A lot has changed for skilled nursing facilities (SNFs) in a short amount of time. In just the past six months, SNFs have had to adjust their business model and processes to align with the new Patient-Driven Payment Model (PDPM) – and then they were hit with COVID-19. The world quickly learned that the highly contagious disease is particularly dangerous for older people and spreads easily in confined environments such as nursing homes where care workers move from room to room.
The Centers for Disease Control and Prevention (CDC) announced that nursing home residents and staff are at a high risk of being infected by and dying from the coronavirus. While only 10% of U.S. COVID-19 cases have occurred in long-term care facilities, deaths related to Covid-19 in these facilities comprise more than 42% of the country’s total pandemic deaths, according to the New York Times. More than 55,000 residents and workers have died from COVID-19 at nursing homes and other long-term care facilities for older adults in the United States. As of the Times’ July 7 data, more than 296,000 people at 14,000 facilities had contracted the virus.
In response to the global pandemic, the White House declared a national Public Health Emergency (PHE) in March 2020. This declaration gave the Secretary of Health and Human Services (HHS) the authority under section 1135 of the Social Security Act to temporarily waive or relax certain requirements of Medicare, Medicaid, and state Children’s Health Insurance Programs. The 1135 blanket waiver for long-term care facilities or SNFs covers everything from reimbursement and Minimum Data Set (MDS) requirements to staff training and certification. It also has ushered in expansive telehealth growth and eliminated the three-day qualifying hospital stay rule, among other changes.
With the number of U.S. Infections topping four million currently, HHS on July 23 extended the PHE designation for another 90 days. The extension means that those measures that have been enacted to help providers manage outbreaks will continue for at least another three months.
Additional Flexibility, No New Benefits
Under normal circumstances, if beneficiaries want Medicare to consider paying for a SNF inpatient stay, they must meet technical and medical requirements set by CMS. This used to include requiring a patient to stay three days at an inpatient hospital prior to moving to SNF care, but the 1135 waiver eliminates this rule for the duration of the pandemic. This means SNF care without a three-day inpatient hospital stay will be covered for beneficiaries who are affected by COVID-19 or experience dislocations.
CMS said the SNF Three-Day Rule Waiver is meant to provide additional flexibility during the pandemic but does not create a new benefit or extend Medicare SNF coverage to patients who could be treated in outpatient settings or who require long-term custodial care.
To apply for the waiver, CMS requires the Accountable Care Organization (ACO) to demonstrate that it has the capacity to identify and manage beneficiaries who, under the waiver, would be either directly admitted to a SNF or admitted to a SNF after an inpatient hospitalization of less than three days.
According to Seema Verma, CMS Administrator: “SNF care without a three-day inpatient hospital stay will be covered for beneficiaries who experience dislocations or are otherwise affected by the emergency, such as those who are (1) evacuated from a nursing home in the emergency area, (2) discharged from a hospital (in the emergency or receiving locations) in order to provide care to more seriously ill patients, or (3) need SNF care as a result of the emergency, regardless of whether that individual was in a hospital or nursing home prior to the emergency.”
100-Day Period & Swing Beds
Waiving the requirement in Section 1812(f) of the Social Security Act for a three-day prior hospitalization for coverage of a SNF stay also authorized the extension or early restart of the 100-day Medicare coverage period for rehabilitation under Medicare in certain situations, without requiring a new benefit period, effective for the duration of the COVID-19 public health emergency (PHE).
Under CMS rules, after a resident uses his or her 100 days of Medicare SNF coverage, he or she must “break the spell of illness” by spending 60 days out of a hospital or SNF setting before restarting a new benefit period. These beneficiaries can’t receive additional SNF benefits until they establish a new benefit period by being discharged to a custodial care or non-institutional setting for at least 60 days.
CMS said it waived this rule to free up hospital beds in the event there are spikes in demand due to the PHE. Waiving the rule also allows care to continue for SNF residents who may need additional services as a result of COVID-19.
The agency recognized that dislocations and discharge delays resulting from the PHE could delay or prevent beneficiaries from beginning or ending the process after their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances.
The change was generally viewed as a positive one for both residents and SNFs, according to Skilled Nursing News. When it comes to reimbursement, however, there are strict guidelines. A recent CMS update directed that any days billed under the benefit period waiver and COVID-19 must show a direct connection to COVID-19.
According to the update, the benefit period exemption does not apply “to those beneficiaries who are receiving ongoing skilled care in the SNF that is unrelated to the emergency – a scenario that would have the effect of prolonging the current benefit period and precluding a benefit period renewal even under normal circumstances.”
Beneficiaries can’t renew their SNF benefits under the waiver if the continued skilled SNF care rather than the PHE prevents them from beginning the 60-day “wellness period.” For example, CMS said a patient who required a feeding tube for a condition unrelated to COVID-19 would not meet the terms of the exemption.
When filing claims, CMS said SNFs should compare the actual care provided with the course of action they would have taken if the COVID-19 pandemic had never occurred. If they are the same, the provider could determine that the treatment was not affected by COVID-19, CMS noted.
CMS did acknowledge that the PHE can cause delays in treatment for another condition, however, and so the beneficiary would be affected by the COVID-19 even though they have not been diagnosed with it.
While the 60-day requirement is waived for residents who are moving toward custodial care or breaking the spell of illness, the waiver does not cover all SNF residents. This differs from the 1135 waiver, for which all beneficiaries qualify, regardless of their remaining SNF benefit days, CMS noted.
“All beneficiaries qualify, regardless of whether they have SNF benefit days remaining,” CMS wrote. “The beneficiary’s status of being ‘affected by the emergency’ exists nationwide under the current PHE. (You do not need to verify individual cases.)”
In an unexpected move, CMS in May released a new waiver allowing all acute-care hospitals to use their beds for “swing-bed services” when necessary. With swing-bed services, facilities can offer skilled nursing care in an acute-care hospital bed. The waiver allows hospitals to provide such services when they can’t find a SNF in their area to transfer a patient to for skilled nursing care. Normally, to qualify for coverage, an acute-care patient admitted to a critical-access hospital (CAH) or rural hospital who needs skilled rehabilitation care is required to stay three or more days as an inpatient. With the waiver, however, patients can be admitted to swing beds without a qualifying three-day inpatient admission requirement.
The waiver noted that the hospital must make a “good-faith effort” to find an alternative facility within the catchment area, as well as have a plan to discharge patients when a SNF bed becomes available or the PHE ends. According to RAC Monitor, hospitals must meet the requirements for participation for SNFs, as stated in 42 CFR 482.58(b), and they must apply for the waiver through their Medicare Administrative Contractor’s (MAC’s) enrollment hotline.
This waiver will help hospitals get paid for caring for patients until a SNF can be found, but it doesn’t cover care for patients who were transferred from a SNF to the hospital due to a COVID-19 outbreak at the facility.
Are the COVID-19 Changes Here to Stay?
After several months of trying to adjust to all the changes spurred by the global pandemic – including lower occupancy and cash flow in some cases, and increased expenses due to testing and buying personal protective equipment (PPE) – SNFs now are being forced to rethink many aspects of their operations.
One big question is: Which changes will stay and which are only temporary? So far, CMS has been clear in communicating that the temporary suspension of rules surrounding the three-day hospital stay requirement for SNF coverage only applies in situations directly connected to the COVID-19 PHE and will only apply during the emergency.
Many healthcare experts and analysts believe the emergency measures the government took during the pandemic – from expanding telehealth coverage to waiving the three-day stay rule – will impact the industry long after COVID-19 finally subsides. When SNFs are able to stop and catch their breath, they will need to assess everything from their facility’s design and ventilation system to their guest protocols.
“A new era of health care is upon us,” Dr. Arif Nazir, chief medical officer for Signature HealthCARE and president of AMDA, the Society for Post-Acute and Long-Term Care Medicine, said on a recent episode of SNN’s “Rethink” podcast. “I really do not believe that many of these things will be reverted back, and they don’t need to be reverted back.”
As the national healthcare industry grapples with the effects of COVID-19, eSolutions continues to be your trusted partner – effectively helping you manage your revenue cycle while your organization focuses on patient care. Our products have been updated with all COVID-19-related diagnoses, HCPCS and CPT codes.
We understand your commitment to providing the best care possible to your patients and communities. At eSolutions, we’re dedicated to ensuring you are reimbursed accurately and rapidly, providing world-class service and enabling access to solutions you need to strengthen your revenue health.
COVID-19 Emergency Declaration Blanket Waivers for Long-Term Care Facilities and Skilled Nursing Facilities (SNFs) and/or Nursing Facilities (NFs):
- 3-Day Prior Hospitalization: CMS has waived the three-day prior hospitalization requirement for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations or are otherwise affected by COVID-19. In addition, for certain beneficiaries who recently exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period (this applies only to those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).
- Reporting Minimum Data Set: CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.
- Staffing Data Submission: CMS had waived 42 CFR 483.70(q) to provide relief to long-term care facilities on the requirements for submitting staffing data through the Payroll-Based Journal system. (Terminated effective June 25, 2020)
- Pre-Admission Screening and Annual Resident Review (PASARR): CMS is waiving 42 CFR 483.20(k), allowing nursing homes to admit new residents who have not received Level 1 or Level 2 Pre-admission Screening. Level 1 assessments may be performed post-admission. On or before the 30th day of admission, new patients admitted to nursing homes with a mental illness (MI) or intellectual disability (ID) should be referred promptly to State PASARR program for Level 2 Resident Review.
- Physical Environment. CMS is waiving requirements related at 42 CFR 483.90, specifically the following:
- Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements under § 483.90 to allow for a non-SNF building to be temporarily certified for use by a SNF in the event it needs to isolate COVID-19 positive residents, which may not be feasible in the existing SNF structure to ensure care and services during treatment for COVID-19 are available while protecting other residents.
- CMS believes this will also provide another measure that will free up inpatient care beds at hospitals for the most acute patients while providing beds for those still in need of care. CMS will waive certain conditions of participation and certification requirements for opening a SNF if the state determines there is a need to quickly open a temporary COVID-19 isolation and treatment location.
- CMS is also waiving requirements under 42 CFR 483.90 to temporarily allow for rooms in a long-term care facility not normally used as a resident’s room to be used to accommodate beds and residents for care in emergencies and situations needed to help with surge capacity. This must be consistent with a state’s emergency prep.