1135 Basics • Who decides? • How do they decide? • What is affected? • What the CMS Rule says about it …
Who decides? You need: • PresidenAal disaster declaraAon under Stafford Act or the NaAonal Emergencies Act • HHS Secretary declares a public health emergency
How do they decide? Waivers are issued to ensure that Medicare, Medicaid, and CHIP reimbursement policies do not limit the level of care available to beneficiaries during a disaster. That’s it.
What is affected? RegulaAons that implicate reimbursement from CMS: • EMTALA • Provider Licensure • HIPAA • Some exisAng COP’s • Medicare Advantage Networks • More to come from Sandra
The CMS Rule: “At a minimum, the policies and procedures must address the following … the role of the facility under a waiver declared by the Secretary, in accordance with secAon 1135 of the Act, in the provision of care and treatment at an alternate care site idenAfied by emergency management officials.”
CMS InterpreAve Guidance Story Ame …
Sandra Pace Associate ConsorAum Administrator (ACA) for Survey & CerAficaAon in the ConsorAum for Quality Improvement and Survey & CerAficaAon OperaAons (CQISCO). An integral member and leader within CQISCO, Sandra iniAally took on the role of ACA in November 2016 while conAnuing her work as the ARA for the Atlanta Division of Survey & CerAficaAon. She began her career with CMS in 1991 as a nurse consultant responsible for surveying all types of health care providers in the eight Southeastern states. Over the years, Sandra has held several leadership and management roles with the Agency. She has received awards and recogniAon as a CMS Outstanding Health Professional, Leadership in Quality Management, Federal ExecuAve InsAtute Graduate, Senior Fellow with the Council for Excellence in Government, Federal ExecuAve Board Outstanding Manager, Administrator’s Special CitaAon, and past TransiAon Team Member charged with reorganizing the way CMS conducts business and looks organizaAonally. Sandra has been a pracAcing nurse for over 30 years on several levels with special interests and cerAficaAons in Coronary CriAcal Care and Geriatrics.
Sandra M. Pace Centers for Medicare & Medicaid Services Associate ConsorAum Administrator ConsorAum for Quality Improvement and Survey and CerAficaAon OperaAons (CQISCO)
1135 WAIVERS WHAT YOU NEED TO KNOW
Purpose of 1135 Waivers Health care providers that provide such services in good Sufficient health care items and services are available to faith can be reimbursed for meet the needs of Medicare, them and not subjected to Medicaid and CHIP sancAons for noncompliance, beneficiaries; absent any fraud or abuse
In short: Are CMS regulaAons impeding your ability to respond to or recover from a disaster?
To issue waivers:
ConsideraAons for Waiver Authority • Scope and severity of event with specific focus on health care infrastructure • Are there unmet needs for health care providers? • Can these unmet needs be resolved within our current regulatory authority?
Examples of 1135 Waiver AuthoriAes Licensure for Emergency Medical Physicians or others CondiAons of Treatment and ParAcipaAon to provide services Labor Act (EMTALA) in affected state Medicare Stark Self-Referral Advantage out of HIPAA SancAons network providers
What waivers DON’T do: • 1135 waivers are not a grant or financial assistance program • Do not allow reimbursement for services otherwise not covered • Do not allow individuals to be eligible for Medicare who otherwise would not be eligible • Should NOT impact any response decisions, such as evacuaAons. • Do not last forever. And appropriateness may fade as Ame goes on.
1135 Waivers Scope • Federal Requirements only, not state licensure • Allow reimbursement during an emergency or Purpose disaster even if providers can’t comply with certain requirements that would under normal circumstances bar Medicare, Medicaid or CHIP payment • End no later than the terminaAon of the emergency period, DuraAon or 60 days from the date the waiver or modificaAon is first published unless the Secretary of HHS extends the waiver by noAce for addiAonal periods of up to 60 days, up to the end of the emergency period.
1135 Waiver Examples CriAcal Access Skilled Nursing EMTALA Hospitals FaciliAes • Request to set • 42 CFR 485.620 • SSA 1812 (f) up Alternate • Requires 25- • Three-day prior Screening bed limit and hospitalizaAon LocaAons Average PaAent for SNF PaAents stays of less than 96-ours
1135 Waiver Review Process Within Can this be Will Regulatory defined resolved within relief requested Emergency current actually address regulaAons? stated need? Area? Is there What is the Should we an actual consider expected individual or need? duraAon? blanket waiver?
Waiver Review Inputs Facility State Emergency Provider and AssociaIons Licensure CMS Staff HHS Regional Emergency Coordinators
ExpectaAons of Waived Providers • Provide sufficient informaAon to jusAfy actual need Request • Providers and suppliers will be required to keep careful records of beneficiaries to whom they provide services, in order to ensure that proper payment may be made. Waived • Providers must resume compliance with normal rules and regulaAons as soon as they are able to do so Normal Ops
CONTACT INFORMATION: Sandra.pace@cms.hhs.gov
To assure timely responses to all inquiries, please send all questions to one of the following Email addresses for CMS Regional Offices: ROATLHSQ@cms.hhs.gov (Atlanta RO): Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee RODALDSC@cms.hhs.gov (Dallas RO): Arkansas, Louisiana, New Mexico, Oklahoma, Texas ROPHIDSC@cms.hhs.gov (Northeast Consortium): Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia, New York, New Jersey, Puerto Rico, Virgin Islands, Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont ROCHISC@cms.hhs.gov (Midwest Consortium): Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin, Iowa, Kansas, Missouri, Nebraska ROSFOSO@cms.hhs.gov (Western Consortium): Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming, Alaska, Idaho, Oregon, Washington, Arizona, California, Hawaii, Nevada, Pacific Territories.
NSPA Budget: BP1 • Budget Process • Input needed from CoaliAon • Staff will take feedback and vote on work plan in July • Budget PresentaAon
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