COVID-19 Post-Public Health Emergency

At the beginning of COVID-19, the Centers for Medicare and Medicaid Services (CMS) issued waivers to enable providers to be flexible and rapidly respond to an ever-changing landscape as they treated patients affected by the virus. The federal Public Health Emergency (PHE) declared for COVID-19 expired on May 11, 2023. While providers will continue to vaccinate against and treat the virus, many of the federal waivers that Rural Health Clinics, Critical Access Hospitals and other rural healthcare providers used have or will expire in the coming months.

COVID-19 Waivers that Expired on May 11, 2023

RHC-Specific

• Staffing Requirements: A Nurse Practitioner or Physician Assistant does not have to be available to provide patient care services at least 50% of the time the RHC is operating.
• Home Nursing Visits: During the PHE, a written request and written justification to provide a home nursing visit outside of a Home Health Agency shortage area was not required.
• Temporary Expansion Locations: RHCs can be separately considered for Medicare survey and certification if services were expanded into more than one permanent location, including areas that would not typically meet RHC location requirements.
• RHC Payment Limit/Bed Count for Provide-Based RHCs: Prior to April 2021, provider-based RHCs tied to a hospital with fewer than 50 beds were exempt from the national RHC payment limit. CMS allowed those RHCs to receive the same payment amounts they would have before the PHE.
• Reducing Administrative Burden: The physician self-referral law (known as the “Stark Law”) prohibits physicians from making referrals for certain designated health services payable by Medicare to an entity that he/she has a financial relationship and prohibits the entity from filing claims with Medicare for any improperly referred designated health services. During the PHE, CMS issued blanket waivers of certain provisions of the law.
• Provider Enrollment: During the PHE, CMS established toll-free hotlines for providers who established isolation facilities to enroll and receive temporary Medicare billing privileges.
• CMS Document

Critical Access Hospital (CAH)-Specific

• CAH Bed Count and Length of Stay: CMS waived the requirements that CAHs limit the number of beds to 25, and that the length of stay be limited to 96 hours
• CAH Status and Location: CMS waived restrictions regarding the rural location of a CAH, along with off-campus and co-location requirements in order to stand up temporary, surge site locations.
• CAH Staffing Requirements: CMS waived the minimum personnel qualifications for clinical nurse specialists, NPs and PAs, allowing for maximum staffing flexibility. CMS also deferred to staff licensure, certification or registration to state law by waiving the requirement that CAH staff be licensed, certified or registered in accordance with applicable federal, state and local laws and regulations.
• Telemedicine: CMS waived 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 services to be furnished to the hospital’s patients through an agreement with an off-site hospital. This allowed for increased access to necessary care for hospital and CAH patients, including access to specialty care.
• Responsibilities of Physicians in CAHs: CMS waived 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.
• Screening patients: CMS waived enforcement of Section 1867(a) of the Emergency Medical Treatment and Labor Act, allowing hospitals and CAHs to screen patients at offsite locations to prevent the spread of COVID-19.
• Limit Discharge Planning: To allow hospitals and CAHs more to focus on urgent needs, CMS waived 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).
• CMS Document

All Providers

• Expedited Enrollment: During the PHE, CMS expedited pending or new applications from providers and suppliers.
• Emergency Preparedness: During or after an actual emergency, the Emergency Preparedness regulations allow for a one-year exemption from the requirement that the provider perform testing exercises. Providers are expected to return to normal operating status and comply with the regulatory requirements for emergency preparedness with the conclusion of the PHE. This includes conducting testing exercises based on the regulatory requirements for provider/supplier types.

Waivers that Will Expire on December 31, 2023

RHC-Specific

• Physician Supervision of NPs: The requirement that physicians must provide direction for the clinic’s activities and consultation for, and medical supervision of, NPs and other healthcare staff. The waiver allows for NPs to operate without medical supervision by the physicians.

Waivers that Will Expire on December 31, 2024

RHC-Specific

• Payment for Medicare Telehealth Services: Section 3704 of the CARES Act authorized RHCs to furnish distant site telehealth services to Medicare beneficiaries during the PHE. Medicare telehealth services generally require an interactive audio and video telecommunications system that permits real-time communication between the practitioner and the patient. Telehealth services could be furnished by any healthcare practitioner working for the RHC within their scope of practice. Practitioners could furnish telehealth services from any distant site location, including their home, during the time that they are working for the RHC, and could furnish any telehealth service that is included on the list of Medicare telehealth services under the Physician Fee Schedule (PFS), including those that have been added on an interim basis during the PHE. For more information, see the list of these services, including which could be furnished via audio-only technology. RHCs with this capability can provide and be paid for telehealth services furnished to Medicare patients located at any site, including the patient’s home, through December 31, 2024.

Telehealth-Specific

• HHS Fact Sheet: Telehealth Flexibilities and Resources and the COVID-19 Public Health Emergency