Learn About CMS’ 1135 Waivers to Help Battle COVID-19

Hello, my name is Julie Clemens. I’m a Chief Solutions Manager here at MOS. Today I wanted to talk about CMS and how they’ve announced section 1135 waivers to help in battling COVID-19.

So everyone know the entire global population is going through extremely trying times with total and partial lock downs and numerous other restrictions put in place to control this COVID-19 epidemic. Recognizing the need of the hour and to ensure patient’s easy access to medical treatments, the CMS (Centers for Medicare & Medicaid Services), they have announced Section 1135 waivers to support the government’s efforts to battle COVID-19. Indeed, in situations such as the present one, making emergency medical treatment available to those affected is most important and in normal circumstances, health insurers may utilize processes such as medical peer review to determine coverage eligibility for their plan members. However, in extremely hazardous and emergency situations such as we find ourselves as of now, all are focused on providing the required facilities and care to patients.

So, what is this Waiver?

Under section 1135 of the Social Security Act, the HHS secretary may temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements. This is to help make sure that adequate healthcare items and services are available to meet the requirements of individuals who are enrolled in social security programs in the emergency area and time periods and also that providers who provide services in good faith are reimbursed and exempted from sanctions, if there is no fraud or abuse involved. Some examples of 1135 waivers are for the following:

• Program participation and similar requirements.
• Pre-approval requirements.
• Conditions of participation and other certification requirements.
• Performance deadlines and timetables may be adjusted, but not waived.
• Stark self-referral sanctions.
• Limitations regarding payment to permit Medicare enrollees to use out-of-pocket network providers in an emergency situation.

Waivers under section 1135 end no later than the termination of the emergency period, or 60 days from the date the waiver or modification is first published, provided the Secretary of HHS doesn’t extend the waiver by notice for additional time up to 60 days, up to the end of the emergency period.

• EMTALA waivers (for public health emergencies that do not involve a pandemic disease) and waivers for HIPAA requirements are limited to a 72-hour period starting from the implementation of a hospital disaster protocol.

CMS Waivers Associated with COVID-19 Pandemic

The following are –

• Critical Access Hospitals: So, CMS is waiving the requirements that these hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours.
• Housing Acute Care Patients in Excluded Distinct Part Units: So, CMS is waiving requirements to enable acute care hospitals to accommodate acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are suitable for acute care inpatient.
• And there are DME (Durable Medical Equipment): If DME Prosthetics, Orthotics, and Supplies is lost, destroyed, irreparably damaged, or otherwise becomes unusable, contractors are allowed the flexibility to waive replacement requirements so the face-to-face requirement, a new physician’s order, and new medical necessity documentation is not required.
• Skilled Nursing Facilities (SNF): So, CMS is also waiving Social Security Act’s Section 1812 (f) requirement for a 3-day prior hospitalization for coverage of a SNF stay to provide temporary emergency coverage of SNF services without a qualifying hospital stay, for people who may have to be transferred as a result of the effect of an emergency or disaster.

And the list goes on. Highly recommended points are aside, so you can read more about this information. Our site is mosmedicalrecordreview.com and you will find everything in bullet points listed out here.

Medicare Appeals in Fee for Service, MA and Part D. So this also talked about

• Extension to file an appeal
• Waive timeliness for requests for additional information to adjudicate the appeal
• Utilize all flexibilities allowed in the appeal process

There is so much kind of information that really make some changes of what people do, how to make it work.

So, CMS doesn’t require states to use any specific form or format to submit a request for the Section 1135 waiver. States must clearly state the scope of the issue and the impact it has made. The request can be made directly to Jackie Glaze, she is the CMS Acting Director, Medicaid & CHIP Operations Group Center for Medicaid & CHIP Services. Requests can be sent as email ([email protected]) or you can send a letter.

As a chart review company serving social security and insurance lawyers, we know how crucial it is for private as well as government payers to rise to the occasion and lighten the financial burden on patients who have fallen victim to COVID-19.

Again please go to our website at mosmedicalrecordreview.com for more information.

Thank You!