SNFs and the Covid-19 Waivers vol.1

Covid-19 information has been coming our way at a fast and furious rate the last few weeks. CMS has been releasing a vast amount of information related to waivers etc. intended to alleviate some of the strain at the facility level. We thought it would be helpful to put together a serial BLOG of the applicable regulatory changes that have been made and links to where to find the specifics, as well as provide some clarity along the way. As always, please feel free to contact us at Ask an Expert on the broad River Rehab Website. Stay tuned for additional BLOG postings that will convey the full scope of the waivers affecting SNF operations.

1.      Here are the two main documents that CMS has released as FACT sheets related to the waivers.



2.      3- Day Stay and Spell of Illness Waiver –

This waiver is a blanket waiver meaning an application by the state, usually required for this type of waiver, is not required before it can take effect. This also means that it applies to all SNFs because the covid-19 situation is a national emergency as opposed to a local one like a flood or hurricane.

3- Day Stay Waiver – In the original 1135 waiver that CMS issues on March 13th, the is indicated:

Section 1812(f1 of the Act allows Medicare to pay for SNF services without a 3-day qualifying stay if the secretary of Health and Human Services finds that doing so will not increase total payments made under the Medicare program or change the essential acute-care nature of the SNF benefit… Therefore, SNF care without a 3-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.

Keep in mind that the requirements to access SNF care via the SNF benefit remain the same as noted in CMS 100-2 Chapter 8. In other words, the waiver applies only if a patient would have needed a 3-day stay but could not because of the Covid-19 situation. Every case must be evaluated individually to determine if the waiver applies.

Most hospitals are trying to conserve beds for an eventual surge in Covid-19 patients and so although Covid-19 may be limited in a particular locality, the hospital stay can be waived due to the national nature of the emergency. This waiver is not a free Medicare for all card. Here are two examples to help clarify.

–  A long-term resident in your facility is being treated for a stage 3 pressure ulcer/injury. It was determined at the time that the resident developed the ulcer that a hospital stay was unnecessary. The waiver does not apply in this case. The fact this resident may be receiving a skilled level of care does not by itself allow the waiver to be applied. The fact that the resident did not have a hospital stay is not a result of the covid-19 situation.

–  A patient is admitted directly to the SNF from the ER after being stabilized due to a fall with a radial fracture at home related to weakness from a recent illness.  This direct admit was the result of the hospital needing to conserve beds for Covid-19 patients. In this case the waiver does apply because the discharged from ER was in order to provide care to more seriously ill patients.

Spell of Illness Waiver – In the original 1135 waiver that CMS issues on March 13th the following is indicated:

Therefore, we are also utilizing the authority under section l8l2(Ð of the Act to provide renewed coverage for extended care services which will not first require starting a new spell of illness for such beneficiaries, who can then receive up to an additional 100 days of SNF Part A coverage for care needed as a result of the above-captioned emergency. This policy will apply only for 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.

Again, this waiver is not a free Medicare for all card.  Notice that this waiver also has conditions that must be met for it to apply. In short, the covid-19 situation must be the reason that the beneficiary was delayed or prevented from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances.

This waiver applies only to those beneficiaries who were unable to start or complete their 60-day wellness period because of the Covid-19 situation. Here are two examples that might help clarify this waiver.

–          A long-term patient with receiving tube feeding who has exhausted their 100-day benefit and continues to receive a skilled level of care. In this case, the waiver does not apply because it is the skilled level of care that they are receiving, i.e. the tube feeding, that prevents them from starting and completing a 60-day wellness period, not the Covid-19 situation.

–          A patient recently discharged home from a SNF tests positive for the SARS-CoV-2 with complications and must be admitted to the hospital. In this case the waiver would apply because it is the emergency itself that causes the patient to be unable to complete his or her wellness period.  This resident would be eligible for another 100-day benefit period without having first completed a 60-day wellness period.

3.      MDS Timing and Submission:

CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the time-frame requirements for Minimum Data Set assessments and transmission. This section of the Code of Federal Regulations details timing and submission requirements related to OBRA required assessments. By waiving this regulation, it appears that CMS will not hold facilities accountable for MDS assessments that are not completed or submitted in a timely manner.

4.      Staffing Data Submission:

CMS is waiving 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. No further guidance has been provided.

5.      MDS v1.18.1 Delayed:

CMS is delaying the Minimum Data Set (MDS) 3.0 v1.18.1 release, which had been scheduled for October 1, 2020, in response to stakeholder concerns. The draft version of this data set that was posted at the MDS 3.0 technical in December of 2019, has been removed. The delay appears to be de to concerns regarding the proposed changes to the MDS 3.0 item sets and more specifically the removal of the Section G items from OBRA assessments. CMS staff are actively engaged in discussions with various stakeholders, regarding the various changes, the impacts of these changes, as well as, the compressed timeline to educate and train facility staff and update software and IT systems.

6.      SNF QRP and VBP Exceptions/Extensions:

CMS is granting exceptions and extensions for certain deadlines to assist health care providers while they direct their resources toward caring for their patients and ensuring the health and safety of patients and staff. In some instances, these exceptions and extensions are granted because the data collected may be greatly impacted by the response to COVID-19 and therefore should not be considered in the quality reporting program. For Skilled Nursing Facilities, the following Exception/Extensions apply.

SNF QRP – CMS is granting an exception to the Quality Reporting Program (QRP) reporting requirements for all SNFs. These providers are excepted from the reporting of data on measures and standardized patient assessment data required under these programs for the post-acute care (PAC) quality reporting programs for calendar years (CYs) 2019 and 2020 for the following quarters.

  • October 1, 2019–December 31, 2019 (Q4 2019)

  • January 1, 2020–March 31, 2020 (Q1 2020)

  • April 1, 2020–June 30, 2020 (Q2 2020)

SNF VBP – CMS will exclude qualifying claims from the claims-based SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510) calculation for the following periods:

• January 1, 2020–March 31, 2020 (Q1 2020)

• April 1, 2020–June 30, 2020 (Q2 2020)

7.      PASRR Waiver

CMS is waiving 42 CFR 483.20(k) allowing states and nursing homes to suspend these assessments for new residents for 30 days. After 30 days, new patients admitted to nursing homes with a mental illness (MI) or intellectual disability (ID) should receive the assessment as soon as resources become available.

Most state specific 1135 waivers indicates the following additional language;

Additionally, please note that per 42 C.F.R. §483.106(b)(4), new pre-admission Level I and Level II screens are not required for residents who are being transferred between nursing facilities (NF). If the NF is not certain whether a Level I had been conducted at the resident’s evacuating facility, a Level I can be conducted by the admitting facility during the first few days of admission as part of intake and transfers with positive Level I screens would require a Resident Review.

The 7-9-day timeframe for Level II completion is an annual average for all pre-admission screens, not individual assessments, and only applies to the pre-admission screens (42 C.F.R. §483.112(c)). There is not a set timeframe for when a Resident Review must be completed, but it should be conducted as resources become available.

8.      Temporary Sequestration Suspension

SEC. 3709. of the coronavirus stimulus package states that During the period beginning on May 1, 2020 and ending on December 31, 2020, the Medicare programs under title XVIII of the Social Security Act (42 15 U.S.C. 1395 et seq.) shall be exempt from reduction under any sequestration order issued before, on, or after the date of enactment of this Act. This includes Skilled Nursing Facilities will not be subject to sequestration from 05/01 – 12/31 2020, i.e. Medicare bills for both Part A and Part B will not be reduced by 2% for that period of time.

9.      Medical Review Suspension

In a recent 2019-Novel Coronavirus (COVID-19) Provider Burden Relief

Frequently Asked Questions (FAQs)  CMS has suspended Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current post-payment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.