmed or suspected diagnosis of COVID-19 or (2) the patient has a condition that may make the patient more susceptible to contracting COVID-19. The rule includes examples with chronic obstructive pulmonary disease (COPD) and cancer patients.
Physician documentation is key. “A patient who is exercising ‘self-quarantine’ for one’s own safety would not be considered ‘confined to the home’ unless a physician certifies that it is medically contraindicated for the patient to leave the home,” CMS stresses.
The Centers for Disease Control and Prevention (CDC) is advising that older adults and individuals with serious underlying health conditions stay home, the rule points out. “We expect that many Medicare beneficiaries could be considered ‘confined to the home.’” CMS says. But homebound determinations, as always, “must be based on an assessment of each beneficiary’s individual condition and care needs.”
Home Health Eligibility Requirements Are the Same
Also, as always, patients must meet the other Medicare home health eligibility requirements — under the care of a physician; receiving services under a plan of care established and periodically reviewed by a physician; in need of skilled nursing care on an intermittent basis (or physical therapy or speech-language pathology); or in continuing need for occupational therapy, CMS reminds.
A visit to administer a COVID-19 test isn’t going to automatically qualify a patient, CMS points out. “A home health visit solely to obtain a nasal or throat culture would not be considered a skilled service because it would not require the skills of a nurse to obtain the culture,” the rule spells out. But “a home health nurse, during an otherwise covered skilled visit, could obtain the nasal or throat culture to send to the laboratory for testing,” CMS allows.
The definition of who is homebound may change as the CDC changes its guidance on who is at risk. “CDC’s guidance … is expected to continue to be updated as warranted,” CMS highlights.
Other home health provisions in the interim final rule include:
Initial assessments. CMS is waiving requirements to allow HHAs to perform Medicare-covered initial assessments and determine patients’ homebound status remotely or by record review, the agency says in a fact sheet for the interim final rule.
“This is huge for home health,” says Sharon Litwin with 5 Star Consultants in Camdenton, Missouri. “It means that an in-person visit is not required to complete the initial assessment.”
Often, the clinician completes the initial assessment during the same visit in which the Start of Care comprehensive assessment is completed, Litwin notes. But they aren’t the same thing. The initial assessment determines “the immediate care and support needs of the patient and … eligibility including homebound status,” she explains.
“The immediate care and support needs are the items and services that will maintain the patient’s health and safety until the HHA can complete the SOC Comprehensive assessment and establish a plan of care,” Litwin clarifies. “Eligibility including homebound status is also determined at this time.”
Now agencies can perform this via phone call, or even by review of the medical records an agency receives as part of the referral, CMS makes clear in the interim final rule.
“The CMS waiver did not make changes to the timeframe for the initial assessment to be completed,” the rule says. “Whether done remotely, through record review, or in person the initial assessment must still be completed within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered SOC date.”
Stay crystal clear that the “initial assessment” is not the start of care, emphasizes reimbursement expert M. Aaron Little with BKD. “There is no relief at this time from the start of care being in-person,” Little says. “If the initial assessment is conducted remotely, that it is not a billable visit and the start of care visit will not be until the in-person visit. If agencies misunderstand this distinction, it will cause problems when it comes time to bill RAPs/claims.”
OASIS. CMS is waiving the 30-day OASIS submission requirement. Accordingly, CMS is extending the five-day completion requirement for the comprehensive assessment to 30 days.
Waiving the requirement that each claim have a matching OASIS file would be much more helpful than just extending OASIS filing deadlines. The rule “does not relieve providers from submitting the OASIS before billing the claims,” Little notes. “This is a critical detail to prevent claims from being denied.”
HHAs taking advantage of accelerated payments don’t have to worry about claims filing dates and matching OASIS files for a while. And at least “the only OASIS that must be filed before billing is the Start of Care OASIS or Follow-Up/Other Follow-Up (Recert) OASIS, and Resumption of Care if it is to be linked to the next 30-day claim,” points out Melinda Gaboury with Healthcare Provider Solutions in Nashville. “The biggest relief … is that they don’t have to stress that all OASIS get completed and transmitted timely.”
Requests for Anticipated Payment (RAPs). CMS is allowing HHH Medicare Administrative Contractors to extend the auto-cancellation date of RAPs during emergencies.
This may not be a huge financial boon given RAPs’ relatively small payment impact under the Patient-Driven Groupings Model. But it is “helpful in the sense that agencies will not have to worry about having to refile [RAPs] to get the small amounts back and can focus on other things,” Gaboury says.
Aide supervision. CMS is waiving the requirements for a nurse or other qualified healthcare professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan. “This may not be physically possible for a period of time,” per a CMS fact sheet. “This waiver is also temporarily suspending the 2-week aide supervision by a registered nurse … but virtual supervision is encouraged.”
What Does the CARES Act Provide?
Other CARES Act home health provisions that CMS is implementing in the final rule include:
Sequestration elimination. “During the period beginning on May 1, 2020 and ending on December 31, 2020 … Medicare programs … shall be exempt from reduction under any sequestration order” the law says.
Telehealth. For home health, “The Secretary of Health and Human Services shall consider ways to encourage the use of telecommunications systems, including for remote patient monitoring … and other communications or monitoring services,” the law instructs. CMS expands telehealth coverage in the interim final rule.
Small business loans. The law enacts the Paycheck Protection Program administered through the Small Business Administration. The program provides up to $349 billion in loans to eligible entities, with such loans being subject to forgiveness under certain circumstances.
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