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With COVID-19 being declared a pandemic and national emergency, CMS has approved 1135 waivers and regulatory flexibilities to give providers, healthcare organizations, and states “maximum flexibility” to implement emergency preparedness plans while staying compliant.

The 1135 waiver allows CMS to waive some requirements in Medicare, Medicaid, and CHIP and remove bureaucratic formalities that can hamper access to needed services. As of March 24, 2020, CMS approved up to 13 approved Section 1135 waivers for states. Waivers for Florida and Washington state were approved last week, the newly approved waiver states are: Alabama, Arizona, California, Illinois, Louisiana, Mississippi, New Hampshire, New Jersey, New Mexico, North Carolina, and Virginia.

The aim of the waivers is to ensure the federal government’s commitment to operating a COVID-19 response that is “locally executed, state managed and federally supported”. With these waivers, states can now focus their resources on combatting the COVID-19 outbreak and providing the best possible care to Medicaid beneficiaries in their states.

“These waivers give a broad range of states the regulatory relief and support they need to more quickly and effectively care for their most vulnerable citizens”, said CMS Administrator Seema Verma.

Medicaid Flexibilities under the 1135 Waiver

CMS has granted state and territorial Medicaid agencies a wider range of flexibilities under section 1135 waivers. Examples include:

  • Waive prior authorization requirements in fee-for-service programs
  • Extension of existing authorizations for services through the end of the public health emergency
  • Temporary suspension of certain provider enrollment and revalidation requirements to promote access to care
  • Relaxing provider enrollment requirements to allow states to more quickly enroll out-of-state or other new providers to expand access to care,
  • Modifying certain timeline requirements for state fair hearings and appeals;
  • Relaxing public notice and submission deadlines for certain COVID-19 focused Medicaid state plan amendments, enabling states to make changes faster and ensure they can be retroactive to the beginning of the emergency
  • Permitting providers to provide care in alternative settings, such as telehealth services with the home as the originating site
  • Temporary suspension of certain pre-admission and annual screenings for nursing home residents

Medicare Waivers

The Medicare waivers to relieve the administrative burden of compliance include:

  • Waiving 3-day prior hospitalization rule for coverage of a skilled nursing facility (SNF) stay
  • Waiving 25-bed requirement to classify as a critical access hospital and that the length of stay be limited to 96 hours
  • Allowing acute care hospitals to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient
  • Waiving the 60-percent rule for inpatient rehabilitation facilities
  • Permitting long-term care hospitals to exclude patient stays from the 25-day average length requirement if the admit or discharge is ordered due to the emergency
  • Relaxing standards for lost, destroyed, irreparably damaged or otherwise unusable durable medical equipment, prosthetics, orthopedics, and supplies

In addition to increasing capacity for hospitals and other providers on the frontline of the outbreak, Medicare waivers will help ensure Medicare reimbursement for providing emergency care in these uncertain times (www.revenuecycleintelligence.com).

These section 1135 waivers are effective March 1, 2020 and will end upon termination of the public health emergency, including any extensions.

Medical billing and coding companies are working with healthcare providers to ensure that they receive appropriate reimbursement as they strive to provide vulnerable patients with the best care.