1135 Basics Who decides? How do they decide? What is affected? - - PowerPoint PPT Presentation

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

• rganizaAonally.

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

Sufficient health care items and services are available to meet the needs of Medicare, Medicaid and CHIP beneficiaries; Health care providers that provide such services in good faith can be reimbursed for them and not subjected to sancAons for noncompliance, 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
• ur current regulatory authority?

Examples of 1135 Waiver AuthoriAes

CondiAons of ParAcipaAon Licensure for Physicians or others to provide services in affected state Emergency Medical Treatment and Labor Act (EMTALA) Stark Self-Referral SancAons Medicare Advantage out of network providers HIPAA

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
• therwise 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

• Federal Requirements only, not state licensure

Scope

• Allow reimbursement during an emergency or

disaster even if providers can’t comply with certain requirements that would under normal circumstances bar Medicare, Medicaid or CHIP payment

Purpose

• End no later than the terminaAon of the emergency period,
• r 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.

DuraAon

1135 Waiver Examples

EMTALA

• Request to set

up Alternate Screening LocaAons CriAcal Access Hospitals

• 42 CFR 485.620
• Requires 25-

bed limit and Average PaAent stays of less than 96-ours Skilled Nursing FaciliAes

• SSA 1812 (f)
• Three-day prior

hospitalizaAon for SNF PaAents

1135 Waiver Review Process

Within defined Emergency Area?

Is there an actual need?

Will Regulatory relief requested actually address stated need?

Can this be resolved within current regulaAons? Should we consider individual or blanket waiver?

What is the expected duraAon?

Waiver Review Inputs

Facility

State Emergency and Licensure Staff HHS Regional Emergency Coordinators

Provider AssociaIons

CMS

ExpectaAons of Waived Providers

Request

• Provide sufficient informaAon to jusAfy actual need

Waived

• Providers and suppliers will be required to keep careful records
• f beneficiaries to whom they provide services, in order to

ensure that proper payment may be made.

Normal Ops

• Providers must resume compliance with normal rules and

regulaAons as soon as they are able to do so

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