Risk mitigation has taken on an entirely different meaning when it comes to the provision of service during a pandemic. Instead of a focus on high accountability reporting, “crossing t’s and dotting i’s”, the entire country is taking measures to waive the usual requirements that may slow down the provision of services. The federal and NC declarations of state of emergency have been critical hoops to get through to allow for these waivers.
1135 Federal Waiver
The US Department of Health and Human
Services has provided waiver authority to temporarily put aside standard
requirements for states for them to adequately address the spiked physical and
behavioral healthcare needs from the coronavirus. North Carolina filed
their request for the 1135 waiver with the Centers for Medicare and Medicaid
Services (CMS) on March 17th. The
approval of the 1135 waiver for North Carolina is expected quickly. As of
March 23, the approval had not yet come through. Here are some of the
temporary waivers and flexibilities that our state has requested:
- Temporary waivers for enrollment fees
and criminal background checks for enrollment purposes;
- Temporary waiver that physicians and
other healthcare providers hold a license in North Carolina so long as they
have an equivalent license in another state and/or with Medicare;
- Temporarily providing payments to
facilities for providing services in alternative settings, including an
unlicensed or temporary facility, if the licensed facility has been evacuated,
compromised or needs extended capacity;
- Waived the limit of 25 beds and 96-hour
length of stay for Critical Access Hospitals (federal designation for certain rural
hospitals);
- Multiple flexibilities for hospital providers;
- HIPAA waivers of sanctions and penalties related to certain
HIPAA provisions;
- Temporary
suspension of penalties related to the Emergency Medical Treatment and Labor
Act (EMTALA) where an individual needs to
be transferred, even before they are medically stabilized, for some
reason related to this emergency.
Single Stream Funding and Risk Reserves
Freed Up for COVID-19 Response
LME/MCOs have received a formal communication from NC DHHS addressing the use of
State funds for the remainder of the State Fiscal Year 2019-2020 and
flexibilities including the following:
- Providing LME/MCOs authority to use up
to 15% from their current risk-reserves for supporting providers who are
accepting referrals, maintaining consumers in their existing residential
placements, utilizing telehealth capabilities to the maximum extent possible,
providing services that keep consumers from needing access to emergency
departments and inpatient services and otherwise making efforts to deliver high
quality services during this crisis, and to maintain the stability of the
provider network and promote robust access to care throughout this pandemic
situation, in accordance with criteria established by the LME/MCO;
- Authorizing LME/MCOs to use state single
stream funds for responding to COVID-19 (e.g. by converting existing
allocations to non-UCR and paying providers for telehealth services and
supports) and authorizing immediate pay out of all remaining single stream
monthly payments for the remaining state fiscal year;
- Authorizing the immediate release of $30
million of funds distributed among the LME/MCOs pursuant to S257, S.L. 2017-57,
the Appropriations Act of 2018 for responding to COVID-19;
- Directing LME/MCOs to re-prioritize
current spending plans of federal grant funds to support the COVID-19 response.
In addition to the waivers the
1135 will allow, NC DHHS is granting other flexibilities for LME/MCOs that
include:
- A “pause” on contractual penalties for
LME/MCOs and all auditing requirements in order to free up administrative burdens;
- Expedited Medicaid and State alternative
services;
- Flexibilities in opioid medication
take-home dosing and telehealth.
Telehealth
NC DHHS is providing a staggered
implementation of telehealth waivers to reimbursement rules in order to get the
most needed waivers and flexibilities in place. On a recent webinar with
providers, Medicaid CMO Dr. Shannon Dowler stated that they will begin with telemedicine and telepsychiatry codes and later
will provide waivers and flexibilities to specialized services such as
occupational and physical therapies and finally work to provide needed
temporary changes for LEAs and CDSAs. Retroactive to March 10, 2020, telehealth billing waivers and flexibilities include:
- Payment parity to in-person care;
- Expansion of eligible technology;
- Removal of restrictions related to
originating and distance sites;
- Expansion of eligible sites for Medicaid
reimbursement to include FQHCs and RHCs;
- No need for referrals;
- Expansion of the types of
providers that can provide telehealth to include clinical pharmacists, licensed
clinical mental health counselors (LCMHCs), licensed marriage and family
therapists (LMFTs), licensed clinical addiction specialists (LCASs), and
licensed psychological associates (LPAs).
Appendix K and Long-Term Care for Innovations
and TBI Waivers, CAP/C and CAP/DA
NC DHHS is seeking approval from CMS for
an Appendix K to the 1915(c) Medicaid waivers in North
Carolina that include: Innovations for individuals with intellectual and
developmental disabilities, Traumatic Brain Injury, Community Alternative
Programs/Children (CAP/C), Community Alternative Programs/Disabled Adults
(CAP/DA). Appendix K must be approved by CMS. LME/MCOs received guidance from NC DHB on the temporary flexibilities,
including:
- Lift of cap on the $135,000 limit for
spending in certain cases;
- Allowance for provision of services in
alternative settings;
- Allowance for provision of services by
relatives of adult waiver recipients and for existing staff while they wait for
background checks, re-certifications, etc;
- Include retainer payments to direct care
workers to address emergency related issues;
- Reduce face-to-face requirements related
to care coordination, Day Supports and in other areas.
On March 23rd,
Governor Cooper issued his most recent Executive Order
and it included some temporary limitations
on visitations at long-term care facilities [beginning on Wednesday,
March 25], including: skilled nursing
facilities, adult care homes, family care homes, mental health group homes and
ICF-IDD facilities. NC DHHS has posted
multiple resources related to long
term care services at their COVID
19 website.
i2i Center Provides a Resource Center
i2i has devoted a webpage to
resources, including public policy and health and wellbeing, as information
becomes available.